But what does that really mean?  The first thing it means is constant vigilance.  I’m a lousy dieter and not a big fan of major deprivation.  It’s much easier for me to try and make fairly healthy and nutritious choices all the time, allowing for occasional small splurges as needed.  That means every day, every meal I try to make nutritionally sound choices. 

[Notice I don't say "good".  I think the word "good" when it comes to food is somewhat emotionally burdened - we say we were "bad" yesterday when we ate a half-gallon of Rocky Road or we think of the extra-large bucket of popcorn as "bad".  But food is not a moral choice - kicking the dog and cheating on your taxes are moral choices.  Food is fuel, some of it tastes better than others and some of it is better for you than others, but it is not evil or a ticket on the express train to Hades.  It's just food.  So don't beat yourself up emotionally about the things you eat, 'cause you can start right back on track with your very next meal. Thus endeth the sermon.]

Ok, back to post: Every day, every meal.  Not: eat a bunch of crap for a few weeks, step on the scale and freak out, then eat nothing but celery and apple peels for two weeks. Dieting should refer to a lifestyle change, an allover attitude adjustment, not a temporary fix.  Bubble gum in the hole will not keep the whole dam from coming down, it just stops the leak temporarily.  Building a new dam addresses the problem permanently. 

So I stay thin because 24/7 I pay attention.  There are a lot of things I simply won’t touch with a ten foot pole.  These include anything that contains the word “fried”, most desserts, and often, a lot of meat.  I’m no vegetarian, but animal protein makes up a fairly small part of my diet and I still manage to eat 50-100g of protein each and every day.  I don’t see those things on the menu and think, “gee I really, really want that but I can’t, I shouldn’t, darn!”.  I just don’t even look at them. I refuse to even think about them.  That way, I don’t feel deprived.  They are simply not for me.  Eventually, you actually start to think of greasy, heavy, sugary foods as kind of gross and unappealing.

Does all of this mean that I never have a french fry? A donut? A margarita? Of course not.  But I take it for what it is: a small indulgence that will make me temporarily happy, but that I’ll be bummed I ate the next day.  If I’m willing to pay that price, I’ll do it.  If I’m not willing (because I’ve got a vacation planned during which I plan to be seen in a bathing suit for instance) than I won’t.  I don’t have a particularly strong will-power or an especially numb sweet-tooth.  I’ve just got a big priority and that’s me and the person I want to see when I look in the mirror.  That person helps keep me in line, day in and day out.

That’s a tough question to answer because it’s different for every person.  Increasing age decreases the elastic stretch of the skin, so older patients are less likely to have their skin shrink back with weight loss than younger people.  Smokers’ skin is dramatically less elastic (which is why they have such dramatic face wrinkles) so they, too, are more likely to have loose skin after weight loss.  Women who have dramatic stretch marks after pregnancy also are more prone to loose skin, especially on the abdomen, given that the skin there has already been over-stretched. 

But all of that is variable: we have patients in their 60′s with minimal loose skin and smokers with no batwings whatsoever. We can’t predict ahead of time which category you will fall in, so it’s a little bit of a dice roll- you’ll just have to see what it looks like when you get to your goal weight.

Having said that, there are things you can do to help loose skin recover as you loose weight.  Remember first that the weight and the skin stretch didn’t happen overnight, so it may take significant time for the skin to recover.  Many plastic surgeons advise waiting for up to two years after you reach your goal weight before doing any surgical procedures for your loose skin.  This is to allow enough time for your skin to “shrink” some on its’ own and to make sure that you are nutritionally stable before trying to heal a major incision. (People in active weight loss phase are “catabolic” meaning they are breaking down, not building up tissues which is counterproductive to healing).

While you are losing weight and while you are waiting your waiting your two years, here are some other things you can do.  Exercise dramatically improves skin quality in several ways: it increases circulation to the skin, it decreases the subcutaneous fat under the skin and it improves the “frame” on which the skin is draped.  All of these improve overall body/skin appearance.  Taking a multivitamin every day, especially with Selenium, vitamin E, C and A will help with skin elasticity.  Smokers benefit from extra helpings of folic acid, B6 and B12 9which can be found in combination in many drug or health food stores).  Adequate protein is crucial, and soy protein appears to have a slight advantage over animal based proteins (like chicken and beef) when it comes to skin health.

Keeping your skin in optimal condition from the outside in is important, too.  Exfoliate your skin with a loofah or buff puff while in the shower or bath, then immediately after bathing and drying off, apply moisturizer with aloe and/or shea butter all over your body.  This gets rid of old dead skin cells on the surface which can trap free radicals causing skin damage and then the moisturizer protects and nourishes the new healthy skin revealed underneath.

After all is said and done though, I want you to remember this: even if you end up looking as wrinkled and saggy as a Shar-Pei dog when you reach your goal weight, I guarantee you will be a happier healthier person than if you were overweight but with cheeks and tummy smooth as a baby’s behind.  Don’t let the fear of loose skin be an excuse to keep you from losing your excess weight.

Fat is your body’s way of storing energy.  It is much more dense in energy than either carbohydrates or protein which are also stored by your body (the latter as muscle).  Fat allows your body to survive periods of “famine” or low food intake.  It does this by burning the fat for fuel when your food intake is low.  If you ate exactly what your body burned for energy each day, your weight would never change.  If you eat more energy, i.e. if you eat more calories, than you burn you will gain weight (fat).  If you eat fewer calories than you burn then you will lose fat (weight).  Every pound of fat is made up of 3500 calories of fuel.  Therefore, to lose one pound, you must burn 3500 more calories than you take in.  Two pounds per week would be 7000 calories more on the burn side than the intake side.

All of this is another way of saying that watching your calorie intake is imperative.  Women should generally shoot for a goal of between 1200 and 1500 calories per day.  The most scientific way of knowing how many calories you need is to get a Korr metabolic test (the breathing test we do at the office) which will measure your metabolism and tell you exactly how many calories you need to take in in order to burn 7000 calories per week more than you take in.  That allows you to have a two pound per week weight loss. 

Simple, right?  Not so fast. All calories are not created equal (there is no Declaration of Food Independence).  When you eat protein calories, your body will tend to store them in the form of muscle, or convert them to use as fuel if your intake levels are low.  Fat generally goes right into fat stores. Carbohydrates can go either way: either storage as fat or used as instant energy, depending on how many calories you’re taking in.  So if you’re eating a fairly moderate calorie diet, where about 25-35% of all your calories come from protein, then the carbohydratees you eat will most likely be used for instant fuel and not stored as fat.  If you eat the same number of calories, but the majority of them come from fat and carbohydrates, you’ll be likely to put on fat – and lose muscle.  Because of the hormones that are released by fatty and high carbohydrate foods, you’ll also be more hungry just a few hours later than if you had a high protein/mod carb/low fat meal.  And remember: muscle is what burns fat, so if you lose muscle (aka “lean body mass”), your metabolism will drop and your weight loss will become even slower.

In practical terms, this means the following: a meal of cottage cheese and fresh fruit, or tuna-fish salad with low-fat mayo in a tomato will keep you fuller, longer and will help you maintain lean muscle (which burns fat) vs. chicken nuggets and sweet tea which will add fat and you’ll be hungry in 90 minutes or less.

Choose wisely.

The most common time for hair loss is 3-4 months post-operatively and the explanation for it requires a quick lesson  on hair growth.  At any given moment, about 90% of the hair on your head is in a growth phase, growing at an average of about an inch per month.  The remaining 10% is in a resting, or dormant, phase in which it is not growing at all.  This hair is “pre-death” as it were and is hair that is likely to fall out after several months and not do much growing.  Surgery or any physically traumatic event (including serious illness, childbirth) will cause a greater percentage of the hair on your head to enter the resting phase, so 3-4 months later you suddenly start noticing all this hair falling out.  It will likely look a little thinner somewhat before then since there will be a greater percentage of your hair that is not in the growing phase.  This is usually a one time occurance, and after the hair falls out, the hair on your head usually returns to the normal 90%/10% split and appear normal to you.

The more concerning hair loss occurs because of malnutrition.  This can occur after large weight loss and is associated with a diet low in biotin, folate and protein.  Low levels of any of these nutrients in the diet can cause brittle hair that is not well anchored to the scalp and is easy to break or pull out, causing thinning of the overall appearance of the hair.  This loss can only be remedied by increasing protein intake (for Lap Band patients we suggest 40-60g protein per day, gastric bypass patients may require even more, and both sets of patients will need more if they are very physically active) and by taking vitamins.  Most Lap Band patients can prevent hair loss with 1-2 multivitamins per day, gastric bypass patients should consult their doctor since they may need 2 multivitamins and other more specific supplements each day depending on the type of operation they had.

So the bottom line is this: if you develop a sudden hair loss in the 3-4 month range after surgery, don’t worry too much.  Do, for the sake of completeness, make sure your protein and vitamin intake is adequate, but mostly we’re going to tell you not to worry too much as it’s likely to grow back normally without much outside intervention.  Hair loss at other times should prompt a discussion with your doctor about your diet.