Digestive system v2.0

As of Wednesday, May 22, I hit 200 pounds exactly. I had three goals going into this:

220 pounds as the maximum weight I would find acceptable

200 pounds as my goal weight

180 pounds as a “stretch” goal

In addition, I wanted to hit my goal weight by the end of the academic year at my college.

I just barely made it. Commencement is today, May 24. Since Wednesday, I have lost almost two more pounds; I guess I’m past my plateau. Assuming the weight loss begins leveling out, 180 is looking like a possibility. But more importantly, I feel great; I haven’t been this healthy in at least 20 years.

Time to go clothes shopping, maybe.

Things have been going reasonably well, but I am facing a few challenges.

The first is that, apparently, sugar does not trigger dumping syndrome in me. During our educational sessions, our teacher explained that–for many people, after surgery–eating a significant amount of sugar in one sitting causes “dumping syndrome”, which can manifest as severe, sudden, and uncontrolled diarrhea, light-headedness, sweating, vomiting, and generally feeling like you’re going to die. Obviously that’s awful, but some bariatric patients regard it as a benefit-in-disguise; by providing a strong aversive consequence to unhealthy eating, it makes it that much easier to eat more healthfully.

I avoided sugar almost entirely for the first four months after surgery, out of fear of triggering this awful stuff. But recently, I decided to test it–gently–and see how things went. So I had a very small amount of sugar-sweetened yogurt. No problem–how about a spoonful of ice cream? Oh, that was delicious. And no problems!

As it turns out, I still have a serious sweet tooth. And for me, sugar doesn’t seem to be a problem. That’s good, of course…but I’m finding that a lot of my bad eating habits are still there, and now that I know sugar won’t make me want to die…I want it. So now comes the real work. I’ve lost about 90 pounds, and I feel generally great. I’m just shy of my main goal (200 lbs). But the weight loss has started to slow (more on that in a moment), and my appetite is returning, and now I know I can have sugar.

Now I need to start finding the willpower and motivcation, as well as putting in the mental and emotional work of finally breaking my link between emotional comfort and snacking.

For example–I’ve observed that if I am sitting and watching something with my wife and kids, I crave snack foods. Seriously crave them. And now I realize I always have, and have just continuously munched on things. And that’s *just what I need to stop doing*. Unfortunately, the habit is still there–so now comes the hard part.

I haven’t been able to exercise as diligently in the last two weeks or so, and I noticed several things. First, my weight loss has slowed significantly. That’s probably mostly due to a gradual increase (not just junk, actual healthful food, mostly), but it’s undoubtedly also connected to less activity. I know that weight loss can plateau at times during this process, and I am still losing *inches* at my waist, but not much actual weight. I think that the solution is to dig in, maintain healthy eating, get back to exercise, and have faith. Honestly, even if it stopped here I am, that would be OK–but I want a few more pounds gone.

I’m slightly more disturbed by a few other things in the last two weeks. One was a serious reappearance of depression–severe at times. My current job is very stressful, and I had been decreasing antidepressant dosage as an experiment, so those are probably part of it. It’s possible that release of hormones from body fat may have contributed as well. But whatever the cause, it was a low like I haven’t seen in at least a year. I’m coming out of it now, which is good.

It was accompanied by feelings of despair at the weight loss plateau, though, and an upsetting combination of feeling hopeless that I couldn’t lose more, terror at the thought that I might regain weight, and feelings that I’d almost rather die than regain it. I’ve read about the higher prevalence of suicidal thoughts some folks experience post-surgery, and these never rose to the point of seriously considering or planning action in that direction, but they were definitely there, and they worried me. It feels like there is a real risk of developing a whole new eating disorder, this time oriented around obsessing over weight loss.

The healthy thing would be for me to focus on eating well, finding sources of emotional satisfaction that aren’t food, and enjoying the fact that I can do more things than I could before. (For example, there has been significant improvement in erectile dysfunction…) That’s where I’ll focus.

Everything is continuing to go well. I have gotten better control over my tendency to eat too much when going out, and haven’t had to throw up recently. I’m also allowing myself a little bit of carbohydrates, including an occasional bite of rice or potato. I even ate one french fry a few days ago!

Ground beef is well tolerated in smaller quantities, up to a few ounces at a meal. I’ve also tried chicken breast and chicken shredded in a sauce (butter chicken curry). The chicken in sauce went well, and felt good. The chicken breast stayed down, but I won’t be in a big hurry to repeat that. I also tried a little bit of fried chicken (popcorn chicken from KFC), and that went just fine. I don’t seem to have any problem tolerating moderate amounts of fats, which is both good and bad. I haven’t tried a significant amount of sugar, though I am eating high-protein fruit yogurt with no added sugars (Oikos Greek Triple Zero).

In terms of calories, I’m generally eating 600-700 each day. Oddly, I seem to do better towards the upper side of that; I feel better.

I bought an e-bike, and am using it to commute to work at least three days out of the week. It’s lovely; the electric assist makes the hills easier and means that I’m not exhausted and sweaty when I get there, but it’s still a mild workout. It’s a twelve mile round trip ride over fairly hilly terrain, and the bike requires pedaling (the motor doesn’t propel on its own, it assists pedaling force). I highly recommend it. Saving the money on gas and knowing I’m not adding nearly as much CO2 to the atmosphere feels good, and it’s a good way to get some exercise each day.

I’m not lifting weights at the moment, but I did spend this weekend building a decomposed granite pathway in the yard, so that gave my back and arms a good workout.

Weight loss is continuing nicely. It had slowed a bit, but seems to have resumed at a fast pace. I set myself three goals:
220 pounds, which I would consider a success
200 pounds, which is my overall target
180 pounds, which is my “stretch” goal. This may not really be realistic, or even entirely desirable; I would actually almost be out of the “overweight” BMI range at 180. But we’ll see.

In any case, I am below 218 today, so we’ve reached goal #1. Yay!

Here’s what’s been going on in the last month:

I started jogging and weight training programs. For jogging, I’m using the Couch to 5K program. Unlike the times I have done it before, I’m not going to hold strictly to the weekly schedule; I’m planning on doing each week repeatedly until it doesn’t feel like I’m going to die. At this point, I’m in week 2, and it’s going reasonably well. For weight training, I’ve joined the fitness center at Palomar College, and (after a brief bit of research) decvided which machines to use. I’m seeing some progress, in terms of how much weight I’m moving, and some visible muscle growth.

My weight loss was progressing very nicely until about a week and a half ago, when it slowed and then plateaued just under 240 for several days. This was something they mentioned in the Kaiser class as a possibility, so I tried not to worry about it. Today, it seems to have broken through again and begun dropping. My caloric intake hasn’t changed, still hovering around 500 calories per day, but it may be related to the weight training. Anecdotally, I have noticed that, when my weight loss slows, it seems to be associated with seeming reductions in sagging abdominal skin.

I’ve been slowly expanding my food choices. Cooked shrimp and raw tuna have both gone well, as have salad greens and tomatoes. I’m trying to aim for 60g of protein a day with one Premier shake and two meals, and usually have managed to do it. I’m still unable to eat more than about 2 oz. at a time, which seems OK but is frustrating; there are times when I really want more food than that. Unfortunately, on the couple of occasions that I have allowed myself to eat a bit more than I know I should (and can feel that I shouldn’t), I’ve had the expected stomach discomfort and vomiting.

Only one real moment of unhappiness with the whole affair. After a pretty lousy day at work recently, I went out to my car and sat for a moment, thinking that what I really wanted to do was (as I had often done in the past) curl up around a big plate of macaroni and cheese, always one of my favorite comfort foods. And then I realized that I would probably never be able to stuff myself in that way again. And despite the fact that I know that that’s exactly the kind of emotional eating I need to avoid, I really wanted it, and was very frustrated and sad. I know that small portions of foods like that will probably be possible someday; small portions are really all I should ever have been eating. Still, it’s hard to get over decades of practice.

I had my one-month follow-up visit with my surgeon today. All seems good. He is pleased with the weight loss and how the surgical sites are healing. I mentioned the one episode of vomiting, and he said that it was evidence that the surgery was doing its job.

I am cleared for all physical activity, and can add leafy greens, cooked vegetables, some meats and seafood to my diet. While the advice is not specific, most other sources I have read (e.g. Kaiser’s) suggest avoiding red meat for the first six months…but I’m making some turkey chili.

The surgeon’s advice sheet also said that 1 oz of fluids every 15 minutes is good, but to increase it if tolerated. So far, I have been tolerating more fluids when I experiment; they seem to clear from my stomach much faster than most foods. So I’m upping that a bit to try and stay hydrated.

Things continue to go well, except that I’m cold. 🙂 My weight loss has accelerated a bit, I’m not sure why. I’m not assuming it’s going to stay that way. However, as of today I am down 44 lbs. I’ve got about 50 to go to the point where I think I’d be pretty satisfied (200 lbs), and 70 to my ideal goal (180 lbs).

I had made a plan that, when I hit 250, I would start trying to jog a bit. I’ve tried the “Couch to 5k” app several times, and I like its training program pretty well. The first time I tried following it, though, I pushed it too hard (as per usual for me) and it didn’t go well. Most specifically, I remember calling my wife one day because one training run left my knees hurting so badly that I needed her to come pick me up.I weighed more than this those times, though, and I have a better ability now to judge when I’m pushing it too hard, so I have hopes that I can make it work.

I’m seeing my surgeon on Wednesday for the one-month checkup (slightly delayed in this case). I’m hoping he’ll clear me for lifting heavier weights; I’d like to start some weight training, and it would be nice to feel sure about doing more things around the house. I’m using the elliptical and treadmills at Palomar’s fitness center, which is a nice way to start the day, but adding some weight training would be nice too. I’m also hoping to expand my food choices a bit. Maybe some ground turkey…I miss chili. I also miss pasta terribly, but I know that I’d have to be very careful about that much refined carbohydrate. Portion control is going to be a big challenge for me.

My blood sugar has remained normal, which is wonderful. Honestly, even if the surgery did nothing but help put my diabetes into remission, I’d consider it a win. But I do also enjoy the fact that I’ve lost enough weight that I am starting to need new clothes, and I feel healthier. I’m still paying a lot of attention to appetite, and when and why I feel hungry. Being able to see that I have eaten to avoid boredom has been a big revelation for me. The surgery is really helping me to understand those issues with food; since the strong physical desire to eat has diminished so drastically, I am more able to assess *why* I feel some desire to eat, and it’s easier to name it and deal with it. I am aware that this much focus on food is, potentially, not a healthy thing either, and so I see some challenges ahead:

1. To avoid developing a different eating disorder, this time focused on how little I can eat, and paying unhealthy attention to quantity and frequency of eating
2. To avoid falling back into the same habits of eating as before, once I am able to eat more different foods, and in greater quantities.

The goal should be to eat reasonable portions of healthful food and enjoy them, without having food take on a greater-than-appropriate role in my life. It should serve nutritive, sensual, and social functions; it should not serve self-comforting, anti-boredom, or anti-anxiety functions. Which means I’ll need to fimnd other things to fill those roles.

As of today, it has been one month since my surgery. It seems like much longer, but given how dramatically it has changed how much attention I pay to everyday things like eating, I guess that makes sense.

I’m down 38 pounds from my peak on December 28. Depending on my goal (aggressive vs. acceptable), I’ve got 56 to 76 pounds to go. After the initial extremely rapid weight loss, I’ve settled into a pretty steady four pounds or so per week, which would put me at target around the end of the school year. I expect that rate to slow somewhat, so I’m hoping for July or so.

I’ve had virtually no complications so far. No dumping syndrome (though I have been good about avoiding sugar and large amounts of fat), no surgical complications. I’m able to walk for easily an hour at a time, and more when I like. My appearance is definitely changing, in ways I’m happy about. Blood sugar is normal, especially when I’m being vigilant about exercise.

I had my first set of labs. My A1C is the highest it’s been by a smidge (7%), but that’s a three-month average, which includes the period just before the surgery, when I was not being very compliant about medication. Uric acid is high, but the doctors don’t seem too concerned about that (I am, because I am somewhat prone to kidney stones, which SUCK, but one thing at a time). Kidney function is normal. Sodium is normal, potassium and chloride are a bit low. My guess is mild dehydration (it’s very hard to get enough fluids when you can drink about 4 oz. an hour!), causing low potassium via aldosterone. The low potassium was the only one they were concerned about, and so they put me on a short course of potassium chloride tablets, to be tested again in a week.

Cholesterol is interesting. My total is 75, with HDL of 24 and LDL of 33. That’s lower than is good for HDL, but the total/HDL ratio is about 3, which is very good. I am taking atorvastatin, which may be responsible for the low overall cholesterol.

I’m still on mostly liquid protein, but I’m experimenting with adding other foods. Beans and cheeses are staples for me now. I haven’t really tried any high-carbohydrate foods. I did decide to try some canned pork and beans, which was a comfort food for me, the other night. I drained off much of the sugary liquid and put about 2 oz. of beans in a bowl. I did eat them pretty quickly, and then–foolishly–drank a bit too much water too soon thereafter. This led to some very uncomfortable gurgling and pain, feelings like something was caught around by heart, sour, thick spit in my mouth, and then–for the first time in about 30 years–I threw up. It was a kind of fascinating experience. Not painful, and entirely missing the stomach acid which (I hear) makes vomiting such an unpleasant experience–just lots of saliva and beans, and then I felt much better. And now I have a much better sense of my limits. I don’t know for sure how much of that was too much food/water and how much might have been a reaction to the pork and beans in particular, but I’ll avoid them for a while in any case.

Food is still very tempting–I want flavor and texture, more than feeling especially hungry (though I do have some appetite returning). But I’m able to resist temptation.

I’ve always enjoyed long walks. I’m pretty introverted, so spending two hours with an audiobook while strolling around the area is usually pretty enjoyable. As a kid, I did some hiking in the mountains of Colorado, and I enjoy the outdoors, so it doesn’t have to be walking on flat surfaces. Thus, I’ve been trying to do good walks when I can post-surgery; it’s what they suggest, after all!

The walking has been fine. I can pretty easily to 3 miles on city streets at this point, and I suspect I could do more. In the last week or so, though, I’ve kind of wanted to challenge mysel a bit more, so I’ve started to add hiking on local trails. I went out to Daley Ranch recently, and while there were a few parts which challenged me in my current state, it was fun. Yesterday, though, I decided to try Double Peak trail in San Marcos.

It’s rated as “moderate”, about 2.5 miles to the top of a local big hill/mountain, with an elevation gain of about 1000 feet. I knew that that would be an interesting challenge, but buoyed by my success at Daley Ranch, I thought I’d give it a try.

I almost immediately ran into a problem I had seen at Daley, but which I had never before encountered before the surgery. Flats were fine and enjoyable, even slight uphills…but as soon as I hit any real ascent, I got out of breath within about 20 feet. I’d start uphill feeling good, and then quickly find myself gasping with legs that felt exhausted. The funny thing was that 30-45 seconds of rest would fix it, I’d start up again, and have exactly the same experience. This was very different from before the surgery–I’d be able to keep chugging along, tired but determined, for much longer stretches.

In little bits like that, I made it about 2/3 of the way up. At that point, I was not just feeling tired, but also having distinct feelings that this might not be a good idea, that my body was starting to respond badly to this. I got to the sign that indicated one mile remaining, saw the upslopes to come, and decided not to try it.

I think I could have gotten to the top–but I think it might have caused me harm. As it was, I descended, and instead walked the 3/4-ish mile flat trail around a pretty little lake at the bottom.

I’m a physiology instructor, and I’ve taught labs on muscle fatigue. I know that fatigue is complicated, and that there are multiple mechanisms involved, and that we don’t understand all of them. And I have a guess about what might have been going on. My current food intake is very, very small, about 300 calories per day–and that usually has less than 15g of carbohydrates. That probably means two things: severe ketosis, and low glycogen storage in my liver and muscles. Given all of the hype about how great keto diets are for fitness, it’s hard to believe that the ketosis is responsible for the rapid fatigue under load.

However, the low glycogen might be. Muscles can use fatty acids for energy quite well, as long as the energy demands aren’t too extreme. If I understand it correctly, fatty acids are converted to ATP through beta-oxidation of the fatty acid and then Krebs cycle/oxidative phosphorylation of the products. This is a very efficient but slow process, which means that the fats can produce lots of ATP but not very quickly. For sustained moderate exercise (walking around a lakeside flat trail, for example), that’s fine. My body can provide fatty acids in abundance. However, trying to push a 260-pound body up a steepish incline means the leg muscles need a lot of ATP very quickly. Normally, that would be accomplished with glucose metabolism…but in this case, my muscles and liver don’t have very much glycogen (glucose storage), so the available glucose is low. Thus, when I try to switch over to burning glucose for more intensive work, the muscles sputter.

That’s my current hypothesis, anyway.

During the class, they said we would probably feel cold. I’ve always been one of those people who didn’t get cold easily; I could tell that my skin was cold, but I almost never *felt* cold.

I am, apparently, no longer one of those people.

It has been cold here, at least by southern California standards. In the nights, it has been getting down into the low 40s. And I am feeling it *much* more than I have before. For a few days after the surgery, I could feel the cold. Then, I was mostly back to how I had been–cold resistant. Yesterday, it suddenly hit me again, and suddenly I’m feeling it as soon as it drops below 55 or so. It’s kind of weird.

I got frustrated with my diet of string cheese and yogurt, and took two risks yesterday. The first was getting some sliced peaches in juice (like the canned type) and eating a few bites. No problems, and it felt very, very good. The other was–at my brother-in-law’s birthday party–eating the tiniest morsel possible of cake and frosting (we’re talking a few grams). No problems, although not as rewarding as I hoped. Resisting the pizza was harder, but bearable.

I’m feeling good. My energy is mostly back; I have been able to walk 2-3 miles at a stretch without much trouble. I’m noticing that stairs are starting to be easier, which is probably due to carrying 30 fewer pounds. And people are starting to ask about the weight loss, so it must be starting to be visible.

My wife mentioned something interesting. In the past, when I have dieted, she would comment that my breath would have a distinctive smell–not exactly unpleasant, but “sharp”. I always assumed that was from ketones, produced from fat metabolism.

She has mentioned that right now, I have much the same smell, except much stronger. It doesn’t seem to have anything to do with oral hygiene, so I am assuming it is arising from the unusually high amount of fat metabolism and extremely low carbohydrate intake (less than 15g/day) producing a state of ketosis. I don’t thin k there’s anything I can really do about it other than apologize and try not to breathe on her.

Research suggests that others have encountered similar things.