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.

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. 

Presurgical Shopping List

I remember getting ready for my surgery and thinking to myself how different life was going to be as soon as I got home from the hospital. I was nervous, excited, anxious...so many emotions at once.

I was well prepared, the program at Johns Hopkins had gotten me ready and I was more excited than anything to get the petal to the metal. Hopkins even makes their guidelines available to the public, if anyone would like to read over the material.

The weekend before the surgery, I went shopping and got two sets of the below list. I got two because I was going to be spending nights at my house, but would be spending most days at my parents' apartment since my mom works from home and is an RN. This list was derived from the guidelines linked above:

• Protein powder
• Lowest fat cottage cheese
• Plain Greek Yogurt
• Dannon Triple Zero Oikos
• No sugar added pudding pops
• Sugar free popsicles
• Fairlife skim milk
• Ricotta Cheese (lowest fat)
• Pudding (powder)
• Jell-O

My favorite items in those first few days were protein powder and pudding pops. I would make my shakes with Fairlife as it increased my protein from 20-25 grams per shake to 33-38 grams.

The biggest key however is getting at least that 64 ounces of water in daily. Before discharge I got a water bottle from the hospital that had increments of 2 hours to get 8 ounces of water in. If I started at 7:00am, and I was consistent, I would get my 64 ounces in by 11:00pm. I still use the one from Hopkins, but I found inspiration here. But, even taking a standard 32oz Nalgene with a Sharpie would work, but you would have to remark it fairly regularly.

Finally, I made a paper chart with goals based on the timeline in the guidelines attachment. I would include all of my new vitamins and medications on this list as well. I don't have any copies of these left, but it looked something like this:

• 7:00am: Protein Shake made with Fairlife and AM pills
• 8:00am: Water
• 9:00am: Greek Yogurt (make sure water goal is met), Lovenox shot
• 10:00am: Water
• 11:00am: Fudgepop (make sure water goal is met)
• 12:00n: Protein shake made with Fairlife and Noon pills

I think you see what I'm doing here...

August 24, 2017: Three month post-op visit

I should start with addressing two issues: first, this appointment was 12 weeks and 1 day post op for those of you paying attention to the dates. Secondly, the three month appointment really started 10 days earlier.

On August 14, I went to the lab to get my bloodwork done for my upcoming appointment. To help anyone going through this in the future, the phlebotomist took seven vials of blood and it took two arms to get this job done. The good news is that this is not a fasting blood test so I didn't get woozy or anything. I could list all of the blood tests they did, but highlights included a standard CBC, protein checks, B12, Vitamin A, Vitamin D, and electrolytes.

Between August 14 and August 24, I got to see my blood tests come back using the MyChart feature Johns Hopkins provides to all patients. Everything was coming back beautiful.

Finally on August 24, I had my appointment which, thanks to nasty traffic, I was nearly late for.

I sat down with my Nurse Practitioner and discussed how the last three months had gone. I told her about a burning sensation I had under my ribs the previous week, but changing my diet and certain routines things had gotten better. She then told me that she thought the best idea was to re-prescribe Protonix, which I would have asked for if she hadn't brought it up. We began going over my average daily diet and I apologized for my diet sounding bland, but I had adjusted my diet to address that burning sensation, which I assumed to be heartburn. She said "I'm already giving you back your Protonix!" jokingly.

I am doing one thing bad: coffee. I was completely off the sauce prior to the surgery but I found coffee to be a helpful part of my daily routine at preventing constipation. I told her this and we addressed changing my constipation prevention routing. The new routine is:

• 1 colace 3 times a day
• 1 Senna at night (was 2)
• 1 serving of Metamucil at night (new)

Then we went over the bloodwork, which as I had seen was great. One deficiency was in Vitamin A, but it was minimal, so they are going to watch and see how it goes for the next three months.

Finally the surgeon came in and she did the standard pain check by touching my stomach, which went fine.

These post op appointments are so important no matter how far out you are. I think I would be hard pressed to find someone who skips an appointment so early, but there are people who just don't want to go to the doctor when they are feeling well. However, bariatric patients, for the most part, have been trained better than this.

When Food gets Stuck

It happened again on Monday night.

My husband makes this dish called "Poor Man's Meal" which is basically cut up potatoes, cut up hot dogs, some tomato sauce, and cheese. Not the most nutritionally sound thing in the world, but he could make a lot worse.

So, I was under my calorie goal for the day and above my protein, so when I came home from my knitting and crocheting group, I figured I would have a little bit of my husband's creation.

As I put the first bite in my mouth, I started talking to him, and swallowed before I was done chewing properly.

Before anything happened, I knew I did something wrong.

The advice to chew for 20 seconds (or 30 times, whatever your nutritionist tells you) is not only to slow you down, but to have your food better prepared to go into your stomach. First of all, I'm only 10 weeks out so my stomach is pretty much still recovering. Second, the point where the stomach passes food into my small intestines is the size of the tip of my pinky finger. Normal people's stomach to small intestine passageway is the size of a quarter.

When I saw my nutritionist for the first time, she didn't say this might happen, but that it would happen. I was told to not drink, because that wouldn't help "de-clog". Drinking would only make the situation worse (I had to learn for myself).

And that's the point of what happened on Monday.

I wasn't careful in chewing and swallowed without thinking and completing my chewing. Immediately I knew simply not puking would be a gold star for the evening. I quickly put the remainder of my bowl away, and went upstairs to start my night time routine. I felt better after my shower, but I knew I couldn't drink or even take my last vitamins for the day.

Sometimes I have to throw up to feel better after a clog. On Monday night, I stayed vertical a little longer than usual and I was able to fall asleep without vomiting. I did however skip my vitamins which would not be recommended.

The moral of the story is that chewing is important. I find myself trying to make meal time about meal time and not about talking to someone else which does not make me the best for dinner company. That adds into my attempts at not socializing around food.

Which is another entry for another day...

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.

August 1, 2017: Eight weeks, six days

Today was back to the office, but only for three days. Not a terribly eventful day. I had a project that really tied me to my desk, so I didn't get to tell stories about our vacation to my coworkers. But I did catch up on my podcasts.

I had a lunchtime workout followed by my "meal planning" of another slice of leftover pizza.

One thing about sitting all day for 8 hours was I found the need for a standing desk to be much stronger than it had been in the past. I spoke to some people in my office to see about getting the ball rolling and plan to write a message to my surgical team agreeing with my need for a standing desk. I also got the blessing to put an IKEA standing desk hack on my desk for the time being! Yay projects!

Food journal:
Breakfast:
Protein shake

Mid morning:
Banana

Lunch:
Slice of pizza
Leftover beet salad (like a quarter cup...two months ago I would have thrown that out but now...different story!)

Afternoon snack:
Oikos Triple Zero

After workout snack:
Slice of Cheese

Dinner:
18 medium grade shrimp
Cocktail sauce

Workout Journal:
Lunchtime:
3 miles in 30 minutes

After work:
Chest:
Pec Fly 4x12 @40
Assisted Dips 1x10 @175, 2x8 @ 160 (lower the weight the more body weight you're pushing)
That badass move where you're between the cables and using two machines making a hulk motion 3x12 @ 15 each arm

PF360
Chest pull with upright cable
Russian Twists with 6lb ball
Shoulder pulls
Box Jumps (level 2)
Rope shuffle
TPX Squats (w/jump first time w/o jumps second)
Kettle Bell alternates with 15lbs

July 31, 2017: Eight weeks, 5 days

Today was the first day back at work since our road trip. Getting back into routine is always a little tough so I mixed up the routine a bit.

First, I went to the Army Wellness Center, as civilians are allowed to do, and got my Body Fat Percentage through a very accurate tool called a Bod Pod. The only comparisons were from about 15 months ago, and 34 pounds lighter than my actual high weight. Still though, I dropped 4% body fat as well as 9 lbs of muscle. Obviously we want to see the body fat drop more than the muscle.

During lunch I did the 30 minute PF circuit and it worked out well.

After work I walked with my friend while she walked her dog then we went out for dinner. I had two bites of a beet salad along with a single slice of gluten free pizza.

Food journal:
Breakfast:
Protein Shake

Morning snack:
Banana

Lunch:
Swiss cheese (2 slices)
1 serving of Halo Top

Dinner:
A couple of bites of a beet salad
A single slice of pizza

Workout journal:
30 minute circuit class during lunch
Mile or so walk after work

July 29, 2017: Eight weeks, three days

We are still in the process of getting back to normal after our vacation. We woke up early and each had different things to do, so we went our separate ways.

I ended up going to Wegmans with my parents just to get out for a few minutes. There, I found that they sold Quest Protein Chips in bulk (only 8 servings) for the same price as Amazon. I excitedly bought a box. We also found French Macaroons in the bakery, and they were surprisingly low carb, at 12 carbs a serving. A few months ago I would have eaten the three servings in the box, but my parents and I each had one serving of two.

After that I came home and continued to do housework and decided to go to the gym a little later. My goal was originally 45 minutes on the elliptical but then I decided to change my goal to 4 miles in 40 minutes. 

I rocked it. 

At night we had a baseball game to go to at our local minor league field. It was a good time to hang out with friends.

Food journal:

Breakfast:

1 egg scrambled

Lunch:

2 macaroons

Think Thin Protein Bar (not a fan)

Dinner:

Canned tuna

1 TBSP of mayo

Quesadilla cheese

Snack:

Quest Protein chips

After the game:

GF Matzo

Workout journal:

40 minutes on elliptical keeping to under 10:00 miles

Added cool down

Arm workout

1-2-3-4-5-6-7-8-9-10-10-9-8-7-6-5-4-3-2-1 curls with 20 lb barbell

Single arm extensions 3x15 @15lbs

Remembering Meds and Vitamins

The deeper I get into life as a bariatric patient, the more I truly believe the mantra of "failing to plan is planning to fail".

Someone, please buy me a bracelet.

Everything, from the gym, to food, to what the meat of this post is about, medication and vitamins, are carefully planned out. In just three months, this has become routine.

But lets turn our focus to strictly medication and vitamins. And lets start with storage. I use this pill holder. It's literally called "Lazy Me" and was the biggest one I could buy. Each day is broken up into four sections, which is exactly how my nutritionist said to pace things. I like it because I can pop one day out and take it with me all day. It's also just big enough for my biggest pills. I just have to worry about one little box all day.

Every Thursday night, I take my pill holder and all of my meds and put them into the proper days and times. In each section, I place the following:

• Morning
• Celebrate Calcium Citrate
• Actigall
• Colace
• Zyrtec
• Afternoon
• Celebrate Calcium Citrate
• Colace
• Protonix (completed regimine)
  
• Evening
• Celebrate Calcium Citrate
• Actigall
• Colace
• Bedtime
• Two chewable Multivitamin plus 60 iron tablets  (changed to splitting the MV from the Iron due to nausea issues)
  
• Two chewable Mutltivitamins
• One Iron 60 chewable

I plan on updating my meds and vitamins very soon. (Updated: 8/11/2017) The change will be taking out protonix and splitting my multivitamin and my iron. The flavor of those tablets make me really nauseous and I want to try splitting them up. It will end up costing me about $30 more every three months if I decide to keep the change.

I think one key to my success in remembering my meds and vitamins is to take everything in that section of pills at the appropriate time.

Speaking of appropriate times...this is a good time to share how I remember to take my pills.

My four times I get reminders are 5:45am, 11:30am, 2:30pm, and 6:00pm. I set these reminders through Baritastic but at three months I really don't need them. They've been great while I've been away though! The most important thing to remember is to space the calcium tablets out by at least two hours. So if I take my first section before leaving the house at 6:00am, and I look at the clock and it's 9:00am, I know I'm safe to go ahead and take it. 

June 21-26: Seven weeks, two days to eight weeks

My husband and I are currently on a whirlwind road trip that took us from our Maryland home up to Toronto. On the way up, we stopped to see some of my family and some family friends before finally reaching Toronto.

The first day of the road trip went right according to plan. The one difference was going out to eat, but of course I had leftovers.

The second day of the road trip took us past some family, who put a lot of thought into what they served us for lunch (I had tuna salad). For dinner I had the leftovers from the night before.

The third day we went to the Baseball Hall of Fame which included a lunch out. Our gracious guests grilled up some burgers and hot dogs and I had half of each.

The fourth day was about 6 hours of driving. First we went to Niagara Falls, where I had a lunch that did not sit well with me. Upon arriving in Toronto, we went out to dinner and bought one meal to split between the two of us, and I think my stomach was already not doing too well since lunch so I spent about an hour vomiting during the first night we were finally at our destination.

The fifth day (and day one in Toronto) went great. My husband had a class all day so I spent the day wandering around the city myself. I made sure to pack a water bottle and a protein bar, and that sustained me through the day. For dinner, we went out with some of his classmates and I had some of the appetizers (oven baked nacho chips with vegan toppings), but by the time dinner came I had to put it all away to take home.

The sixth day was day two in Toronto. I spent time in the city again today and packed my protein bar and water again.

This was the first big trip we took since the bypass. I had spent a few days in Wildwood but the added complication of whole days in the car made this trip more difficult. This is what I've learned:

• Don't test the waters with food while away. Have what you know works
• Make time to sit down and drink water
• Order one entree to feed two people. The leftovers we had floating around got tough to manage on the road
• Start the day with a protein shake even if there is a free breakfast at the hotel. On day five I had probably one egg and a single bite of sausage from the hotel breakfast and was stuffed (and unable to drink for 30 minutes). This was only 10g of protein at most. on day six I had a protein shake and things went better
• "Failing to prepare is preparing to fail" has basically become the mantra of how we travel.

As for workouts during this time, I got 15K and 10K steps in Toronto but besides that I was mentally and physically exhausted from driving. I can't wait to get back to the gym on Friday and get back into my routine.

July 20, 2017: Seven weeks, one day

Today was a day where a workout was just not going to happen. I'm still on the fence about workout out during lunch as this heat wave is upon us, but today was also a potluck for lunch (my first post-op) so that decision was made for me today.

For the potluck, I made a really simple deviled egg recipe. I've decided this will be my go to for potlucks and church events.

We're also going away tomorrow, and I had to buy stuff to make this road trip as successful as possible. I went to WalMart right after work hoping they sold a particular brand of protein powder and they did! And at the same price as Amazon!

Directly related to my needs for the trip, I bought the following (for the record I don't get any money/kickbacks from any company):
Chocolate and Vanilla Pure Protein
Quest bars
Applesauce packages
Think Thin bars
Beef Jerky
Already made Premier Protein Shakes

So...no lunch, not right after work, and I had support group. Prospects for working out were not good.

AND there was traffic galore. To the point where I nearly didn't go to support group, but as always I'm glad I did. The topic of discussion was hydration, which has been a struggle, and I was also the most recent post-op patient and plenty of pre-op patients had questions for me which I was glad to answer.

Food journal:
Breakfast:
Celebrate Protein (1.5 servings)

Lunch:
3 deviled eggs

Afternoon snack:
Oikos triple zero yogurt

Dinner:
1 serving of corn pasta with tomato sauce and quarter cup mozzarella cheese

May 31-June 1, 2017: Surgery and Hospital Stay

6:30am
The first thing I had to do this day was re-wipe myself using the instructions from my pre-op appointment. Since part of this involved my back, I woke up before my husband left for an appointment to help me out. I put on a new set of clothes, and went to bed.

8:15am
I woke up again and drank a bottle of Gatorade given to me from the pre-op appointment. I was told to have this done by 2 hours prior to my appointed arrival time of 10:30am. I got up, made sure everything I needed was in my bag, and my parents were due to arrive at about 9:30am to bring me.

In my bag, I packed:
2 pairs of underwear
2 pairs of comfy pajama or workout shorts
2 t-shirts
iPad
Charger (extra long)
Yarn and a crochet hook
Folder with all of my papers I got so far
Wallet
A hoodie in case I got cold

I wore comfortable clothes to the hospital. Something worth noting was that all of the clothes I brought were clothes I wouldn't mind losing. I kept the charger, my phone, iPad, and wallet in a place where someone would not easily be able to sneak in and grab them. Everything else stayed out of arms reach on a windowsill.

10:30am
We arrived at the hospital a few minutes early but soon enough they brought me into the back. First thing was first, they needed to make sure I wasn't pregnant. I remembered not to pee from the gatorade knowing this was coming, so I gave them my sample and came up negative. I changed into the hospital gown, and got my final pre-surgical weight.

Then, I got my first of 63 Lovenox shots that I would get or self-administer over the next 30 days. The nurse put a motion sickness patch behind my ear to help with nausea, and took a couple of tubes for testing. Then, they started the IV and hooked me up.

At that point my parents and husband were allowed to rejoin me. I was by far the least nervous person in the "room" if that's what you want to call it. It was probably about 11:30am by this time. I was due to go in at 12:30pm. Then the parade of medical professionals started. I don't remember the order, but that's probably not important. The surgeon stopped by to answer any questions my family had and I signed a consent for the surgery. The anesthesiologist stopped by to see how much I could open my mouth, and confirm what he already knew about me. Another anesthesiologist stopped by (there were two on the team) to introduce herself, and its a good thing she did because she was who I really talked to once they rolled me into the OR.

At around 1:00pm, the team came out to take me back. I gave my glasses and phone to my husband (taking off my glasses is my least favorite part of any procedure). I got rolled into the OR and shifted myself onto the table. The anesthesiologist got me positioned and explained that they have found that just a few minutes of CPAP therapy has proven to help patients going into surgery. The OR nurse strapped my legs into machines that pumped air into stockings to prevent blood clots. A few minutes passed by as they got me ready, and suddenly the time came where they instructed me that I would taste a metallic taste, smell something metallic, and possibly feel a burning sensation at the IV point.

5:35pm
The next thing I remember is waking up in the Post Anesthesia Care Unit (PACU) and the first feeling I felt was absolute nausea. A nurse was right by me and she was able to push Zofran to help with the nausea and was able to call out to my family that they could come back. In a few minutes I was reunited with my glasses (yay!) and they held me there for about 2 hours as I got more and more aware. The PACU is the only place I got inject-able pain management, but my pain was only at about a 5/10. My nausea on the other hand needed a second type of drug to finally get controlled.

7:45pm
Finally, a room became available and they rolled me up. For context of how well I was doing pain-wise, I was told immediately that I could have 10mg of oxy if I wanted. But I wanted to walk and use the rest room first. It took my husband and a nurse to get me out of bed, and I walked to the bathroom. I was able to do everything behind the privacy of a bathroom door, which was unexpected. My husband however had to help me put my underwear on. Once that was on, they gave me a second gown to use as a "cape" and cover that gap. I went for a walk, two laps around the floor I was on. Before he left for the night, he helped me put shorts on, so I wouldn't need to put the cape back on. The nurse then hooked my legs back up, and gave me my oxy and tylenol to take orally.

I was shocked. I was awake for a little more than two hours after a surgery that drastically changed the size of my stomach, and here these people were telling me to take drugs orally. They gave me water and the pills, and I took them. Immediatley I started dry heaving, but nothing produced and the feeling passed. A few minutes later I took another sip without any trouble.

And I quickly fell asleep.

Overnight
This was the four hour pattern I went through the whole night

1. Oxy
2. 90 minute nap
3. Slow wake up
4. Called nurse to disconnect my legs
5. Walk
6. Play on phone
7. Repeat list

Sometimes I would take another walk. Every time I walked I wanted to get an additional lap in. By the time my night nurse was being let off duty, I was up to seven laps.

6:30am
I was woken up by two surgeons to check my incisions and ask how my night went. The nurse said I was training for a marathon all night. Right after the surgeons left, the phlebotomist came in to take blood.

9:00am
When my mom came back the next day (dad and hubby had to work), I was walking when she got there. She literally could not believe it.

I'm going to stop the timestamps here, as the day filled with activity. I had a dietician come in to visit and remind me how important the post operative diet is. At this point, I had only had water, and Vitamin Water Zero, and I knew how important protein shakes were, so I asked for a protein shake to make sure I was okay drinking that before my discharge. The dietician helped me out by getting me a protein shake and made it for me. I had no issue getting this protein down.

Another surgeon also stopped by, and apologized for my surgeon as she was stuck in hellish traffic (by this point I had heard how bad traffic was from a few nurses and my mom). She stressed what the dietician had already said, and was willing to answer any questions. She had also heard I was up and about all night and confirmed I would be going home some time today. A case manager stopped by to ask me questions about my home life. She wanted to make sure I had support, asked if there were stairs, if anyone hurts me at home, etc.

Finally, the head nurse came in to start the discharge process. She had a whole pile of information she had to go through before I could leave, but most of it I knew already. My mom was told to go and get the car and bring it to a certain door, and I would meet her there as they had to wheel me out.

And just like that at about 1:00pm, about 24 hours after being rolled into the OR, Johns Hopkins Bayview was in the rear view mirror.

May 30, 2017: Day and Night before surgery

May 30 was the day before the big day. As mentioned in the nutrition post, I was to follow a "full liquid" diet this day to not put much more into my intestines.

I was able to work from home this day and my husband had a day off. On his days off, he teaches ukulele lessons, so the house had people in and out all day which was great to break up the day. Our pastor also stopped by.

For food that I ate that day, I basically followed the liver shrink diet with a protein shake for dinner instead of a somewhat normal meal.

As I got ready for bed, I had specific instructions. I was to take a normal shower, then not apply any lotions or powders, then wait two hours, and wipe my arms, neck, and torso in a specific fashion using wipes provided at my pre-op. I was also to clean my belly button out with a cotton swab.

My instructions were also to sleep on clean sheets and wearing clean clothes this night as well. And, without pets in the room, which both kitties were NOT happy about. We had kicked them out a few nights earlier to make it less traumatic for us.

Then, I slept. Probably better than my husband.

Next up: Surgery day and joining the loser's bench

May 2017: Pre-op appointments

After I finished all of my pre-surgical requirements, I let the office manager for my doctor know so she could submit to insurance. Besides the initial appointment, I had the following to complete:

1. Four appointments with my Primary Care Provider known from here out as PCP (or three appointments at JH Bayview)
2. An appointment with a Nutritionist (here I covered vitamins and here I covered food)
3. An appointment with a Psychiatrist
4. Attend a Group Support session
5. Have an EGD done
6. Have a sleep study done

I only covered one of my PCP appointments because how many times did you need to read that I went to my PCP, got weighed, talked about changing my diet to keep my body guessing as to what was coming next, and my monthly mental challenge. 

Just a few days later, I was told my surgery would be May 31. Less than a month away. I literally couldn't believe it and all the sudden everything was in motion. The office sent me a pile of papers of all of my appointments before and after surgery along with a reminder about the pre-surgical diet, and reminding me to get a pre-op with my PCP, which would include a blood draw, and a chest x-ray.

For the sake of readers who don't actually know me, my PCP does not actually have an x-ray on premises. So one day I had the afternoon off for a clinical trial I'm in (its super cool and I can't wait to share about that), I asked her to send the request in for my x-ray so I could get it while I had time off.

Chest x-ray...check

I had my visit with my PCP lined up for a few days later. She looked at the chest x-ray with me and basically gave me a physical including an EKG. It was uneventful but exciting because after months, this meant I was getting very close. After the EKG I got my blood drawn, so I was done with that step.

Finally I had to go see the surgeon for a pre-op. I asked why, and they said I had not been to the clinic hours since my initial visit in January and there was special stuff they had to give me. I went to the visit and the nurse practitioner on my surgeon's team was thrilled with all the progress I made (by this point I was teetering at 35lbs lost since January). She gave me two bottles of gatorade, special pre-surgical wipes, and a pretty blue bag. More details on all of those (including the pretty blue bag) later.

That was May 19. Next up was the big day.

I write this post because I see a lot of people online getting very nervous about their pre-op and the bottom line is, its just a physical. The doctors on your team need to know as much as they can about what's going on in your body before they put it through the incredible stress of surgery. For example, every other provider I've met claims I'm an asthmatic. I personally think I just get sick badly in my lungs for a longer period than others (something my cat Finn must have gotten from me), but the chest x-ray showed literally in black and white, something resembling asthma. Seeing as someone, namely the anesthesiologist, was going to be controlling my breathing for about four hours, this is an important detail.

Next up: May 30, 2017

April 26, 2017: Nutrition Visit (Food)

In a previous post about nutrition, I realized this single visit was a huge amount of information. I covered vitamins previously with the promise to cover nutrition.

I feel now is an appropriate time to again remind readers that I'm a patient, not a doctor or dietician. I have a history degree, not a medical degree. I do however read everything put in front of me, which I highly recommend, and I take advice from outside of my surgical program with a big grain of salt.

I'm going to break up the nutrition by day and week and only until the point I'm at now. I'm sure I'll have nutrition updates as my diet expands.

Two weeks prior (really thirteen days, see below): Pre-surgical "Liver Shrink" Diet
A little known fact about most obese individuals is that their livers are swollen with fatty liver disease. It's a medical fact of life.

In order to perform a successful laparoscopic surgery, the liver must be as small as it possibly can be. In order to do this, surgeons assigns a special pre-surgical diet.

Starting two weeks out, my diet looked like this:
Breakfast:
Protein Shake
Mid morning snack:
Fat free yogurt or fruit
Lunch:
Protein Shake
Snack:
Fat free yogurt or fruit (usually whatever I didn't have earlier)
Dinner:
3-4oz of lean meat/fish with 1c. steamed veggies OR 1c. salad with 1 TBSP of low fat dressing

It was hard at first, I'm not going to lie. But I knew that this was still A LOT of food compared to what my life was going to look like post op. Also, I knew following this diet to the letter was the difference between a laparoscopic surgery and an open surgery. Open surgeries require a much longer recovery time.

One day prior: Full Liquid Diet
One day before it's time to make sure you have as little in your digestive system as possible. This day looked very similar to the previous two weeks, but just yogurt twice instead of fruit, and dinner was also a protein shake.

One week after: Full liquid diet
For the full liquid diet, there were more options that one would think. I was able to have yogurt, ricotta cheese, cottage cheese, pudding, jello, and frozen treats such as sugar free popsicles and fudge pops.

The most important parts of this week is to get the 60-80g of protein in daily and to get at least 64oz of water daily. This would become quite the challenge, but it should literally be the only two things your focusing on.

Weeks two, three, and four: Puree
This was an annoying part of the diet. Honestly I just bought baby food for the most part to get veggies and fruit in. There were also little baby food treats that I treated myself to. For meat, I discovered that chicken did not work for me, but ground beef that was then put into a food processor worked great. Tuna (pureed) also worked great.

Weeks five, six, seven, eight: Soft foods
This is my current place. I can basically eat anything except for the skins of vegetables and fruits, rice, and some other stuff that doesn't come to mind but I don't miss it. Take a look at any of my food journals to get an idea of what I'm doing these days.

I will say this, through this whole process, foods should be fat free or low fat as much as you can. A little fat is healthy to get into a diet daily, but do look for the lower fat items when given options.

Next up: Pre-op

July 18, 2017: Six weeks, six days

Today was a much better day than yesterday. Probably mostly because I avoided pit beef...

A big change I made today was I started using MyFitnessPal (MFP) over Baritastic for tracking food. This is simply because I can leave MFP up at my desk all day on the monitor and add stuff. Baritastic depends on data usage on my phone, which is spotty at best at work.

I ran three miles in 34 minutes at lunch time and I'm getting to the point where I may need to start showering at lunch time. Gross, but could affect the routine I've been working at. After work I did two PE@PF classes (Chest and PF360), then spent about two hours on the pool deck for tryouts. Soooo I basically was a gross sweaty mess from about 11:30am til 9pm when I finally took a shower.

Something interesting that happened as a result of this change was that at the end of the day, I can "Complete Entry" and it will give me a estimate of my weight 5 weeks from today if every day were like today. The weight popped up, and it was about 30 pounds less than I am right now, but I am seeing myself at 30 lbs higher than I am right now.

If anyone is interested, I am updating a lot on Instagram, and I put a side by side up with a picture from 2012 and the difference in unreal. Check me out @Jackienelli

Food Journal:
Breakfast:
Pure Protein with water

Mid Morning:
Oikos Triple Zero

Lunch:
Single egg salad

Afternoon Snack:
Applesauce packet

After workout snack:
Quest bar

Dinner:
Bubba burger patty (nothing on it)

Workout Journal:
11:45-12:20: 34 minutes on elliptical at level 1. Ran 3 miles

3:30-4:00: Chest workout
Flat chest press one arm at a time 4x12 (each arm) w/7.5 lbs dumbbell
Incline chest press both arms 4x12 w/7.5lbs
Incline fly both arms 3x10 w/7.5lbs
Overhead press  3x10 w/single 15lbs dumbbell with 2 hands

4:00-4:30: PF360 (each activity is done for a minute with 30 sec. rest between, repeated circuit a second time with the wall sit happening a third time)
Wall squat while throwing 6lb medicine ball at trampoline
Mountain climbers
Weighted step ups (step on level 2, first round with 10 lbs, second round with 20 lbs)
Ropes, squatting, 10 sec w/arms together, 10 sec w/arms alternating
TPX suspension squats
Modified one leg dead lifts (most bearing on back) (first round 15 lb kettlebell, second w/20lbs)
Overhead tricep pulls (17.5lbs)