Nutritionist appointment, 5 months in

This picture is from my girls' night out last weekend, not the nutritionist...these were Derby Punches, in honor of the Kentucky Derby--bourbon and lemonade from someone's grandma's recipe. The cool glasses had all the Derby stuff on them and you could buy them for a buck and keep 'em, so I bought mine. I have always wanted to go to the Kentucky Derby just so I could wear the big picture hat, but in reality, I think I just want the hat.

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I saw my nutritionist Monday. She was very encouraging and told me what a great job I was doing, which felt really good...I just feel like I'm treading water so much of the time. I had lost a couple of pounds, which surprised me because I haven't been exercising (my ankle is still popping and sore--my regular doc is sending me a written referral to have it looked at; one of my tasks for today is to find an orthopedist my insurance covers and to make the appointment). I've stayed within five pounds of what I was when I first went in to see her, but I still weigh less than I did at the beginning.

She praised me for using my time well by joining this group and really trying to get to the bottom of everything within me so I can succeed in the long run, and also complimented me on my food journal--its detail and follow-through. All of this just felt really good; too often, I am caught up in feeling guilty for being unemployed/not productive enough, not to mention overwhelmed by all the emotional stuff I'm working through. She kept saying things like how I was "on it" and "ahead of the game". This was my five-month appointment with her, meaning the six-month one is next month (June 12!) and the pre-op stuff can really begin then, if not before. (Another task for today is to contact the surgical center and see if I need to anything to start the ball rolling, as I know there are some pre-op procedures that need to happen--an abdominal ultrasound, bloodwork, etc.)

We talked about what I would be eating as surgery gets closer. I do not have to do a liquid diet prior to surgery as I had previously thought, but I do have to go to a very low-carb diet two to three weeks prior in order to shrink the liver. Low-carb in this case means a total of 40 total grams of carbohydrates per day. Fiber content can be subtracted against the carbohydrate amount. She gave me a couple of sample menus. The daily fiber goal is 25g, and the daily protein goal is 50g prior to surgery, but 60-80g after.

Thirty days prior to surgery, I will need bloodwork done. I also need to make sure my medications can either be crushed or will be available in a liquid form, and that I have vitamin supplements on tap for after--she recommends Bariatric Advantage.

I thought about getting a book on making baby food for afterward, but she referred me to a pureed diet on the Web through University of Pittsburgh Medical Center under "info for patients". She also said netwellness.org was a good resource for pureed foods information, and lent me Susan Maria Leach's book, "Before and After: Living and Eating Well After Weight Loss Surgery". Apparently this book is like the Bible of weight loss surgery, and the author also has a very comprehensive-looking website--I believe it is bariatriceating.com.

We talked a bit about sugar. I have been fairly successful in giving it up and just using artificial sweeteners. While a lot of programs suggest giving those up as well, I don't think it's realistic for me for any number of reasons. My diet is restrictive enough (and going to be even more so)--I don't want to set myself up to fail. I am not keeping it in the house, which seems to be a key point. Times like this weekend, I am always aware that this could be my last piece of pie or my last whole martini, and I have been enjoying those things in moderation and feeling fairly serene about it.

(Apparently the magic amount of sugar that usually causes dumping syndrome is just over 5g, though she cautioned me that this is not an absolute--some people take one bite of cake and that's it.)

I am going to have to discover all the natural stores in the area, which is previously uncharted territory (except for Trader Joe's). I need to start stocking up on healthy protein drinks, for one. Muscle Milk is one she likes, and Pure Protein drinks is another.

I have been using nutritiondata.com for a lot of my nutritional information for the food journal, but my nutritionist also recommends calorieking.com.

Day 86, Part Two: This Time, It's Personal

Phone appointment this morning with regular doctor went well. She is upping my Seroquel (sleep med) to 75 mg with optional 5 mg Ambien chaser if I wake up and can't go back to sleep during the night.

"Has it changed your mood?" she wanted to know.

"To what?" I answered. No, my mood pretty much stays at half-mast, Doc; I just want to sleep. I am having one of those puffy-eyed, flat-affect kind of days as it is. We debated about eventually changing the Lexapro, but when she consulted my chart notes she discovered I have already tried every freakin' antidepressant that was ever so much as a glimmer in Eli Lilly or GlaxoSmithKline's eye.

We talked about the sleep apnea, and she wants me to see the specialty dentist to get the mouth guard made ASAP. I have to see if I can get it covered first; they are not cheap. If I have to have another sleep study, I will straight-up plotz. She is willing to write me authorization letters for everything. I heart my doctor.

(A side note/update about Fun With Insurance Coverage--insurance still has not settled on my psych eval charges. They continue to debate back and forth with the provider's office as of 11:30 this morning. The date of service was January 16.)

*****

Next up: the nutritionist.

I weigh in. I have gained a couple of pounds. I am two pounds less than I was on the first appointment. This is not a shock. I am rather grateful I didn't gain more.

We procceed to Talk Seriously about What I Think Happened. What I think happened is as follows: I am not feeling motivated, I am sick of the BS, I have a hitch in my gitalong, I am discouraged. I have gone out to eat and I wanted a cocktail. I have gone out to eat and split dessert with Mr. Salted. I have gone out to eat and felt like crying because I'm not going to be able to enjoy food as I once did. I have eaten chocolate because it remains the most reliable source of pleasure on the planet. So sue me. I am still writing every blessed thing I eat down (give or take a Hershey's Kiss here and there), complete with calorie counts and protein content. I am exercising roughly half the time. I am not a complete and total screw-up; if it was Pass/Fail, I'd get a Pass. (I think. If I smiled a lot. Probably.)

I tell her I'm looking into getting counseling authorized by insurance and--DA DA DUM!!!!! turns out the wellness center is hosting a support group. It isn't free, but the cost isn't outrageous. It starts tomorrow night, goes until June 3. The flyers says, "help break the cycle of food addiction and emotional eating." It's facilitated by a nutritionist/counselor and there will be no more than eight members, which sounds like a good size. Support, therapy, reading, assignments, etc. I bit the bullet and took the money out of the tax-return/pipe-dream-of-further-education fund, which is flying out of the bank to pay this bill and that anyway. I really need to talk to some other people who are dealing with the same stuff; I think it could really benefit me. (Since I coughed up the actual cash, I know that I will not run screaming into the night; once I part with any money, to run screaming ceases to be my way. My way is, "I will get everything out of this that I possibly can, dammit.") I participated in a similar group fifteen years ago, and although it was not about food issues, it was extremely helpful. The book they are going to use in this group is called "Anatomy of a Food Addiction". It discusses brain chemistry and other contributing factors.

I have never talked about my food issues in a group of people I didn't know. I barely talk about them with people I do know. I wonder if I will be the fattest (SHALLOW!), and I wonder if there will be any men there. (It would be really interesting to talk to an acknowledged male food addict.)

I am feeling some (inevitable) dread, but also that this is a positive step in the right direction.

Nutritionist appointment

Just got back from nutritionist appointment #3. I lost (get ready for it) ONE (1) WHOLE FREAKIN' ENTIRE POUND. Two months = five WHOLE FREAKIN' ENTIRE pounds. To spare the expense of paying for a skywriter, whoomp! there it is. A concrete illustration of the reality of insulin resistance, sleep deprivation's effect on the cortisol hormones (I did not sleep one minute last night, fyi), and why I need medical intervention. 60 !@#$%^&* days, and I would say I deprived myself of anything that tasted really good for at least 55 of them.

I do like the nutritionist. She's easy to talk to, reasonable, and realistic. I forgot to turn my phone off and got a text during the appointment--the text ringtone is "Bust a Move", so she started dancing to it in her chair and we had a giggle. She didn't give me too much guff about that ridiculous craving assignment--she said a lot of people didn't even try to do it, at least I had tried. (I didn't try all that hard, it took all my energy to hold back the bile, but she didn't have to know that. I take my positive strokes where I can get 'em.)

She praised my food diary, which I have kept faithfully (grumblegrumblegrumble) and added caloric content when I had it. She recommended a couple of websites, calorieking.com and fitday.com, that have calorie counts on them. The new assignment is to incorporate more protein into the diet and begin to calculate that.

Protein becomes extremely important because immediately after surgery you are only taking in 400-600 calories per day. Post-bypass, the recommended protein intake is 60-80 grams of protein per day, which is a LOT. You're supposed to eat all the protein you need in a day before you eat anything else. I think the low-sugar Instant Breakfast and I are going to become even better friends than we already are. Apparently Atkins makes some protein drinks, and there is one called Muscle Milk that they sell at Costco and Super Supplements. SlimFast and Ensure have too much sugar (I thought I was the only person in the world who gained weight on SlimFast; now I know why I did). Milk, yogurt, cottage cheese, meat, tuna, tofu, peanut butter, nuts, beans, peas, lentils, cheese. She gave me a protein foods list with happy Clip Art illustrations of happy, happy food. Happy.

We talked about the water-drinking requirements for post-op. I'm drinking enough water, it's just how I drink it that is going to be different. You have to drink 16 ounces of water half an hour before eating, not drink anything while you eat, eat the protein first, drink 16 ounces of water after you eat.

We discussed the dreaded dumping syndrome, or specifically, sugar and dumping syndrome. I'll have to post more about dumping syndrome when I have the fortitude to research it further and make an articulate blog entry with some good information in it. Basically from what I gather, if you eat too much sugar, fat, and grease post-gastric bypass, you'll get violently sick. People don't know what foods are going to trigger dumping until they've had the surgery, though some have proven to be universal, and sugar is one of them. Simple sugars are apparently a huge culprit, so even the sugar-free chocolate isn't so hot because the sweeteners used in making it--the sugar alcohol derivatives, such as sorbitol--are catalysts for dumping syndrome. Splenda and aspartame sweeteners do not pose a problem.

She told me I won't be able to use chocolate to cope anymore. She wasn't mean about it, it was just a statement of fact. I told her I seriously thought I was going to need some kind of rehab. She gave me a food addiction website to look at and some sample questions to ask counselors if I got to the point where I could afford to see one. Since money is an issue, maybe a support group would at least provide some balm. It's not the amount of food or even the type of food I eat; it's the relationship I have with it. It sounds so trivial and silly, but it's a very real concern.

Tomorrow, the exercise physiologist. I'm so thrilled (NOT). It looks like I have to see him every time I see her, so, once a month. I'm not doing any more than I have to, and I told them that today.

Re: the disputed psych eval payment--I had to eat the $220 written report fee, but the billing person spent a good half hour on the phone with my insurance while I was there, who are now "reprocessing" the claim for the remaining $300.

Oh yeah, and it's snowing. WTF?

Nutritionist appointment today

Day 30 of write everything down that I ingest; appointment number 2 with the nutritionist. I was surprised to learn that I have lost four pounds, not that I get that excited about losing four pounds at this weight. I know all I have to do is look at a piece of apple pie and I will gain 20; to paraphrase comedian Ron White (who, it should be noted, makes me laugh until I snort most unbecomingly), "I know. I've seen me do it." Still, it was nice to receive praise, even if it made me think of what positive rewards for toilet training must be like (I was relieved not to receive any sort of sticker). I maintain that I lost the four pounds because dread burns calories.

She looked at my food diary and actually said I was doing well there, too. The only thing she would have me change is to get in another serving of vegetables a day, which is exactly what the last nutritionist I saw told me to do. I told her I could do that. And I can.

Insurance wants me to see the exercise physiologist, so I see him Wednesday. He looked young and nonthreatening and seemed upbeat, but not in a vomity way, so it might be okay. We'll see how it goes...hey, if insurance pays, I'm there with bells on; I am nothing if not educable.

We also discussed my sweet tooth, my nocturnal need for sugary sustenance, and my assignment for the month is about cravings. She gave me four strategies to control cravings. The point of this is to write about which strategies I try and how they work or don't work. More on that later.

After going grocery shopping post-appointment and buying all kinds of healthy food, I am tired and on the way to celebrate my meager weight loss by getting in bed with a book--even better, a trashy true-crime book that has absolutely no redeeming social or academic value. Let's hear it for the printed word!

Why we eat?

According to psychologist Pavel Somov's book entitled "Eating the Moment" we eat for three reasons:

1. "to satisfy the need of the body,"
2. "to satisfy the need of the mind," and
3. "and out of habit when triggered by the environment."

Exercise 1--first 2 weeks

The following exercise from his book is meant to help you gain insight into why you eat.

1. After you ask yourself, "Why did I just eat?" keep a written log in a notebook.

Were you hungry? Did something in the environment trigger you to eat? Did you eat to cope, to address emotional needs?

If you ate out of hunger, write down "need based". If you ate because of stress, write down "ate to cope", and if you ate on a craving triggered by an environmental cue, write down "environment triggered". If several difference reasons coincide, try to determine the primary motive for eating.

Exercise 2--second 2 weeks

After completing the first exercise, move on to this one. Ask yourself before you eat "Why am I about to eat?" After you clarify to yourself the reason you are eating, then eat or don't eat. For right now, you make the conscious decision. Continue with this for as long as you feel as it is helpful.

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So this is my assignment from the nutritionist for the first month.

I did something like this before in therapy many years ago. It was a little different, as I was to write down how I felt on a numbered scale (1-5 or 1-10, I think) when I ate; it wasn't important what I was eating, but why. It was actually helpful. I was still having some issues with bulimia at the time. I did learn a lot about my own triggers and patterns and ultimately at least become conscious of why I ate, which was the whole point. I was definitely an emotional eater. To this day, when I get angry and feel trapped and pushed to the brink of stress, I want some chocolate. Half a regular-size candy bar is plenty.

The writing down everything I ingest is driving me nuts. How many bottles of water did I have today? And I'm supposed to write down my exercise. I consider cleaning the entire house exercise--it takes all day, and it wipes me out. And I don't care what anyone else says, a big solo Costco trip is exercise, too. That store can be full of frighteningly fertile people with a well-developed sense of entitlement--many of them unpleasant--and that could make anyone need a nap afterward.

Nutritional Assessment

Today I had a "nutritional assessment". I talked about what I eat every day and my entire history with food while a thin woman took notes about it. (In all fairness, I liked her--she was nice, easy to talk to and very helpful.) It was actually kind of exhausting. (Did you have to clean your plate? Was food used as a reward? Do you have religious restrictions? When you say you have a bowl of cereal, how big is the bowl? What kind of milk? And so on.)

There were these pieces of crazy, wobbly rubber food everywhere--some of it looked frighteningly real, while some of it resembled cat vomit. I've been to a nutritionist once before, and this one did the same thing as the other one--picked up pieces of the rubber food for emphasis while she spoke.

I was reminded of this movie I rented years ago called "Eating". It came out in the late 1980s or early 1990s; I believe it was a Canadian film. One of the characters in the movie was filming a documentary about women and their relationships to food for her thesis. The "mockumentary" parts of the movie were what made the movie good, in my opinion--women talking about what their specific comfort foods were, among other things. Fiction or nonfiction, much of it was incredibly personal. Even though it was a scripted film, it felt very intimate. I checked a few years ago, but was unable to find it on DVD.

I have watched that movie with different female friends two or three separate times, and it always provoked conversations that were every bit as interesting as those included in the film (which was probably the whole point). I think everyone's relationship to food is incredibly personal (how could it not be?) but I don't know if it's as fraught with conflict for men as it is for women. I suppose it could be argued that the issue transcends gender and just depend on the individual, but a lot of women like to eat when they get together--happy, sad, or otherwise. One of my female friends and I used to have what we called chocolate parties--everything we brought had to have chocolate in it somewhere. Another of my friends--who is an amazing cook and loves food--asked me, "Who will I eat with [after you have surgery]?"

"Me," I answered. "I can still have a couple of bites." (I can also inhale...deeply.)

I didn't learn much about nutrition growing up. I know a lot of people didn't, particularly if they are my age or older. As a friend of mine in his 60s put it, "It just wasn't done [then]." Nutrition is truly a luxury item when you are worried about being able to afford food to eat at all.

I have a vague recollection of a food pyramid being addressed in school at some point. I also remember, as a child, ferociously coveting the picture of the breakfast pictured on the side of many cereal boxes of the day. The photos included the cereal in question, but also juice, toast, AND eggs, if I remember correctly. It was a veritable fiesta of cholesterol and sugar and more food than I could imagine having to choose from at one time, then or now.

I have a couple of assignments to do before I see the nutritionist again next month. I have to write about my relationship to food in quite some detail. I also have to keep a food and exercise journal for the next six months and probably the indefinitely foreseeable future. It includes what vitamins I take, how much water I drink, and what exercise I do every day. The nutritionist told me that the main concern of insurance is to track my weight over the six-month period, ensure I show up for appointments, that sort of thing, but they say they require this journal as well.

None of these specialists can tell anyone what surgery to have, but they can make recommendations. The one I saw today also recommended gastric bypass for me, due to my sweet tooth and several other factors. She thought stomach sleeve gastrectomy might be even better, but insurance isn't covering it yet because it is still considered experimental.

Truthfully, I'm already annoyed by the food journal, and this is DAY ONE. I'm writing down how many calories is in the food if I know it, and a lot of the amounts are still branded into my brain from my eating disorder days. I really, really, REALLY hate being told what to do when it comes to diet and exercise, for obvious reasons. "Chafe against" would probably be more accurate. (This is why, in part, I believe this surgery will work for me. If I eat the food and the food makes me sick, I have enough respect for my body to listen to what it's telling me to do and do it. After all, I live in there. Listening to someone tell me what they think I should do, when they have no concept of what it truly means to live in there, on the other hand...)

The drill sergeant approach to weight loss absolutely does not, will not, cannot fly with me, and I was open about that with the nutritionist. I don't think humiliation motivates most human beings to do anything but self-destruct and/or rebel, and I think the medical profession is just beginning to figure this out.

Health Insurance and Finding a Surgeon

I've had a lot of health issues in the last ten years, not only the ones already mentioned but also depression, insomnia, migraines, unspecificied stomach issues, and a lot more. As the song says, I'm much too young to feel this damn old. I've gotten used to calling doctors and insurance companies, saving copies of things, filing appeals and the like. My advice is: document, document, document. Save everything until you have the statement showing $0.00 in your hand, then have a shredding party.

I haven't been working full-time for a couple of months, so I am dealing with my spouse's insurance on this procedure. They were taken aback to find out they were my primary insurance, so that had to be verified recently. Then they told me the only bariatric surgery provider they covered was over 50 miles away. I watched a web seminar on his site and went to the initial appointment, thinking his practice was my only option unless I was going to self-pay.

Well, I didn't like the doctor. He wasn't listening at all, he didn't bother looking at my medical records, and he was ready to run a bunch of tests I'd had in the last couple of years when the results were present in the medical records he wasn't looking at. He was extremely dismissive. In effect, he said, "We do the surgery, we make you sick if you eat ice cream, you get thin, end of story. Bye bye." That approach did not do it for me.

I had recently read about another facility in the newspaper who had gotten some positive attention for their standards in minimally invasive and cutting edge weight-loss surgeries. They happened to be more conveniently located. My husband and I went to their free seminar, and it was fantastic. It was interactive, informative...I took pages of notes and was ready to sign anything and go to work for them, too, if they'd let me. The bedside manner of the doctors was like night and day from the previous surgeon. This particular facility emphasizes nutritional classes, follow-up care, nutritional coaching, support groups if you choose to participate in them, etc. I was really excited by their approach, because it actually sounds like it can work. They gave us information on how to finance surgery if insurance would not pay and that was that. Imagine my surprise when they told me they were a contracted provider with my husband's insurance! Glad I asked!

I then went to retrieve my medical records from the first bariatric surgeon--there were about 600 pages of them, so I was grateful not to have to accrue them all again. It also made it much easier to fill out the new facility's application accurately--they want every bit of medical history and then some. My intake appointment, as they call it, involved meeting with a lady who does billing and is the liaison with the insurance, and then a consultation with the surgeon. A lot of it was review from the seminar and other research I've done.

The surgeon I met with recommended gastric bypass for me because I have "what they call" classic metabolic syndrome, where I gain all my weight in the torso, also known as the apple body type or, as I once heard it explained, "egg on stilts look." (Apparently, there is a connection between which bariatric surgery might achieve optimum results for each specific body type.) I asked him if PCOS was still present when there were no longer ovaries, and he said, "That's a really great question!" I don't know if anyone knows that answer.

My particular insurance wants 6 months of a physician-supervised diet, two years of chart notes at a certain weight and BMI, the psych eval, the nutritional assessment, and a monthly visit to check in with the nutritionist. There are nutrition classes prior to surgery and after it.

Another thing I like about this facility is that they call the providers to find out what your benefits are initially, instead of you doing that. It sets a precedent with insurance, and a good one--insurance is always going to be more attentive to the provider. Still, you have to be loud if you want anyone to listen to you at ALL. Loud, persistent, with your headache cure of choice at the ready.