Constipation(!)

I'm just going to start here:

Having a gluten intolerance and diagnosed with IBS (likely Celiac but faulty blood tests) I've always been open to talking about my bowels.

But I have talked more about my bowels in the last six months or so than I ever thought was humanly possible.

Bariatric patients deal with constipation for several reasons. First of all, we drink protein shakes like they're going out of style, and they can bind you up. Second, we take a high amount of iron daily, which also binds. And, for the first 8 weeks post op, we don't get a lot of vegetables in, which doesn't help us correct the issues. Further, our bodies need to adjust to the new much smaller portions and there isn't as much moving through to help things along.

I started experiencing constipation during my Liver Shrink Diet two weeks before the surgery. At my return to clinic visit about ten days out, the Nurse Practitioner told me to get myself unconstipated before the surgery to make things less painful. I was told when they pump the gas into your abdominal area (common for laproscopic surgeries) if you have constipation it hurts a lot more. So starting at 10 days out, I had a cocktail of Miralax every night. Which did it's job...but the time I was constipated led to hemorrhoids. Yea. I'm going to go there.

Hemorrhoids have lived to their description as the biggest pain in my rear and lurks where ever I go. It has led me to change how I sit, remembering to take a cushion with me, and using a Squatty Potty whenever I am at home. For those of you that have seen the commercials, Squatty Potty really does live up to expectations. The hemorrhoids are also a double edged sword: they flare if I don't go every day, but they're so painful I don't want to go.

So by about two weeks out, I realized that if I had a little bit of coffee, I would be able to go. Now this was a huge bariatric no-no, but I couldn't see another way out. A few weeks later, that trick stopped being so dependable and I started having fiber every morning, which also helped.

Also, getting the proper water in helps a lot. Like, I think it prevents constipation all in all.

After a long trial, I have developed a system that works for me.

I take Colace three times daily.

I now take my vitamins in a powder that I mix with water. This powder includes a little fiber which has replaced my separate fiber drink (for the most part). I take this twice a day.

Daily, I try to get vegetables in.

If I have not gone by my bed time, I set aside 10 minutes to sit on the "throne" using the Squatty Potty and if I haven't gone in 10 minutes, I take 2 Senna Tabs and go to bed.

If the Senna has not worked overnight, I take a fiber drink in the morning and go to work, and hope for the best. At this point I carry hemorrhoid cream with me.

Constipation and hemorrhoids are not pleasant but they're a realistic side effect.

Goal Setting

If you participate in any form of social media, you know you're friends tend to fall into groups. If you're in your early to mid thirties like most of my friend group you have a little from the following:

The Mommies
The Nerds
The Harry Potter Fans (insert other fans here too)
The Crafters
The "Always at the Gym"

So when one of my dearest friends put up she was interested in doing a half marathon, I thought "Well this is unexpected". So I commented something along the lines of "Really?"

Then the text conversation started.

A few minutes later, both of us were signed up for our first half marathon. I wish there were more to it but it was really as simple as that.

This happened on Saturday night, but Sunday morning she was putting me to shame by already going for a run and telling me that she was going to do the leg workout I did on Saturday on Monday morning. But she didn't have a lot of guidance.

At this point, most half marathon plans I've found run for 12-13 weeks, which gives us two months to get to that point.

Until then, I made a plan for us to increase time by 10% every week to two weeks and get three runs in at first, then move to four. I will be sharing this math on my Instagram (@jackienelli) seen in the upper right corner of my page.

I've run since essentially my peak weight, so running is nothing new to me. However, since I started running post-op I've noticed an adjustment was needed for nutrition. No longer can I have a carb filled dinner the night before.

I ran the 10K Across the Bay a few weeks ago and finally got a 10K PR for myself. I attribute part of my success to taking Gu Packs every 40 minutes or so. This will likely be continued in a blog post as training continues.

Anyway, we're both very excited for this run. I'll be posting many of my workouts to Instagram and I'll put some summaries on here from time to time.

Coping with New Normals

Dealing with not being able to overeat again.

There are a lot of fears when it comes to surgery. For me, the fear of the surgery itself was shadowed by the fear of what was to come, and I know I'm not alone.

I can remember in my days pre-op I would over eat from time to time and I would be incredibly uncomfortable. I wanted to sleep, but the rock in my stomach was uncomfortable. I wanted to walk, but the desire to stay still was just as strong.

It's not something you think about until you know this is a sensation you won't really experience again.

For those of you who are pre-op/searching/looking for a friend. The three stages most patients go through, however the timelines are different, are:

Full Liquids: Protein shakes, yogurt, cottage cheese, ricotta cheese, water, jello, pudding (1 week)
Pureed Foods: If it blends you can have it (3 weeks)
Soft Foods: Pretty much everything except nuts, raw fruits and vegetables, and the skins of fruits and vegetables (3 weeks)

During the first week, the goal was literally a tablespoon at a time of "foods" besides water. This number increases as even the week goes on. By the time I got to pureed food, I had half of a baby food container at a time.

The sensation of overeating makes what I used to go through look like a walk in the park. Every time I overate until about three months in, I would get the foamies.

There are tons of articles about the foamies. But I would describe it was a mucusy, saliva vomit. Very little food comes up, but after a few minutes with the foamies, I would be ok. Not 100%, but more comfortable.

I don't get the foamies anymore because I don't allow myself to get there. Every once in a while I'll eat something my pouch doesn't want to process, or I'll have just a little too much, and I just take a nap to deal with it.

There are times where I'm eating, and I'll literally have food in the spoon, and that's all I have, and I'll leave it there. Literally, one spoonful is the difference between being comfortable and foamies.

So, people wonder how I do it. Because I know what's coming if I eat even just a hair too much. It's as easy as that. I had several bouts with foamies and being uncomfortable, and I think of those as learning experiences. Once a patient gets a handle on that, they should be ok.

Finding a New Self Love and Self Improvement Balance

On October 19, 2017, I hit my second weight loss goal, and my first since the surgery. I finally hit 100 pounds down.

I get on the scale regularly, honestly probably more than I should, and I knew this day was coming sooner rather than later.

I thought of the ways to celebrate hitting 100 pounds off of me forever, and I came up with the idea to take a day off and spend $100 on myself, no guilt allowed. Originally, I was going to get a facial or a massage, because I was afraid I would return whatever I bought.

The day finally came and a few "life happened" moments occurred. First, I couldn't take off the next day (a Friday) or the following day (a Monday) because of a deadline. Suddenly the rest of the week didn't look good, nor did the next two weeks (being a grown up is overrated). Also, in a good way, a friend gifted me a massage the week before, so I got my planned happy treat for free. Earlier in the month, I did spend a frivolous $100 on a TENS machine to help my aches and pains after workouts, and my husband's painful feet.

So back to what happened on October 19. I came home from work and for the heck of it, I stepped on the scale to see this. I was on my way to the gym, so I went there, shared the good news with my friends there, had a killer workout, and took a super cute Instagram picture. It didn't feel right just to go home at that point.

How was I going to express self-love in this process?

Before I tell you the embarrassingly nerdy way I celebrated 100 pounds, I want to touch on the journey I've gotten to for my self care, love, and improvement.

From the start of my medical weight loss journey in January of 2017, I eased into a workout routine. I started with alternating cardio and weight training and fell into doing both cardio AND weights at least twice a week. Part of this was possible because my part time job as a swim coach was ending with the conclusion of the season. This is an important point.

Then came surgery day, and I couldn't wait to get back to the gym. I had more time to work out because I cleared my schedule for healing, and working out was a big part of my emotional and mental well being. I found myself (safely and with the blessing of my medical team) working out regularly. As I went back to work, I struggled at first to find the right levels of energy and the right timing to workout, and I found it. But I let my body decide more than my social schedule or any outside influence.

Now as I approach five months out, I listen to my friends and husband's suggestions but when it doesn't work for me, I tell them, and there's not an issue because I'm being honest and everyone is understanding.

This has made for its fair share of uncomfortable situations. The most recent one is that my husband, on his own bariatric journey, committed to weekly aquarobics classes at the Y. I went with him for the first class, but I realized it was not a very challenging workout for me. I felt bad telling him, but I had to be honest and tell him that on Tuesdays (his chosen day for now), I get a more quality workout at Planet Fitness with my friends than I would at the aquarobics class. I know it was hard for him to hear, but we all only have 24 hours in the day and I need to make them work for me.

I also had to quit my job as a swim coach. This was a hard an unexpected turn of events, but the head coach was making the schedule and was not considering my new needs. We had an established schedule, but then she changed it, and wanted to keep changing it, and I told her this would simply not work for me. More importantly, as the season hit its crazy stride, I knew the schedule would get tougher, so I had to make the tough choice to walk away from my "sanity check" job.

So the theme here is that I had to find time for self love/care and self improvement. I told my husband and my former coach that my old schedule wasn't going to work for me anymore. Additionally, I enjoy journaling my weight training so I can see a clear improvement.

Finding time for self care is a little more difficult. I love to crochet, so it's been easy to find projects and circles of others who enjoy getting together to crochet. Other good hobbies friends of mine enjoy are adult coloring books, bullet journaling, and volunteering at local organizations.


So back to how I celebrated my loss. I left the gym, and decided to go to GNC to buy some good protein.

Yes, how very "bariatric patient" of me.

The week before, we bought my (former) favorite Pure Protein in vanilla from Wal-Mart. I had a scoop and it didn't taste right to me, but they say tastes change over time, so I didn't think much of it. A couple of days later, my husband complained and I thought that this might be a quality issue. But, we bought it, it was a little pricey, so we're stuck.

At some point on the day I discovered the loss, I decided we deserve better even if it means throwing the protein shake away. A recent visit to GNC taught me that they stand behind their products with a 30 day guarantee, so I went there to get us a new flavor that was actually halfway decent. Also, the quality of protein is likely higher.

The bottom line is, that day I realized, we deserve better. We shouldn't have to stomach our way through a protein shake.

So there you have it. The day I lost 100 pounds, I celebrated by working out, and buying protein.

Stress Eating and Travelling: A Two for One Deal!

Just as a little bit of background before I jump into it, my husband's family with little exception all lives in a town in Southeast Texas. We've gotten out there about once a year since we started dating because we can see so much family in a single shot. Also, his grandmother (Meemaw from this point forward) had Lou Gehrig's Disease. She passed away on September 6, 2017.

If you have put a few pieces of this puzzle together, she passed away during a time of a natural disaster (Hurricane Harvey), and partially due to this the services had to take place nearly two weeks after she passed away.

When we got the sad news, we assumed things would happen quickly and the price of last-minute flights made it cost-prohibitive for both of us to go. A day later, we found out the service would be in about ten days, and we managed to find cheap airfare so both of us could go. After all, if Meemaw knew you, you were her grandchild and she loved you as such.

So today's story hits on two things, dealing with a high-stress situation, and traveling.

This was not my first post-operative trip, we went to Canada when I was eight weeks out. But, when we went to Canada, I was not cleared to eat all foods yet, so I found myself reverting to be safe as I didn't want to have an emergency so far from home.

At nearly 16 weeks out, I can eat practically anything, so the thought of what to eat for safety was no longer present which made some things easier, but also presented a danger for eating the wrong things.

I'm not going to sit here and write that I made every perfect decision and I would proudly present my food journal to my nutritionist or surgeon. The facts remain that I wrote everything down, and I did the best I could. A few key points made this possible:

1) I have a supportive husband who is willing to share plates. I'm going to start a new series of entries about my husband going through his own WLS journey (he starts in a few weeks from writing). So he understands where I'm coming from, and also that portions at restaurants are so huge, me having my three or four bites does not take anything away from his experience. Especially since the surgery, we haven't eaten out all that much. We would discuss what to order, then when it came to the table I had a small plate for my own serving. I know some hospitals give out cards to keep in your wallet that you have a medical necessity to order from the kid's menu. After this weekend, I am solid in my choice to not even ask for that card. The choices on the kids menu are generally less healthy than the main menu. They are there as usual kid crowd pleasers.

2) Planning planning planning. I have said in past posts that failing to plan is planning to fail. From the start of planning out our flights and our day of travel (we were landing at 3:30pm, getting lunch with my in-laws, who were on the same flight, and driving the 90 minutes to the destination) we planned out how we were going to get what we needed for a good trip. Before we even got on the plane, we made a list of things we would need at Walmart when we landed. This list included pre-made Premier Protein (a luxury to us), Cheerios, water flavoring, and fiber laxative. We stopped at Walmart and made our purchases, which carried us through the trip.

3) Think "protein" first. Every time I put something in my mouth, I thought "protein" first. I tried to keep my normal day for as long as possible every day, and no matter how the day ended, I restarted with the normal day the next morning. My normal day is my fiber laxative, protein shake, and a little later Cheerios (dry). At that point my days change as I mix up lunch and dinner. While the family was eating the food local organizations had so generously brought, I had my lunchbox. On the way in, I bought beef jerky from Buc-ee's. For non-Texas people, Buc-ee's is just a magical rest stop with the cleanest bathrooms you'll ever experience, along with fun food options. What caught my eye was the beef jerky bar, and we bought enough jerky to share with everyone. Also, beef jerky takes so long to chew, especially post-op that it would really keep me busy.

This wasn't the happiest of trips either. It was the first time I found myself in a situation where I would have eaten a lot from stress eating before the surgery. I was a little nervous going into it, but honestly I had no desire to overeat. I wonder how this will change in the future, but I had no issue saying no, and more importantly, no family pushing anything on me. This was the first time everyone had seen me since I lost any weight, so I was down 90 pounds since the last time I saw them.

This trip proved a lot to me about what I'm capable of and what level of planning it takes. The most important part is that as long as I am able, a Walmart should be my first stop, even before I get to a hotel. Research and preparation will allow anyone to have a successful trip.

My Own Decision

Some of the most common things I see on the various Facebook support groups I follow include what brands of vitamins to take to save money, and what finally made people decide that surgical weight loss was the way to go.

If you've ready my story, you know how I arrived here. For those of you that didn't read it, my size was defining physical limitations that were becoming more limiting by the day, so it was time to do something about it.

I thought about surgery from the start of physical therapy for a knee and hip injury in July 2016 and applied through Johns Hopkins in October 2016. I was still not convinced when I applied, but since that twelve-page application deemed me eligible, I decided it was something to really consider. Still, however, I told myself not to make up my mind until I saw the surgeon. Even after the appointment with the surgeon, I made the first couple of appointments, which were an EGD and my first appointment with my Primary Care Provider, I still wasn't convinced. Either way though I was going to lose a little weight. I don't know exactly when my mind was made up, but by the second month of my process, I knew that surgery was the right choice for me.

To oversimplify my thought process, I'm going to break this up into Pros and Cons.

Pros:
1. I will lose weight quickly: This one speaks for itself. No other program boasts up to a 75% excess weight loss in 18 months.
2. I am more likely to keep it off: Of course everyone I talk to has a cousin that has a friend that had the surgery and then gained it all back and then some. But, the numbers tell me that more people have greater long term success due to surgery. This surgery is altering how my body absorbs food, so as long as I'm not actively seeking out all of the loop holes, I will be successful.
3. All of the other pros of weight loss: More energy, less over all pain, better fertility. All the things that other programs can offer as well as weight loss surgery.

Cons:
1. Surgery is scary: Someone is knocking you out to the point where you can't even breathe on your own and rerouting your body. Yes, its scary. But I was deemed medically necessary by the surgical team as well as my insurance, so this must be a risk worth taking.
   Counterpoint: My first surgery was when I was 28 years old. It was a tonsillectomy and I needed it. Like, my tonsils touched when I swallowed and were terribly infected so my quality of life was not too good. I was scared, but I knew I had to do it, otherwise every few months I would be sick for a week at a time, and each time I got sick, it got worse. Finally one day I realized that I'm one bad turn of the steering wheel or even one bad step, away from needing emergency surgery where I would have the time to go through my own existential crisis. That actually soothed me.
2. There are no guarantees it will work: Yes the surgery makes your stomach a lot smaller, but I can just change my eating habits and get it all in. There are ways for this to fail and the surgeon and your team are not with you all day helping with your choices. One side effect of the long pre-op is you have plenty of time to think and decide if this is really right for you.
3. Possible complications: Every surgery carries risk and unfortunately these risks are multiplied for those who are overweight/obese.
   Counterpoint: See con 1. You never know when you need surgery. Also, if you follow the instructions to the letter, you decrease the chance of complications significantly. 

Living on a budget (vitamins and protein)

It is no secret that eating healthy is more expensive than not eating healthy. 

I can go to Little Caesar's and get a medium pizza that will feed both my husband and myself for $5.99 or go next door to Panera and spend over $6 for each of us to get a salad. All of this is situational seeing as I'm gluten free by medical necessity.

I'm not going to go over this fact again as many blogs and sites have done it themselves.

But Bariatric surgery has an added level of complication. Post-op, patients need to buy protein supplements and vitamins. These can add up to astronomical levels. Some say that the money you're saving on food can help balance the budget, but I haven't completely found that to be true as I am still feeding my husband.

Let's start with saving money on protein:

Addressing once again that I'm one of the cheapest people I know, I will remove a little satisfaction from my food to save significant money. That is exactly what I do with Pure Protein. I have had better brands with better flavors, but Pure Protein is $17.98 for 29 servings. That means I go through one of these every four weeks.

Going on to vitamins:

I decided to use Celebrate vitamins when I started this process simply to take less vitamins any given day. But, does this add up to savings at the register? I'm going to compare two options at prices for every thirty days. All vitamin intake must meet these minimum standards.

1. Daily intake of 65mg Iron
2. Daily intake of 1500mg Calcium Citrate
3. Daily intake of 800mg Folic Acid
4. Daily intake of 3mg Thimine
5. Daily intake of 2mg copper
6. Daily intake of 3000IU Vitamin D3
7. Daily intake of 500mg B12
8. Preferably has selenium and zinc 
9. Oh, and chewable only for the first 6 months
10. AND you can’t take gummy vitamins

One option that many seem to take is to take Flintstones Vitamins and then supplement what else they might need. Looking at our list, if you use the iron minimum to decide how many vitamins to take, you must take six Flintstones a day (and this is with enhanced iron). At six Flintstones a day, you meet the requirements for Iron, Folic Acid, and Thimine. This means you are still missing Calcium Citrate, Copper, Vitamin D3, Vitamin B12.

Some quick math on walmart.com showed me that:

• Best value for Flintstones was $27 for 180 pills (or $27 for 30 days)
• Best values for Calcium Citrate (includes part of daily supply for D3) was $15 for 155 pills (or $12 for 30 days)
• Best value for Copper was $7 for 300 days (or $1 for 30 days)
• Even with the Calcium Citrate in this scenario, you still need one D3 which was $13 for 240 pills (or less that $0.50 for 30 days)
• Best value for B12 sublingual $4 for 200 days (or $1 for 30 days)
• Total vitamins daily: 12 (6 Flintstones, 1 Copper, 1 D3, 1 B12, 3 Calcium)

Flintstones come to about $41.50/30 days to meet all requirements. 

At first, I thought it was going to be more expensive to buy the special brand name bariatric vitamins for my needs. Due to the values of the needed minerals and vitamins, there is no need for extra supplemental items to buy. Let’s see how they measure up:

• Multivitamin chewable (without Iron) is $42 for a 90 day supply ($14 for 30 days)
• Iron supplement (chewable): The price discrepancy is significant depending on how much you need. I’m on the high end as I had gastric bypass and I still have my period. The cost range is $21.50-$35 for 90 days (or $7.17-$11.67 for 30 days) 
•  Calcium is interesting because this vendor offered soft chews, which taste better and have a better texture, but in my (cheap) opinion is not worth the extra price. The cost comes to $45 for 90 days ($15 for 30 days) 
•  Total vitamins daily: 6 (2 MV, 1 Iron, 3 Calcium)

Going with Celebrate Brand means less work organizing your vitamins weekly. This is something I spend about 10 minutes a week doing to get me set up for a full 7 days. 

Celebrate Brand vitamins would cost $36.17-$40.67/30 days. This means that a patient would save a little less than a dollar to go the Celebrate route.

Stigma, Judgement, Myths, and Misconceptions

I'm going to start with this fact: I applied for my weight loss surgery in October of 2016 and I was not too open about my application. I would like to think that I wasn't open about it because I honestly had not made a decision, and wanted this decision to be mine and mine alone. I told my family, but I did not tell my husband's extended family so when one of them came for a visit in the spring and I was well into preparations, it took her by surprise. After all, I had not mentioned anything over Christmas.

As the process continued, I was open with people I spoke to and saw every day. But there was an audience that was in the dark about this decision: my extended army of Facebook friends. Now, I personally know all of my Facebook friends, and I occasionally go through and delete people that I don't see myself getting back in touch with. I had a tentative surgery date of June 14, so I decided I would tell the greater Facebook community on April 14, two months to the day when I was to go under the knife.

The support I got was amazing and I wondered what took me so long to tell more people what I was going through.

Before becoming a bariatric patient myself, I always wondered why people would decide to make the decision to have weight loss surgery. As I developed my own reasons for the surgery, I gained a new respect for friends that had taken this path before I did. I never thought as surgery as an easy way out, I just thought it was extreme.

The other night I came across this article written about a woman who has had bariatric surgery and denies it when people ask her how she lost weight. The stigma that surrounds weight loss surgery patients is deep and complicated. Bianca mentions an article, published in the peer-reviewed medical journal Obesity Surgery. In the study, individuals are shown before and after pictures of individuals who had lost weight and rated them based on their opinions of the pictures (Vartaniam and Fardouly, 2013). Then, the individuals are told which ones had weight loss surgery. The opinions of the individuals in the study towards individuals who has the surgery dropped dramatically. Further more, the individuals who had weight loss surgery were seen as "significantly more lazy and sloppy, less competent and sociable, less attractive, and having less healthy eating habits" as compared to those who lost weight using more traditional methods having less harsh descriptions.

I had a hard time wrapping my head around this idea that people are judging me negatively based on this decision I had made. After all, I'm still watching what I eat and going to the gym. Only rarely does my stomach dictate how much can go in, I usually stop eating well before that pressure reminding me that my stomach is the size of an egg begins.

Ultimately, the overwhelming opinion is that everyone will lose weight if you eat less and move more. Most bariatric patients will tell you that is not the case. There are nutritional considerations to make, and types of exercise to consider. The solution is not a one-size-fits-all situation.

I have surprised many with the depth my journey took me before having my surgery even scheduled. The design of the Johns Hopkins program is to get you ready for surgery by starting to develop good habits beforehand. Like most stereotypes, if someone took the time to get to know someone going through it, many misunderstandings will go away. Which is a big reason why I started this blog. If you have the time to want to understand the process, I'm hoping this blog can help.

I'm going to end this with two stories of resistance I've met in the last year:

During my pre-op diet, I found great success. But, I knew I usually lose between 40-60lbs and then maintain it for about six months before gaining it back. Several people asked me why I would get the surgery when clearly I'm able to do it on my own, and I would explain to them that I've never been able to keep it off. One person went so far as to treat me as if I were in hysterics and told me "we are going to do this together, without surgery". The message I had to tell her was that I don't think her less for not wanting the surgery, but this is a decision I have made because the time is right and it's time for a change.

The second story is from December, right after I had applied and I hadn't told anybody outside of my immediate family. My husband's family is mostly in Texas and I had strongly considered not telling them and surprising them with our next visit. When we were at one of the houses on our circuit, my husband's uncle came up to him and commented (note that his verbal filter has been eroded by years of substance abuse) "not getting any smaller, why don't you get that gastric bypass?" My husband was so mad just knowing the process, not living it as he would within two months' time.

To overcome the overwhelming feeling of stigma, attending in-person support groups as well as online ones can help a lot. There are so many people involved in those groups, when I look at my newsfeed these days, I wonder how many people on my newsfeed have not had weight loss surgery.

Like all choices in life, we are judged. I don't judge people who don't get the surgery because insurance and time off can make that tough. I just hope that my decision to get the surgery warrants the same respect.