RickM

I have been working to optimize nutrition pretty much throughout this whole process, within the limits of our restricted volume/calories and high Protein requirements of our sleeve – to me, the popular ketogenic diets leave too much nutrition behind to be worth whatever benefit they’re supposed to provide. From relatively early on I have regularly had small salads with a couple ounces of meat, mixed in an ounce or so of raspberries with my greek yogurt, frequently along with some almond and oat or wheat bran for added Fiber. I averaged a 2-3 nominal fruit/veg servings per day (against 7-8 pre-op). Potatoes were frequently present as an efficient source of potassium and mid-way thru the process some whole grain bread was added strategically as a complex carb source for fueling extended workouts. Now, in the transition to maintenance mode for the past month or so, I’m getting in 4-5 fruit/veg servings per day and my stretch goal is to minimize supplements long term. A few days have avoided Calcium supplements (2000mg per day is my target) and I sometimes see 80- 85% of the potassium RDA (that’s a tough one to supplement without Rx.) I have added back the morning snack that I dropped early on in the loss phase and sometimes have two small afternoon Snacks as needed to boost the calories and nutrition. Today’s menu as follows – B: 3 turkey breakfast sausage, with wheat toast/butter (good pre-workout profile for morning personal trainer session.) S: non-SF instant breakfast (the moderate sugar dose aids in transport of protein to muscle cells: SF version used where appropriate. I used to use Protein shakes for this but don’t need that much of a protein load anymore.) L: salad with chopped turkey breast, spinach, avo, tomato, snap pea, carrot, broccoli, yellow pepper, green onion, cheese S: can of low sodium V8 (great source of potassium), greek yogurt w raspberries and almond granola D: pot roast, roasted potato, broccoli S: protein loaded pudding on a piece of eggface protein cake. I have been evolving my practices of high density nutrition for several years, since my wife when thru her WLS journey with a DS several years ago and worked toward beating her down the scale (only partially succeeded, but did attain good weight stability prior to going with the sleeve to finish the job.) There’s no particular single source that we’ve used but a combination of various nutrition (as opposed to “diet”) books and the tracking software we have long used (an offline program called Nutribase, which is a slightly lightened version of what is marketed to the professional trade, as we weren’t satisfied with the online resources such as Fitday that were available at the time,) along with continued fiddling with recipes and personal preferences. As I had already worked out healthy dietary practices (other than the volume problem solved by the sleeve,) I was rather averse to the idea of doing any of the fad diets, medically supervised or not, which have such a low probability of success instead of WLS (and certainly wasn’t too keen on doing any of them post-op, either – thankfully my doc hasn’t gotten caught up in any of those fads.) With the lower volume available with the sleeve along with the general protein and caloric restrictions involved (I averaged 1000-1100 cal per day) I was able to adjust my pre-op dietary practices to my post-op needs by emphasizing the protein and dropping some of the less nutrionally dense items off the menu during the weightloss period, but generally still maintaining a reasonable nutritional balance within the remaining calorie allotment. Now, in the maintenance phase, I can add back some of those less nutritionally dense items as I work to optimize things, and don’t have the problem of having to wean off of a special deficiency diet back to normal practices – the downfall of most of the special ultra low cal type diets. I never needed to make major philosophical changes to my diet to make the sleeve work, nor to move into healthy maintenance practices. Good luck in your efforts,

If by ketosis state you mean going with one of the ultra low carb Atkins/ketogenic type diets, that clearly isn't the case; if you're talking about the biochemistry of fat metabolism that will have you excreting some ketones, then that's a function of chemistry and doesn't require an overly low carb intake - just enough caloric deficit to draw on your fat reserves. I have clearly burned a lot of fat without ever going near that magical 30-40g or below level - I was typically in the 80-120g range thru my loss phase but was not going to get into the nutritional deficiencies that go along with those atkins type diets - but if you look at my labs then, yeah, some ketones were detectable in there.

While the bypass does have long term data to review, it is unfortunatly not very good reading. What caloric malabsorption it provides is temporary at best - after that it is a restrictive only procedure like the sleeve, and the consensus of study data shows that the weightloss character of both are very similar, averaging in the 70-75% excess weight loss which is better than the bands at 50ish % but less than the DS in the 85-90% range. What isn't temporary about the bypass, however, is the mineral malabsorption, which is with you for life, the most troubling typically being Iron and Calcium. Another long term issue is the problem of the piece of intestine that is joined to the RNY pouch is not resistant to stomach acid like the bypassed duodenum (the part of the small intestine immediately below the stomach that is also the entry point for bile and digestive enzymes from the liver and pancreas.) This means that the suture line between the pouch and intestine never really fully heals and often weeps a small amount of blood, which compounds the iron malabsorption issue. This is also the reason that NSAIDs are not to be used by RNY patients for pain relief - for life. Regain resistance with the RNY is also not very impressive - being calorically a restriction only procedure like the sleeve, you are pretty much on your own to make the long term lifestyle changes to keep the weight off; there is a school of thought that the sleeve may be somewhat better on the regain front due to it keeping an intact pyloric valve in its reduced stomach. If one is interested in a malabsorptive procedure, they should seriously check out the duodenal switch which does offer long term caloric malabsorption and better regain resistance, less severe mineral malabsorption since the duodenum is only partially bypassed, and like the sleeve (which is a part of the DS) has no limitations on NSAID use. The DS is a more technically challenging procedure than the sleeve or RNY which is why you don't find as many surgeons offering it, but those that do tend to be at the top of the class. All of these procedures have benefits and detriments that need to be evaluated relative to individual needs. but overall the RNY comes off as the less attractive procedure for most - it has similar weight loss and regain performance to the sleeve but at greater cost in lifestyle and medical treatment limitations, but poorer performance to the DS at a similar or greater cost.

The various charts and calculators are guidelines that tend to apply more to populations on average rather than individuals. Various body composition indicators give a better overall view of an individuals health. My goal was to get into the middle teens on body fat %, which is the middle of the normal range for men of our advancing age (the range it typically sited as 11-22%, give or take a point or two on each side depending on the source) which. at 5'10 and 190, still leaves me "overweight" on the BMI scale. When I started out, I targeted 200 as my initial goal as that would put me into my target body comp range under the admittedly gross assumption that only fat would be lost; I readjusted the target on the way down as my body comp changed and settled into the 185-190 range as a healthy weight for my musculature. Also, be cautious on the "big boned" label as that is almost cliche amongst us when we are heavy, and some of the classical measures can change with substantial weight loss. By the measure of fingers around your wrist, I was always about medium framed on their scale, but am somewhat below that now. So that's a guide, but about as valid as any of the other quick measure guides like the calculators - take it with a few kilos of salt. Good luck on your loss.

It's all part of being a healthy male, and we are all getting healthier now - less weight, better circulation, more exercise, hormones, hopefully more attention from those of the XX persuasion.....

It is hardly emerging science, as this has been known for years, though they are still trying to fully understand the mechanism involved. When my wife had her DS 6-7 years ago it was thought that the intestinal rerouting was responsible for the success in resolving diabetes - there is certainly more to it than simple weight loss or enforced dietary changes as many see their diabetes resolve at the outset. As noted by others, the DS also resolves diabetes, and at a rate somewhat better than the bypass (on the order of 98+% for the DS vs around 90% for the bypass from the figures I've seen), however, the sleeve has also been showing good success at early resolution of diabetes, so the docs are now hypothesizing that there are hormonal changes involved with the stomach changes that are also influential on the diabetes front (that is the more emerging science.) It is certainly understandable that your doc advises that you go with the bypass, although how much of that preference is technical/scientific and how much is liability concern would be uncertain. (Put yourself in your doc's position - he may believe that the sleeve is the better choice for you overall, but the bypass has a longer documented history of diabetes resolution than the sleeve, so the bypass is the more legally defendable position should your diabetes not resolve. Unfortunately, defensive medicine is a fact of life in our society.) A further complicating factor in your decision making - (my wife was a type II diabetic, treated for around twenty years and nearly at the end of med only treatment for its control when she had her DS) my wife's doc told her that in his experience, the longer one has had or been under treatment for diabetes, the longer they typically take to resolve post-op, which is why hers took around nine months or so to resolve while others walked out of the hospital with it resolved (and yes, there will be long termers who resolve quickly and short timers who take a while to resolve, but on average that relation holds). This implies that the longer you have had the diabetes, the stronger the tool needed to resolve it, so if you are a long timer with it and seriously want to resolve it, then the DS should also be under consideration. So, research, research research this to become comfortable with it. As noted by others, the sleeve is having good success at resolving diabetes, but doesn't have the hard data behind it yet. The bypass may be better (and the DS better still,) but has more hard data to show for it. Not an easy decision, but good luck with it.

That's a great point, given the relative newness of the sleeve, particularly to the insured world - looking for an experienced DS surgeon gets you a lot of sleeve experience, and as with most surgical procedures, it's hard to beat experience with the particular procedure one is interested in. Bands and RNYs, while both bariatric procedures, aren't the same as sleeve gastrectomies, and they all have their subtleties that make a difference toward success. Generally, one should look for a surgeon who has done at least 300-500 sleeves or DS's to be reasonably proficient with the sleeve.

From the second week on out I was taking in 900-1100 calories per day; we had no distinct mushy or liquid stage, just a combined liquid/mush/soft protein as tolerated for the first month moving on to most anything else within tolerance after that. That worked well for me, providing a fairly consistent 2-3lb per week loss, but I'm a fairly large (final weight) guy who's fairly skinny at 190lb goal weight. YMMV

At 9 calories per gram of fat, that doesn't leave a lot of room for your Protein. At this point (and for most of your weightloss period for that matter,) you should be concentrating on getting in your requisite protein (60-80g per day is typical, more for some) and not worry about fat and carbs until you are consuming more, as in about 800 cal per day if you go that high. Even at that, I never worried about fat and carbs, but just protein, Water and then getting the most nutrition from the remaining calories in my day (which for me was typically 900-1100 overall).

I alternate days between cardio (which is primarily swimming) and strength training, and just do maybe five minutes of cardio on those days to get things warmed up. Arguably, we don't need a lot of cardio for fat burning as our enforced caloric deficits from the sleeve are already doing that for us, and we get more benefit from building/preserving muscle mass to enhance our metabolism and burn more calories long term. I tend to combine the two with circuit work by switching between muscle groups rather than resting between sets. There are rules of thumb all over the place for the amount of Protein that we need, but it's hard to see any of us needing more than something in the low 100's. Someone into serious body building may need more than that, but the consensus of those not into selling protein supplements seems to fall into the 160-200g per day range being the most that anyone can benficially use. Our (wife and I) trainer is fine with the 100g per day range for our moderate strengthening/toning. I would agree that generally the free weights are preferred for providing compound movements and strengthening, though the machines are great early on for isolating muscle groups and avoiding over-doing the abs and core when that part is still healing (never did like hernias!) Our trainer is big on core work, but we mix it up between free weights, machines, TRX, and stretching/flexibility work.

I was typically running in the 30-40g of fat per day, with some days down in the 20's and others in the 50's. I didn't control fat or carbs, just protein and overall calories and trying to maximize the nutrition within those limits. I don't/didn't specifically try to go low fat, but at 9 calories per g of fat, my brain sure wanted to make the most of those calories, but if your protein and calories are in within your guidelines (or close), go for it.

That's right - mostly likely the dreaded three week stall, which hits most everyone to one degree or another. This article - http://www.dsfacts.com/weight-loss-stall-or-plateau.html gives a good explanation of what's happening. The bad news is that when you resume losing it will likely be at a somewhat slower rate, but the good news is that now it will be primarly fat, which is what we are here for in the first place. So rejoice, and enjoy the trip.

Yes, they're an online product (questproteinbars.com); I haven't found any over the counter retailers for them (though I haven't really looked, either. They do have a spot on their website for inquiries from prospective retailers, so you may find them somewhere) On the other hand, they're local SoCal for us, so you'll get your order in a day or two.

I had settled on the Pure Protein bars as the best compromise that I had found at 20g protein for 200ish calories, and then I tried the Quest bars. I am now struggling to use up the Pure Protein bars that I still have around. The fiber in the Quest bars is sure a help for many of us who have had problems getting enough in, and most of them have no or minimal sugar alcohols which don't sit well with many people. My wife had settled on the Atkins bars as her favorite meal replacement and has been converted to Quest as well. They are certainly worth getting their sample box and explore their flavors. Even their unusual flavors like lemon cream pie and cinnimon roll have a quite plausible resemblence to their stated target without any of the odd flavors that are common to protein bars.

This is another area where there is a fair bit of variation between plans and individuals. Some plans limit calories to 6-800 per day and ultra low carb, while others are less specific and people doing well at 1000-1200 per day. A lot of it depends on individual metabolic rate, how much one needs to lose and individual activity levels. I was a relative lightweight at a BMI of about 42 and around 100lb to lose, averaged 1100 calories per day without any particular regard to carbs and got to goal in 7-8 months. Most tracking programs will throw up some warnings at very low intake levels, as those are generally unsafe without proper medical supervision (surgery or no surgery.) The very low calorie levels can lead to various nutrient deficiencies that need to be monitored which we presumably are getting one way or another; the more restricted our diets, the more the need for wider monitoring to keep things in check.

The stock answer from many on these boards is that anything over 6-800 calories or 40g of carbs will bury any chances of weight loss for the rest of your life, and while I have never been an adherent of such extremes, it does seem to me to be on the high side for continued weight loss for the majority of us, though that can be quite dependent upon activity levels - some who are budding marathoners may require quite a bit more while still losing. I also had about 100lb to lose and I averaged around 1100 calories thru most of my loss period and never tried to limit carbs, preferring to maintain a better nutritional balance within our Protein limits; I typically ran 80-100g carbs in the first few months, rising to the 120 range later on as I selectively added more complex carbs to better fuel workouts - timing of that intake seemed to make a bigger difference to me for that function than overall carb level. A pre-workout meal/snack of moderatly high complex carb (like in the mid-20's), moderate protein and low to moderate fat is a common fitness nutrition guideline. I adopted a small sandwich of whole grain bread with some meat and cheese an hour or two before a workout as a workable solution for me. Crackers and light cheese was another suggestion by my RD. That strategy seems to work well if I'm swimming beyond a mile at a time, but doesn't seem to make much difference on days that I do strength training, even though those workouts are also in the 60-90 minute range. As a reference point now that I transitioning into maintenance mode, I have lately been running around 15-1600 calories and 150g carbs and 120g protein, and talking to my RD today we are looking to move toward 1800 cal and 180 carbs to stabilize things and move away from supplements to the extent possible, so at least with my metabolism, moving into the 1400 cal range would certainly have slowed me down. Some people find that they stall out if they move beyond the very low cal/carb limits quoted in some plans; some find that they stall out at those low levels and need to boost their intake to break stalls. What are your typical recent cal/carb levels? If you are running in the 1000 cal range, it might be helpful to boost your intake toward your NUT's suggestion temporarily to see if that gets things moving, or dropping things a couple hundred cal to see it that stimulates things - change of some sort is often useful in breaking stalls. Going too low can sometimes be counterproductive as that can slow down your metabolism, while increasing activity or exertion levels can increase metabolism. I found after 2-3 months that I had lost enough weight that low level exercise like walking lost a lot of its value as my heartrate for a given pace had dropped substantially - I could no longer get my heartrate up into that recommended 80% max rate range for heart health and fat burning. It's something that just crept up on me - it sure didn't feel much different but the monitor sure knew the difference, so that's something to check on, and another reason to change up the workout routine. Good luck in working this thru,

I have never been restricted on liquids, even in the hospital, though some do have a harder time with them (a tighter pyloris, perhaps?) I don't restrict liquids before eating since they go right thru me, but do wait the half hour or so to drink eating (if I remember, which I usually do.) I may occasionally take a sip of Water while eating if necessary. Early on, a cup of milk with Protein powder was no problem at a sitting, and I often made a 2 cup batch with the second cup reserved for later if I needed more protein. On the other hand, when my wife went thru this a few years ago, she was pretty much restricted to her nominal stomach size in liquid capacity which meant that her Protein shakes had to be overly concentrated for her to get in the protein she needed, while mine could be relatively dilute with other flavors added to make them more palatable (even tasty.) That's just from the variations in how our bodies respond to the procedure. I was probably a couple months out when I was shifting from sipsipsipping water to drinking more normally (and being able to take pills several at a time rather than one at a time, sipsipsip), and not long after that when I was drinking pretty much the same as pre-op when exercising (I was never into chugging in college, so that level of drinking was never normal for me!) I often eat more than 4 oz at a meal (i'm about 8 months out and at goal, but this has applied for many months) but am still restricted to about 3 oz of firm protein. If I cut that back to 2 oz of meat, I can add in around 3-4 oz or more of veg to make a salad, stew, chili, or stir fry. I've never had much of a problem getting in the protein (doc started adding veg to my diet at day 10), so I can cheat some on the "protein first" rule if I know how much I will be getting in for that meal and the day. There are lots of things that are so-called "sliders" because they slide on thru your pyloris, and many consider them to be an evil thing, which they are if one is talking about twinkies as sliders. But if one is talking about veg and some fruits that are very nutrient rich and low in calories, then they're a nutritional bonus that helps you on your way to normalcy. I have long had a snack of 4oz of greek yogurt along with a couple oz of berries and some chopped almonds. So, it's mostly a matter of how different foods fit you comfortably, and fitting them within whatever calorie (and carb, if you are into that,) restrictions you are using.

I would second (or third,) the motion for the Y if you have one in your area. When my wife and I started getting serious about this before her WLS some years ago, we joined the Y to start the insurance required diet/exercise program. The first time we drove into the parking lot we saw a morbidly obese woman walking in, and said to ourselves, "this is the place!" Most of them (at least in our region) have a special introductory program for those just starting out, providing some individual instruction using a separate workout room and machines so one isn't so intimidated by working out in the main room with all the mirrors (which I always called the "Narcissus room"). Overall, a very friendly environment.

That does seem a bit low and limiting - most that have their patients on the low carb thing just use the typical 40g per day limit.

My doc normally has our PCP do the bloodwork and fax him a copy, which I need to now before my 9 month/goal visit with them. (At least it's a fairly routine blood draw, unlike my wife's annual post-DS draw that takes around 17 vials!)

I never seriously considered the bypass as its performance in weightloss and regain are very similar to the VSG but at a much higher cost in lifestyle and medical treatment limitations. My main alternative was the DS had I decided that I needed something more powerful than the VSG or had better regain resistance - it's the only procedure that has any statistical advantage in the regain department over the others.

I was adding some chopped or slivered almonds to my yogurt and berries after a couple of months, but my doc has one of the more liberal dietary progressions relative to the RNY based plans that many docs use. Overall, nuts are a poor tradeoff of protein for calories so shouldn't be overdone, (at least until getting into the maintenance transition mode where one is trying to slow or arrest the weightloss,) but I was usually just adding 5-10g of them to the mix for some crunch along with a bit of protein and fiber.

The NUT sounds like she's quoting RNY advice - oatmeal and cream of wheat were on my doc's first month liquid/mush/soft Protein phase, and he's been doing sleeves for around 20 years, so he knows a thing or two about what a sleeved stomach can take - those RNY pouches are a lot more delicate. That said, people tolerate things at different times, so watering them down some may help those who can't take them straight up. The rest of those things - the breads, pastas and cereals are mostly a caloric/carb concern - get the protein in first, then veg and fruit before getting into the starchy things too far. The potatoes do have a useful amount of potassium in them, even the flesh, and are one of denser sources out there - about twice the potassium per calorie than avocados, which are one of the popular low carb sources. I have long had some in occasional meals - an ounce or two maybe - but I usually had little problem with protein intake, so tradeoffs were possible (other fruits and veg were also on the menu at different times to maintain some semblance of balance.) Of course, if the potatoes or breads are a trigger then they should probably be avoided until that issue can be resolved (if it ever can!) About the best nonprescription potassium source I've found is low sodium V8 juice, at around 1100mg per 11ish ounce can and 70 calories. I didn't get into using bread (whole grain, of course...) much until I was into that 75% down range, not from any particular post-op plan but rather as a needed complex carb source for fueling workout endurance.

I was within a pound of my original goal at six months, which was to be down about 92lb before I lowered it another 10lb to better match where by body composition was going, but I wasn't focusing on any particular time target. I can't offer any particular tips as this is just how it worked for me and I did all the wrong things (except exercise - that was a constant) according to the no-carb evangelists. The best way to get to goal quickly is to start closer to it and according to popular perception, have a Y chromosome (guys seem to lose quicker than gals, though I suspect that has more to do with higher average "should be" weights driving higher ending metabolic rates.) The exercise is a major part of it, and seems to be common in most who have been successful long term - I suspect that building/maintaining a higher metabolic rate thru the exercise, particularly strength/resistance training to build/maintain muscle mass, is more valuable than a very low caloric intake, and certainly is long term for weight maintenance according to the consensus of studies on the topic. You shouldn't expect to lose weight consistently, as the loss gets harder as time goes on - your caloric deficit shrinks as your metabolic rate drops some with the loss, and most particularly, your exercise burns less as you are moving less weight around. Typically, you would expect to see declining loss numbers as you proceed, and some will be more or less consistent on this depending upon stalls and the like. I lost at a fairly smoothly declining rate - 33 the first month (when we all typically have our largest drop due to the adjustments our bodies are making) followed by a couple months at 14-15 down, then three months at 10 down and the seventh into the goal range was down 9. This past month since then I've only lost a couple of pounds, but more importantly to me is that my body composition has continued to move in the right direction, dropping around another 3% in body fat down into the mid teens (mid-normal range for men). I never had any stalls of note (only one week in the middle where I didn't lose anything) which I suspect may be from not going too far into starvation mode from being ultra low cal/carb. Philosophically, I would rather lose what I need to lose over 18 months rather than 6 months, if there were some way of being assured that I would actually lose it all - rapid weight loss isn't the healthiest condition for our bodies, but it's something that we put up with to make sure we lose it this time. Post-op, I quickly settled into a 900-1000 calorie per day routine as something that was comfortable that satisfied and provided requisite Protein along with enough for some additional essential nutrition - some fruits and veg in there, and some complex carb added later to help fuel some workouts as intensity increased. Seeing that my loss rate was reasonable, I made no effort to drop my intake to the 6-800 cal levels that some docs advise, but did let it rise slowly over time into the 1000-1100 range as I worked to add nutrition. I generally have focused more on proper diet leading toward long term weight maintenance habits, but consistent with continuing the loss to goal, than in speeding toward that goal - for many, if not most, of us VSGers, long term weight maintenance will be a bigger challenge than the loss itself.

My wife before her WLS was never an exerciser, and couldn't get along with it pre-op or post-op. She was one of the "lucky" ones who lost all her excess weight despite the minimal exercise (having a DS helped, too) but now is paying the price with overall poor functional strength. When we first decided that we had to do something about our mutual weight problem, we joined the Y as part of the typical insurance company 6 month roadblock to surgery, and I found that I liked it, - liked getting back into the swimming and like the strength training bits, too - something that I had never done before. Between that and evolving dietary preferences, I lost a good part of my problem and maintained much of that loss, but not enough to be healthy and normalish weight, so I finally went with the VSG to finish the job. My improved strength and overall health certainly made the surgery and recovery easier. Seeing some positive results certainly helps it go down! As a side note, one of the long term post-ops in my doc's practice is a retired football player - typical retired athete syndrom of continuing to eat like they were still playing full time - who had ballooned up over 500lb. He absolutely hated to work out, but when he was playing professionally, it was part of the job but he swore that he would never do it again when he retired, Of course, he realized that he was wrong and that the workouts needed to be as much a part of his life now as it was when he was playing. He may have gone a bit overboard, getting to a 4%BF level (talk about obsessive-compulsive!) but he realized that that was what it would take for him to make it (he did let up after a while and let himself degrade to a 6%BF level.)