RickM

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.

It's more a matter of how quickly different things go thru it. Steak and most meats or otherwise dense Proteins can sit in there for quite some time while the stomach works on breaking it down to be passed on to the intestines, while other foods can just slide on through (the so-called "sliders") because they need minimal processing from the stomach. 3 oz of meat, give or take a bit depending on the type, is my comfortable capacity, but if I cut the meat back to 2 oz and throw it into a salad with some chopped spinach and a bunch of other salad veggies and a bit of dressing, that meal can be 6-7 oz. Some have reported that they can down an whole sleeve of saltine crackers in a sitting, and certainly things like ice cream or milkshakes can slip right through. If you choose your binges right, you can torpedo any of these procedures. Then there are individual variations - my wife could barely down her nominal stomach capacity in liquids for quite a while after her DS (same sleeved stomach, though a little larger, with intestial rerouting added) while I have had virtually no liquid restriction - I had a 6-8oz bowl of broth and a half cup of juice as a meal in the hospital with no particular distress (other than my own thoughts as to where is this restriction!)

That depends on what is included in your "soft food" stage - there are lots of variations. Mine included most seafood, rice & Beans, veggieburgers, eggs, etc.

It sounds like one of those "punish you because you're fat" ideas. In other words, she doesn't know either. I'm sorry that you have to put up with that.

That baffles me, too. I wish someone who has a doc who does this would ask them and post the answer. Ditto for the extensive post-op liquids - I can see a short time on liquids (tho some docs don't even do that,) but the stomach is muscle and while it does need some rest to heal, it also needs exercise to heal as well like the rest of our bodies. My suspicion is that this harkens back to RNY practice, where the structure and function of the remnant stomach is quite different.

If you're not familiar with them, look up the Merry Wives of Windsor. "The Swallow" should tickle your surgeon, if you don't mind a bit of laughter in the OR. Drunken Barmaid isn't bad, either.

I've played with these things for years, since my wife rejected them after her DS and I started mixing them into my instant breakfasts. At the moment I have settled on the EAS chocolate powder that's available at Target and many other places, as I find that is has a fairly delicate flavor (including any objectionable "protein" taste, at least to me) that can be boosted as desired with a little unsweetened cocoa or SF chocolate syrup depending upon level of sweetness desired. I use the unjury unflavored powder for non-chocolate use but that's an online order - I would give the EAS vanilla flavor a try based on how their chocolate works for me. I also use the powders to add to SF Jello pudding as a high Protein snack - sometimes I add greek yogurt instead for a little different flavor blend. I haven't used the powder with yogurt itself since adopting greek yogurt as my standard as that is plenty high in protein for my needs (about double standard yogurt, 20-22g/cup). The unflavored powders can be added to jello for use during whatever clear liquid phase you may have (mine was only a day pre-op, so I didn't use it much). Good luck and enjoy the journey, and particularly the destination.

I'm not quite as much of a lightweight as you at a 40ish BMI, but close; these have been my thoughts in going thru this as a relative lightweight. With the band you have less to worry about in the losing too much department, and may not lose enough; and there is the higher risk of complications down the road with erosion and slippage problems. The bypass presents you with a lot of long term lifestyle limitations (malabsorbing minerals, inability to use NSAIDS for pain relief, dumping prospects, dietary restrictions for the pouch to name a few) that probably are not worth the trouble for the amount of weight you have to lose. Some people report losing beyond goal with the VSG, but not specifying what those goals were and if they actually wound up losing "too much". Most people find that there are enough "sliders" (foods that just slide on through) that they worry about eating too much despite the restriction, but I don't think that it is that much of a problem if you can adjust to having a sane diet (and some exercise with it) long term - a lot of fruits and veg are sliders as well as twinkies and chips, so it's largely up to you how you balance things out once in maintenance mode. You can also discuss this with your surgeon (or prospective surgeons if you haven't settled on one yet) as there is still some controversy within the VSG world as to how big to make the sleeve - too small and it is thought that there is excessive reflux problems while too big and it is thought that weight loss and regain resistance may be inadequate (but they really don't know as they are all waiting on more longer term - 5+ years - data to confirm their assumptions). If possible, find a surgeon who has as much VSG experience as possible - 500+ procedures is best - as he will have a better feel for how different patients fare with the sleeve and how best to tailor the sleeve for the individual. Good luck on the decisions,

I can certainly understand the rationale for a pre-op diet in reducing calories, improving liver condition and getting used to the post-op hi protein routine, (though my doc never used one,) though the logic of the extensive liquid pre-op diet still escapes me. I can see more negatives to it than positives.

I think that what you may be seeing is a mix of comfort with a greater variety of foods along with the old discipline issue on the sweets front. At 75 lb down, you are in the 70-75% of excess weight lost range that is average for the sleeve, but at only a year out you still have some time left in the typical 18 month weight loss window - many people do beat the averages and lose all of their excess weight with the sleeve. Are you still fairly restricted if you have only meat at a meal - on the order of 3oz or so? That's my typical test for capacity and restriction - even though I can eat much more of other things, the so-called sliders, I try to make that an advantage rather than a problem by willingly having more veg and fruits to balance out the Protein rich meats, and avoiding the empty calorie sliders. I can readily (comfortably full rather than stuffed) have 6-7 oz of salad including a couple ounces of meat which is a nice balanced meal, but if I have only the dense meat my limit is still about 3 oz, give or take a fraction depending on the meat. Are you still tracking your intake (if you ever did)? I find that that still helps in keeping my mind on what I am eating, and can highlight how much damage the sweet cravings may be doing (be honest with yourself!) As is noted many times on these forums, the sleeve is still just a tool, and you have to learn how to use it, particularly in the long run; it can still be defeated by drinking calories or even letting them slip past in high calorie sliders. Also, while it's good to keep an eye on your carbs, despite your sweet tooth, how is your fat intake doing - that still counts despite low carb being the fashion of the day. At 9 calories per gram versus 4 cal per gram for carbs and protein, they can sneak up on you quickly, and the overriding factor in our weight control is still calories in versus calories out - it does no real good to limit carbs in the effort to burn fat sooner if we throw a bunch of fat back into our stores; we really need to watch all of it, even if we "only" have a particular weakness for one or the other. This gets back to the tracking discipline to help make sure things aren't slipping past us. Another issue that may be coming into play here is that the exercise that you have been doing all along may not be doing that much good anymore, at least on the caloric front - as you lose the weight, the exercise becomes easier and of less value, even if you feel that you are still working as hard as you ever were. It can really sneak up on you. I don't do a lot of walking since the first month or so (at least not as "purposeful exercise"), preferring the gym and swimming, but I noticed that sometime between the second and fourth months my heartrate when walking as fast as possible, just short of a jog, had dropped from 130ish (in the healthy cardio range of 80% of max heartrate for me) to barely 100 - it still seemed like I was working as hard as ever, but I really wasn't. I can still get that exertion level when swimming, but I have to work harder, and keep reminding myself to do so. On the diet pills front, I would check with your doctor on that - most of the infomercial pills are near worthless and can be outright dangerous while the more legit pharmaceuticals, prescription and OTC, have some value in certain cases, but I suspect that with the restriction that we already have with the sleeve, that their value would be limited; but it's worth a chat with a doc who knows you and how those drugs work. Good luck with it all, things can be jump started and you can get back on track,

I can't add any specifics about that kind of band, but with the current crop of bands it does seem to be fairly common for the revisions to be staged with the removal done in one procedure and then the sleeve done in another procedure some weeks or months later to allow the stomach to heal from any damage that may have been done by the band. I don't know how many are planned that way versus decided upon when the surgeon gets inside, but there is a band to sleeve forum here where you should be able to get some general insight on that issue. Good luck in making the change,

Neither my wife nor I had any major problems and recovered normally. I was outpacing her on the walks within the first week, though I was relatively fit and healthy pre-op. The second week had me down some with lower GI problems (body couldn't make up its mind whether it wanted to have diarrhea or be constipated.) I never had any particular issues with self care, though my wife had a harder time since she wasn't in as good a shape pre-op (she was a BMI 60-65 range, I was about a 42 and a semi-gymrat). She found a battery powered portable bidet unit that helped her quite a bit with toileting, given her size and post-op stiffness, I would expect that five days would normally be enough outside help, but that's another of those variables where some people may drag on longer. We do know people who have had some complications (going to the support group meetings for eight years, you do pick up on the occasional problems some people have,) and perusing these various forums you hear of the occasional person who was in the hospital 5-6 days or more with a leak or obstruction. Relatively rare events, but something to be prepared for in the unlikely event something like that does happen. We have no experience with drains after WLS as our docs normally didn't use them for their WLS procedures (I'm not sure what the differences between surgeons and techniques are where some use them while others don't,) though my wife did have several after her reconstruction surgeries where they are commonly used due to the large volume of incisions involved.

It's great that you are going on this journey together, considering the difficulty some couples can have when only one is going through it (whether the other spouse needs it or not!) My wife and I started on it together as well, though our paths diverged along the way to our destination (we wound up being six years apart, but that's another story.) My general philosophy on this, and one we discussed when starting out, is to plan for the best, but be prepared for the worst - what happens if one has a particularly difficult time, either with the surgery and possible complications, the immediate recovery in the hospital or shorter term post op issues at home (first couple of weeks or so.) Our thoughts when contemplating this issue was to schedule things maybe a month apart. That way the later spouse can help the first one out of bed, our of chairs, toileting, etc. as may be needed (usually shouldn't be a big deal, but people differ in how they respond to the surgery and how quickly they bounce back.) The recovering spouse may not be too eager to be cooking (such as it is, post-op) or preparing meals, going to the store, driving to the doctor if needed (or the ER - hopefully not.) etc. After a month's time, the first spouse should be recovered enough to take over those chores, and if not, the second spouse's surgery can delayed if needed. Good luck on your collective journeys - it's a great thing for a couple to do (even if not at the same time!)

I haven't had my sleep apnea formally tested, but it's still there to a much lower degree based upon the wife test and how I feel. It's much better than when I checked it a couple months ago.

It all depends on what your doc's program specifies and defines as mushy or soft protein; there are so many variations between programs that it's hard to generalize. I didn't have a "stage 1, stage 2, stage 3, etc." type program but a farily simple first month (puree and soft proteins) and then second month and beyond (everything else) with some overlap as tolerated. My plan didn't specify ground beef the first month but tuna and other fish and veggieburgers were on plan - fish are generally flakey enough that the stomach doesn't have a lot to do to process them so they are often considered to be "soft proteins" like eggs and yogurt. Ground beef makes some sense from the same perspective, though some people can't tolerate ground beef for a while (when my wife was having problems with ground beef after her DS, the surgeon suggested filet as being better tolerated, though this was well beyond her first month at the time.)

That depends upon whether your doc has you on one of those low carb diets or not. The most important factor is the caloric deficit (calories burned minus calories consumed) while the composition of those calories is a minor point (beyond the minimum protein levels.) Your drinks and vitamins are less than 50g carbs per day which is still low, though not as low as the dedicated low carbers like to see. But protein is by far the most important thing and all through this weight loss phase we are making compromises in our diets to accomodate our weight loss goals, particularly early on when we are so very limited on what we can eat. Not getting in the requisite protein and Water will screw up your weight loss and health big time, while a few extra carbs will not do much of anything.

It is very common to have no pre-op diet, just as it is common to have one - it depends upon the surgeons' preferences.. I don't know of any survey as to how many docs do a pre-op diet versus those who do not, but both are common practices. I didn't have a pre-op diet and have done just fine - I'll be hitting goal weight around month 6-7. Some docs insist that patients lose X amount of weight pre-op or they won't operated, while others who use a pre-op diet just want patients to be low cal and/or carb and hopefully lose something as they feel that it helps with the patients' liver condition (since the surgery is going on in close proximity to the liver.) My doc is a liver specialist aside from his bariatrics and doesn't do a pre-op diet - I guess that he works with livers in much worse condition on the other side of his practice. Some docs use a liquid only pre-op diet (though I could never understand why,) while others just go restricted calorie or carb and hi Protein. It's just one of the program variations that we see, and is one more factor that can be considered when choosing a surgeon (though a bit late for you now,) - some people may not feel that it's worthwhile while others may find it helpful. Another variation that you will find as you progress is the wide variety of post-op diets from extensive liquids for weeks to puree/soft Proteins from the start progressing to firmer foods as tolerated. Some docs are high on the low-carb forever fad while others go for the basic hi-protein but otherwise balanced nutrition philosophy. The two common factors that they all have is protein first, protein first, protein first and sip,sip,sip your Water most anytime that you aren't eating or sleeping. Goodl luck with your adventure,

My program is also a mushy/soft Protein for the first month (tho we don't have ground beef on the list, just veggieburgers - I'm jealous!) Beyond what you listed, I have oatmeal and cream of wheat on the list in addition to grits, wheat germ can be sprinkled onto lots of foods for extra protein, yogurt (greek yogurt by preference as it has more protein,) Healthy Choice soups, tofu, soybeans, tempeh, rice and Beans, egg or soy noodles, Peanut Butter, liverwurst, pate, hummus. I extrapolated from that list and had some homemade chicken noodle Soup (dark meat chicken is on our second month, but I tried a bit of it first and it went down well) and french onion soup (broth, cheese and I figured that the bread/croutons are so soaked with broth that there's minimal expansion risk.) I added Protein powder to the SF puddings to boost the protein, and later substituted some of the milk and powder for greek yogurt for a taste and texture change. Good luck with it all, and yes, it does get boring (but not as bad as for those on liquids for another month!) I haven't had any of the soups since that first month - gee, did I get tired of them?

You might be ready to progress, but it really depends upon what your doctor's program states - those are your default instructions. My program was puree and soft Proteins (and liquids as needed, of course) from the outset, so things like rice and Beans were on the menu the first month as tolerated; other programs call for liquids only for an extended time. It isn't particularly clear why there is such disparity between programs, whether some docs are more cautious due to inexperience with the sleeve and draw from their RNY experience on post op diet requirements, or if there is a difference in the surgical techniques used to make our sleeves that allow some patients to progress more rapidly than others. My doc's practice has been doing sleeves for about twenty years, so I have confidence that they know what is required for the care and feeding of a new sleeve (or at least their sleeves.) Maybe your docs don't have the confidence in their sleeves yet to allow more rapid progression, or possibly they have had some negative experiences with more rapid progression - I would not contradict their opinion on their work as they know what they have done to your insides. If you are on one of these liquid intensive post op programs and feel that you are ready to go further, discuss it with your doc or their staff. People progress at different rates and their program should reflect that. If their practice is fairly new to the sleeve, they need the feedback to learn how to tailor their program to the needs of sleeve patients (my doc's guidebook has a section in it on "what we have learned from our patients".) Good luck with it all - I know how tiring Soups and the like can get in a short time.