RickM

It does serve as a good reminder that there are other sources of Protein than meat, though for them to consider a fast food cheeseburger like that a "meat dish" may be stretching things a bit, particularly amongst our crowd. Much of calories in there are from the far from lean meat used and the bun - a 4oz patty of 85% ground beef pan fried with cheese is around 240 cal and 27g protein. And, while some of the veg mentioned, like broccoli and cauliflower, may have a decent amount of protein per calorie, it doesn't help us much with the volume restrictions that we have. Nevertheless, it is still a good lesson that we can mix things up some and still get in our protein.

I set my goals based upon body composition rather than BMI, looking to get into the 15% bodyfat range (which is on the lean side of "normal", "recommended" or mid-"fitness" range on most charts, women would be around 28-29% on the same charts) which would still put me "overweight" on a BMI basis (26-27) because I am still maintaining much of the muscle mass that I had built up over my pre-op fitness efforts. I'm lower now than any number I can remember from college, though in better shape now than I was then, and still have another 10-15lb to go. BMI really only applies to populations rather than individuals, but is a good starting point until one figures out how their body comp works out - one can be an "overweight" BMI but still lean as I will be when I get into goal range in another month or so, and one can be a "normal" or even "low" BMI but still be overly fat if there isn't enough lean muscle mass left, though most in the normal BMI range will still have a fairly normal body composition. Both factors really need to be looked at to determine a healthy goal range - body comp is the most important factor, but most of us shouldn't be too far off of the normal BMI range either - some of the serious body builders qualify as "obese" on a BMI basis, some being in the upper 30's while still incredibly lean, but that's a real high maintenance place to be, to say the least.

A good pace and distance is whatever you are comfortable doing, and is working your heart some. I don't walk a lot since the immediate post op period, preferring gym and pool work to our boring SoCal neighborhood, but I do walk more when I'm up in Monterey (like next week) since there's more interesting places to walk. They occasionally have nice 5k walk/runs that are fun to do - I just did one about three weeks ago in Pebble Beach. You're working at a good pace and as much time as you can spare for it is great. A suggestion on finding a healthy pace is to get a heart monitor - the cheaper ones (maybe $50) are just built into a watch and you put your fingers across the face when you take a short break. The general guideline is that you should try to work your heartrate to around the 80% of maximum rate for good cardio workout and calorie burning. A rule of thumb max heartrate is 220 - your age. One of the things that sneaks up on you as your weight drops is that the walking becomes easier and it's a bigger challenge to get your heartrate up into that zone by simple walking - it doesn't feel like it's any easier, but your body can sure tell the difference. During the first couple of months post-op I would have no problem getting my heartrate up into the low 130's, which is that good working zone for me, but a couple of months later I could barely break 100 when walking as fast as I could without breaking into a jog (which the knees still don't like) This is one of the reasons that the weightloss slows down as we progress - our daily activities and purposeful exercise burns less calories unless we make a significant effort to ramp it up as the weight comes off. Some people on these forums have reported that their docs don't even consider walking to be exercise after a few months because of this effect. Good luck and keep it up - you're off to a good start.

I get pretty much the same feedback from my surgeon's staff and an unaffiated RD that I see. Keep the simple carbs/sugars in check but otherwise keep it balanced within the confines of the Protein requirements and calorie limitations consistent with the required weight loss. I just can't see doing the low carb diet and leaving all that nutrition on the table - we are already unbalanced enough with the limited volume we can consume during this time without compounding the problem. As we often see with the packaged goods that advertise low carb but boost the fat to keep the flavor, (or low fat that boost the sugar for the same reason) so goes the real food world - potassium is one of the nutrients I track since it isn't conveniently supplemented and many of the best sources come attached to carbs. Some suggest low carb alternate sources such as avocado, which i do use in my salads, but avo is twice the calories per unit of potassium as a baked potato, and about 50% higher than a banana - is low carb really saving anything if one is interested in nutrition? There are specific therapeutic uses for low carb, just as there are for most any kind of dietary restriction, but it certainly isn't a one-size-fits-all complement to the sleeve, or WLS in general I will admit, however, that the low carb fad does provide some amusement, particularly over on OH where we have the carb nannies that come in waggin their fingers at anyone having a banana! (BTW, did anyone headslap you for last weekend? lol) I don't measure by volume like that, preferring the scale, but roughly those proportions but maybe still biased a bit toward the meat. 3 real meals and 2-3 snacks of Protein Drink, yogurt/fruit/nuts, or protein loaded pudding; have normally dropped the morning snack from earlier practice. 11-1200 cal/day. Classic fitness nutrition of heavier complex carb (typically low-med fat, med protein, med-high complex carb - like meat and cheese on whole grain) before and readily absorbable protein after. I have found that the whole grain toast for lunch before the afternoon pool workout does let me work longer and with greater intensity, though I haven't noted a significant difference on my strength training days between the sandwich lunch and my more typical salad with meat. I do weigh daily and frequently twice daily but not for obsessive'compulsive reasons; rather the impedance scales give a more accurate reading of body composition in the late afternoon when one is usually fully hydrated, but a first in the morning is a more repeatable weight measurment (ok, so maybe not ob/com but latent engineer....) As Rootman noted, this seems odd due to the conflict between iron and calcium absorption. I'm not overly worried about iron since we don't have the mineral absorption issues of the RNY or DS, and I'm typically getting in double or more of the RDA of iron thru my normal Multivitamin and food; calcium is my greater concern and I do space that out from the morning iron containing multi and split it up so that no more than 5-600mg are taken at a time. (Eight years of going to DS oriented support group meetings tend to hammer these things into one's brain....) I lost a net of 50lb a few years ago with the classic balanced/sane dietary/exercise adjustments when my wife was going thru her WLS, and maintained the loss but couldn't make much more progress on any sustainable basis, so that's why I went with the sleeve - I have high confidence that the maintenance issues have already been resolved, rather than depending/hoping on making the necessary lifestyle changes after the fact. Good luck to all,

It sure does. I'm right about 29 BMI now, but 21-23 %BF which is just at or above normal for men on the charts I've seen (they list "normal" as being 11-21 or 22) but there's more variation in how BF is classed by different groups than BMI. I'm targeting 15%BF, which will still put me at an overweight 26-27BMI. BMI only really has value on a population basis and as this chart shows, has little value to the individual. One can have a "normal" BMI and still be over-fat. I'll take a lean "overweight" anytime.

I don't think that you're losing too fast, and there are things that can be done when/as you near goal weight. I was down 80 lb at the five month mark (a couple of weeks ago,) with another 20 to go to my goal range. I'm losing at a comfortable 2-3 lb per week which is managable, and I have room to add more nutritional calories as I get to goal (Thanksgiving will probably help - early December is about when I should be bottoming out.) Losing too much is rare with the VSG, though I suppose there are some who may get overly obsessive on the diet front and keep going beyond what is healthy, but excessive loss is usually only seen with the DS where they are fiddling around with metabolism with the intestinal work they do, but even with that it's not an overly common problem. There are plenty of ways to get calories past your sleeve (which will be a problem for some in the long term) so over-losing shouldn't be a big worry. Does your doc do any body composition measurements - body fat, lean mass, etc.? That is a better guide to where you should be than simple scale weight.

My understanding of it is that is less a matter of shrinking the liver (you're not going to do a lot in a week or two) but more of removing some of the slimey coat that can be present with fatty liver which is very common with us obese folks. Some docs require the pre-op diet while others don't. My doc doesn't require one, other than the day before purge, and he's a liver specialist who does transplants aside from his bariatrics (go figure!) Presumably he has specific skills from that where our typical liver condition isn't a big deal for him. Irrespective what other surgeons do, you should do whatevery your doc wants you to do - he's is the one who's digging around inside of you and it's in your best interest to make him as comfortable as possible when he's doing so! I would agree with Felicia - try to stay busy and keep your mind off of it as much as possible. The Protein helps as it's usually very satisfying even if it isn't "real" food. The VSG didn't cure me of hunger as it does some, but it has become less of an issue as I recovered and became busier with normal life.

I haven't had any particular problem with them, but that's just part of the variations between us all, and there are options. I have been using the Bariatric Advantage chewables since surgery and they work well, but I also take the standard Citracal pills when I travel. I also have some Citracal gummies that I have used off and on as well. If possible, you should be using Calcium citrate as that provides better absorption with our altered stomachs - I don't know what type of calcium the costco ones are but calcium carbonate, which is the most common type since it's cheapest, is the least desirable form. There are some gummy/chewable calcium supplements that Costco sells, and the Viactiv brand is similar, but they are the less desirable carbonate form, but may be worth a try if others don't work - my wife uses them (the Target brand version, but they're all similar) because she has a hard time tolerating the more desirable citrate form. How much calcium is in each of your pills? We shouldn't be taking more than 5-600mg at a time as that's about as much as our bodies can absorb, so we need to space out our calcium supplements to 2 or 3 times a day depending on how much we need to supplement. Also, does your Multivitamin contain Iron, as many do? If so, then you need to space out your calcium by a couple of hours since iron and calcium compete for absorption in the body. Doesn't this get delightfully complicated? Thankfully it gets better as time goes on and we can get more nutrition from real food instead of pills.

You're welcomed. I kinda fell into liking their dark chocolate variety when they introduced it a few years ago, and then the local markets stopped carrying it. Then I stumbled across it at Drugstore.com..... While you're looking there, they also carry different Protein drinks and they let you check the nutrition/ingredients labels so you may be able to find one of those that meets your needs at the same time.

The docs invariably want you up and walking the day of surgery (or the next morning if you were done late in the day,) so low level elliptical should be no real problem as it's pretty low impact, though you may want to particularly take it easy with the arm movements if it feels like it's stretching things thru your abdomin - double check with your doc to be sure! Ditto on the hula-hooping - it doesn't seem like that would be as rigorous as doing crunches and sit-ups, but it may be a bit intense early on. After three weeks I was cleared to go back to the gym and resume some mild strength training, isolating the abdomin - no crunches, etc until about week 12 for me - and back into the pool after 4 weeks or so (a little later than some because I was still having a bit of seepage from one of the incisions that needed to stop before soaking it.) Good luck with your journey,

IB is made in dark chocolate, vanilla and strawberry in addition to the standard chocolate or milk chocolate flavor; they also sell a variety pack. Drugstore.com stocks most if not all of the varieties if your local markets don't have a good enough selection. On the Protein powder front, check with a GNC, Vitamin Shoppe or similar supplements store that should have a large selection of products. They should have something that meets your needs as the body builder market is more interested in protein than low cal/carb, and some sugar is helpful in the transport of protein to muscle cells.

I don't remember the number of days, but it seems to have been within a week or so when I went thru it earlier this year. The surgeon's insurance coordinator was prepared for a long back and forth battle with them since they often put up a fight but they surprised us when they called him with the approval so quick. Now, getting them to pay the surgeon's fees is another issue..... I hope you get as speedy response on their approval,

If you can make it out to the coast for a weekend, the Big Sur Half Marathon is being held on Nov. 20 in Monterey, and they have a 5k walk/run associated with it. There is also a Pacific Grove 5k being held the day before if you want to double up on them. The full Big Sur Marathon is in late April and they have 5k, 9 mile and 10.5 mile events along Hwy 1 between Big Sur and Carmel. It's one of the prettiest events that you can do. My wife and I will be doing the Big Sur 5k (more like a 10k for me since I have to orbit her to match our paces!) but not sure if we will get up there for the half marathon in Nov. I just did one in the Pebble Beach forest a couple of weeks ago, a more laid back event where we could power walk with the dog walkers. http://www.bsim.org/ gets you info on all those events. http://www.marathonguide.com/ has a calendar and links to marathons around the country, many of which have 5k's or other shorter events run alongside. I see that there is one in Silicon Valley on Oct. 31 that has a 5k linked to it. Good luck - they are fun events to work up to and progress thru.

If you haven't been doing the low carb diet that's en vogue with many of the programs, you can try that - the extra kick from the ketosis derived from keeping under 30-40 g per day may be of help for you (and it may make no difference, but it's worth a try.) Also, try ramping up your exercise - whether you have noticed or not, whatever exercise that you were doing early on isn't doing so much anymore since you've lost a fair bit of weight and everything has gotten easier. I have to keep reminding myself to keep working a bit harder because while it still feels the same, my heartrate has a much harder time rising to the effective cardio and calorie burning zone than it did 2-3 months ago. Good luck on it - weight loss does slow down over time and you are losing at a reasonable rate if you have patience, but I understand wanting to be down as much as poss for the holidays.

No alky forever is a bit overboard, but there is concern about transfer addictions so there is a vulnerability there that has to be watched. Healing of the sleeve is the main issue with most docs and is why they have variable restrictions of a few months. Some docs, like mine, are in the no alky for the entire weight loss period due to liver health concerns - the liver is already overtaxed from being in an obese person and in metabolizing all the fat that we're losing, so it's not good to stress it further with alcohol, but then my doc is also a liver specialist along with the bariatrics, so gets a bit anal about liver care. After the weight is off, then the primary concern is psych/addiction rather than strictly physical/medical, so most docs back off at that point (somebody else's problem...)

Many of the long term or permanent no-no's like corn, etc. come from RNY practice due to pouch restrictions, but the sleeve has no particular long term restrictions. You may have long term restrictions from the dietary & weight maintenance perspective but the sleeve itself is very forgiving (this from practice that's been doing sleeves for around twenty years.) And, of course, we all have varying shorter term restrictions for the benefit of healing and weight loss, but most of us chose the sleeve to avoid the restrictions and limitations inherent in the RNY.

There is a good basic article on the subject over on OH: http://www.obesityhelp.com/forums/revision/gastric-bypass-revision-surgery.html While it seems that the more common revision is to the duodenal switch, the article says that revising to the VSG can also be done. The DS generally has better regain resistance than the RNY or VSG, so that seems to be the more common revision, but this can be an even more individual issue than choosing the original WLS. The article goes into some of the considerations in revising including analyzing why the original surgery failed and determining the appropriate response - behavior mod, reworking the original procedure or revising to another. Another good article is this one: http://www.dssurgery.com/about/publications/duodenal-switch-safe-operation.pdf Revising an RNY is a complicated procedure that relatively few surgeons are qualified to do (or that one would trust to do,) so travelling is often involved. Is your sister near you in NJ? Dr. Roslin in NY is one, Rabkin and Keshisian in Calif are also well qualified. Posting to the revision board and DS board on ObesityHelp will get you some more help on this issue (even if the desired or appropriate revision is to a VSG, the folks on the DS board there tend to be very protective of their procedure and picky about surgeons' qualifications, so they can steer you to the best revision surgeons who can help guide your sister to the best answer for her.

The rationale for the 1 year (or longer) wait that some surgeons impose is to help preserve liver health - being obese (or worse), our livers are not in the best of shape to begin with (which is why some surgeons impose the pre-op diet, to help improve the liver condition since they are working in such close proximity to it when doing the sleeve) and then it gets seriously taxed in its role im metaboliziing all the fat that we are losing. With all that going on, it doesn't need any more stress from handling the alcohol. My doc's rule is no alcohol during the entire weight loss period (and reinforced in the psych eval as to whether one can give it up for 18 months, give or take - whatever it takes to get the weight off.) My surgeon also specialized in biliopancreatic transplants, so needless to say he's a bit anal about liver care. I also tend to listen to him on such things as he has a better perspective on the issue than most bariatric surgeons. Take it for what you will - we're all adults here.

I would suggest that you ask your surgeon or his staff what he suggests under the circumstances as you are primarily doing the diet for him - some surgeons do a pre-op diet and some do not. Since the primary rationale for the pre-op diet is to improve liver condition to make the surgery easier for the doc (and therefore on you as well - you want to keep the guy who's digging around inside you happy,) I would ask him. Since fatty liver is the condition that they are trying to improve upon, I would think (in my non-expert opinion) that the higher fat content of the Atkins variety would be the one that you would want to avoid. I would go for the lowest calorie and highest Protein variety at this point and not get too worried about carb count or anything else until after your surgery (if your doc even cares about counting carbs - many do not.) Does he do a clear liquid diet the last day or two as most do? If he does, then you should also seek out some of the Isopure clear liquid Protein drinks, (or similar products) and maybe make up some hi-pro Jello with unflavored Protein powder (which is usually acceptable as a "clear liquid".

Generally, whey protein isolate is lactose free, but is more expensive that non-isolate which is why they are usually blended, but 100% whey isolate drinks do exist if you look for them. Check the usual suspects like Vitamin Shoppe or GNC.

You are correct that the VSG is part of what has been done in the DS for quite some time (though the stomach for the DS is usually made a little larger than is done for the stand-alone VSG,) which can be an advantage if your selected surgeon has good DS experience, as there are quite a few around who have been doing DS's for 10-20 years as opposed to some who are just now adding the VSG to their RNY practices. The longer term effects of the stand alone sleeve are not as well known as the more established procedures, but most of the problems that are seen with the DS are with the intestinal part of the procedure or incompatibility of the common channel length to the individual's metabolism (too much or too little malabsorption - not the easiest thing to determine ahead of time), or intestinal adhesions causing problems later on. I know quite a few DSers (have been going to their support meetings for about eight years with my wife who had one) and even those who have had problems are still glad that they did it - it is better than the problems of severe obesity. That said, many of them are also older and delayed having surgery until there was little choice (their health had deteriorated so much) and all wish they had done it sooner. However, being younger than most, you have a lot more time to live with your decision, so taking the "minimal change"option of the VSG makes a lot of sense. While it does permanently remove part of your stomach, it also leaves more options for the future if something stronger needs to be done; while we don't like to thing of such things as needed, a revision to a DS is fairly straightforward with the sleeve, while revising an RNY to a DS is a complicated procedure for which only a relative few surgeons are really qualified. Adding to Tiffy's great list of questions and considerations, I would add a couple more. On the post op diet front, some surgeons overlay a very low carb diet on top of their VSG - this is appropriate for some, not so appropriate for others. It's something to ask about and consider relative to your own experiences and needs (I'm sure glad I didn't have to put up with it, and am healthier as a result.) Also, there is a wide variety of pre- and post-op diet schedules - some docs have patients do a couple to several weeks of pre-op dieting, sometimes extensively liquid, sometimes requiring a certain amount of pre-op weight loss, while other docs have no such requirements. Likewise, post-op, some programs are heavy on liquids for weeks before moving to mushes, soft Proteins and ultimately real food while others start out with mush and soft Protein in the hospital. This are not real big deal in the overall scheme of things - this is a long term health benefit we're after here - but makes a difference in the overall experience and are worth asking about and preparing for. Good luck, and it's great you're getting on top of this problem early!

The best that I have found on a protein for the calories basis (at least that I have tried and are reasonably palatable to me) are the Pure Protein bars. The 50g bars have 20g of protein for 180-200 calories depending on the variety.

I don't know what bougie size my doc used (if he used one at all,) but he told me that my stomach was about 2.5 oz when he leak checked it in the OR, His DS stomachs are usually on the order of 4 oz. I/2 oz sounds awfully small for a sleeve (I'm not sure if they can make them that small, and if they could, I'm not sure that I would want one that small.)

Protein intake is the only way we can get the amino acids that are involved in virtually all of our bodily functions including muscle maintenance; carbs, as the low-carb evangelists love to tell us, our bodies can do without (for a while) as our fat stores can be converted to the glucose that's needed for various bodily functions (at least if you aren't too demanding of them in your lifestyle - sometimes the body can't keep up) and of course, fat we all have in abundance. But we have very limited stores of protein and when we run out, the body starts stripping our muscles to get what it needs. One of the reasons that strength building exercises are emphasized is that building muscle mass increases our metabolic rate, burning calories even when we aren't exercising. If we start losing muscle mass, our metabolism slows down so weight loss slows down too.

There is a self-pay & Mexico board here, so you may want to cross post over there, too. We went thru these thoughts when we self paid my wife's DS a few years ago, and our conclusion was that the insurance would not pay for complications immediately related to the non-covered bariatric surgery, so there is a gap there if the absolute worst happens. The self pay plan with our surgeon and hospital put a cap (I think it was about $70k) on the hopital stay and complications, but IIRC that only applied to continuous hospitalization after the surgery (so if she were discharged, went home and had a problem requiring more work, that was beyond that coverage) so that did put a premium on making sure all was well before leaving the hospital. I don't know how the insurance would have reacted if we had had to make an ER call in the weeks afterward since we thankfully never had to test that. The insurance WAS willing to pay for the hernia repair that was no doubt linked to the WLS, but in typical med/insurance industry fashion, it was cheaper to self pay for it and her unapproved reconstruction surgery in a surgical center and private recovery center than to go to the network hospital for the hernia repair and add the reconstrution onto that. So, there is some window of vulnerability in the middle term (and there probably somebody somewhere that has an insurance product to cover such things at a breathtaking cost) but longer term it seems that the WLS drops into the background and becomes just another part of your medical history (that may be wrapped up in the pre-existing condition clauses of the contract - maybe someone more familiar with the nuances of the insurance contracts will chime in on this.) On the house lien front, while it's not something desireable, it might be a good idea to establish a line of credit on the house (if all the numbers and eligibility, etc. work out), just in case - it doesn't cost much to establish it but not use it.