Meal Plan After Bariatric Surgery

All Bariatric surgery shrinks the stomach down to a much smaller size than a typical stomach. The purpose of the surgery is to limit the amount of food a person can eat at one time. Eating more than this new stomach can hold leads to discomfort, pain and even vomiting.

The risk of overeating and the lack of familiarity with this newly transformed organ often leads to severe food restriction and a fear of eating. A significant number of people lose a lot of weight in the months after surgery because they are afraid or unable to eat enough.

Clearly, as explained in the last post, undereating is not a sustainable way to live. One possible result is surgical anorexia, and another option is a new form of disordered eating aimed at overcoming the limitations of having such a small stomach.

The most successful people after surgery learn a new, sustainable and reasonable way to eat. This new plan takes into account their caloric and nutritional needs, the capacity of their stomach and the rhythm of their daily life.

Sadly few nutritionists appear to focus on helping the many people who now have Bariatric surgery. The worst culprits are the ones who work in the Bariatric centers. Their sole goal appears to be short-term weight loss, the overall sign of success for these centers. Long-term health and quality of life rarely factor into their suggestions.

The new meal plans need to incorporate a few simple ideas.

First, meals need to be small, rarely more than a cup of food. This basic fact acknowledges the limitations of the new, small stomach.

Second, a cup of food is not enough to sustain someone more than a few hours. Thus, the typical plan of three meals and two snacks is rarely effective after surgery. Instead, a new meal plan needs to include eating a small to medium size amount of food more often through the day, usually every two hours or so. Instead of meals and snacks, this plan has mostly snacks.

Third, the food needs to be varied throughout the day. Since it is harder to eat enough due to the small stomach, the new plan needs to consider the nutritional value of the food to ensure one gets enough nutrients through the day. Typically, a varied diet will always include enough nutrition. Since a small stomach only allows limited food per day, it is important to be sure to eat enough nutritious food.

Essentially, people who have had Bariatric surgery have to manage a damaged stomach the rest of their lives. Just as anyone who has had an injury, these people can accommodate their diet to take into account the injury and ensure adequate nutrition.

Surgical Anorexia: the Long Term Effects of Bariatric Surgery

As a psychiatrist treating people with eating disorders, I find that I have specific but unexpected expertise to help people after Bariatric surgery. These procedures aimed at reducing weight induce what I have started to call surgical anorexia.

Chronic anorexia leads to poor functioning of many organ systems due to long-standing malnutrition including the gastrointestinal system. Slow digestion, an inability to tolerate many foods, delayed emptying of the stomach and poor absorption of energy and vitamins are ways anorexia can affect the GI system. Thus, poor nutrition damages the GI system and makes it more difficult to absorb the needed energy.

Bariatric surgery shrinks the size of the stomach significantly which leads to an inability to eat a normal amount of food at one time and to more difficulty absorbing nutrients and vitamins. Essentially, the surgery mimics the same GI symptoms that chronic anorexia causes. Over time, these GI symptoms lead to starvation and the same medical effects of anorexia unless steps are taken to ensure adequate nutrition. It’s not a stretch to call this surgical anorexia.

After the surgery, patients I have encountered receive minimal instruction about how to alter their diet and their eating pattern to accommodate their transformed GI system. They need to learn new foods to eat, how much they can tolerate and when to eat through the day. Nutritionists at Bariatric centers tend to give a formulaic meal plan without any detailed, individualized instruction about how to maintain a normal diet.

The end result is often a patient confused about how to eat, eating an insufficient about of food and, after a few months, experiencing symptoms of malnutrition and starvation. These symptoms include nausea, weakness, dizziness, trouble concentrating and irritability. Often patients are afraid they are sick and don’t understand they are starved. And the Bariatric programs refer patients to other doctors and don’t take responsibility for a common effect of Bariatric surgery: surgical anorexia.

In time, patients start to find ways to eat. They eat more often through the day. They eat foods that are easily digested. They start to drink alcohol which loosens the stomach muscles. They overeat or binge and purge but are able to absorb some foods. These are not constructive ways to manage food intake.

However, the longer they are starved, the more their body’s survival instinct kicks in. They start eating large quantities to assuage the starvation which leads to regaining any weight lost from the surgery. In other words, the lack of instruction after surgery means the effects of surgery are usually temporary and can trigger new disordered eating patterns.

Bariatric surgery is not the panacea people often hope it is, but many people seek the surgery after years of desperation. For those who do take this step, there are some basic facts about eating with a surgically damaged stomach that can help avoid surgical anorexia. I’ll discuss them in the next post.

The Philosophy of an Eating Disorder

Eating disorders often present a much more appealing and clear philosophy of the world to young people just starting their lives. For adolescents and young adults afraid of the unknown and the lack of clear guidelines for living, the certainty of the eating disorder rules can be very appealing.

These rules determine how one should feel, the overall goals for the day, how to determine a sense of accomplishment or failure and the best way to move through daily life.

The rules typically entail aiming for certain weight goals, clear rules around food and exercise and a way to decide which personal or profession al events to attend or skip. The eating disorder makes up these rules for one simple, straightforward goal: weight loss.

With this goal in mind, the other more vague goals of life go by the wayside. All other potentially important aspects of living pale in comparison to the concrete and simple goals around food and weight. Life becomes simple, and the philosophy boils down to one measure of success.

Even though eating disorders can seem nonsensical or even vain to many, these illnesses present a lure to young people scared about the uncertainty of life and looking for a way to take away the prospect of having to make decisions in a very confusing world. The eating disorder is an easy out from daily life into a very simple way of life.

The reality of living in the eating disorder world is that young people don’t learn basic life skills: developing friendships and relationships, managing emotions through a normal day or making decisions as an adult.

When entering recovery, people often feel lost without any means to cope when they cannot rely on their eating disorder anymore. The immediacy of relationships, emotions and decisions can quickly feel overwhelming.

Getting better from an eating disorder isn’t only about learning how to eat and manage a healthy body. It also means learning how to face the vagaries of life without a parallel set of rules dictating how to live.

In the end, recovery must focus on living without an eating disorder. It means a crash course in developing coping skills, interpreting internal reactions and stimuli and managing the uncertainty of life as we all must.

It’s a tall order while also learning how to eat and makes the entire process hard. Successful recovery needs to entail the process of learning how to live as much as the process of learning how to eat.

Emotional Maturation during Recovery

Once eating is largely normal and behaviors mostly diminished in recovery, there is room for emotional and psychological development that is impossible in the throes of an eating disorder.

The disorder in full swing is debilitating. Disordered eating and obsessive thoughts about food dominate one’s mind. In addition, completing the eating disorder tasks and following the rules feels like an accomplishment each day. These goals trump all other aspects of daily life and leave no room for other ways to grow into yourself.

After the symptoms subside, the person in recovery faces the realities of life in new ways. The trials and tribulations of work, family, friends, relationships and personal growth all come to the fore very quickly.

Without the guideposts of the eating disorder lighting the way, the uncertainty, confusion and emotions of life feel overwhelming and confusing very quickly.

The months or years of development that would occur otherwise stop almost completely when an eating disorder is present. Most relationships stagnate and all emotions disappear under the intense pressure of the eating disorder rules.

Emotional and psychological development in the process of recovery entails learning how to manage relationships and friendships, identifying emotions, finding ways to cope with life events and managing the uncertainty of daily life. In an eating disorder, none of these issues truly matter. All that demands attention is food and weight.

Fortunately, the period of development for someone in recovery is usually fast and furious. Once the eating symptoms subside, emotional maturing begins immediately.

Although the process is challenging and scary, the mind has developed even though the psychological changes have not occurred. So one’s mind is ready to charge ahead and learn all the components of development and maturity quickly. It’s important for the person to have help identifying emotions and learning new ways to cope with a world no longer guided by this illness.

Focusing on emotional and psychological development solidifies the gains in recovery and, in the end, makes it hard to return to the illness. The success of managing life with an eating disorder, as hard as it can be, well outweighs the misery of being trapped in this illness.

Eating Disorder Recovery during the Holiday Season

The holiday season can be very hard for people in recovery from an eating disorder. They feel pressured to appear more well than they are and to put on a veneer or comfort and calm when the holiday meals elicit anything but that feeling.

Recovery and progress cannot move forward any faster because of a holiday, and the most important decision in anticipation of these days is to stay grounded in what works in recovery.

Practically, the person in recovery needs to follow their meal plan and expectations of the treatment team as a top priority. Often, this plan will mean eating at times others don’t eat or types of food other people may not be eating.

It’s also critical for people to explain to families that the plan for recovery is more important than any family tradition. The goal is not to make this specific holiday better but to pave the way for real recovery in the future.

Moments of seeming normalcy that only hide the severity of the illness perpetuate the lie that things are getting better. Transparency, even if it reveals the difficulties of recovery, is much more honest and promotes progress towards wellness.

Families can focus primarily on compassion and support. The holidays shine a spotlight on togetherness and food, both things people in recovery struggle with. The food is clearly difficult and the time together makes it much harder to hide the eating disorder. This feels very exposing for people fighting to get well. When families show love and support, the environment encourages openness and decreases the urge to hide.

Last, I encourage families to try to celebrate the gains in recovery and recognize how hard the process is. The changes someone makes in a year time might seem small, yet the work and progress lay the groundwork for more and more health and for breadth in one’s life.

The Veneer of Success Hides the Suffering of an Eating Disorder

Many people with eating disorders appear to live relatively normal lives. To the uneducated or ill-informed observer, the limitations of the eating disorder don’t diminish someone’s life considerably.

Except for the most ill, people with eating disorders can maintain careers, relationships, friendships and family. Part of what can be so confusing to many is that the only issue between health and illness is simply eating food regularly through the day.

Although eating appears to be straightforward, nothing is harder for someone with an eating disorder.

The experience of those who are sick is diametrically opposed to how the bystander views the illness. The sick feel as if their entire life has been hijacked. They are able to cobble together a life out of sheer force while constantly battling thoughts and behaviors around food which dominate their internal world. They live in a constant state of self-loathing, rumination about food and misery. Any accomplishments pale in comparison to the suffering.

The behavioral and medical components of the eating disorder are just ramifications of the powerful psychological and emotional toll of the illness.

All the success does not represent the true difficulty of surviving with a chronic eating disorder. In fact, people often feel as if they lose any sense of who they are and instead function as a puppet controlled by the eating disorder thoughts.

Compassion for someone with an eating disorder begins with understanding how powerful the eating disorder is and how hard it is to function with it every day. The more someone understands the daily struggle with the illness, the stronger they feel to fight against the thoughts and behaviors.

In addition, support involves helping someone remember who they are deep down beneath the eating disorder. Since they often lose connection with their true selves, any real relationship in the world helps them remember that there is a real person underneath the illness.

Concrete accomplishments don’t represent steps towards recovery. Escaping the relentless thoughts of an eating disorder entails daily, grueling work, and any help connecting with the deep, meaningful relationships in recovery helps a person keep fighting to get well every day.

The Truth about Full Recovery from an Eating Disorder

The notion of full recovery from an eating disorder remains controversial in the media and lay world. Eating disorders may be very specific diagnostic entities to clinicians; however, the terms are used more broadly by the public. Similarly, many if not most people see eating disorders as a way of life rather than an illness with an actual cure.

Two phenomena lead to this fallacy: clear evidence of people with chronic eating disorders and the cultural acceptance of food and weight obsession. These two realities help propagate the myth that no one can get better from an eating disorder.

The truth is that some people have chronic eating disorders they need to manage throughout their lives. Sometimes the eating disorder is disabling and extremely limiting and in other circumstances people can manage larger lives while also dealing with a chronic illness.

A significant percentage of people do fully recover, including people with all different kinds of eating disorders. These people tend to have certain similar experiences that increase the likelihood of recovery.

First, people have a higher chance of getting better the earlier they enter into effective treatment. The longer someone is ill, the more ingrained the eating disorder thoughts and patterns become. This is especially the case when the eating disorder persists in early years of adulthood and becomes a key component of adjusting to life in the world.

Second, the more fulfilling a person’s life is despite the eating disorder, the higher the success of treatment. People need to have things that matter more than the eating disorder. This enables them to deal with the persistent discomfort of eating normally because there is something else to eat for.

Third, people need to be able to believe the thoughts that counter the most basic argument of the eating disorder. These thoughts include fear of gaining weight, the need for regular nutrition and that there are other ways to handle stress and emotion. When the eating disorder is the sole way someone handles life, recovery looks much more daunting.

Last, the more support someone has in life enables recovery to proceed more smoothly. Support isn’t absolutely necessary but makes a difference so the person feels less alone.

Completely recovery is a very common end result of treatment. An eating disorder is not a life sentence despite the general belief otherwise. Getting treatment early and fully committing to the work of getting better really can pay off.