I had VSG (2015) to RNY revision on January 18th due to GERD.

I also had regained almost 70 pounds from my VSG post-op low weight. I've so far lost about 20 pounds since the pre-op diet & surgery. I need to lose another 20 pounds (for normal BMI) to 50 pounds (for calculated ideal body weight).

I'm now on unrestricted food textures, and per my program's dietician, I'm supposed to be on my "maintenance" diet now. However, they refuse to discuss any calorie goals or macros other than protein. I'm someone who needs very clear goals and guidelines (thanks, long-undiagnosed ADHD), and I'm feeling very lost about what my diet should look like moving forward.

The lifelong guidelines for my program, as I understand them:

• 60-80g protein per day
• Up to 4 oz. (1/2 cup) per meal, consisting of:
  • Up to 3 oz. protein per meal
  • Up to 1 oz. (total) veg, fruit, or starch per meal
• 3 meals per day
• 1 snack per day (the program guide I was given says 1-2, but per my surgeon I'm only allowed to have 1 snack per day and it has to be between lunch and dinner) - I have no guidelines for the amount I'm allowed for the snack. I assume it's not supposed to be as much food as the meals, but I don't know.
• Protein shakes/powders are frowned upon

The only sample menu provided in my program guide is as follows:

• Breakfast: Egg omelet with sautéed peppers & onions
• Snack: Protein shake OR Greek yogurt with berries [removed per my surgeon's instructions]
• Lunch: Lettuce wrap with turkey and avocado/cheese [it is not clear to me if the / means avocado OR cheese, or avocado AND cheese, but I assume the former]
• Snack: Apple slices with 2 tablespoons nut butter OR carrots with hummus
• Dinner: Pesto chicken with spaghetti squash, sautéed spinach, and cherry tomatoes

I plugged this menu into the Baritastic app to try and get a sense of what the calories and macros are supposed to look like. The sample menu gave no amounts other than the nut butter, so I used the 3 oz. protein + 1 oz. veg/fruit/starch rule.

With the carrots & hummus snack option, here are the macros for the day:

• 593 calories
• 62g protein
• 32g fat
• 17g carbs (13g net carbs)
• 4g sugar
• 4g fiber

And here are the apple & nut butter (I used natural peanut butter) macros for the day:

• 739 calories
• 67g protein
• 43g fat
• 21g carbs (16g net carbs)
• 8g sugar
• 5g fiber

So from that, I'm extrapolating that I should be aiming for the following daily:

• 600-750 calories
• 60-80g protein
• 30-40g fat
• less than 25g carbs
• less than 10g sugar

I have a few concerns...

1. I have already been going well over those amounts at just over a month post-op. I've typically getting around 800-900 calories per day.
2. It seems like a real struggle to get to the upper range of protein daily while sticking to the allowed amounts and without using any shakes or protein supplements. Even then, 80g seems low for a protein goal. I have never been a big meat eater (I was vegetarian through most of my teens and 20s), and I absolutely cannot stand any fish or seafood. I do eat a lot of dairy, eggs, and beans, but it seems like that's not going to do it.
3. The standard daily fiber goal I've always heard is 25g per day. I've been getting about 12-15g per day right now, but knowing that I'm overeating and already having too many carbs means even that's not sustainable. I've struggled with post-op constipation... I have gotten to a much better place recently, but if I need to cut back to 4-5g of fiber per day to be within my other limits, I'm afraid of going backwards.
4. That I'm limited to 1/2 cup of food per meal for the rest of my life came as a shock to me, as a revision patient. I knew that my pouch would be smaller than my sleeve, and like with my original surgery, the amount I'd be able to eat at one time would be very small initially. But with my sleeve (which was done by a different surgeon in a different program), there was definitely not the expectation that the amount I could/should eat at 1 month post-op would be the same as what I could/should be eating at 6 months or 1 year out. My bypass surgeon also told me that she left my pouch a little larger than normal so that I wouldn't lose too much additional weight, so my pouch is already larger than a regular bypass patient's.

Do these amounts seem in line with other people's experiences? Or am I way off-base?

Honestly, this seems way off-base, with the exception of 60-80 grams protein, which is completely sufficient for most people (but not all!). Your calorie estimations are much too low for the vast majority of people in maintenance mode. So rest assured, you won't be on 650 calories for life! Also, 25g carb is extremely low carb and not a lifestyle most people are eager to embrace. If a doctor insisted on 25g carb for life as the only way to succeed, I would seek out a second opinion for sure.

From what I see people saying around here, 1200 to 1500 is a much more realistic calorie range for the long term, although that is for maintenance, not for weight loss or for early days after surgery. If you eat to maintain your current weight right now, that would seem to go against your goal of losing 20-50lbs more.

I have two suggestions. First, check out some bariatric cookbooks because they will tell you appropriate portion sizes for maintenance as well as give you some ideas for what types of foods to be eating. My favorite is Kristin Willard's Bariatric Meal Prep Made Easy: 6 Weeks of Portion Controlled Recipes to Keep the Weight off. She's a registered dietician specializing in bariatrics and every recipe has a gorgeous color illustration.

Second, take a look at the Portion Perfection brand bariatric plate. It's kind of expensive, so you may not want to buy it, but the concept is really good. Basically it's an 8 inch plate (with a one inch rim all the way around, so a 6 inch circle of eating space). There are lines and illustrations to divide up the plate and show you where to put your foods and how much. If you're a visual person, this may really help.

Other than that, you may want to check out some of the nutrition videos as well as the weekly podcast done by Dr. Matthew Weiner (Pound of Cure). I find them so insightful and he and his dietician, Zoe, are very keen on plant-based nutrition, which may be perfect for you.

Edited to add: Here is a link to a dietician article about post-op goals that might help: https://www.mybariatricdietitian.com/mbd-blog/portion-sizes-after-weight-loss-surgery

Edited February 28, 20242 yr by NickelChip

I agree with @NickelChip, this seems quite off. I've seen 800 calorie plans for bypass patients in the active weight loss phase, but most people are in the 1200 calorie range for maintenance... And your portion size will naturally increase a bit over time as you are able to eat more as your pouch heals. It won't be as much as a "matured sleeve" can eat, but it won't be a few tablespoons either.

At the bariatric clinic I go to I attended nutrition class with sleeve patients and bypass patients, even though I'm a DS patient. We were all told to keep each meal to 10 grams of fat or less (general aim at 1 year out is 60 grams of total fat as per the ASMBS guidelines for a year out), and 10 grams of carbs or less, for less than 50 total grams of carbs a day, as they want us in ketosis during the active fat loss phase (this amount will double to about 100 grams of total carbs in maintenance). And protein varies for each group but bypass was to aim for 80 grams of protein a day, since they malabsorb some compared to the sleeve patients. NONE of us were given a calorie goal, only macro goals.

We were ALL told to aim for 5-6 small meals a day for consistent energy, aiming for 4-5 meals if we go to bed early or get up late. So we were encouraged to eat about every 3 hours, allowing 2-3 hours between our last meal and bed. And told a fair amount of our carbs should come from high fiber, low carb vegetables and low sugar fruits, with a fiber supplement (SunFiber is amazing and non-bloating) and Miralax as needed to maintain regularity.

Edited February 29, 20242 yr by ChunkCat

I'm nine years out and have been in maintenance for the last seven years. I eat around 1600 calories a day to maintain my current weight. The only macro I pay attention to is protein, because we learned very quickly after surgery that I malabsorption it. So I aim for 100 grams of that a day. Besides that, I just try to eat a balanced diet - protein, vegetables, a little fruit, some whole grains, an occasional handful of nuts, mostly.

but if you're still trying to lose weight, 1600-ish would be too high (at least for most women). And even in maintenance, people's caloric needs are so different. There are women on here who maintain on 1200 calories and others who maintain on 2000. Depends on your metabolic level, how active you are, how muscular you are, what amount of weight you're trying to maintain (I'd have to eat a heck of a lot less if I weighed 110 lbs) - it's really just trial and error to figure out at what level you can maintain your weight.

Oh yes, way off the mark. You’re not in maintenance yet. You’re in a weight loss stage if I read your post correctly.

You have every right to ask for the details, guidelines recommendations around your food intake & options, macros, calories, & whatever else you need to make you feel comfortable & confident about what you are doing. They are supposed to be there to help you & provide you with the depth of information you need to be successful regardless of current thinking or their own beliefs. It’s then up to you how you use that information - a guide or rule. Plus you have to work out what you (your body) needs to function best & most effectively.

While some plans recommend getting your calories up, it seems to begin after you are on more solid food so 2+ months. From puree I was advised to eat 1/4 - 1/3 cup of food, slowly increasing to about a cup at 6 months. I was a bare cup & maybe 900 calories at my goal at 6 months. Ate about 1200 at my lowest weight (48.2kg at 18 months) & maintain 48.5/49kg consuming about 1600 calories. My portions only became about what is considered a recommended portion size around the 2 year + mark (3-4ozs protein & 3/4 cup vegetables). Oh & I didn’t have another shake after the liquid stage either. But that’s me & what worked/s for me. You could be totally different.

To me a snack is generally a couple of bites. My snacks can be a level teaspoon of peanut paste, 1/2 a protein bar, 8 grapes, 1/2 a small apple, a stick of string cheese, about 6 macadamias to give you an idea. I used to eat a tub of 20g protein yoghurt over an hour as a snack too.

As @catwoman7 said we all have different caloric & nutritional needs. Age, gender, general health, weight, height, metabolism, activity levels, etc. all factor in. And yes, if you want to lose more you will have to eat less than you are eating now & you’d have to eat less to maintain the lower weight than you would to maintain a higher weight.

My Dr was different and said to work towards eating 1 cup by 6 months and up to a cup and a half per meal with 3 meals per day at maintenance. While in the losing phase I found out that if I was under 800 calories per day I would stall and if I went over 1200 I would stop losing. So for me personally I had to sit pretty strictly right around 1000 calories per day. I was told to have the protein goal at 60-80 and they did not want me limiting carbs too much and said to aim for 100 per day. They felt that a low carb lifestyle was not something that they saw people able to maintain so they want people to practice eating a sustainable diet and still able to lose. So many different ways to do things that its very confusing. I hope you are able to find something that works for you, good luck!