RickM

You certainly need to get a second, and probably third, opinion to find out what's going on; they should be able to explain to you, in layman's terms, what your situation is and what the options are for treating it. That is usually a straightforward and insurable step here in the States, but I don't know what hoops you may have to jump through in the UK. It does sound like something's not right in what they did (which is why you want a second, impartial and uninvolved opinion,) as strictures are not common with sleeves that are done correctly; they are common and easily treated with an endoscopic dilation in and RNY, and that may work with a sleeve stricture, or may not depending on what caused it (usually a misshaping of the sleeve.) I did quite a bit of research on these topics a few years ago when they found a cancerous polyp in my stomach; fortunately it was very early and all treatable endoscopically, but all of these various options were discussed and researched. There are some Facebook groups specifically for patients with partial or total gastrectomies, which is what they are proposing for you. The most common approach here, and what it sounds like they are proposing for you, is a Billroth 2 gastrectomy, which has been around for about 140 years, and is the basis of the RNY gastric bypass, The main difference between a partial or total gastrectomy is whether they can use some of the remaining stomach to form an RNY like pouch (partial) or remove all of the stomach and attach the esophagus directly to a loop of intestine, or an additional roux limb as in the RNY, and form "stomach" pouch in the intestine where the esophagus is attached. So, going without the stomach is possible and entirely livable (there are several books on Amazon about "eating without a stomach" which go over what is basically a normal bariatric diet progression.) To the surgeons I was dealing with (at a major regional cancer center,) the total gastrectomy was a much bigger deal surgically and recovery wise than the partial, as attaching the esophagus directly into the intestine was a much touchier procedure with a more extended recovery and healing time (on a feeding tube for several months,) than going through even a small pouch of stomach tissue - something else to consider with whatever choice you have in surgeons (try to find one who has done a lot of these.) One of the things that stood out as fairly common amongst the Facebook group was problems with bile reflux, and you can see how that could easily happen by looking at the altered anatomy. The surgeon I was dealing with said that he did not experience those problems if he kept the various limbs within certain minimum lengths (which presumably some other surgeons didn't do in order to minimize malabsorption and weight loss,) so another point to consider in finding a surgeon who has some direct experience with these problems.

The issue at hand here is that NSAIDs are a big NO-NO for bypass patients, owing to quirks of the bypass anatomy, specifically that the anastomosis where the stomach pouch is tied to the intestines (the stoma) is at a downstream part of the intestine that is not acid tolerant, as the duodenum is (the part of the intestine immediately downstream of the normal stomach.) Consequently, that stoma is easily irritated by the acid from the pouch, and doesn't need any additional stress from stomach irritating medications such as NSAIDs. The most common place for ulcers in a bypass patient is at the stoma. The sleeve based procedures like the VSG or DS don't have that problem as the normal anatomy is preserved in that respect. It still pays to be cautious as the stomach has been cut and reduced, but all the suture lines are amongst normal acid resistant stomach tissues, so there isn't nearly the sensitivity that there is in the bypass. Many practices simply carry over their bypass experience and advice to their sleeve patients owing to an (over)abundance of caution, simplicity, and their lack of direct experience with the sleeve and NSAIDs. When I had my sleeve around twelve years ago, our surgeon's advice was to use them as needed post op as soon as the narcotic pain relievers were no longer appropriate (so, within a week or two,) though when I talked to him more recently he was more of a mind of within a few months post op.

I would want to look closely at this, verifying the bile reflux and determining if there is any acid reflux component to this before getting into long term treatment options as the treatment can differ widely depending upon that diagnosis. If it is bile, then I wouldn't expect Pepcid or other anti acid meds to do much as the are treating acid and not bile, a base. I'm not sure what meds they do use but likely different ones. Bile is used to neutralize the acid coming out of the stomach along with the digested food into the intestines. Is your surgeon in the loop on these findings (I assume so, but check if you haven't heard from them yet,) as that may change his prescriptions. If it is strictly a bile problem, then a bypass will probably correct it, but not guaranteed as it moves the stomach/pouch outlet downstream into the natural path of bile secretions; the key, according to one surgeon I discussed this with, is the length of the roux limb, as that is the one that connects the pouch with the mainstream intestine and how far any bile would have to travel to reflux into the stomach. This doc noted that at 80cm or greater (IIRC) he didn't run into any bile reflux problems. The basic RNY procedure has been around for some 140 years for gastric cancer and gastroparesis (it is usually termed just a partial gastrectomy, or likely some other fancy latin names as well,) and it that use, bile reflux is a not uncommon complication. My non-MD take on it is that in those cases, they tend to keep the limbs short to minimize malabsorption and weight loss (last thing a cancer patient usually needs is more weight loss!) So, the longer limb makes sense here. Discuss this and make sure that your surgeon is up on this aspect of it. The other option if it is basically a bile problem is the DS, duodenal switch, which is pretty much a guaranteed cure for any bile problems owing to the very long path between the bile ducts and the stomach, but relatively few bariatric surgeons offer it owing to its greater complexity. Note this only applies to the "traditional" or Hess DS and not the newer SIPS/SADI/"loop" or simplified DS, which like its mini-bypass cousin has bile reflux as one of its common complications. The DS will not help any acid reflux problem as it uses the existing sleeve (though may resleeve it if it was malformed causing GERD rather than just overproduction of acid,) while adding the intestinal rerouting for malabsorption. The DS is a better choice over the RNY revision if slow or inadequate weightloss is an issue, too, as it is a stronger metabolic tool. Good luck on this - bile is surely a much less common problem with the sleeve than acid reflux, so the industry isn't quite as settled on solutions for it.

Yes, very common, and here is one of the factors - In the middle of the video he goes over the typical progression of meal volume that we can expect, and it is consistent with my experience. I you simply let things happen and eat the same way we did the first year, but more, then there will certainly be the tendency to gain. While I'm not a big fan of everything this guy preaches (or any online guru, for that matter,) one of the things that I do like is his "eat your vegetables first" concept, which he applies after the first few months of protein first. My general evolution was to increase the veg content of my meals over time, rather than the protein, as the protein that we are advised to consume early on is usually our basic requirement, as we can't get that from pills like we can most micronutrients. So, I still have about 3 oz of meat in a meal today like I did the first year, but a lot more veg in there. And, it's still something of a struggle because the junk still wants to creep back in there stimulating old habits (we usually spent a lot more time getting fat, and getting used to it, than we have trying to be healthy now!) With a sleeve, or a bypass, at this point it is basic dieting/healthy balanced eating that we are all familiar with; it is somewhat easier than before as our volume rarely returns to where is was pre-op, but our old bad habits sure can come back.

insurance can vary widely from state to state, even from the same company or the same policy name. Are you working with employer provided insurance or from the open market/Obamacare (it sounds like it)? Finding an insurance broker can help sort through who pays what benefits for what cost - they get their commission paid by the insurance company, so it doesn't cost you any more than just choosing one off the web.

This doc presents a typical volume progression which fits my general experience (though my wife continues to be somewhat more restricted than I am even after 18 years.) Some will progress faster or slower than others, but you do seem to be on the slow side. You might have a minor stricture at the stoma which is overly restricting things - not an uncommon thing with the bypass. Have you talked with your doc about this - it is usually easily treated with an endoscopic dilation if that is the problem. But yes, over time you should be able to have a healthy diet full of fruits and veg - the doc in the video above is a big fan of this - but it may take you a little more time than others. Throughout my loss phase I always maintained at least an homage to a healthy balanced diet with some whole grains, veg and fruits in there, even if it was at times a minimal amount. BTW. what group did you have your surgery through? I have a nephew who works for Atrium, so am always curious how people got along with them. Good luck in your venture...

Another possibility with this is a lack of carbohydrates (yes, those evil things!) We don't get much early on owing to the protein emphasis (and with the low carb and sugar free things, too.) Some programs specifically call for some minor carb loading early out to avoid these problems and promote recovery - not overboard, but some simple things (depending upon dietary progression) like sloppy oatmeal, cream of wheat or even mashed potatoes (bit of unflavored protein powder optional, or made with some broth) or diluted fruit juice. Not major dietary staple, but just some worked into the diet. just one more thing to try, good luck!

No direct experience, as I'm out here on the left coast, but by reputation I would want to talk to Dr. Mitchell Roslin. He gets mentioned occasionally in our support groups from the doc's interfacing with him at the ASMBS conferences, and I like the papers and talks that I have seen him present online and response from other patients of hisi; I like his approach. He is capable of doing all of the major bariatric procedures, including the complex RNY to DS revision, and like most DS capable surgeons, he is not a big fan of the bypass (because there are better things out there,) I have heard patients for whom he specifically recommended the bypass because that is what was the best procedure for that case. Most bariatric surgeons give you the choice (maybe) of the sleeve or the bypass, whether or not either of those are really the right thing for you. Again, short answer, I would have a consult with him as part of the process of deciding. Good luck in this venture....

I don't know the specific hoops that need to jump through with Kaiser as I have never been with them, but your PCP is the primary gatekeeper, and they do have an incentive to keep things cheap, while keeping you alive, so the system does make it difficult. There should be some form of appeal process that lets you go around the PCP without endless doctor changes, and there is an ultimate appeal to the state department of managed healthcare to override insurer's decisions when appropriate, but you aren't there yet. My surgeon is (or was) contracted to Kaiser Norcal to do the DS for them when they lost those appeals, as they don't do that procedure in-house, but it is part of the accepted standards of care for obesity, so they are obliged to cover it (they just don't make it easy.) A bypass will be more straightforward to get as they do those in-house, but they're hoping that all the hoop-jumping will get you to lose enough weight that they don't have to do it! Good luck and perseverance.

Yes, as catwoman says, it is common for them to have you on a PPI, or increase the dosage of the PPI after any of out bariatric procedures; I've been put on pantoprozole (Protonix generic) after other minor procedures unrelated to the GI tract because the body often reacts to the stress of surgery by increasing acid production. Talk to your surgeon's team to get it resolved.

The DS as a virgin procedure is more challenging to perform than a VSG or RNY, which is why relatively few bariatric surgeons offer it, despite its' demonstrably better performance (the RNY is "good enough" for most patients...) That's your first challenge - finding a reliable DS surgeon. Converting a VSG to a DS is straightforward for any DS surgeon, as the DS uses the VSG as its basis, so it's mainly a matter of adding the "switch" part - the malabsorptive part - to the VSG. Revising an RNY to a DS is another, much more complicated matter, and surgeons who can do that are few and far between. It used to be, a few years ago, that there was maybe a half dozen surgeons in the US that reliably did them, and I have seen references to a few more have joined the ranks in recent years. Rabkin and Keshishian in CA have both done them for many years, as has Roslin in NYC. I've heard that someone in Salt Lake has done some, along with some docs at Duke University in NC, possibly Kemmeter in MI. Some surgeons who don't do the DS will offer to revise to a distal RNY instead - that is a "long limb" RNY that has malabsorption more akin to the DS. However, it does not have a great reputation, and is usually not approved by US insurance as a primary procedure (but often will as a revision under the right circumstances.) My take on why it seems to be more problematic than the DS is that it is rarely done, and the surgeons and their practices aren't all that in tune with its' long term requirements. A DS, and by association the distal RNY, has a quite different nutritional and supplement requirement to the standard proximal RNY, which is well known to those in the DS world, but not all that well appreciated by those in the RNY world. Like with the RNY, and much more important with the DS, is to commit to having annual labs and follow ups for life - with the altered absorption and nutrition/supplement requirements, things can go askew in sometimes if you don't stay on top of them. Those who do stay on top of things typically have minimal long term problems. I would not go to MX for a procedure like this, as you really don't know what you will end up with. Historically, there has only been one reliable DS surgeon in MX - Gilberto Ungston - who, if not retired, is heading that way. He has trained a couple of others to do the DS, but I haven't heard of him doing the RNY to DS revision. There are, of course, the various horror stories of MX surgeries gone wrong, and in particular of those seeking a DS and getting "something else" (who knows what.) There are great, reputable surgeons down there for the VSG and RNY, but I wouldn't go there for something more complicated like a DS, unless it was someone well vetted in that procedure (such as Ungston,) - the differing legal systems leave one with no recourse is something doesn't go right (and the chances of that happening with something as complex and an RNY/DS revision are high there.) Good luck - it is a long search for what you need, and be prepared to travel. Being in CA myself, and my wife is a Rabkin DS, we have seen several successful revisions like this from both Rabkin and Keshishian, so it is viable when done by someone experienced with it. It, also, is not a simple outpatient procedure, and Rabkin's standard practice for travelling patients is to remain in town until at least the 10 day post op follow up. Most everything else can be done remotely (and they are set up for doing so.) Keshishian is similar in this regard.

It sounds like something is out of balance to be that lethargic at six months - most tend toward the energizer bunny side of things with a big chunk of weight off. Have you had labs done recently (six months would be a typical time for most programs)? Low iron or B12 are common bypass problems, which is why they usually recommend extra, but the recommendations tend to be an average and may not be enough for everyone (while being too much for others.) I would certainly check in with the surgeon or RD on this.

The good news is that this seems to be fairly normal - our weight loss when we start a major effort, surgical or not, tends to be front loaded - lots of initial loss, mostly water weight, and then slows down. Plus you are just getting in.to the "three week stall" window where weight loss typically slows or stops for a bit while the body absorbs what has happened to it, and then resumes (though usually at a slower rate.) The not so good news is that as a revision, weightloss is typically slower and less than with the original surgery. My simple minded thought on this is that originally, our stomachs will hold 32-64 oz, but now after your original WLS and whatever stretch and adaptation it goes through over the years, it might hold 4-6 oz, yet you have adapted to that (learned how to eat around your sleeve/pouch) and still regained. So things will be slower. And, the biggest loss tends to be around surgery time when we are stuck with the highly restrictive pre- and post-op dieting. Additionally, the RNY is metabolically similar to your original VSG, so it doesn't provide a big change over what you had - so it is much slower going the second time around. (The DS, duodenal switch, is stronger metabolically than either of the others, so does work somewhat better on regain, but few surgeons offer it, or mention it.) Those who I have seen who have done really well with revision weight loss are those who take the "I'm not going to let that happen again" attitude and really knuckle under and get, and stay with, the program.

This is a big maybe - talk to your surgeon and see what their position is. They may have one thing published in their guidebook (don't take them, ever...) and something else if you talk to them directly about your specific condition. NSAIDs are a big NO NO for a bypass, which has been well established owing to specific problems with that configuration, which doesn't exist with the sleeve. When things started with the sleeve, most docs simply carried over their same instructions to their sleeve patients - intellectually they knew there was a difference, but their experience didn't tell them how much. Many now consider them to be a small no no for the sleeve, while still prohibiting them for the RNY, but that still varies. Occasional use is usually approved, but they want to avoid consistent use. Our team had been doing sleeves for some twenty years, mostly via the DS, when I had mine done twelve years ago, and their experience indicated no problems with NSAIDs even shortly after surgery (more recent conversations with him indicated waiting a couple of months or so.) I like to be conservative on such things, so I avoid them mostly, but use them occasionally. These days I mostly use Rx meloxicam for occasional orthopedic issues, which is a Cox-2 inhibitor and supposedly somewhat friendlier to the stomach than NSAIDs.

Yes, absolutely possible, as Catwoman suggests; indeed, many talk in terms of this as being a "completion" of the DS rather than a "revision". I don't know specifically of anyone in those states who does it - DS surgeons are still fairly few and far between, at least ones who do the "traditional" or Hess DS. The simpler SADI "loop DS" has more who do it, but that's really a distinct procedure that should be considered on its own merits. In earlier years, Dr. Rabkin in SF (who did my VSG and my wife's DS) had an active support group in the Seattle area as he had a fairly large contingent of patients there, though they have dissipated in activity, as we tend to do over time. For a DS, one should usually count on having to travel for them, even if one is in a major metropolitan area. Fortunately most DS surgeons are very used to travelling patients and are equipped to do remote consults before and after surgery, so it's mostly a trip of a couple weeks time for the surgery and everything else can be done remotely.

Yeah, as Arabesque said, NSAIDs are a big no no with your bypass, but better tolerated with a sleeve (our doc doesn't even restrict it to occasional use like that, though it's still a good idea to restrict it.) It is definitely a check with your surgeon thing, as they will differ as to what their experience tells them - some are OK with NSAIDs for an occasional day's use and many aren't, but a month would very likely be a big NONO. There are COX2 inhibitors like meloxocam that might help, they tend to be somewhat better than common NSAIDs on the stomach, but not entirely safe. The narcotics are a lot more restricted than they used to be, even at low doses, so those may or may not be appropriate these days. The warm rinses help with open tissue problems (like recent incisions or cavity) but this is likely more inflammation which tends to respond better to cold - try ice packs (or a bag of frozen peas) around the area for 10-15 minutes at a time in addition to the Tylenol until you can get a reading from your surgeon.

First, your BMR is a bit of a guesstimate, but 2100 isn't unreasonable for a guy. Some calculators/formulas are way off because they simplify things by using body weight, while it is lean or muscle mass that is the important factor (all that extra fat we carry around does little to BMR, though whatever extra musculature we may have to carry around that extra fat does help. There are some tests that they can do (VOx, etc.) that can give a closer reading to your personal BMR, and many body composition scales give an OK estimate based upon their reading of your lean mass. The most important thing is at what caloric level is your weight stable - that gives the best clue as to where you stand metabolically. My BMR was probably around 2100 also, though my stability point by experience and tracking intake was in the 2600-2800 range (consume more consistently and I would gain, consume less overall and I would lose.) BMR represents our resting metabolism, while the extra burn if from exercise and daily activities; most calculators and tables (and ourselves) tend to over estimate the burn from exercise. After surgery, and you lose what you are going to lose, you will likely have lost some muscle mass, I lost around 10 lb) as you aren't carrying that extra 100, 200 or whatever pounds around with you 24/7, so your BMR will likely decline some, but not a lot (maybe down to 2000). This is why most programs emphasize getting in adequate protein, and doing some load bearing exercise, to minimize the loss of muscle mass, to keep our BMR up. If you can maintain a diet of 1100 calories (not at all difficult for the first year or so post op) that will yield a caloric deficit of around 1000 calories to your BMR (and likely more considering activity burn,) which will equate to an average loss of around 10 per month (more initially, and tapering off over time) - that's about what I did at 1100 calorie average, and my final few months before goal was a consistent 10lb per month loss; after goal and into maintenance, I settled into around 2100-2200 per day to maintain a stable weight. Some people, particularly the shorter ladies, may be stable at 11-1200 per day after all is done, so they will need to go much lower to lose their excess weight - this is why we see 6-800 calories as a common intake for the loss phase, and they will often lose more slowly because they have a lower caloric deficit (figure about a pound per month per 100 calories in deficit, on average.) In short, figure on 1000 calories or so while losing, and probably around 2000 or so, give or take, to maintain, as a quick guesstimate.

My wife is coming up on 18 years out on her DS, but can't offer any real advice on the preop diet as we didn't have one. The best general advice on the shakes is to try several ahead of time (some manufacturers/retailers have sample packs of different varieties that you can get to try). Try both the RTD (ready to drink) and mixes as suits your needs, but there is more variety in the mixes. Generally, 100% whey isolate is preferred to the cheaper whey blends or concentrates as it is better absorbed (and also more expensive...) and is also better tolerated by those who are or develop lactose intolerance as the lactose is filtered out in the processing. But if a blend or concentrate fits your tastes better, one that you will drink is preferred over one that just sits on your shelf. An additional option is unflavored powder (though there is no such thing as one without taste...) and flavor it with one of the sugar free flavor syrups that are available. Also, when just to complicate things further, when/if you hit on one that you like, don't load up on too much of it, as your tastes may change post op (or they may not...) Good luck in getting through this - lots of changes in these next few weeks pre and post op, but things settle out over time.

A general gastroenterologist should be fine for starters - with the bypass being the most common current and legacy bariatric procedure, most should have a reasonable amount of experience with cases such as yours, and be familiar with the common maladies (such as marginal ulcers.) They are usually the ones to do an initial EGD (endoscopy) to take a look and see what's going on inside. If necessary, they can then refer you to a specialist interventional endoscopy center, usually associated with a major regional cancer center hospital. Such hospitals usually have a bariatric practice associated with the cancer center, and they are often a good place to go for more unusual cases as they tend to see a wider variety of odd cases; while they, too, tend to be primarily surgeons, they usually have a broader staff of specialists beyond surgeons, though sometimes they may require a referral from a generalist - step one, your general gastroenterologist. Another step you can consider is to try to establish a relationship with a local bariatric practice for annual follow ups - some practices actively encourage this, while others are more cut and done type of practice. My wife and I still see (12 years out for me, 18 for her) our bariatric practice, which is 5-6 hours away, but they have long done telephone consults, but it does serve as a means of keeping them "on retainer" in the event that questions such as this come up - we, or our PCP, can call or email the doc with questions about these types of situations (is this a common thing for your patients, is there something else I should be looking for, etc.?) Check and see if any local practices have support groups open to others beyond their patients as an entry point, and to see if they have a long term interest in their craft.

Are you working with your bariatric surgeon on this or your primary care family doctor? While this may well be unrelated to your WLS, a bariatric doctor will, of course, be more sensitive to issues specific to their specialty than a generalist. My thoughts, not as an MD but just from having been around the WLS world for a couple decades, is that if it is WLS related, then given the fairly rapid onset of this, I would be looking for some bloodloss somewhere. With an RNY, the likely place would be the stoma, as that is a delicate structure that is easily irritated - if the semi-common marginal ulcers occur, that is where they usually happen. It may not be particularly symptomatic, but some minor blood loss can occur unnoticed until something like this shows up - one of those simple fecal smear tests can show whether there is any blood in your stool. If there is, then an endoscopy can show where it's coming from, and if there isn't any, then you have eliminated one possibility. Iron supplements may or may not do much for an RNY person, as most of our mineral absorption occurs in the duodenum (part of the small intestine immediately downstream of the stomach) which gets bypassed along with the stomach; this is why iron infusions are not uncommon for malabsorbing WLS patients with iron problems. Were you on iron supplements to begin with and then increased the dosage, or just started when this problem showed up? I had an internal bleed a few years ago (non-WLS related, though certainly symptomatic) that sapped my iron levels, but not quite to the point of needing an infusion, and they came back after a few months of doubling my normal iron supplement (but I have a VSG, so not the same absorption problems as an RNY or DS will have,) and now I don't take any at all. For now. Good luck in getting this worked out....

We started them again within the first week. Never had any particular problem with tolerating them, though some do, The only chewables I used were for calcium as those tend to be horse pills (though some brands do have petite versions), but the other pills worked ok when taken one at a time with a sip of water (as opposed to taking them all in a handful as before, and later after things settle out in time.)

We didn't have any liquid only diet; we had puree and soft things (yogurt, scrambled eggs, etc.) in the hospital along with a lot of liquids, of course. The general rule the first month was to move between liquids, purees and soft solids as we could tolerate them; if we came across something that wasn't tolerated, then move back to proven foods and try that one again in a week or two. Some progressed more quickly than others. With protein shakes as a staple to ensure adequate protein, I started with broth, then graduated to thicker soups like vegetable or chicken noodle or rice with the chunks strained out, then just mashed the chunks as the next trial, then went unmashed and well chewed, etc. As the group had around twenty years experience in working with the sleeve (at that time), I wasn't about to argue with them being different than others online.

I was low a few years ago after an internal bleed (not related to the WLS) but not down to infusion level, or particularly symptomatic of anemia, but I (under direction from PCP) doubled by iron supplement and that brought it up over a few months. I'm not a big fan of the iron used in most multivitamins as it is usually the cheaper and less well absorbed forms, but normally use a chelated iron bisglycinate sold by Solgar under the "gentle iron" branding. Even at a doubled dose it didn't yield any objectionable side effects for me (typically constipation, which we usually don't need more of post op!) These days, I don't use any iron supplement as everything is stable in that regard, but that is what I use when needed. https://www.amazon.com/Solgar-Bisglycinate-Non-Constipating-Vegetable-Capsules/dp/B0001OP028/ref=sr_1_1_sspa?crid=1A814LJNJAFJ6&keywords=solgar+iron+gentle+25mg&qid=1677253207&sprefix=solgar+iron%2Caps%2C162&sr=8-1-spons&psc=1&spLa=ZW5jcnlwdGVkUXVhbGlmaWVyPUE3UDZOTjZONU9SS1gmZW5jcnlwdGVkSWQ9QTA4NzQ3MjIyTDhYRUpONUhKSElKJmVuY3J5cHRlZEFkSWQ9QTA5MDg3NDUyVDE5SVVWM1JSTDJTJndpZGdldE5hbWU9c3BfYXRmJmFjdGlvbj1jbGlja1JlZGlyZWN0JmRvTm90TG9nQ2xpY2s9dHJ1ZQ==

Hopefully, they are flexible, I know of one program that is seriously into the low carb thing, as published in their guidebooks, and preached in their seminars, etc., but individually are more flexible with their more athletically inclined patients, as that is more appropriate for them.

When I was running into similar problems - not specifically light headedness, but an energy wall - after about an hour in the pool, my RD at the time suggested that a common recommendation for pre workout is something that his relatively high in complex carbohydrate, moderate in protein, and low to moderate in fats. Extra protein ahead of time did not do much by my experimenting, but that bit of extra complex carb did - it allowed me to break through that wall. It seems that with the complex carb, you will get that extra bit of insulin lift an hour or two after consumption, so that helps to fill in the energy gap you get at that time; at least it worked for me. I also didn't find that I needed it on days that I was only doing weight work, even when that lasted 90 min or so, only on swimming days. YMMV. For convenience, I ultimately settled on a small meat and cheese sandwich, with a good quality multigrain bread (or toasted.) That may or may not fit with your needs at two months out (I was about four months out when I was playing with this.) IIRC, my now RD nephew used to use some of the original CLIF bars that had a similar profile for this, so that may be something to look into. But that rough macro profile seemed to be the main trick - more fat or protein didn't do much for me, but the complex carb did (and I was never agonizingly low carb to begin with.) Calorically, it was mostly just a reshuffling of what I was already consuming, just rescheduled. Your plan at this time is somewhat limiting, but maybe some high fiber fruit - berries or the like - as the complex carb may do it, Talk to your RD, as you may get some adjustments to your allowance to accommodate your needs - this would not be unusual for those who are more active than average, as the plans are written with the averages in mind. Good luck, and have fun, but also don't overdo it - it's easy to do, particularly with trainers!