RickM

The default position of ASMBS (that's the American Society of Metabolic and Bariatric Surgery) is that vitamins for life. The two qualifiers on that is that ASMBS is somewhat RNY-centric, and the other is that we will likely need to be taking something for life, if not from the surgery, then from some other health issues we may have, or just simple aging. Periodic labs will point us toward what we need individually, In time (as in a few years) we can indeed eat enough volume to have a healthy, balanced diet that provides all, or at least most, of the nutrition that we need. The key is whether or not we maintain a diet that can do that - many get into various fad diets that can have significant deficiencies, or just fall back into a more typical Western junk-filled diet that is likewise deficient, so supplements are needed. I currently only take a multivitamin every other day as my labs were running high on most everything covered, so we are cutting back on them and may eliminate it altogether. I do still take calcium as that was a need for me pre-op, but no major change on that from the surgery once diet once again moved toward normalcy. Here are a couple of videos from a surgeon who describes some of these issues. The main take-away from the first is how our eating volume progresses over the years, so that in time we can eat upwards of about half of what we could pre-op, which is plenty to maintain a healthy diet (though I don't necessarily buy into everything this guy says...)" This second one addresses vitamins more specifically, and how different procedures influence vitamin need:

Two points that I think of here - 1 - you really don't have to worry about special cups or sipping pre-op as everything works normally; post-op you will likely have some inflammation in the stomach that limits the flow through the stomach, so we need to sip, sip, sip all the day long to get our fluids in until the inflammation resolves and we can drink more normally (which can vary widely from a few days to a few weeks.) 2 - do you even need to do any kind of liquid diet pre-op, or do you just want to "practice" for post-op? Most don't have to do an exclusively liquid diet pre-op, and many don't need to do any diet at all, so check with your program before going overboard on preparing based upon what others may have to do. As to the idea of "practicing", I found that my body regulated things quite well - it will tell you quite quickly if you are drinking too fast. A shot glass or 1 oz medicine cup works well. If you can sip 1 oz every five minutes, that's 12 oz per hour and you can get your nominal 64 oz of liquids down in a little over five hours spread through the day; that, of course, is unnecessary pre-op when you can down 12 oz in a minute or two.

I set my goal by body composition, as BMI (as others have noted) is a flakey measure that applies more to population studies than to individuals. I aimed for a mid teens body fat percentage - on the lean side of normal for guys (mid twenties for the ladies) and started with an initial goal weight based upon the (very gross) assumption that all my loss would be fat mass, and then corrected that as I got closer and saw how the BF% was shaking out. As it turned out, I adjusted goal down another 10 lb (to 190 from 200 lb) to reflect about 10 lb loss of muscle mass - we can minimize that, but next to impossible to avoid altogether. I am "overweight" on a BMI basis at 26-27, but lean - ish by body composition. There has been some discussion within the ASMBS ranks that over-emphasis on BMI can lead to excessive loss of muscle mass, particularly amongst those starting in the higher BMI range, so it is something of an individual judgement thing.

Usually it is the first month that is the biggest, even with the third week stall, as there is a big slug of water weight that gets lost at the outset. If someone loses a lot on a pre-op diet, they may have already lost that water weight so that their first month post op may be lower than someone who didn't diet ahead of time. In either case, we usually have a slowly declining loss rate as we proceed as it simply takes fewer calories to move us around at 300 lb than we were at 400 lb. and fewer still at 200 lb vs. 300 lb. Just a general trend, as some months may be higher or lower than adjacent months, and we stair step our way down - we may go through several days or even weeks with little or no loss (or even a bit of gain - that water weight thing again) and then, boom - a big loss that gets us back on trend again. Within that, and beyond the semi-normal third week stall, stalls may happen at any time - or not at all.

Bumping up minerals is a good start, but to know for sure (or closer to it) you need to have labs done to see if you indeed have any deficiencies. Potassium, unfortunately, is difficult to supplement without prescription as OTC supplements are limited to about 3% of our RDA - not overly helpful. The best non - Rx source that I know of is the low sodium version of V8 juice, which has about 1200mg, or about 25% of RDA in a 12ish oz can and about 70 calories. Other real food sources are bananas, potatoes (about the best real food source per calorie), melons, berries and mushrooms. which can all help, but are hard to get a useful amount in early on with our volume and calorie constraints.

It really doesn't make a significant (if any) difference, as we all typically go through stall, pause or slowdown after 2-3 weeks (do a search for "three or third week stall') as that is about the time that the body is shifting gears and adapting to working under a major caloric deficit. It happens whether one is on liquids, "full" liquids, purees/mushes or more solid foods; many get the impression that it makes a difference because most are usually transitioning between phases at about the same time, but even those of us who were not transitioning (we were on soft foods from the outset on our program) experienced the same thing. https://www.dsfacts.com/weight-loss-stall-or-plateau.php Once we get through that initial stall and transition away from living on our glycogen and start making up for the caloric shortfall with predominantly burning our fat stores, the loss rate will slow down some as fat burns more slowly than glycogen (carbohydrates, mostly), and our loss rate will typically decline over time as it takes fewer calories to move ourselves around at 200 lb than it does at 300 lb, etc.

Yes, NSAIDs like ibuprofin are classic redflag no-no's for bypass patients (it's that marginal ulcer thing that the bypass is prone to); however, I have seen them prescribed (by bariatric surgeons) for limited use in certain specific cases where the risk/reward trade off makes sense. So, check with your surgeon as to what he would prescribe for this particular instance.

...then you resolve to get into better shape, exercise and join a gym, and all the TVs in the room are tuned to the foodie channels!

1 - have your surgery younger (get out that time machine!) as we lose elasticity with age, and 2 - choose better parents - genetics plays a big role. The various creams and lotions may do something, but it is very hard to do any kind of scientific investigation (because of the variables involved) and the manufacturers of such products aren't inclined to fund such studies. The best that one can do for such a study is to gather a group of WLS patients together and apply the product to half of their body and do nothing to the other half (or use a placebo cream) and who will sign up for that? Exercising and toning can help some, but what one really needs to do is to build muscle mass (rather than just tone) in the areas where the fat is being lost to fill in the lost fat volume - plausible in the upper arms and legs, not gonna happen in the abs (think of classic six-pack abs vs the folds of flab we usually have there - muscle won't fill that.) Resolve within you that you will probably need some kind of reconstruction done and start saving your pennies for it. Do what you can on exercising and try whatever products make sense to you and hope that all those various factors work out in your favor - then you can buy a new car instead with what you have saved up.

Your surgeons should tell you what they want, but the recommendations generally fall into the 60-80 g range for women and 80-100 g range for men.

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It is very individual to different programs, so no one can really say. Most pre-op diets (for those who have them - not everyone does) are notionally to help shrink or improve the texture of the liver, which fundamentally just needs a low carbohydrate diet (so consider that in what is in the soup you are considering) but does not require a liquid diet. That is done for other reasons that one can only guess at, though some say that it is to help get you used to a liquid diet post-op (which never made sense to me as you likely won't feel like much of anything else for a while anyway - even though I was allowed soft foods right out of the box. Go figure.)

I haven't needed it, but as it is not an uncommon problem during the rapid weight loss phase, I would expect that most would have it done by their original bariatric surgeon as that is where most will turn for help with any apparently related problems during that time. However, it can be done by most any general surgeon if their original bariatric surgeon isn't local or otherwise available.

I wasn't thinking specifically of your statement, but rather that people often see online what some others need to do (certain pre-op diets, crushing pills, not using straws, etc.) and assume it to be a standard protocol for their procedure, rather than something specific to that patient, or the program that they are on. Since pill crushing isn't normally needed with the VSG, it's an obvious first question to ascertain whether or not the OP actually needs to do it for her program or other specific needs. Sorry for any misunderstanding!

Do you even need to crush them (that's more of an RNY thing due to the fear of pills getting stuck in the stoma)? Some programs give the same instructions to both sleeve and bypass patients more out of convenience than necessity - what does your program recommend (don't just go by what you see others online doing)?

Refried beans are a fairly classic soft food after surgery, and I usually throw some black beans into my salads. Gas may or may not be a concern depending upon whether or not you are used to having them regularly (your gut biome tends to adapt to these things. You may read some people online calling them down because they are "carbs" and a no-no to them, but that's just them. If you aren't into low carb dieting, then don't worry about it.

First question is - does your surgeon even require one (many don't)? Some specifically don't want their patients doing a multi-week fast as they want them as strong as possible going into surgery (and fasting liquid diets don't do it.) So, see what your program requires and prefers, and if you want to do a diet, tailor it to their needs. If they don't require a diet, then go moderate if you want to do one, and just cut out the junk food. It is never a bad idea to start working on the long term habits of healthy eating that will serve you long after surgery, Exploring different protein drinks to find ones that you like, or at least tolerate, as they will be a staple for a while after surgery. Beyond that, start by cutting out junk food and increasing fruits and vegetables, whole grains instead of processed white stuff, etc. Do what you can to adjust your tastes for the better.

You probably can (check with your medical team) as the concern with drinking at meals is trying to avoid conflicts with the food that is going through, and to avoid washing things through more quickly than they should - you want to keep the food in your stomach as long as possible to avoid hunger afterwards. So, water with a liquid meal doesn't really do anything, but it would be best to avoid it just from the perspective of practicing good bariatric habits.

Dumping usually isn't something to worry much about with the sleeve (it's more of a bypass thing) though it can happen to some occasionally (as it can for even those without any WLS, just rare.) It is the result of rapid emptying of the stomach, typically due to the lack of pyloric valve in bypass patients, but is possible for those with a VSG if one were to consume something high sugar or fat that is liquid or otherwise flows through the stomach quickly. Early on, if I sneaked in a piece of chocolate, I would get a quick flash of "oh, I shouldn't have done that..." but it would pass just as quickly. That is a version of what one might call "mini-dumping" but it was nothing worrying - far from disabling like some may get with a bypass.

Yes, keto has been around for a long time, as has most of the popular diets that have gone in and out of fashion - there really isn't all that many things that can be done in a weight loss diet that hasn't been tried before and found wanting, often multiple times. Keto has some apparent benefit in the treatment of epilepsy but beyond that it is fundamentally just a fail safe or backup mode for our bodies in time of famine - we can get by but the body really doesn't like it (that's why if provides you with the bad breath and BO, telling you that this really isn't a great idea....) Over the short to intermediate term, it can work well - as most diets do - but in the longer term for the morbidly obese, beyond a year or so, it shows the same 95+% failure rate as any other diet effort (though WLS tends to extend that years' grace period some.) Indeed, if you go back 20-30 years in the WLS world, many were often told to simply eat as they did before, but just less (courtesy of their WLS) and it overall worked well for the first year or so, but obviously since they never learned to eat sustainably and correct the habits that caused them to need WLS in the first place, they typically regained. So, from a strictly weightloss perspective (as opposed to longer term weight control), almost any diet will work with your WLS for the first year or so. What really counts is how well you adapt to a sustainable weight maintenance life in the long term. If keto works for you to do that - great; if going vegetarian or vegan does it, that is also great. Balanced diet, South Beach, Zone, Atkins, low fat, Mediterranean or whatever - go for it, and don't worry about what others do because if it doesn't make sense to you, then is isn't right for you. Clinically, high fat, low carb diets such as keto or paleo (or at least the current commercial interpretation of paleo) are used for minimizing or avoiding weight loss after a gastrectomy (such as when done for cancer or gastroparesis) owing to its high caloric density - one needs lots of calories in a small volume to maintain weight, which is just what such diets provide. This isn't to say that they can't be used for losing weight, but the odds are more stacked against one in doing so, and one needs to be aware that just because a food or recipe is labelled as keto (or paleo, vegetarian, vegan, etc.) doesn't mean that it is appropriate for weight loss or contol - one still needs to watch what one eats.

I didn't order any alcohol in bars or anywhere while losing as that was the Cardinal sin for our program (doc was also a liver transplant specialist and didn't want any of his bariatric patients coming back onto his transplant table - seriously).

No - I followed a very strict no-fad-diet regimen (and still do) so I concentrated on developing/maintaining healthy and sustainable dietary habits for the long term rather than short term miracle diets that fail after a few months. Skipping major food groups and the nutrition that they provide doesn't do it. Besides, keto wasn't a "thing" when I got started. While losing, I just concentrated on getting my requisite protein, and then getting the best nutritional bang for the buck with the remaining calories in my allotment, be it from fats, carbohydrates or whatever.

Yes, they usually inflate the abdomin to make room for the laparoscopic tools they are using, and they may also inflate your stomach at some point during the procedure (this is normal during an endoscopy so that they can see the inside of your stomach take their pretty pictures), at least my doc does as part of checking for leaks after he is finished sewing up the stomach. This really has nothing to do with the liver thing and pre-op diets, as that is more of an individual surgeons' preference - some are more comfortable working around a potentially fatty liver than others.

Doctors' philosophy on this vary from a few weeks to never again depending upon their experiences. The basic issues are: Healing - alcohol is somewhat corrosive to the stomach lining so one needs to give things a chance to heal first, Alcohol tolerance - rapid stomach emptying means it tends to hit faster, and with less (i.e., a "cheap drunk") so care must be taken there, Transfer addiction - we can no longer satisfy whatever addictive tendencies we have with food, so it is easy for transfer that addiction to something else, like alcohol, drugs, shopping, gambling, etc. What was a casual habit of a glass of wine with dinner occasionally can easily turn into full blown alcoholism. Liver health - starting as morbidly obese, or worse, our livers are not usually in very good shape to begin with (hence the "liver shrinking" pre-op diets that are often prescribed) and the liver is further stressed from its role in metabolizing all that fat that we are rapidly losing. It doesn't need any more stress from ingesting a known liver toxin like alcohol (not a judgemental thing, just our physiology at work). My surgeon is also a biliopancreatic (livers and pancreas) transplant surgeon, so he is in the no alcohol as long as we are losing weight camp (and ideally forever) and indeed we sign a contract to that effect - he doesn't want any of his bariatric patients coming back onto his transplant table! Those are the issues in play, and some aspects bother different surgeons to different degrees, so they have different policies. Check with what your surgeon's policy is, and decide for yourself - we are all adults here.

I would check with your surgeons office about it, as you have the tests and data that is required - if a bariatric surgeon doesn't know how to interpret an endoscopy, then he shouldn't be in bariatrics! Mostly, they are looking for a CYA from another doctor before they proceed, but if the report is clean and there is nothing to worry about, then it should be OK. The important thing is to know what is going on inside as that can influence what procedure is done or how to go about it, which is what the report would tell him. To be somewhat fair, the gastro doesn't necessarily know what the surgeon may want as a clearance in this case - that is often an interpretation on the surgeon's part - and not just a "yes/no" thing from the gastro. One surgeon I know prefers to do some of these things himself rather than depend upon a gastroenterologist report (particularly when he is doing a revision) as he knows better than the gastro what he is looking for. A cardiac or pulmonary clearance, which are also common, are more of a yes/no thing ensuring that there are no big showstoppers that will cause grief under anesthesia, but an endoscopy or upper GI gives the surgeon information that is useful for planning his operation, so should be something that he can handle.