Weight Regain after Sleeve Gastrectomy - Mercy Bariatrics Perth

So welcome to our 8th support group meeting which as you know we have one Sunday a month here in Perth so wait we won after

sleeve

gastrectomy

it's a really hot topic for people and those of you have passed through our program. You probably remember when I first met him when we started talking about what we can expect from the results of bariatric surgery. I told him that all bariatric surgery is going to fail. It's a pretty provocative statement, but it's true, but the moderator is that all bariatric surgery surgery is going to fail to some degree over time and it really doesn't matter what the operation is and I think it's important to understand, accept and embrace that concept to that you don't end up disappointed in the future and I guess It depends on what you mean by failure, so what we tend to see with the

sleeve

is that normally people reached a maximum

weight

loss around the second year and then remained stable for a few years and by the fifth year they had recovered a small amount. of that excess

weight

that they have lost, usually around 10 to 15% of the excess weight that they have lost and we believe that there are a number of determining factors of how much weight you lose originally and how much weight you are able to

regain

subsequently.

It is your sleeve size which is determined by the bujji size we select beforehand. It is very important that you are starting with the BMI because the higher the BMI, the heavier your weight is to start, the more weight in kilograms you lose, but because you have Beyond reaching your ideal, how small of that percentage is seen and then , very important, there are your factors, this is how you will comply with your dietary choices, then how you will comply with your exercise and how you will comply with your tracking. and we think those factors are what we should focus on after surgery and probably account for 10-15% of variance in our outcome and Sleeve is not the only one to do this, any bariatric surgery will do about the same thing.

Now these are the results of the Swedish obesity study, which is a very famous study in bariatric circles because it was very well done and the unique thing about Sweden is that they have a universal healthcare system and it is able to capture data on almost their entire population. , private or public and then they looked at three or four different operations, the traditional gastric bypass, a restrictive operation called vertical banded gastroplasty and the adjustable gastric band because it was just coming out of that stage and they compared it with controls who were having the best operation not surgical. therapy for their weight and they were able to follow it for 20 years and saw that they reached maximum weight loss around the age of two and then

regain

ed a small amount of their lost weight, so the BPD bypass sleeve was banned and everyone tends to do the same.

Same thing, this is our data for sleeve

gastrectomy

and when I started doing sleeves in 2003 I used a particular size of plug which is 50 French about the diameter of my thumb and I did about a hundred of those and then in 2006 I got a a little bolder and I went down to French forty, which is about the diameter of my index finger, and in 2010 I went completely crazy and went down to French 36. There are some surgeons who are going down to 32 french, but I think they go looser than me on the bougie and with each drop in bougie size, we have typically seen about 10% more excess weight loss over time, so now our standard probe for most people is 36, but if your BMI is less than 35, I can offer you a smaller or larger probe.

I don't want you to get the impression that this is a big deal. It is not. Over the past 14 years, our unit has performed over 1700 x' sleeve gastrectomies and they are the type of The dimensions we have used over the past seven years have been predominantly the French 36. So far I have performed revision surgery through Reis Live, which I will talk about later on 46 patients, only about half of them were originally my patients. the rest come from other places and maybe another 8 or 9 had bypasses, either by me or another surgeon, so if you think there are 33 cases of those original 1700 sleeves that I did, they had to have revision surgery. to regain weight is a rate of only about 2%, so this isn't really a big deal, so what do we mean by a faulty sleeve?

Well, it could be that they originally failed to lose the expected amount of weight or they have regained the weight. or have intolerable side effects due to their manga, mainly related to reflux and vomiting, and today I will mainly focus on weight regain. I have the concept that bariatric surgery is like a three-legged stool on which the patient's weight is supported. on that stool trying to push your body to regain its weight our weight is under the control of the deepest part of our brain which is the hypothalamus the hypothalamus controls our respiratory rate controls our heart rate controls our temperature and would control our body weight through a series of very robust mechanisms, it can detect what our maximum weight used to be because it measures a hormone that fat cells produce called leptin and it is always trying to get back to that maximum leptin level once it has reached it because that is what it thinks is the new norm and requires a very powerful complete surgery to overcome that urge and if you think you can win a battle with your hypothalamus, try holding your breath for three minutes and see who wins so that the three-legged stool we need to does surgery work has a leg, what is the correct surgery, what is the correct design of the operation, the correct size of the operation and then it is the correct behavior of the patient, the decisions they make afterwards and then it is the follow-up. and if any of those three legs are weak, the entire stool will collapse and that is what I typically find when I see a patient who has regained a significant amount of weight.

Generally there are components of all three that we need attention to. so I never blame a patient when they have regained their weight, okay the only thing that bothers me a little is that they don't come back sooner when it's not a big problem, if they came back sooner it would be less of a problem and these are some of the common elements that we see in patients who are struggling or regaining a lot of weight and we'll look at that in a little more detail later, so there are things like snacking and grazing, choosing the wrong foods and the typical culprits.

They are alcohol, lattes and sweets, poor monitoring and lack of exercise, but the only physical attribute that I am responsible for as a surgeon and that I am responsible for correcting if it is wrong is increased gastric capacity and we have become interested in gastric capacity. capacity for some time and we have, as you know, the cream of rice test, so at three months, at six months, at twelve months, at 18 months and at two years, we sat down with the dietician, We eat some cream of rice and measure the volume you can eat, so we have a pretty good idea of ​​what a typical volume should be in any particular time period and we've also been able to look at the thresholds that that volume translates to. in a frequent weight regain, so for the three different Bujji sizes are not surprising, the French 50 have reached the maximum tolerated volume, which is the volume in which you do not fit and feel that you can eat more.

The French 40 are down here and the French 36 are down here, so you see about twice as many. of food capacity for one or two years and then it tends to stabilize very typically when the gastric volume exceeds about three to 400 mils, we start to see weight regain and we are not seeing that very often in the French 36 now because there are We start with a very small volume, we have seen it much more frequently in French 50s or in patients from other units where they simply left too much stomach at the top and bottom and it is a bit like one of those long thin party balloons, as You know what I'm talking about, when you start blowing up one of those at first, it's very difficult to blow up the balloon, but as the balloon starts to expand, it becomes easier and easier to blow up because the wall tension decreases as you diameter increases so the same goes for the gastric sleeve, the smaller the sleeve to start with the harder it will be to descend and if you start with a large sleeve you will become more sensitive to support, not surprising if you can eat the more you will get more calories.

I just want to explain a little bit about what I call the caloric imperative. This is a really bad graph. Okay, I don't want you to think this is entirely accurate. There are a lot of good variables that come into play, but it gives you an idea of ​​how this paradigm or imperative works, so we all eat between two thousand five hundred and three thousand calories a day on a Western diet and most of us will. you remain fairly stable with slow recovery over time. You need to reduce your caloric intake below about a thousand calories per day consistently.

If you want to lose weight on a particular day, you can reduce it to 1500 or increase it to 3500 and your weight will not change, but if you want to lose weight, you can do it steadily. You need to consume less than a thousand calories. That's what a very low calorie diet offers and that's what manga offers, so after manga you probably only eat about 600 to 800 calories a day and you lose weight to a tremendous weight, somewhere time your caloric intake because your gastric capacity has been steadily increasing, we will reach that threshold of over a thousand and somewhere between a thousand and maybe 1400 is a weight maintenance zone, so your weight will remain fairly stable, but if you exceed 1400 calories, you will begin to regain weight.

Now it varies from person to person, so men tend to have a higher metabolic rate, younger people tend to have a higher metabolic rate, so they can tolerate more calories, so what that means is that you can be in that weight maintenance range with a reasonable caloric intake of one thousand to twelve hundred calories per day, but you only had to add a small amount of discretionary foods or treats that can increase that weight. for just three or 400 calories in that day and suddenly you're in the weight regain zone so there really isn't much wiggle room and these are the common spoilers that we spot in flat targets, a couple of those could add up three hundred and forty calories a day, alcohol, same problem, energy drinks are terrible, even protein bars, if you have one or two of them as your snack of choice, you will surpass that weight maintenance threshold and start gaining weight , since not all calories are equal.

So when you eat something that is full of carbohydrates, you will absorb and retain 90% of them; fat is only about 80% and, with protein, you need to waste about 30% of the energy of that food in order to assimilate it. Also, with protein you can't get fat from protein, you can get fat from fat and you can get fat from carbohydrates, but protein can only be burned as a source of energy or converted into another amino acid that is used in a bottling process, so if you choose a high carbohydrate meal, very sweet things that will have more impact on your weight than a high protein meal, so this is what we look for in part of the evaluation, there is a normal diameter sleeve right there, but it has two or three. times the diameter at the bottom and probably twice the diameter at the top and that person is very likely to fail and for that person a recent casualty is a reasonable choice in the other spacious nessee area and it is a real problem for our patients who have had a lap band in the past and been checked for sleep, particularly when that band has been too tight for too long and what happens is their esophagus above the band responds to the back pressure and expands and dilates and may not recover its tone and the esophagus begins to accommodate and tolerate food and that becomes a second stomach for them and although the sleeve has a good shape and a good volume, they retain their food up here and that is why they can eat more.

We know that the hunger hormone ghrelin, which is produced throughout the stomach, but particularly in the upper part, drops quite significantly after surgery and levels probably increase a little over time, so people also they do it. regain some of your appetite over time and another consequence of eating carbohydrates and I suspect all of you have experienced this to some degree is dumping syndrome and what happens is if you eat something high in carbohydrates smoothies ice cream iced coffees those high carbohydrates hit the small intestine in a hurry the small intestine does not like that it needs to remove water to dilute everything. your blood sugar goes up a lot, but then it usually goes down quite a bit and you start to feelhungry again and you can enter this cycle of hypoglycemia where you wake up in the morning feeling ravenously hungry because your blood sugar is low, if you choose something high in carbohydrates, transit Li will increase your blood sugar blood, but then you get a low rebound and feel hungry again, so you reach for a snack and that vicious cycle continues.

The way you break that cycle is not to have a chocolate bar, but to have something that is good quality protein or low GI. Another pitfall we sometimes see is reflux, where patients experience reflux. then they misinterpret that as hunger or they choose dairy products to try to buffer the acid and that works but then they get heartburn again so they drink a little more milk and gain weight back and the solution is to use a medicine to buffer the acid and reduce acid or, in very serious cases, we consider surgeryDuring your break, there are some other situations with antidepressants, especially a medication called Matassa Pain or Avanza, a very effective antidepressant and more and more GPS are turning to this medication, but it has poor reputation for stimulating acid and sugary food cravings and usually anyone who follows it.

Avanza increases 10 to 15 kilograms, so that is what kills the sleeve and we work with the GPS to try to find an alternative if a patient has to take prednisolone for an autoimmune disease, she will gain weight and become pregnant, especially in the first year there's nothing like pregnancy to reduce weight loss, so we asked people who weren't pregnant in the first year and if they do, great, let's work with you on a regular basis to manage your weight, so if someone comes back with weight. recover, how do we work on them? You will see me or one of the advisors.

You will spend some time with the dietitian and usually we will do a cream of rice trial and then try to discuss your eating style and eating options I can arrange a barium meal to look at your sleeve shape and you may need do an endoscopy, then we determine the best way to address your problem and, very typically, that will involve getting our back on track. Of course, now Stephanie is leading the course back to normal and at the end of this talk she'll talk a little bit more about the details of that, but basically it's based on Colleen Cooke, an American bariatric patient who helped develop the lifestyle habits framework. successful than in which he would have been involved and aims to identify and replace sabotaging behavior and reintroduce better diet and exercise principles and is a mandatory component of moving forward with any potential surgery.

We hope that is all you will need if it does. It is not like this? It provides a very good foundation that we can build on once you have had surgery so that you don't repeat the same mistakes that got you there in the first place, so when we will move on to offer revision, there is no set number. We are all different here, but if we see that your BMI has returned to a dangerous range, perhaps over thirty-five, when it is clear that your weight regain trajectory continues, when your excess weight loss has fallen below forty percent, when there are new or old comorbidities.

They come back and when there is a logical correctable problem like a very large pouch and when all other means have failed that is when it is time to consider bariatric surgery and the reason we don't jump straight to bariatric surgery is that revision surgery is more dangerous and we will put you in danger and although the risks are now reassuringly low, we have to be sure that we are doing it at the right time and for the right reasons, so my current paradigm for the surgical management of The failure of the sleeve is to observe the volume of the sleeve mainly and see if that volume component is formed by the sleeve or by the dilated esophagus, if it is just a dilated sleeve, it seems logical to me that Reese leaves if the and that is measured by the capacity gastric capacity and what we see in barrier food if the gastric capacity is low below 400 below 300 and what has them there is more their style and eating habits, then we need a more punitive operation, which is one of the referrals because it brings to the table an element of malabsorption and a deeper impact of dumping syndrome to discourage them from making those decisions, so why do I like the Reese's permit?

I believe sleeve volume is an important determinant of weight loss and also allowing weight to be regained. as we have seen in the evolution of bujji size and better weight loss with each smaller bujji, what it does is give you back a smaller volume, thus restoring your feeling of fullness and your sense of appetite suppression, and you can further reducing ghrelin. The production that Reese leaves me reproduces a familiar operation, resets the watch and is one of the reasons I like the case because you can receive it and in fact, you can change the case recently if necessary, you do not take it to the recipient for a long time. long-term nutritional problems like you do with a bypass and if Reese's license failed, you still have a full arsenal of revision surgeries, so I've done that.

I think now of the 40 or so Reese sheets, this is old data, most have been in the The group of 50 French bujji is a smaller cohort of the group of 40 French and so far none of the 36 French in the last seven years and this is what we have seen normally, so it could be their initial excess weight loss: they have gained to 60. They have regained it and around the 30 mark we have decided to have Reese leave them and that is their peak weight of weight loss after Reese's loss and then their current weight, so essentially putting them back on the curve that we would expect them to be on. in it he resets the clock, the alternative to Reese leaves and this is appropriate.

I think that if your sleeve volume is low or if the problem is that you have a dilated esophagus following a band, you should look at one of the bypasses and the Right now my preferred option is this style of bypass called mini gastric bypass with Omega loop or simple bypass and in case of stenosis and combine two thirds of the sleeve and then we divide the stomach at that point and then we measure the small intestine. until we got to the DJ flex and we measured our 200 centimeters from there and took it to the end of his proximal sleeved stomach and attached it to the small intestine.

Now what he does is the stomach empties very quickly into the small intestine and there is something about delivering undigested food to this level of the intestine that very quickly quenches hunger. There are what are called gut brake hormones involved and therefore patients after an Amiga loop find that they begin to feel full and not hungry very soon after. They will have a very profound dumping syndrome if they choose the wrong foods, so I think this is a good review option for non-dilated sleeve or dilated esophagus and it also has a very profound impact on type 2 diabetics, so my main advice is still valid. and come back for a follow up, that's what we're here for, eat like a carnivore, is it your meat/your carbs?

Exercise like a caveman, so get up there and lift something and chase something and that will increase your metabolic rate, which is a whole. lecture yourself and pay attention to the little things because when you hit that weight zone, regain the weight and maintain the weight, there isn't much wiggle room and what may be just an occasional treat that then becomes an everyday occurrence may make a difference, yeah, so I'm having a band revision from a different surgeon and I don't think I can remember which plug I had about six years ago and I've probably regained about 15 kilos in the last six years, so I'm little little by little.

I sneak up on it and looking at that, I'm embarrassed to go in because I've put on a lot of weight and I feel like I've failed, so this is quite confronting for me. Are you saying that maybe if I go back, do a complete rework and just re-evaluate, start again. Maybe I can get back on track to where I hope to be one day. Yes, I absolutely believe that. Now I think we have to evaluate what our objectives are. To be one, you have to go through the evaluation process to see what element is causing the recovery.

Why is it more than the kind of programmed expected recovery that we would see when I hear that someone has had a band before? I always worry that this is the case. your esophagus, which is the culprit, and your ability to eat is greater because of that, it may be that some bad habits have crept in and we would evaluate all of them, it doesn't mean we have to jump straight to surgery. That's fine and I wouldn't necessarily consider you a failure. I mean you are doing what the surgery is expected to do and you shouldn't be hard on yourself and you shouldn't not come back and the sooner you come back the easier it will be.

For us to offer you a solution, you are always welcome. It is very common for shape to fluctuate around the five kilogram mark and reflects the fact that you are in that border zone, isn't it somewhere between weight stability and weight regain? you know it only takes two or three hundred extra calories constantly for a few days to start going up and then you can control that and go back down and that's not a problem and although we've seen people go from you know a typical BMI, a BMI average 44 and have lost their 85% excess weight and are now back down to 70% excess weight loss.

When you look at the new BMI in that cohort, it's still below 30 and that's a healthy range, so we don't necessarily go in and operate on that person because they've regained 15% of their excess weight when their BMI is 30. Yes, I have always had a very bad diet, that is why I gained so much weight, the worst part. As a butcher, most of my meals included vegetables and potatoes. I don't need many vegetables at all. It's been a still fun learning curve because it's been about three years over the last 12 months. I have fluctuated only between, say, 92 to 95 after going down from 140 to one day it seems like you can eat more than other days.

This is me. I seem to have fallen back into my bad habits, but one day your bad habit doesn't seem to be as bad as the next. day and I can gain 2 kilos in 3 or 4 days I can gain and one day when I weigh myself and then two days later I can have more like a big day in which I have eaten much more than I normally eat and it seems that I have lost weight, so luckily for me I don't have to join a gym like some people because I had a pretty physical job which seems to keep my weight down, but I'm really surprised that I now eat a small amount of food compared to what I used to do.

I'm working a lot better and the way I am now, I think I was that in grade school and I'm 63 right now and I just can. I don't think so, well, people still say that when I listen to some people what they eat, I can give them. I eat smaller amounts than that and it amazes me how some people can eat so much. I still have a bad habit of Eating Quickly, something I sometimes suffer from for the next half hour or hour afterwards, but lately I've found that I can eat a fraction more than I did before, but still one day you can eat like, say , one cake for the next. two days you can about half that amount, it's a real yes, it's not just the volume of your stomach of course, it's the rate at which you eat and one of the ways the sleeve works and has this in common with the bypass is that the sleeve actually empties more quickly, so if you give some of that food time to leave your stomach and get to the small intestine, the small intestine will start sending a message to your brain.

Actually, I'm getting full. It is known that you can stop eating, so if you eat slowly during any given portion, it will happen more quickly or before you have finished the entire meal. If you eat quickly, then your sleeve will be full before you receive the benefit of that message. to the brain, so it's one of those styles that you have to adopt and also how you will chew your food, wash it down with liquids, for example, all of these things can affect the capacity of your stomach, no Forget you know we all start with about a liter to a liter and a half of stomach volume and I have removed many, many stomachs in my time and I am always amazed at the variation in stomach volume that I see that someone who has a very high BMI may not have a particularly large sized stomach and someone who only has a relatively small BMI has a very spacious stomach and I'm using six or seven loads of staples instead of four or five loads of staples so it's not just the volume of your stomach that determines your weight gain, but the rate at which it drains on your ability to tolerate the stretch before feeling hungry.

I wouldn't be hard on yourself if you were a butcher and eating the wrong thing. things actually eating protein is the best thing you can do it's very difficult to gain weight when you eat mostly protein the realblame our society our refined carbohydrates well it's still strange because I used to eat a lot more foreign beef and lamb. I can't tolerate more chicken and a little fish as much as I used to, but it's funny, I can still go a whole day and not feel hungry and then the next morning I get up and go or I'm hungry. today but after about half an hour I'm fine, I might eat something at some point in the day and it's really yes, so everyone's manga is different and it's the natural variations that you have to learn in your new manga and work with them so you're not fighting your stomach or expecting it to be a particular way, but I think you had a fantastic time.

Okay, other questions, yes, 800 calories a day or 1500. I can't lose weight. Would that be because this is where my body needs to be? Yeah, so you know one day it won't. It is a constant tendency that tends to go up or down. It's also a calorie. It's not a calorie. So 800 calories of protein is not the same as 800 calories of carbohydrates and on any particular day you can exercise more or less and it all comes down to your metabolic rate, so when you eat one calorie you can do one of three things. with it you can burn it immediately as fuel, you can store it or convert it into another chemical or make something from it and you do a third thing that we don't really pay enough attention to and that is you can break it off. as heat and we know that after eating, if you put someone in front of an imaging camera with a thermal imaging camera they will glow red because they are emitting heat and that is the metabolic flywheel like in an engine that keeps the marais stable and the idea is that when you are consuming enough calories or when you are eating more your The body responds by increasing its metabolic rate and by increasing the proportion of food that is given off as heat.

When you are in a starvation situation, the body slows down the metabolic rate and reduces the proportion of food we waste as heat and you. I'll see someone who's starving, they're listless, they're tired, they want to go to bed, that mechanism is abnormal in people who are morbidly obese, so as their caloric intake increases, they don't tend to increase the Baalak rate as much. your model, either when you get bigger, you insulate yourself better and you simply can't give off heat or your body would overheat, so the surgery we perform drastically reduces your caloric intake and over a fairly long period of time the body feels it like hungry and are trying to slow down your metabolic rate until you reach that new steady state of weight stability;

Over time things can start to build up again and the only thing we recommend to counteract that dropped metabolic rate is exercise and it's not just the calories you burn while you exercise, it's the afterburn effect that when you build muscle you increase your rate. metabolic, so you are essentially burning more calories while you sleep and that is why exercise is such an important part of maximizing your weight loss. Exercise alone is not good. vehicle for weight loss, you tend to get hungry and eat more, but when you combine it with calorie restriction, you see a magnified effect, so you have experienced some weight regain, which is natural and doesn't seem like it to me. excessive, there are some fine adjustments you can always make to get back to where you want to be.

You may not get back down to your nadir weight, but you don't have to. I'm getting in trouble for mentioning that this is only three months ago, but I just did my cream of rice test and I can eight or almost double that. I would fold a little more than I'm supposed to be able to, so they told me not to panic, but of course I'm panicking. that you know it's going to affect my weight loss and that kind of stuff I mean I've lost 20 kilos which is really great and Adam looks at my sleeve and he's really happy with my progress and everyone says you know it's okay, do not stress.

Don't stress, but of course I'm emphasizing that I'll be the first to have a sweet, absolutely de-stressed one, so yeah, I just wanted to mention it because you know, in case there are other people who are in the same boat. and we are worried about that so we are interested in two stages in the cream of rice test: the first is the volume of satiety and that is the point at which you start to feel full and then the dietitian will ask you to taste and eat a bit. more and we go to the maximum tolerated volume.

Interestingly, we find some people where there is a very clear difference, a gap between the two, and then there are other people where the two volumes are very similar, as if it were one more bite and we have the feeling that If you are in that group, you may eat more than you should and we encourage you to try to recognize your early satiety volume and eat up to that volume and then don't feel obligated to go back to the food and throw it away. next time put a smaller plate, you know it's been drilled into us, finish your plate, it's a bad strategy so panic, no your weight loss is a rhythm and just work with the sleeve you have, yeah, okay, you know, hand it to him, Chris.

You understood it. I'm just talking about the dilated esophagus. Can you tell us with patients what we feel when that happens? Because I'm not sure if that's what I'm feeling, but while you were talking about that extra sting that we all want to have that and it might have something to do with that and can you tell us a little bit more? I don't think you can tell when your esophagus is dilated, it just means you can eat more and the food stays there. and you are not really aware of it, we see that although in a barium meal sometimes pieces of marshmallow are soaked in barium and people eat them and we can see a raft of barium in the esophagus and they are not aware of it and little by little It leaks so that you don't feel like you have a dilated esophagus, we see it in the barium and that is a concern for us.

If someone previously had a band, now I don't have it. I don't know if there is an answer to that problem, but even with bypasses they may not provide the solution, particularly bypasses as the traditional rule on why gastric bypass depends on a small pouch and a narrow outlet if you have a dilated esophagus . Above that, you're going to eat more than the bag is supposed to hold, so I don't think the traditional gastric bypass rule will work very well, which is why I prefer the Omega loop concept, where the output is not restricted. and it relies more on the stomach acting as a conduit to get food quickly to the small intestine, but the Amiga loop has only been around for about five years just to say if it's a top operation, yeah, so I.

I'm keeping a close eye on that space, so the back-to-track course that we run is based on the bariatric support centers international back-to-track course and I say based on because we've adapted it to better meet the needs of our patients, it is designed. because, as León has already said, for patients who are struggling to maintain their weight loss or who have regained a significant amount of weight since surgery or also as a prerequisite, as you would say, to undergoing further bariatric surgery, It is a series of four sessions with myself, with the dietitian and now that we also have the psychologist on board in our team, this can be an added advantage if we think it is beneficial for you.

The goals of the Back on Track program are to really identify any behaviors that may be sabotaging your weight loss and while we find that most people are quite aware of some of these ideas, not many have really thought about the behaviors that are actually they hide behind them, so it could be stress or lack of sleep or lack of sleep. of exercise and that kind of thing, so we use what we call the habit sharing process to work with all those habits and there is a process for it, we identify them and then we figure out what benefits you really get. those habits because you are clearly getting something, if you keep repeating them, we will also look at the negative aspects of the habits and then brainstorm how you can overcome them or create some newer habits to exchange for healthier ones. long-term habits, a big part of the course is also about reviewing the maintenance guidelines that we would have explained to all of you here today and in the success habits program, but for many of our patients who are having a Ries left or happened to have a loop like León said, if they have had the sleeve 50, many of those guidelines have changed in the last 10 years and many patients, if they did not go through us to begin with, have had the surgery in somewhere else and I find that many of them simply don't know the expected guidelines;

For example, they don't know not to drink with meals, so we spend quite a bit of time setting goals, it's another very important factor, so while we will have your long-term goals, we also have to set short-term goals that can achieve along the way only to achieve it again. Exercise that will be part of any long-term maintenance. It's all an individual program. Not everyone can just go to the gym and lift weights, but there are always ways around it, whether it's as simple as walking in the pool using ferrah bands, any exercise band that's much easier to use if you have joint problems. , etc. will put together a sustainable and achievable program for you as far as the dieticians part is concerned, she will explore your dietary history quite thoroughly and again the breakdown of your meals, so as León was saying, while you are in Cour, all the calories They are not the same too. the satiety of your meals if you have too much carbon your food does not have enough fat it does not have enough protein you are going to be hungry or you are going to get hungry much faster and many times what I see is that people do not have a good eating pattern to throughout the day, so if they come home from work and they haven't had enough protein at lunch, some healthy fats, then they go straight to snacking until dinner, possibly they haven't had enough dinner and then the process continues until the end. night as well, so like I said, the psychologist that we now have on board can also take that a little further if people have had a history of psychological problems, possibly eating disorders that maybe have come back, so she'll take that part as well. , and its sessions last approximately six weeks.

I like to see people say two weeks and then each week you have four sessions with myself, with the dietician and although not all of our patients will be in the metropolitan area it is possible to set up Skype or FaceTime sessions and, at worst, cases, by phone, and if that's the case, we don't want to exclude anyone there and the expected result of getting back to normal is not so much that you're going to lose an incredible amount of kilos in six weeks, but you need to reset your behaviors so that that in turn drives further weight loss or if you are having another surgery that you are well prepared to handle. those changes and that they are necessary for you to achieve maximum benefit from the surgery, okay that's it in a nutshell, does anyone have any questions about the actual program?

So we'd expect him to see Leon first, so that's not really the case. an independent course like the one León was talking about, you would have an evaluation with him and then possibly also do a barium test and then you will see the dietician at that appointment as well so she can do a cream of rice test so we can measure the volume expected gastric and then from there, León would refer you to me for the course back to normal. He was asking the process to get back to normal if necessary, if you thought you needed it, does anyone else have more questions, yes, microphone. so one more question, yeah, go ahead, sorry, I was thinking how often is something that is set up at any time or run in that specific way.

You know, I do the intervals individually, so you will have approximately a 45-minute session. With me, I don't like to do it in a group because I think it's very common for there to be an emotional problem behind weight regain and I really don't feel like anyone wants to share that in a group. group, so I think the results are better if we do this as an individual session and also it just hasn't been a big enough problem to make it worth designing as a group class. I know that in the United States Colleen Cookies designed the program, she offers that as a group class, but it covers a much larger bariatric community, so it's worth it, but I like Stephanie's model and Taylor's privacy, so What if you do the course back on the road and don't start. to see the results you expected, so how long until we start thinking about the next stage?

Yeah, look, it could be a few weeks from now and Stephanie and I can agree almost from the beginning, going back to normal probably won't be the time. vehicle that will cause the loss ofweight if you have a huge dilated sleeve or a dilated esophagus, it is still worth it and necessary to complete the course because it lays the foundation for a better outcome after surgery, so know that we can't just fix the stomach or fix the gut We also have to fix our heads every time we operate, the return is lower and the risk is higher, thank you all for coming, there is still some light left.

Go for a walk. I encourage you to use the trails around here, it is a beautiful walk. Thank you Stephanie, Caroline and Luke for running the program today. Our doors are always open for you. We are glad to see you again. Our team will be available at any time and we encourage you to stay in touch. Go to our website, leave us a message, let us know how you're doing, the sooner we address this issue the better and knowing where you are, even if it's been eight ten years, adds to our database and increases our knowledge. about our program so thank you for coming thank you very much