RickM

Perhaps there is a support group meeting that is closer to you, one from another surgeon maybe? The group I go to, which is a local meeting for the practice that's 6 hours away, attracts people from other practices including a couple of RNYers who don't like their doc's group or have time conflicts with it (my doc doesn't do RNY's) and the group leader is from another surgeon who is too far away. I don't see a lot of the coddling and agonizing over slow loss for obvious reasons, as Tiffy notes, in this group, though at this point much of this local group are long term post-ops 5-10+ years out, so their issues are somewhat different than initial post-ops. Much or their emphasis is on nutrition, supplements (which forms and subgroups are most useful and bioavailable, etc.) and Probiotics. The local group leader likes keeping up on the latest research on these topics, and the program director occasionally recruits him to present at the main practice meeting up in San Francisco. I've been going to it for about eight years now, first as pre-and post-op support for my wife and then for my own surgery. There's usually something worthwhile to pick up from it. It's also about an hour away, but is at a restaurant that serves decent fare (not one we would go to on our own, but acceptable) so it makes as worthwhile night out with my wife and semi-friends (as we've known most of them long enough!) I would certainly try to find a group that has a lot of other VSGers in it as one from a doc who mostly does bands or RNYs will probably not be as helpful.

Trader Joes, if they have invaded your area yet, has a good one that's uncured, 6g protein, 0.5g fat, 30 calories per 1 oz precooked slice. I haven't found anything in the supermarket brands that touches in for nutritional density.

The basic government guideline is 2400mg per day max, though there is no real minimum amount of sodium needed (at least until you get into serious endurance athletes who can lose too much sodium to sweat.) The typical American diet handily exceeds that amount, which is why it is such a concern amongst those who are concerned about what other people do. With our limited (by volume, if nothing else) diet, I am comfortably meeting that number, despite routinely having turkey sausage or bacon for breakfast. Something on the order of 1300mg per day or less is used for those who need to reduce their sodium intake for blood pressure or other medical reasons. The other side of the sodium coin is potassium, in which the typical American diet is usually deficient. Sodium and potassium work together to control Fluid flows thru the body, specifically in and out of our cells. Our legacy diet (when we were all hunting and gathering in the bush) typically had around five times as much potassium as sodium, and that tends to be what our bodies prefer. The modern western diet tends to be the reverse of that. Recommended potassium intake is 4700mg per day which I used to routinely hit pre-op, but am only getting in 30-40% with my limited volume post-op diet (fruits and veg are thegenerally the best dietary sources) so that is something that I am watching with my labs - potassium is difficult to supplement without prescription. The sodium intake is certainly something that should be watched with whatever tracking tool that you are using (you are tracking your intake, aren't you?) and this is as good of a time as we will ever have to get a handle on it before our doc (or cardiologist) sometime in the future tells us to cut out the sodium. Much of the sodium in our diets comes not from salt or what we think of as salty foods, but from the processing of much of the packaged foods we eat (as in MSG - monoSODIUMglutamate - and other preservatives), so that is part of the reasoning behind the movement to avoid packaged/processed foods. It has not been something that I have agonized over, but is one facet of my general move to a healthier diet - I was decent pre-op other than volume - and am seeking to improve that long term as part of getting into maintenance mode. Yesterday I was at 1600mg sodium, of which a third was those breakfast sausages (and was surprisingly at the 50% level on the potassium - maybe my efforts are working if things are improving without specifically thinking about them.) Good luck on your journey, and congrats on your friend's results with the band - it sounds like she should have some useful advice that is transferrable to us.

A typical day for me in the middle to end of the second month (and actually not much different today) is: Breakfast - 3 turkey sausage links (15g) or strips of turkey bacon (18g) AM Snack - 1/2 cup greek yogurt with raspberries and almonds (13g) lunch - salad including about 2 oz leftover meat (tri tip, filet, chicken, etc) and 10g lite cheese (20g) dinner - 3 oz light meat chicken w token veg (peppers, onions) w 1/2 oz lite mex cheese blend (must have been fajita night) (28g) Eve Snack - 1/2 cup hi pro SF pudding (ok, it has some Protein powder in it, and greek yogurt) (12 g) Total of 91g protein, 850 calories and two nominal servings of fruit/veg for that day, and coincidentally within the magical 40g carb limit that some impose upon themselves, though I don't control to carb count. I often do still have a Protein shake in the afternoon of heavier workouts, but that's more for workout recovery than meeting the protein bogey, but does mean that I can have a more veg intense dinner.

I think that the variation in advice stems from the differing experiences and backgrounds of our surgeons - some have noted their docs as not caring about the nutritional aspect of the plan, as they are the surgeon and that's the nut's job. My doc is one who is in the no alcohol at all for the 12-18 month (or whatever it takes) weight loss period camp (which also gets brought up in the psych eval - can you give up drinking for a year or more?), and that comes from his experience as a liver transplant surgeon, which he still does along with the bariatrics. Needless to say that he is a bit anal about liver health. His view is that being obese, our livers are in bad enough shape to begin with, add to that the load it has metabolizing all of the fat that we're losing, so you don't want to give it any more to handle in metabolizing alcohol. Other surgeons don't have that perspective, but may bring other experience to the table (hence, you find some docs heavily into the no carb trend while others stick with more classic balanced nutrition concepts.) I do find it curious, however, that my doc doesn't go in for the intensive "liver shrinking" pre-op diet that seems to be so important to some docs. These program variances may be disconcerting to some, but on the other hand, it does give us some choice in programs when choosing a surgeon.

It isn't an essential part of the process, but more of a preference on the part of your surgeon. The extensive pre-op diets that some docs impose doesn't really shrink the liver, but is said to help reduce the fatty/slimy coating that is often present on us fatty liver/obese patients. My doc doesn't do the major pre-op diet program, just the day before clear liquids bit, but then he also does liver transplants aside from his bariatric practice, so I guess he is used to dealing with livers in crappy condition. He said my liver was in good shape when he was in there (and I gained a little in the weeks leading up to surgery, for what that's worth!)

The saltines are often suggested as helping with stomach upset. As with your pharmachist's thoughts, I take meds that need to be with food just before the meal with water. I routinely take an omega horse capsule which really needs to be taken with food to avoid thier fishy recoil, and that works well for me.

We never had to do the weeks of liquids, but ground meats can be a problem for some. My wife had a problem tolerating ground beef for a long time, and our surgeon suggested ("prescribed" in our vernacular, now) filet as often being better tolerated than ground beef. After six years (for her, four months for me,) we still use the excuse of going to Outback as having to fill her "prescription." Likewise, the higher fat cuts are often better tolerated at first - dark meat chicken is moister than light meat, etc., though long term, of course, you want to stick to the leaner cuts as dictated by basic nutritional sanity.

I never had much problem with Protein, (they were telling me to add veg to my diet by day 10) though it does seem like you are having some overall eating problems. I understand the problem with tolerating the taste of Protein shakes, though there are many different kinds out there, and some taste better than others (and taste is such an individual thing.) - I find the EAS protein powders work for me as they have a relatively mild flavor that can be built on with additions (see below.) My wife had similar problems after her DS as she couldn't drink a lot either, so the protein powders had to be so concentrated that they were gagging. There are several possible things that you can do: Mix the powders with other things with stronger flavors - the Instant Breakfast suggested is a good start, but I boost the protein by mixing an envelope of Instant Breakfast with a scoop of Protein powder and 2 cups of milk for two servings - that significantly cuts the Protein shake taste; adding a little unsweetened cocoa to the mix deepens the chocolate taste with an insignificant calorie/carb addition. SF Hersheys syrup can be used for the same thing. Greek yogurt is a great protein source - 10-12g per half cup of plain, and can be sweetened to taste with your favorite sweetener, or even a bit of jam or SF syrup for flavor. I typically have it with some raspberries, granola, chopped almonds and wheat or oat bran to add flavor, texture, nutrition and Fiber. The SF instant puddings work well - I found that the classic hi-pro recipe of adding 2 scoops of protein powder to the 2 cups of milk and pudding mix still left a bit too strong protein powder flavor to it, so I substituted a cup of greek yogurt for 1 cup of milk and 1 scoop of the powder - that dropped the protein powder taste into the background, though added a bit of the yogurt tartness that some may not like. Peanut Butter is often suggested, and usually goes down well, though as with most plant based Proteins, it is an incomplete protein and should really be eaten with a complement like whole grain bread or crackers to complete the protein (which may not help you at this stage.) unjury makes a chicken soup flavored protein powder that you may tolerate, especially if you mix it with real chicken soup or maybe mashed potatoes. Good luck with it all - believe it or not, it does get better!

NSAID use is one of the classic reasons for getting a VSG or DS over an RNY. The main reason I have heard sited for RNY intolerance is that the portion of intestine that they join into the stomach pouch is not designed/evolved/created to be exposed to stomach acid, so that suture line never really heals fully so it doesn't like the added irritation of the NSAIDS.That's not an issue with the VSG, DS or bands.

My wife lost about 210 from her DS, and had another 14 removed with the lower body lift and didn't get a figur for the thigh lift.

Nexium was created as Prilosec was going off patent by slightly tweaking the molecule to make it different enough to patent (so it could be sold exclusively at elevated prices). It works in the same way as Prilosec and with rare exceptions, works as well as Prilosec/Omeprazole (except that it is the pretty purple pill...) If the cheaper, OTC Omeprazole works for you, Nexium provides no additional benefit.

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If you are not particularly a drinker or wine person, grape juice is supposed to provide the same health benefits, anti-oxidents, etc., as wine. Similar amounts (a 4-6oz glass) are fine for the same reason - limiting the excess sugars/calories while getting the proper amount of benefit and lessening the load on your liver during weight loss (some of us are on programs that avoid alcohol altogether during the weight loss period as our livers are already heavily taxed metabolizing the fat that we are losing - can you tell that my surgeon is also a liver specialist?) Addendum: any of the plant based foods with similar colors will have the same healful components - grapes, raspberries, blueberries, strawberries, etc.

San Francisco has a cluster of some of the best bariatric surgeons in the world - Drs. Rabkin, Jossert and Cirangle - all in different practices (though Jossert did train with the Rabkins years ago,) and all with extensive experience and long lists of satisfied patients. Many people travel extensively to be worked on by one of these guys (I came up from LA to Dr. Rabkin - my wife's DS was a self pay several years ago, though my VSG was insured). Check into them all, as they each have somewhat different programs, one of which may make fit you better than the others, and their self pay rates will vary some as well. None will be as cheap as going to Mexico, but they all give pretty extensive post-op support and follow up as part of the service. It's hard to go wrong with any of them. Good Luck

Everybody is somewhat different in what they can tolerate when. My doc''s program is pretty liberal (mushy/puree from the hospital, no big liquid only phase) with the admonition to experiment with small amounts of new foods, one at a time. If something doesn't settle well, try again in a couple of weeks.

It's not that unusual for those who don't have insurance coverage for WLS (or cosmetics/reconstruction, either.) There are many good doctors around the world, and most countries don't have the legal cost drag on their systems; the trick is finding them, and this is where sites like this one or obesityhelp are useful as part of that research. Many people go to Costa Rica or Brazil for cosmetic/reconstruction surgery where there are a number of renowned surgeons in that field. When my wife was going thru her DS journey 6-7 years ago, Spain was the major non-US alternative for that, and Dr. Baltasar was (and still is) one of the top DS surgeons worldwide. Mexico wasn't really an option then - they were not as big in doing WLS procedures for US patients then, and I'm not sure if I would go to any of the docs there for a DS, though the simpler VSG seems to be fine. Ultimately we went to San Francisco and self paid with Dr. Rabkin for her DS - for us, the cost savings from going to Spain once all the travel and lodging costs were figured in wasn't worth the added risk and hassle of going overseas for a procedure such as hers. Mexico has lower travel costs and the stay requirements aren't usually as long as they were for the DS in Spain, so the case for a VSG is much more compelling now. Still, it pays to shop around as there is some comfort in staying domestic - from what I have seen, my doc's program (one of the best in the business, though we didn't self-pay this time as our insurance covered my VSG with him) in SF is only about 2/3 the cost of the Alabama program quoted here, but that's still a lot out of pocket, and you still have travel expenses, but it does show the variation in pricing.

If you dig through the Aetna website you can find their latest WLS policy bulletin on what is required - it's in reasonably plain English - or your surgeon's insurance coordinator may be able to lay their hands on one. When I went thru this earlier this year I needed either a 6 month Dr. supervised diet/exercise program or a 3 month program thru the surgeon (which my doc doesn't do.) I did the 6 month program with my PCP with a couple of visits with his associated nutritionist. I didn't get in monthly dr. visits as implied in the policy bulletin - scheduling issues made it more like 4 visits over the 6 months. I'm not sure about the 2 yr diet history (perhaps weight history is what they mean?), I didn't supply it specifically, but the data is in his records that were submitted. The pulmonary and cardiac clearances are requirements of your surgeon depending upon your medical history (I did neither); the support group meetings, pre-op classes and psych evaluation are likewise your surgeon's requirements, but are typical. Aetna is notoriously slow in approvals, but they shocked the insurance coordinator by approving within a week or so (though they are still dragging their feet on paying the surgeon's fees after 4 months) I didn't lose any notable weight during the 6 month period, but continued my long term stall (which is why I needed the surgery - hello!) I actually gained some in the time between approval and the surgery with the serial last suppers out while doing all the requisite pre-op med appointments.

Tiffykins has a good point by point response to this list. I would further break down the list to those issues that are VSG specific and those that are general to all WLS procedures, or rapid weight loss in general. The chronic GERD and possible twisting of the sleeved stomach are the only ones on the list that are really VSG specific. When you start looking at procedure-specific side effects, the sleeve starts to stand out from the others, and it's easy to see why it's gaining popularity. Issues that may be important to some is the general requirement by most WLS surgeons that patients stop smoking and drinking alcohol before surgery and for some variable period of time post-op, and that alcohol tolerance may be reduced long term. Another "issue", of sorts, to note is that all of the WLS procedures take some lifestyle changes and committment, which vary some by procedure, to be really effective long term - none of them are cures unto themselves.

Absolutely. I wasn't going to lose the weight in any other sustainable manner. I got part way there with the typically advised lifestyle adjustments (have been a semi-gym rat for about eight years now, combined with maintaining a sane balanced diet) but couldn't get over the volume requirements my body was making, despite eating primarily high nutritional density foods. The only change I would possibly make is to take the VSG as part of a DS if I find that I can't maintain the weight loss, but that is something that I won't know for several years. Many of the most common "issues" people have with the sleeve, such as constipation, diarhea, and gas, are as much a function of the dietary changes imposed upon us as they are a result of the sleeve itself - our bodies get used to what we were eating (all those little buggers in our gut that promote digestion,) and major changes to our habits often result in such symptoms until our bodies adjust. Other issues are common to all WLS, and different individuals have varying responses to the trauma that their stomachs have experienced - whether that trauma is the result of being sleeved, pouched or banded. Surgical complications such as leaks can occur with any of the common procedures; less so with the bands, but they have a much higher rate of other problems down the road due to slippage, erosion, etc. The only real issue that seems to be more common in the sleeve than in other procedures is reflux; the other procedures all have a longer list of issues, many of them more severe than what is typically seen with the sleeve. Yes, I would do it again.

Walking from the day of surgery, of course - as is the recommendation of most surgeons. Started back into mild strength training, avoiding ab/core work, after the third week - used the machines to better isolate muscle groups and dropped weight to about half the pre-op level; got back into ab/core work after twelve weeks. Resumed swimming after about five weeks (had a tempermental incision that continued weeping a bit for a while.)

The companies that make the lap bands (Johnson & Johnson and Allergan) lobbied the FDA to get the BMI lowered to 30 for their band products; whether or when the insurance companies will follow that recommendation is anybody's guess. As far as I know, the standard 35/40 BMI standards still generally rule amongst the insurance companies for general bariatric surgery approval, with some companies demanding higher BMIs for some procedures (including the VSG, strangely enough.).

The white meat has a litle more protein than the dark meat, (around 15% more,) along with about half the fat (4 vs 8g in 100g roasted) and about 15% less calories. Overall, not that much of a difference, particularly at the amounts that we can eat. Dark meat is often better tolerated by our sleeves early on due to it being moister, but I haven't noticed much difference between them in my tolerance.

I am in somewhat the same boat as your husband - if I get down into their recommended weight range for a large frame (by some measures I am a medium frame, others would say large,) and my 5'10" height, I would have to lose an excessive amount of muscle mass and/or get into the seriously athletic body comp - which wouldn't be all that sustainable long term. I use an impedance scale (a Tanita) for everyday body comp measurements, and will get dunked again when I get into my goal region (about another 30lb to go for that). I was dunked a few years ago after I had lost some of my problem thru classic diet/exercise efforts and it correlated well with the Tanita. But my wife, who had lost around 200lb with a DS and had lots of excess skin hanging around (lost another 10-15lb when she had reconstruction surgery later) had readings that didn't make much sense. She was reading about the same 34% fat mass that I was at the time, and well above the average Tanita readings, but there is no way she had that much fat on her (even though women are supposed to be carrying more). There just isn't/wasn't that much fat on her, even in the places women normally carry it!

It is certainly something to discuss with your surgeon (and maybe the psych, too,) and get their views on the pros and cons of it. Sleeves are not made the same size- there is some controversy amongst the surgeons as to how big to make the sleeves - too big and weight loss may be insufficient and regain may be more problematic, while too small and reflux can be a bigger issue. They're waiting for more 5 year data to provide more guidance. As is often the case in this world, this may not be a simple case of more (restriction) is better. You may not actually need the smallest sleeve, which may be more appropriate for someone in the 50-60 or more BMI range; a somewhat larger sleeve will probably allow you to lose all that you need to lose if you eat reasonably well with it, and a smaller sleeve may not help you if you don't. Also, the sleeve may not be the right procedure for you. The duodenal switch, for instance, often provides better loss (which you don't really need at your moderate condition) and also better resistance to regain. It tends to allow one to eat more normally and somewhat larger quantities (it uses a larger version of the sleeve as its basis) while still keeping the weight off. As always, there are tradeoffs to consider carefully. Of course your surgeon may not make such a suggestion if he doesn't do them. I chose the sleeve because I have not had major regain or yo-yo issues and had already made substantial lifestyle changes which helped keep my weight fairly stable, but volume was still an issue keeping me from losing more than I was able to "the old fashioned way". YMMV The major "cure" that comes from any of these surgeries comes from the lifestyle changes that you make, which the surgery helps you make. At your moderate size, most any size sleeve will likely provide enough restriction for you to be successful - even the smallest sleeves can be defeated if you drink your calories. The RNY typically leaves a smaller stomach and more nominal restriction, but regain is still a problem with many RNYers. It can be a tough decision deciding which procedure is right for you, as none of them are a silver bullet that will cure all. They all take commitment and a willingness to make changes, though these are somewhat different for each procedure.