RickM

One note here is that lab tests, and what counts as low normal or high, can vary from one lab to another depending upon what precise test is done, reagents, etc., so what is just "low" in one place can be "critical" in another. Also, having it done in a hospital may bias the action some - since you're already there (and maybe they have beds to fill) they admit your, whereas if you were in the doctor's office or at home when the results came in, she would just send you home with an Rx. I suspect that your surgeon wasn't overly concerned about the diuretic because the small amount used in the blood pressure meds (usually HCTz) doesn't have that much of an effect. There are some potassium sparing diuretics that can be prescribed if they are hitting some other water retention problem with heavier doses. IIRC, I was on an BP med that included HCTz and it wasn't an issue, though your PCP may want to reduce your dosage, or take the HCTz out, in anticipation of falling BP levels as you lose weight; my PCP was somewhat aggressive in dropping BP med levels, preferring my BP to be a bit high than fall dangerously low (as can happen sometimes with rapid weight loss.) My wife is chronically low on K - nothing to do with her DS, just her - so we have been playing with this for a long time. Normal OTC supplements don't really touch it as the legal FDA limits are so low (3% RDA, or 99mg) as to be useless. She now dissolves here K tablets into her daily smoothie (which also gets some of her calcium citrate added, too) which is also K heavy - tangerine juice, banana, starwberries, kiwi sometimes, so dissolving the tablets in something is a workable solution - just make sure it is something that you drink slowly as it is otherwise a time release pill for a reason. The best non-Rx source that I have found is the low sodium version of V8 juice - an 11 oz can has around 1200 mg in it. Overall, hydration seems to be the biggest factor, and as has been noted before in these forums, is the quickest way to get put back into the hospital after WLS. A friend of ours got food poisoning on a trip across Canada a year or so post op (dehydration is one of the worst side effects of that) and by the time they got to Nova Scotia, he could barely get out of the car. The ER docs there told him that he had the lowest K level they had ever seen on someone still living (IIRC is was in the 1.x range), so take your hydration seriously.

This is something of a tricky situation, and the real experts would be your surgeon and your gastro getting their heads together on it. I'm not that familiar with your situation, but implicitly, there is some imbalance between your stomach acid and bile, and how they neutralize each other. Normally, your stomach acid is neutralized in your duodenum, (the part of your intestines immediately downstream of your stomach where the bile ducts enter the picture.) That will remain the case with the sleeve, as that part of the anatomy remains unchanged. Speculatively, it might improve things as with the sleeve we have some tendency to over produce acid (the stomach volume is cut down much more than the acid producing potential of the stomach) so this might better neutralize the bile secretions. With the RNY, the stomach is divided into two, with the small pouch that produces some acid connecting downstream of the duodenum, and the larger blind remnant stomach remaining in its natural place just upstream of the duodenum, wiht its acid still there to neutralize the bile secretions. The route from the duodenum down to the rectum will be a couple of feet or so shorter as the roux limb is brought up to the stomach pouch, and what acid secretions that you get from the pouch will be introduced a bit farther down. Another consideration to look into (ask your doctors) is the prospect of bile reflux - the opposite of what you are having, where it goes back upstream into the stomach and above. The RNY, and other allied procedures such as the mini-bypass and SIPS/SADI, have some predisposition toward bile reflux. This isn't usually a problem with the way RNYs are constructed these days, but it may be a consideration if you are starting out with an imbalance (again, this is amateur speculation, but talk to your docs about it.)

Some classic soft foods that are good for this would be oatmeal, cream of wheat, unsweetened apple sauce, refried beans, greek yogurt, and mashed potatoes (lace them with some unflavored protein powder to help your protein goals). As you noted, you don't need to do much carb loading, and it may be a while before you get toward 100 g, or even need to, but this will help with your energy levels (some surgeons specifically want their patients to do a bit of low level carb loading for this very reason.) As you have found, it can be hard to fit in much good, complex carbohydrate at this time (and some people actively avoid them owing to current diet fashions,) but that is part of why many experience low energy levels for quite a while after surgery. Most chalk it up to "you just had major surgery..." which is a factor, but mostly it is their diet.

My wife was a twenty year diabetic, just short of being insulin dependent on about the strongest drug cocktail of the day when she had her DS, and it took her the better part of a year to be fully off of all meds for it, and 16 years later is still in solid remission. The doc told us that this is fairly typical, that the longer one has been diagnosed/under treatment, the longer it takes to fully go into remission. This is just a gross generalization, as we see many in these forums who walk out of the hospital free of meds and insulin with only a VSG or an RNY, so there can be a wide variety of responses. Your DS, particularly the "traditional" BPD/DS, is indeed the strongest tool against diabetes - our doc's experience is in the 98-99% remission rate area, which should not be too surprising as it started as a surgical treatment specifically for diabetes, to which the sleeve was added to make it a weight loss procedure. It also seems to be the most enduring procedure for it, as it seems to usually stay in remission even with a fair bit of regain, which happens sometimes, though less with the DS than with other WLS. A few years ago we had a gal come through our support group who had been a successful RNY patient for 20+ years, (the practice was not yet doing the DS at her time of surgery) but whose diabetes had come out of remission with only some moderate weight gain, so she was back to get her RNY revised to the DS to knock it out for good. So, it is an excellent first choice for a diabetic WLS patient. Good luck in your adventure!

It's more a matter of time than stage or phase, as even those of us who never had all of those phases still experience a stall or at least a slowdown at around 2-3 weeks. So, proceed with whatever phase you are supposed to be in without worry - you will still stall or slow even if you keep doing what you are doing now,

That does seem like overkill (particularly for one who was on a soft diet from the hospital through the first month, and then on to regular foods; our basic rule was to try new foods one at a time to test for tolerance and if something didn't work, then try it again in a week or two, as people can vary widely as to how the tolerate things and how quickly they can progress. There was someone else on here recently that had a fairly slow progression, but not quite that prolonged. I think that it mostly stems from the surgeon's overall philosophy on things - some tend to be kinda one size fits all, so they pace everyone based upon their slowest progressing patients, while others may be more individualized in their treatment. Our surgeons tended to encourage experimenting, within limits, as they found that their patients did better as they moved more toward regular foods (but then recognize that not everyone can progress at the same pace.) My wife was somewhat slower to progress than I was - for a long time she couldn't drink (sip) more than her nominal stomach size in a normal meal sitting time (say a half hour) while I could down a bowl of broth (8 oz?) and a box of juice in one sitting in the hospital - both within our surgeon's normal expectation for that time.. I would just chalk it up to differing philosophies - perhaps your surgeon had a bad experience with a patient once upon a time and wants to make sure he doesn't have a repeat of it. As an aside, I have seen a couple of references to programs requiring up to six months of liquid pre-op dieting, so there are some pretty extreme programs out there.

We didn't have any pre-op diet, either, neither me nor my wife, who was around a 65 BMI; they don't require it for any of their procedures, though they do (or did) a colonooscopy bowel prep the night before - overkill for the sleeve that I had but reasonable for the DS that they routinely perform. From what I have seen, most of the legacy DS surgeons don't do any pre-op diet, either which at first seemed strange to me, given the very fiddly work that they do underneath the liver for that job, but then those who go into that end of the business tend to come from the top of the class, so it seems that they have developed the tools and skills to not need the diet. Either that, or they ate totally clueless, but their record seems to refute that, so it seems that you have indeed chosen one of the good ones - congrats.

From what I have seen, you may or may not be off of insulin and meds immediately - I think your surgeon is just being optimistic and won't actually discharge you without verifying your status. My wife was diabetic, just short of being insulin dependent and under treatment for it for around twenty years, and it took her the better part of a year to be fully off all of diabetic meds. The surgeon explained that generally, the longer one has been under treatment, the longer it takes to get off of the meds, though there are some long term diabetics who leave the hospital free of all meds, even with just a sleeve or RNY rather than the stronger DS. Her diabetes is still in remission 15-16 years later, despite some subsequent regain and losses. A few years ago, we talked to a woman in our support group who had an RNY some twenty years prior, and now her diabetes was coming out of remission with only some moderate regain, so she was in line to get that revised into a DS to knock it out for good. So, it is still very much worth getting the surgery even if you don't immediately go into remission. Note that I am referring to the "traditional" BPD/DS, which is known to have a 98-99% success rate with T2 diabetes, rather than the simplified SIPS/SADI/"Loop DS", which is not as well established.

Our program didn't have an RD at the time, so I was mostly winging it by reading and using common sense *what we know we should be doing, dietwise.) I did consult a couple of times with a fitness oriented RD that was associated with our PCP who did give some useful advice, combining my needs, her experience and the surgeon's program guides. One of the good reads that I found were some books by Dr. Michael Colgan, who is a sports nutritionist. Particularly useful is his Sports Nutrition Guide (All New! - as of twenty years ago, but nutrition science hasn't changed that much over time, only "diet science" changes with the fads.) A nice part of it is that he has a chapter 3-4 pages typically) dedicated to each micronutrient, what it does, where do we get it from, and what are the appropriate levels we need, often with comments about how specific activities may require more of this or that nutrient than average. These are quite distinct from the RDAs that we normally see published which are typically oriented toward avoiding deficiency disease rather than optimum function. He may have a newer edition (mine is published in 2002) or a follow on title - he doesn't seem to be afraid to change his views as newer validated science comes along. Check Amazon to see what's newer.) He also has a short booklet on "The Right Protein for Muscle and Strength" that is also useful, and may be a good counterpoint to some of the more promotional sources found in magazines pushing supplements.. Sorry, I don't have any particular online sources, but there are a couple of other guys on here who are more into that who may chime in on this. there is a popular notion that we see that it is impossible to build muscle mass while in the deficit required for weight loss. I don't like like words like "never" and "impossible" but I do find that it is very unlikely to do so - minimizing muscle loss during the loss phase is usually the best that can be hoped for, and then rebuilding. We did have a retired NFL guy in our doc's group who may have done that - if anyone can he would as he already knew on a professional level how to do that kind of workout (he just hated it and was glad he didn't have to do it anymore once he retired - that's why he ballooned to 500 lb and realized it was still part of his job! Got himself down to a 4% BF before letting himself go, and crept up to 6!) He also had the time to dedicate to doing as much work as he needed to, which most of us can't do. Good luck - it sounds like you are well on your way to good success. It may not be a direct route to where you want to go, but you can get there,

IIRC, I had some the day after getting out of the hospital as it was one of the things in the hotel breakfast bar to try that fit our plan. I'm not big on that type of thing but it was OK. I would expect that it would be on most any plan by this time, unless they are seriously carbophobic, but you can check with your team if in doubt, and it wasn't covered in your post op guidelines.

It likely depends upon where the hernia is. As noted, if it's a hiatal hernia, where the stomach is being pulled up through the abdominal wall, that will be repaired along with your WLS as they pretty much can't do one without the other. If it's elsewhere on the abdominal wall, then it may depend upon where it is and whether it's in the way of the WLS procedure; something like an umbilical hernia they will usually fix at the same time as they often cut through that area to do the WLS. If it's elsewhere on the abdominal wall that's not directly in their way, then they may or may not fix it; from what I have seen, they will usually fix it even if it's not directly in their way to avoid putting you through the stress of another anesthesia event and recovery. I would certainly prefer to get both done at the same time, but there may be extenuating circumstances as to why that isn't appropriate in your case, or it may just be your surgeon's preference (does he get paid more by doing two procedures?) If you have the opportunity in your health system, I would get a second opinion on it from a different surgeon - maybe he agrees with the first (ideally) or maybe he has a better idea, or doesn't have a problem doing both at once.

There is your key right there - whenever you see very rapid weight change, there is going to be a lot of water weight involved. Indeed, most of our initial loss is concentrated on water weight (it is associated with the glycogen/carbohydrate that we burn off initially,) and then we tend to pause to let things catch up before changing gears to start burning our fat reserves. We may just have a stall and not lose anything for a few days, or week or two, and we may even gain a bit as things stabilize. But they will stabilize and you will start losing again, albeit at a somewhat lower rate than before - expect that - as then you will be primarily burning your fat stores, which burn more slowly (on the order of 3500 calories per pound, versus around 2000 calories per pound when we are in that initial glycogen depleting state.)

Let the surgeon's office handle it, as it was their judgement that you needed to be there an additional day. That happens all the time - there are minor complications, or the patient isn't quite ready to be discharged so they are kept an additional day. I was only scheduled to be there one day but it turned into two; my wife had an outpatient orthopedic surgery but was kept overnight as she wasn't ready to be discharged on the original schedule. The insurance works it out with the doctors.

Things like veggie burgers, tuna and some other seafood items (usually start out with tuna salad or other mushified or lubed up version,) refried beans, etc. were on our first month diet, so it's not that far out of line - dietary progressions do seem to be accelerating some over time as different programs learn what people can actually tolerate - it's a lot more art and experience than science. Doc was adding more veg into my diet at day 10 as my protein intake was more than adequate. It's a big YMMV thing, which is why we see some programs that may still have their patients on liquids while others have theirs on steak. A bit of surgeon's personal philosophy in there as well, I suspect, as some may treat everyone cookie cutter style, forcing all to work to the lowest common denominator (one patient had problems with soiidish food at four weeks, so all must avoid that until everyone can progress together) while others are content and confident enough to allow more individuality, recognizing that patients' tolerances can vary widely. So, if you are working within your program's boundaries, all is good as long as your are tolerating things well. A couple ounces of the softish meats that are permitted at this point is not unreasonable - some may not be able to have that much yet, and others will have no problems. Likewise the veg, half a cup may or may not be too much depending upon what it is and how an individual gets along with that. Some things are more slider-ish than others, and go through with little problem, I suspect that what is considered to be "soft" even if we perceive them to be fairly solid, like a veggie burger, has more to do with how it is processed in the stomach (or not needing much processing) than how "solid" it may seem before we eat it. Most of the things in this 'soft" phase are things that usually go through fairly easily; this also means that we may be able to eat a bit more of them than we would "real" solid food like a tougher steak or pork that has to sit in the stomach for a while being processed before it is let through.

There are a lot of magical properties ascribed to IF, but from a weight loss perspective, it is a convenient way to reduce the amount of calories that you consume in a day, if you don't overcompensate by loading all of your normally consumed calories into that reduced time slot. It's much the same with any of the other popular diets over the years - cut out fats, that's a lot of calories; cut out carbohydrates, that's a lot of calories. It all comes to an end when you learn to adapt and start consuming as many calories as you were before when you were gaining.

Many don't do a pre-op diet (ours didn't) as they don't feel it provides them, or the patient, any benefit. It only seems here, online, that they are a standard practice as they are so objectionable (particularly the all liquid ones that some docs impose) that it's all people can talk about - those who don't have them have nothing to complain about so they don't post about it.

Another approach to weaning off of the PPIs (in addition to, or an alternate to the simple cutting the doses or spacing them out more is to substitute doses with an H2I class drug such as Pepcid or Zantac, or their OTC generic equivalents. They are considered a friendlier class of drug and preferred for longer term use if they do the job (they usually don't last as long.) Talk to your surgeon, but taking a Pepcid on the "off" days of Prilosec will probably remove the minor symptoms that you are feeling, then you can move on to completely substituting the Pepcid for the Prilosec, and if that works, try cutting that out, too. Just an common alternate approach that is a bit more conservative than simply cutting back the PPI dose by itself.

The third week stall that is so common signals a change in your weight loss character, from the initial loss which comes primarily from glycogen (short term reserves of stored carbohydrate) and the associated water weight to the longer term draw from our fat reserves once the glycogen has been depleted. This can take some time to shift gears (and sometimes very little.) I, too, never had a third week stall, but there was certainly a slow down in loss rate right at the three week mark (fat burns more slowly than glycogen/carbohydrate, on the order of the classic 3500 calories per pound vs. around 2000 calories per pound.) My only real stall (a week without loss, by my definition) was at about four months for a week, when I was travelling, so it was possibly a result of increased sodium intake from eating out more (I usually would gain 2-4 lb on those trips, which would dissipate within a week - classic water weight.) Why didn't we stall and others did? It might be random chance, or it might be that our metabolisms are still fairly robust, or maybe diet is not a low in carbohydrate as many maintain, so the glycogen reserves were able to more quickly return to a functional level. Whatever the cause, enjoy the ride!

Assuming that you are not anemic - iron and B12 levels OK - then another thing to consider is your basic diet and compatibility with your activities. When I was about four months out, I was routinely hitting a wall after about an hour in the pool. Working with my RD, we rejiggered my diet to provide a meal/snack ahead of the workout that was relatively high in complex carbohydrates, moderate in protein and low to moderate in fats (this is a fairly common pre-exercise suggestion.) For me, that worked out to be a small meat and cheese sandwich on whole grain bread. That made all the difference, and I never had a problem with that again. My diet before was not specifically low carb (was never into the fad diet game,) but with the small amount that we are eating during this phase, we will by default be low carb and low fat. But timing the intake appropriately, concentrating on what the body needs when, can make a difference when our activity levels are variable through the day. Check with your surgeon or dietician for other possible suggestions.

It really has nothing at all to do with what phase you are in - liquids, mushes, solids, etc., as the same general timing of loss progression happens even for those of us who never had a liquid phase. Do a search for the "three (or third) week stall" and you will see that most everyone has this problem at around this time. The majority of the weight that we are losing initially is water weight as that is associated with the glycogen (basically carbohydrate stores) that we are burning at first. Once that is depleted, there is usually a pause, and often a pound or two of water weight moves around as your body attempts to restore some of its glycogen reserves as it moves into burning you fat reserves in the longer term. There may also be some hormonal effects that play into this as well, but this is completely normal. The important thing is your loss trend week to week and month to month (which will be declining overall, but usually at a decreasing rate over time.) Day to day, it's anyone's guess and often completely random as to what you might see on the scale, so don't sweat that.

Did I try blended foods a bit early? Yes, and no. Yes, in that I did work with blended foods - strained, and not so strained, soups, and lumpier things, in that time frame, but no, as in it was not early - it was part of our normal progression to try those things from the first week out, if we could tolerate them (scrambled eggs, yogurt, pureed anything in the hospital, for that matter.) The key rule was to try new things one at a time to test for tolerance, as one may or may not be ready for it. Things like tuna salad were on our menu for the entire first month as part of the transition to all other "real" foods in the second month. And one mushy or pureed item may go down better than another, so one "failure" doesn't necessarily doom an entire class of foods. If something doesn't work, go back to familiar things and try it again in a week or two. Go easy on it, but don't fret about having damaged something if you aren't feeling anything off.

Our weight loss tends to be "front loaded" with a chunk of water weight loss when we first start a major weight loss effort (figure 10-15 lb) Most people who have a pre-op diet will see that big drop when they start it; those who don't have pre-op diet will see that big drop soon after surgery; those, while those who lost it during a pre-op diet are often disappointed that they don't see a bigger loss immediately post-op. If you are doing an earlier diet than the week or two diet that many surgeons impose, then you will likely see that big drop when you start that, but less, if any, when you start the formal pre-op diet a week or two before surgery. And, you are right, that if if were easy for you to lose, you wouldn't need the surgery, yet some, but certainly not all or even most, surgeons have this type of requirement lose X lb or % before surgery, or at least threaten to do so (guess they think that it is in incentive for you to "try your best". Good luck,

The main thing that I can think of would be improvement in diabetes issues, as eyesight is one of the things influenced by diabetes. If you were diabetic pre-op, whether you knew it or not, better blood sugar control improves your eyesight. When my wife was first diagnosed and got under medication for it, she had just had new glasses made and they were near useless afterward. I never experienced any notable vision changes after surgery, though I was specifically not diabetic before or after, nor was I under any vision care, so that was subjective observation rather than objective measurement.

Here is a good reference that I like to use - You don't need to follow his dietary guidelines, but I do find that his progression on meal volume over time is consistent with my experience. In short, some increase in volume capacity is to be expected and is normal. Call it stretching, adaptive growth (the body will adapt to the changes that surgery has imposed upon it, like it or not) or a more varied diet that includes more slippery foods that move through rather than stay in the stomach, or more likely, a combination of all three. On the volume vs. weight issue - a basic physics lesson to start with. When measuring water, an ounce of volume weighs an ounce - that is a definition and is the basis of our measurement system (similarly, a ml or cc of water weighs a gram in the metric/SI system. Most of our food is mostly water (as indeed, we are,) so on average, an ounce of food by volume will weigh about an ounce, give or take maybe 20%, and over the different components of a meal meat, fruit, veg, starch, etc. - should about average out to about one for one. Another consideration is that the important thing to your stomach is what the volume is when it hits your stomach, not when you put it into your mouth before you chew it and soak it in saliva. Once that is done, you have a blob (bolus) hitting your stomach that will be about, wait for it..... and ounce of volume that weighs about an ounce. This really saves you from agonizing over how to measure a cup of spinach - how big a leaf, chopped or whole leaf, how finely chopped, how densely packed into the cup...? Dr Weiner in the video above notes that we ultimately, on average, will be able to consume in a meal about half of what we could before surgery which is consistent with my experience ten years out, and in looking at others whom we dine with in our support group (pre Covid) who are all in the 10-20 year out range, and most every one is taking something home or leaving it on their plate, so some increased volume is normal. The tricky part is keeping your caloric intake steady as this volume increases over time - you still need to keep it at 1200,1500, 2000 calories - whatever level keeps your weight stable.

You can worry about it, but it won't do any good - you will or won't get it to whatever degree that you will. On the positive side, you are young, so elasticity should still be good and things haven't been stretched out for as long as with most of us. You are also "only moderately" morbidly obese, so things haven't likely stretched out as far as someone who was a BMI 50-60 or more. So, there is good hope that things will not be bad in that regard, though you will probably not be left with a perfect bikini bod without some work.