Journey References and Resources

References • Links • Information

Reference 1 • page 11

Diabetic patients had an overall 78.1% resolution of their clinical manifestations of diabetes, and diabetes was improved or resolved in 86.6% in the 621 bariatric patients studied. Diabetes resolution was greatest for patients undergoing biliopancreatic diversion/duodenal switch (95.1% resolved), followed by Roux-en-Y gastric bypass (80.3%), and then laparoscopic adjustable gastric banding (56.7%).

Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, Bantle JP, Sledge I: Weight and Type 2 Diabetes after Bariatric Surgery: Systematic Review and Meta-analysis. The American Journal of Medicine. Volume 122, Issue 3 , Pages 248-256.e5, March 2009.

Another source reports these rates for remission of type 2 diabetes mellitus after bariatric surgery:

Remission Rate by Bariatric Procedure

  • Laparoscopic adjustable gastric banding 40–47%
  • Roux-en-Y gastric bypass 83–92%
  • Biliopancreatic diversion + DS 95–100%


Mechanick, J. I., Kushner, R. F., Sugerman, H. J., Gonzalez-Campoy, J. M., Collazo-Clavell, M. L., Guven, S., … & Dixon, J. (2008). American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocrine Practice, 14, 1-83.

Reference 2 • page 14

Studies have shown that patients who attend support group meetings have a higher success rate for long term weight loss. Of the patients studied, those who attended support group meetings regularly had a statistically significant difference in percentage decrease of BMI compared to patients who didn’t not attend meeting (42% vs. 32%).

Orth, W. S., Madan, A. K., Taddeucci, R. J., Coday, M., & Tichansky, D. S. (2008). Support group meeting attendance is associated with better weight loss. Obesity surgery, 18(4), 391-394.


Reference 3 • page 30

A randomized clinical trial evaluated the efficiency of intensive medical therapy alone versus bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) in 150 obese patients with uncontrolled type 2 diabetes. Of the patients who underwent bariatric surgery, more than 60 percent had moderate-to-severe fatty liver disease on the basis of biopsy samples obtained during surgery.

Schauer, P. R., Kashyap, S. R., Wolski, K., Brethauer, S. A., Kirwan, J. P., Pothier, C. E., … & Bhatt, D. L. (2012). Bariatric surgery versus intensive medical therapy in obese patients with diabetes. New England Journal of Medicine, 366(17), 1567-1576.


Reference 4 • page 31

For every 1% of your excess body weight you lose before surgery, studies show that you will have a 1.8% higher weight loss at 12-months post-op than those who did not lose weight pre-op. Plus, it’s been shown that those who lose more than 5% of their excess weight will have a shorter operating time by 36 minutes. Conversely, weight gain before surgery comes with consequences. For every one unit on the BMI scale you increase your weight, you will lose 1.34% less weight than those who did not gain pre-op.

Alvarado, R., Alami, R. S., Hsu, G., Safadi, B. Y., Sanchez, B. R., Morton, J. M., & Curet, M. J. (2005). The impact of preoperative weight loss in patients undergoing laparoscopic Roux-en-Y gastric bypass. Obesity surgery, 15(9), 1282-1286.


Reference 5 • page 35

An average adult has 30 billion fat cells with a weight of 30 lbs. If excess weight is gained as an adult, fat cells increase in size about fourfold before dividing and increasing the absolute number of fat cells present.

Pool, Robert (2001). Fat: fighting the obesity epidemic. Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-511853-7.


Reference 6 • page 40

The average human stomach can hold up to two to four liters of food/fluid, that’s about 52 ounces or 6½ cups! At rest your stomach is about the size of a man’s fist but when filled with food and liquid it can expand to the size of a football.

Curtis, Helena & N. Sue Barnes. Invitation to Biology. 5th Edition. New York: Worth, 1994: 529.


Reference 7 • page 42

Studies have shown that the size of your pouch has very little to do with your overall success with weight loss. Your success has more to do with how well you follow your eating and exercise plan and how well you follow the rules of the pouch. Success depends on changing the way you live your life and the behavioral changes you make in the way you eat and think about food.

Bond, D., Leahey, T. M., Vithiananthan, S., & Ryder, B. (2009). Bariatric surgery for severe obesity: the role of patient behavior. Medicine and health, Rhode Island, 92(2), 58.


Reference 8 • page 41

Sites of nutrient absorption in the gastrointestinal tract diagram. Reprinted with permission.

Sareen S. Gropper, Jack L. Smith. Advanced Nutrition and Human Metabolism. Cengage Learning Nelson Education. Published February 14, 2008. ISBN-13: 978-0495116578. p 51.


Reference 9 • page 43

Although there are few human data, observations in animal models of short bowel syndrome have indicated that following massive enterectomy (surgical removal of a portion of the intestine), the bowel lengthens some and it increases in diameter. The number and size of intestinal villi increase, and therefore the absorptive surface area increases. This complete process is generally thought to occur over 1-2 years in humans, although there are isolated cases that have taken 5-7 years for adaptation.

Alan L. Buchman, MD, MSPH. Intestinal Adaptation Following Massive Enterectomy. Medscape General Medicine. 2004;6(2):12. Published online at:


Reference 10 • page 46

Dumping syndrome is a common side effect after Roux-en-Y Gastric Bypass surgery. About 85% of gastric bypass patients will experience dumping syndrome at some point after surgery. The symptoms can range from mild to severe.

The American Society for Metabolic and Bariatric Surgery (ASMBS). ASBS Public/Professional Education Committee. Bariatric Surgery: Postoperative Concerns. Published: May 23, 2007. Revised February 7, 2008. Published online at:


Reference 11 • page 46

In persons with long segment Barrett esophagus treated with a truncal vagotomy, partial gastrectomy, plus Roux-en-Y gastrojejunostomy, 41% developed dumping within the first 6 months after surgery, but severe dumping is rare (5% of cases). Clinically significant dumping syndrome occurs in approximately 10% of patients after any type of gastric surgery.

Thomson, A. B., Padda, S., Ramirez, F., & Aguirre, T. (2008). Dumping syndrome. EMedicine Gastroenterology, 6, 1-6. Published online at:


Reference 12 • page 47

“Head Hunger is very real and even feels like real hunger, but if you are truly listening to your body (and not your head)… you will realize Head Hunger is that thing that makes you think you want to eat even when you know you’re already full or when you know you have already eaten.”

Tracy C., Barix Support Group Leader. Combating Head Hunger. Healthful Tips Newsletter. Copyright 2009. Forest Health Services.


Reference 13 • page 80

This ASMBS supplementation regimen is a part of the ASMBS Bariatric Nutrition report published in 2008. This information is intended for life-long daily supplementation for routine postoperative patients and is not intended to treat deficiencies. A patient’s individual co-morbid conditions or changes in health status might require adjustments to this regimen.

American Society of Metabolic and Bariatric Surgeons (ASMBS). Bariatric Nutrition: Suggestions for Surgical Weight Loss Patients. Society of Obesity and Related Disease (SOARD) Publication . March 12, 2008. Published online at:


Reference 14 • page 83

Mean calcium absorption in the patients with achlorhydria was 0.452 (45%) for citrate and 0.042 (4%) for carbonate. Absorption of calcium from carbonate in patients with achlorhydria was significantly lower than in the normal subjects and was lower than absorption from citrate in either group; absorption from citrate in those with achlorhydria was significantly higher than in the normal subjects, as well as higher than absorption from carbonate in either group.

RR Recker. Calcium absorption and achlorhydria. New England Journal of Medicine. Volume 313:70-73, July 11, 1985.


Reference 15 • page 85

A cross-sectional survey was conducted on 144 patients of whom 80 had not undergone bariatric surgery, while 64 had bariatric surgery at a mean of 36 months previously. 25(OH)D levels were defined as being normal (>50 nmol/L), insufficient (2550 nmol/L) and deficient (<25 nmol/L). RESULTS: 80% of the patients presented low vitamin D levels.

Ybarra J, Sanchez-Hernandez J, Vich I, et al. Unchanged hypovitaminosis D and secondary hyperparathyroidism in morbid obesity alter bariatric surgery. Obes Surg 2005;15:330 –5.


Reference 16 • page 85

Ethnic minorities such as African-Americans have an increased risk of developing low vitamin D as a result of increased skin pigmentation conferring a natural sunscreen effect. A significant inverse correlation between 25OHD levels and BMI existed; 84.8% of all patients had vitamin D insufficiency and 75.8% had vitamin D deficiency. African-Americans were more likely to have hypovitaminosis D (95.5% vs. 60%) versus whites.

Dubin, R. L., Rasul, K., Allerton, T., Cefalu, W. T., Uwaifo, G. I., & Paige, J. T. Hypovitaminosis D in Patients Awaiting Weight-Loss Surgery in Southern Louisiana.


Reference 17 • page 85

D3 is approximately 87% more potent in raising and maintaining serum 25(OH)D concentrations and produces 2- to 3-fold greater storage of vitamin D than does equimolar D2. Given its greater potency and lower cost, D3 should be the preferred treatment option when correcting vitamin D deficiency.

Heaney, R. P., Recker, R. R., Grote, J., Horst, R. L., & Armas, L. A. (2011). Vitamin D3 is more potent than vitamin D2 in humans. Journal of Clinical Endocrinology & Metabolism, 96(3), E447-E452.


Reference 18 • page 85

The current government recommendation for Vitamin D intake for adults is 600iu per day.

Office of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheet: Vitamin D. January 24, 2011. Published online at:


Reference 19 • page 85

The Vitamin D Council was founded in 2003 by John J. Cannell, MD as a 501(c)(3) nonprofit organization, spreading reliable information on vitamin D, sun exposure and the vitamin D deficiency pandemic. The Vitamin D Council recommends the following amounts of supplemental vitamin D3 per day in the absence of proper sun exposure. These are only estimated amounts:

  • Healthy children under the age of 1 years – 1,000 IU
  • Healthy children over the age of 1 years – 1,000 IU per every 25 lbs of body weight
  • Healthy adults and adolescents – at least 5,000 IU
  • Pregnant and lactating mothers – at least 6,000 IU

The Vitamin D Council. Vitamin D Factsheet. As published online at:


Reference 20 • page 86

Emerging science is showing that Vitamin D lab results above 50nmol/L or above 20 ng/mL are helping patients realize many amazing health benefits such as reduced risk of certain cancers, inflammation leading to chronic diseases and a reduced risk of developing neuromuscular diseases such as muscular dystrophy.

Office of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheet: Vitamin D. January 24, 2011. Published online at:


Reference 21 • page 92

The chart entitled Common Vitamin Deficiencies is a compilation of information I’ve gathered over the past five or six years from various sources on the internet, in medical journals, nutrition textbooks, and publications provided by various bariatric surgical practices. I was not the original creator the framework and I’m unable to identify the original source because it is published, in one form or another, on many different websites by many different people or organizations. The original chart has changed since I got my hands on it and added information as I researched various nutrient topics. My version of the chart has been online for several years, so it’s difficult to determine if all the sources listed below contain original information or if the information was gleaned from mine.

However, please know that I’m publishing this chart as an informational tool and do not wish to infringe on anyone’s copyrighted information. To the best of my knowledge, the information compiled in this chart either comes from these online sources or is additionally referenced on these websites:

  • World’s Healthiest Foods:
  • Lab Results Online:
  • Changing Shape:
  • National Review of Medicine:
  • 1st Holistic Nutrition:


Reference 22 • page 135

The purpose of bariatric surgery is to induce substantial, clinically important weight loss that is sufficient to reduce obesity related medical complications to acceptable levels.
Bariatric Procedure Follow-up period

Procedure 1-2 years 3-6 years 7-10 years
Gastric Banding 29-87% 45-72% 14-60%
Sleeve Gastrectomy 33-58% 66% –
Roux-en-Y Gastric Bypass 48-85% 53-77% 25-68%
Biliopancreatic Division + DS 65-83% 62-81% 60-80%


Mechanick, J. I., Kushner, R. F., Sugerman, H. J., Gonzalez-Campoy, J. M., Collazo-Clavell, M. L., Guven, S., … & Dixon, J. (2008). American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocrine Practice, 14, 1-83.


Reference 23 • page 137

Among adults who reported losing weight or trying to lose weight, 31.0% had been successful at both losing weight and maintenance after weight loss. Assessment of reported weight loss strategies, found that exercising ≥30 minutes/day and adding physical activity to daily life were significantly higher among successful versus unsuccessful weight losers. Significantly more successful versus unsuccessful weight losers reported that on most days of the week they planned meals (35.9% vs. 24.9%), tracked calories (17.7% vs. 8.8%), tracked fat (16.4% vs. 6.6%), and measured food on plate (15.9% vs. 6.7%). Successful losers were also more likely to weigh themselves daily (20.3% vs. 11.0%).

Kruger, J., Blanck, H. M., & Gillespie, C. (2006). Dietary and physical activity behaviors among adults successful at weight loss maintenance. International Journal of Behavioral Nutrition and Physical Activity, 3(1), 17.


Reference 24 • page 138

The essay “I can do hard things!” was written by Shari (aka Jupiter6 on as a forum thread. It quickly went viral within the WLS community and became the mantra for many of us as we persevered in the face of hard things. You can read the entire essay at:


Stories of Fellow WLS’ers

There are many bariatric patients online who are chronicling their journey to health. I have found inspiration from these people and I hope you do too. Please visit their websites to read real life stories of others in our weight loss surgery community.

  • Nikki | Bariatric Foodie |
  • Michelle | The World According to Eggface  |
  • Beth | Melting Mama & Bariatric Bad Girls  |
  • Rob | Former Fat Dudes  |
  • Andrea | WLS Vitagarten  |


Online Support Communities
  • Obesity Help |
  • WLS Boards |
  • Thinner Times |
  • Connection WLS |
  • WLS Journey |
  • iVillage | (search “weight loss surgery support”)


Finding Protein Powder Samples
  • Vitalady |
  • Netrition |
  • Nashua Nutrition |
  • Chike |
  • Click |
  • Unjury |


The Minnesota Starvation Study

The symptoms I experienced in the early days of my pre-op diet – and in the months after my surgery – are typical of people who severely restrict calorie intake. Obsessive thoughts of food and obsessive preoccupation with any topic related to food were common in the study participants during WWII. Read the full accounting of the study at: