RickM

My program doesn't specify any numbers beyond the basic 60-80g of protein that's common to all of the programs, and the general instruction to avoid simple carbs and otherwise empty calories. I'm typically running in the 1000-1100 cal per day range, and have been for much of the post-op period and the weight has been, and is continuing, to come off at a quite reasonable rate that should be hitting goal weight around month seven; the 6-800 cal levels in some programs may be more appropriate for the ladies who should end up in the 120-130lb range and have an RMR to match, or those with hundreds to lose and need to maximize their caloric deficit to reach their goals. I don't control to carbs, fat or any of the other trendy indicators - our bodies really don't care what form the calories take as it will rearrange those resources to meet its need; it does care about getting all the amino acids that make up the proteins, and the other essential nutrients that come along with the carbs and fats that we consume, so it's better to concentrate on getting as nutrient dense and energy (calorie) light foods that we can since we are so restricted on the volume we can get in. Cutting out major food groups can have some value short term for special cases but is a long term nutritional loser.

Good for him, I'm glad he's catching up (and that shows the value of cheating, within reason, when things don't feel right.) I could never understand the extensive liquid diet requirement as my doc's program starts at mush/puree/soft Protein stage (and liquids as needed, of course) from the outset at the hospital, and they've been doing sleeves for upwards of twenty years in their practice and they obviously haven't had problems moving their patients along at this pace. Obviously, people progress at different rates, with some having trouble with liquids for a while with others able to progress more rapidly; it's good to have a program that recognizes this and isn't one size fits all. Their experience has been that patients do better with more real food, so they try to encourage that progression within the patients' ability and good medical sense.

I second kemo's suggestion of becoming familiar with the boards here, and also the surgeon's program. I went thru this with my wife when she had her DS a few years ago. Going to the support groups and doctors appointments are a big part of it, too. My wife and I both needed the help, so we were both going thru all of the pre-op business together for that reason (though her health issues made her the lead patient.) Helping to keep track of instructions and advice that may be indiviidual and not in the program books is helpful (although, for some reason, my wife didn't have any problem remembering that the surgeon 'prescribed' filet mignon when she was having problems digesting ground beef - strange how selective our memories can be!) Obviously, any physical help that you may need is essential - that's a variable thing on the amount and type needed depending on individual circumstances. She gives me a lot of credit in helping with her dietary requirements post-op. I was already doing much of the cooking, but ignoring that, helping with the serving would be a big help - I would serve up the appropriate amount for her, she would say 'that's not nearly enough!" "That's three ounces, that's all you can fit in." Afterward it was, "you're right, I couldn't/shouldn't eat any more than that...." Hint - get a digital food scale for weighing things if you don't already have one. It also helped that she didn't have nearly as much to do when I went through it this year since I was already well up on the learning curve on these things, though she does get dragged to the support group meetings (it's good for her, as a long term post-op!) Good luck with your journey, and it's much better when taken together!

Your instincts for the orange juice was probably a good one - that is often used by the diabetics to counter a dive in blood sugar as is one of the quickest absorbed forms of sugar; it's also good in potassium if that is part of the problem, though that level of symptomatic potassium deficiiency usually needs more intensive treatment. Saltine crackers are good for absorbing stomach acid - my doc recommends them for helping to counter stomach upsets, and says that if we dont have Breakfast prompty in the morning, to have a couple saltines to soak up the acid from overnight. Are you on blood pressure meds? Too much of them can cause some of these symptoms that you're having - my PCP was fairly aggressive in dropping my doses as he preferred that I be a little high for a while than risk being too low. You probably should have stuck around the doc's office, even if the staff wasn't being too helpful - if something more serious had happened they could have moved you up the priority list, or at least had you in a place where emergency treatment was close by. I don't think that my doc's staff would have let me leave if I was showing those type of symptoms - if the docs weren't available that day because they were in surgery, they would have gotten me in to see someone else, to the ER next door if they thought it was serious enough, or at least rest/hydrate and eat something until I was stable. It does seem that you have something going on here, since this isn't the first time now. I would certainly get some medical attention from your PCP if not the surgeons office, or maybe one of the walk in urgent care clinics that can do some labwork. Something is wrong, some sort of deficiency or imbalance most likely, that you need answers to.

125ish would put you into the 24-25BMI range that most docs use as their 100%EWL standard (looks good when they publish their results!) But a lot of it also depends upon you and how you are built - if you are heavier boned and somewhat muscular then higher would be OK, while someone lighter framed and leaner could be less. My goal puts me at around a 27BMI because that would put me on the lean side of normal for men (or "fitness" range by some standards) due to my musculature. Does your doc use a body composition or body fat scale when you weigh in with him? That's a good guide as to how much you should be losing, since it's the fat we want to lose, not the muscle mass.

The surgeon's and hospital's past experience does seem to make a difference, both on the outcomes of these procedures and on their expectations. My doc is primarily a DS guy, so he expects good results, particularly with relative lightweights like myself where he is used to seeing 90+% EWL as an average. His program is tailored from the DS program, but at least they do change the title pages! (There are differences inside, too, mostly simplifications from the DS requirements - my wife had a DS with him so I'm intimately familiar with that program and can see the differences.)

These docs must be doing a lot of bands to be that discouraged about their own work!

I don't know about the validity of those claims, but I have been evolving my diet for several years, minimizing the bad fats and carbs while emphasizing the good fats, carbs and Proteins - I haven't noticed a significant change in the taste of things post-op (the past 4 1/2 months) while others have reported significant taste changes. So, there might be something to it, or it might just be another one of those variations between us all. My wife experienced numerous taste changes after her DS several years ago - not specifically intensity as this claim implies but more of an alteration in preferences - is that a function of the metabolic changes brought about by the intestinal rework of the DS, or was our dietary evoluton less advanced at that time? Our diets did not change markedly after her surgery, mostly just the volume that she could have (just like with mine after the VSG) yet her tastes changed and mine did not at that time. Too many variables to contemplate early on Sunday morning - my brain is starting to smoke! There might be something to it. Maybe. Something to think about, though.

Most procedures that are marketed as reversable really are not in the long term - body parts that are not used atrophy over time. That part of the stomach that they sew off and is no longer used, may be able to be put back into service for a few months if needed, but over a few years time there will be nothing to reverse. Same applies to the RNY where the remnant stomach is set aside where it can, in principle, be reattached and reused, isn't really in any condition to be used after a couple of years. The bands are heavily marketed as reversible, but more accurately they are removeable, as the damage they can cause is often not reversible. The best thing that you can do is to choose the procedure that makes the most sense to you, and go with as experienced a surgeon in that procedure as you can reasonably work with. As Tiffy noted, gastrectomies of different kinds have been done for decades for correcting other problems, and the sleeve technique has been done for weight loss purposes for 25 years or so as part of the duodenal switch, and as a stand alone for ten or so years, so there is quite a lot of experience with it

So far, so good, and no regrets. I won't know for several years (hopefully) whether the DS with its better regain resistance would have been a better choice, but all indications pre-op and so far post-op (75+% to goal in about 4 1/2 months) were that the VSG was the way to go for me.

The body composition scales are sensitive to your hydration, so they will vary some day to day depending upon how well you are doing on your hydration efforts, and during the day as your hydration naturally changes with the time of day. i routinely see about a five point shift in my fat% between early morning, when we are dehydrated from sleeping, and late afternoon when we are typically fully hydrated. The instructions with my Tanita says that a late afternoon reading, before dinner, most accurately represents your actual body composition. With as much hydration variation that we have, it is difficult to put much significance to a percent or two change in a snapshot reading at the doctor's office every few weeks or months. What is most significant for me is not any particular reading, but the trend of the readings. Those late afternoon readings I have been doing are now showing some 24's and I'm rarely seeing 27's anymore, so I figure that 25.5-26 is about where I'm at right now (which is a lot better than the 42 that I started at, but still short of the mid teens where I would like to be.) We will naturally lose some muscle mass with our weight loss, as our body no longer needs as much strength to carry around that extra weight, and adjusts to it. The body adjusts to our usage, so if it's not used, we lose it. One rule of thumb that I have heard is that we will normally lose about a pound of muscle for every nine pounds of fat lost. I don't know the validity of that figure, but it is consistent with my own experience, and I do regular strength training (and have for several years.) Likewise bone density will tend to decline with weight loss as there is less weight for the bones to support; strength/resistence training helps to maintain and improve the bone density by giving the bones something to do - resisting those stronger muscles!

Some people stall earlier than others, particularly if they have lost weight with pre-op diets. Part of what is happening is that you have now used up your readily available stores of carbs and Protein, which burn at a rate of around 2000 calories per pound, and are now finally shifting to burning your fat, which burns at around 3600 calories per pound, so when you do start losing again, it will probably be at a somewhat slower rate scale weight loss, but now it will be fat. which is the whole idea here. Sometimes it takes a while for the word to get to your brain that you need to start tapping that fat savings account, and for it to give your body permission to do so - those are reserves to be saved for some serious famine and it can take some time for your brain to work out that you are serious about using that up! It's just one of the variations between all of us - some will stall for just a couple of days while others will stall for a couple weeks or more - it's hard to figure out sometimes. There will be more stalls along the way, too - it's just the natural progression that more resembles stairsteps than a ramp. As long as you are maintaining that large calorie deficit, you can't help but lose it.

Generally, you should follow your doctor's guidelines. That said, docs have a wide variety of programs and sometimes it's hard to figure out why. Some are very slow moving you from Clear liquids to thicker liquids to mushes to soft Proteins to more solids while others (like mine) start you on mushes and soft proteins in the hospital and never do a liquid only phase. Go figure. It seems to me that the docs with the extensive liquids programs are drawing from their RNY experience which may be overly conservative for the sleeve, which may be relatively new to them. My doc's practice has been doing sleeves, as part of the DS and stand alone, for around twenty years, so I figure they have a good handle on the care and feeding of the sleeve. I was having no problem with yogurts and puddings during the first week, though I was being conservative on amounts, experimenting with tolerances. There can be a wide variation in what we can tolerate when - my wife, who had a DS a few years ago, could barely drink her nominal stomach capacity in a sitting, which made Protein drinks particularyl nasty as they had to be so concentrated for her to get any usable amount of protein in, while liquids were flowing right through me from the hospital on out. My program has the general admonition of trying new things one at a time to judge your tolerance for them and if they don't feel right, try again in a couple of weeks. Again, despite the wide program variations out there, I would follow your doc's guidelines as closely as you can. It is certainly worth talking to them about it to see if you can quicken the progression some as you are well tolerating things - my doc was having me add veg to the diet at the 10 day follow up since I was getting in more than the requisite protein; they should have some flexibility built into their program to accommodate the variations in patient responses, but their experience level may not be ready to provide that variety yet, and if you have any problems down the line it will be assumed it was because you were "non compliant" rather than anything that they did. Good luck and be patient - I got sick of protein Jello and Soups fairly quickly, too, and have little interest in going back (though the yogurts and hi-pro puddings are still with me.)

You might also look into aversion therapy, since smoking is a combination of chemical addiction and behavior/habituation. Aversion is what the Schick-Schadel centers provided 20 years ago or so and used a minor shock (like from a 9V battery) to replace the pleasant sensations you get from smoking with unpleasant ones. My wife went through it (a few sessions within a week) and has been smoke free for the past 20+ years. I don't know who does this these days as Schick Shadel seems to be into alcohol and drug addiction treatment these days, but it's something worth checking out if the chemical/drug based solutions don't work.

The main thing is that if your multivitamin has a load of iron in it, then you want to space it out a couple of hours from any calcium supplements you are taking as they both compete for the same receptors

I can't understand the three meal a day restriction with our limited capacity - most docs allow a snack or two (or three) in between as long as they're healthy Snacks. We aren't supposed to get into grazing as that is a good way to torpedo our sleeve, but we do need to be able to work with this limitation that we have given ourselves. What is your problem with greek yogurt - taste, texture, stomach toleration? I'm not a fan of plain yogurts as they're just too tart and bitter for me, but the sweetened ones tend to be too sweet. I make my own blend of plain and sweetened vanilla that fits my taste. You can also add a little jam to flavor and sweeten it some. I usually have it with some berries, almonds and granola to add texture and other nutrients (and now a little wheat bran for some added Fiber.) I understand the taste problem with the Protein shakes and bars as many are downright unappetizing. I have settled (for now,) on the EAS protein powder as its taste is mild and I can add some unsweetened cocoa powder, SF hersheys syrup or instant Breakfast to it to build up the flavor and hide the protein taste. A SF instant breakfast can add 5g protein to your glass of milk - not as good as the dedicated protein powders, but better tasting than most of the, too. I make a protein enriched pudding using the SF instant puddings. The typical hi pro recipe calls for 2 scoops of protein powder along with the 2 cups of milk and pudding mix, but that still leaves a bit of the protein powder taste in it according to my taste buds; I substitute a cup of greek yogurt instead of one of those cups of milk and scoop of protein powder and that effectively masks the protein powder taste, though it does bring in a bit of tartness from the yogurt that you may or may not like. Sometimes ground meats don't settle well with us, particularly the drier/lower fat versions like chicken and turkey - my wife had a problem tolerating ground beef for a long time after her DS, and the surgeon suggested that filet often works better - and it did. Fatter meats at the early stage often work better than leaner ones as they are moister - dark meat chicken instead of light meat. Deli meats are often suggested as being well tolerated for the same reason. Meats are usually the slowest thing to go thru your stomach, so it's not surprising that you can only do 2 oz of the shrimp, but that's not a bad protein load for 2oz. - most of your meats are going to be in the same ball park. I'm not a coffee person, so I can't help you there, but the others are correct in that you have to be careful in heating the protein powders (whidh is why the instant puddings are usually used for this rather than the cooked ones. I believe that unjury says that you have to keep their powder under 130F, so you can't brew it with the coffee, but can usually add it after it is made and cooled a bit. Also, some protein powders mix better than others, so that is useful if you aren't frapping it in a blender - I find that the EAS powders mix better than the Unjury ones, which tend to clump a bit (at least with colder liquids). How do you handle cheese? String cheese is usually well tolerated and a common recommendation, and is 8g per stick. Most cheeses are in the 7-8g per ounce region. Good luck with it all, it can be tough at the beginning but it does get better

I was on basically the same plan - nothing special until the day before. There is a lot of variation in programs - intensive pre-op diets or none at all; extensive Clear Liquids to normal liquids to mush to soft to normal over weeks post op to mush and soft from the hospital on out; no carb trendiness to basic good nutrition with hi Protein. It's mostly based upon what experience the surgeon has and what has worked for him in the past. With the VSG being relatively new, much of it is based upon the surgeon's experience with other procedures, so I suspect that a lot of the intensive liquid post-op diet is a holdover from RNY practice. I was one who was on mush/puree/soft stuff in the hospital, so if their program says that garden burgers, egg noodles, mashed potatoes, tuna, rice & Beans, oatmeal, etc are fine in the first month, they have a lot more experience with sleeves, some 20 years worth, than I do - who am I to argue? If the doc doesn't feel that an intensive pre-op "liver shrinking" diet is necessary, and he's a liver specialist along with his bariatrics, I figure that he knows that aspect of it better than most (I also won't argue with him about his no alcohol for the 12-18 months prime weight loss period policy, either - he knows our livers better than most docs.)

I'm not particularly concerned or afraid of the intestinal or malabsorptive issues as my wife has had a DS for the past six years or so and we know many DSers who are 5-15 years out, so we are very familiar with all of the issues, major and minor. My objection to the RNY, and why it was never really considered, is that it goes to all the trouble of the intestinal rerouting, and it doesn't really buy you anything positive (compared to the VSG.) All the data available indicates that the weight loss and regain characters are similar but the RNY has a lot more issues. Beyond the more common incidence of dumping (which some surgeons promote as a benefit,) it doesn't significantly malabsorb calories, particularly long term, but does malabsorb minerals due to its bypassing of the duodenum where the bulk of the minerals are absorbed (the DS only bypasses part of the duodenum, so mineral malabsorption is usually not a bad.) The construction of the stomach pouch and connection to virgin intestine means NSAIDS are a permanent no-no, and while men don't typically have the iron issues that women do, the iron malabsorption is compounded by a typical slow blood loss at the pouch/intestine junction that rarely fully heals due to the exposure of stomach acid to tissues not designed for such exposure. Overall, lots of negatives without a real benefit compared to the VSG. The DS has somewhat different issues, though generally not as severe, but provides, on average, better overall performance, particularly on the regain front. The DS costs more, from an "issue" perspective, but you get something for that added cost. You don't get your money's worth with the RNY. There are probably some individuals for whom the RNY is the appropriate choice (aside from the surgeons promoting it) but they are few and far between now that the VSG has become mainstream.The RNY is rapidly becoming obsolete.

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.