RickM

That's fine - you want to do what your program instructs you to do. Many in these forums make assumptions based upon what is commonly posted (it is "standard" to have a liquid pre-op diet - because so many post about problems with them - or that one has to do a low carb or some other diet post-op - because that is what is popular at the moment, etc.) that it helps to sort out the program instructions from the common chatter. Your doc's diet may or may not "shrink the liver" as well as some other diet that others have, but if that is what your surgeons are comfortable with doing, that is the most important thing. The liver shrinking thing is somewhat controversial in the surgical community as to what really works on whom and to what degree. I know some surgeons who specifically don't want their patients doing any of these liquid fast type diets as they want them to be as strong and healthy as possible going into surgery, and fasting for weeks doesn't do it. Different philosophies for different surgeons, and we just follow along.

Is your diet intended to "shrink the liver" or are you assuming that it is based upon what some others have to do?Many docs don't need their patients on that kind of diet but may impose some other diet for some other purpose, or often, nothing at all. Classically, a low carb diet of some kind, liquid, solid or a hybird, is what is specified if improved liver condition is intended, but some may just want to move their patients in the right direction toward a healthier overall diet for the long term, so one with some fruit or other complex carbohydrates in it would be appropriate.

There should be a policy bulletin on the insurance company's website that spells out exactly what is needed for WLS, and that is your bible. Your surgeon's insurance coordinator may be able to help with this as well, as they live and breathe this stuff and know what it really says. Typically there is often a requirement for three or six months of "medically supervised" diet and exercise, or weight loss effort, supervised by some kind of medical professional MD, RD, etc., and sometimes a commercial program such as Weight Watchers is acceptable. I used my PCP as my supervisor and at each meeting gave him the printouts from my diet tracking and my exercise tracking and he included that in his notes. Usually they want weight noted and often some kind of words about diet counseling or discussion. The insurance may also want some kind of documentation of past weight loss efforts - some do, some don't - which can be receipts or notes from Weight Watchers, etc., doctor notes about loss effort, weight loss med prescriptions, etc.

Can you get a little more fruit or veg in your diet (is a bit early for some,) as that is the root cause of the problem - diet that is overly low in carbohydrate. I tried to maintain a reasonable balance in my diet, beyond our basic protein needs, and never had this problem (or the BO that can go with it.)

That's a good start, so there is hope. Look for a surgeon who specializes in reconstruction after massive weight loss - there is a big difference between tummy tucks, etc. after bariatrics and a mommy makeover.

It should be something that is in one's calculus in deciding upon surgeon and procedure. Practicality is a variable - with a DS, local choices are usually limited if not non-existent, so travelling is always a consideration, weighing differences in experience and technique with the convenience and cost differences of staying local. I traveled for my VSG as at the time, no one local had much experience with it, even in a major market such as southern California. This can weigh in on choice of procedure, too. A bypass done by someone well experienced with them (fairly common in the bariatric world,) may be a better choice than a sleeve done by a noob - even if that is the same surgeon under consideration - as even a fairly straightforward procedure such as a VSG has its subtleties and nuances that only get mastered with practice. One can mitigate this some by exploring what kind of training the surgeon went through to learn the procedure in question. The DS (at least the "traditional" BPD/DS) is acknowledged to be complex enough that most surgeons seeking to offer it go back to school to learn it, often doing several months of residency with an established practice to learn the in's and out's of it, while the VSG is deemed to be simple enough that most just learn it on their own, and the results often show that. Going the residency route helps to get the doc further up the learning curve before he starts in on his own patients, and helps him gain confidence in the different post-op protocols that benefits the new procedure; looking at the number of practices that combine their RNY and VSG dietary and supplement protocols is a good way of seeing how many are still working up the learning curve on the newer procedure. It is a choice as to whether one wants to be a guinea pig, but it should be a choice that is made with knowledge. I have spoken a couple of times with my wife's surgeon's DS patient #1, and she came out just fine, as did, presumably, most of his other early DS patients, though patients 500-1000 no doubt, on average, did somewhat better techniques (both his and the industry in general) improved. But she did make an informed choice between a bypass that he was well experienced with and this newer and better procedure that he had just come out of residency on and was still learning.

My short answer is not enough to have made it worth figuring out, lol. Multivits - Costco brand Centrum analog: $10-15 per 400, 1 per day then, 3-4 per week now Calcium Cit - Target analog to Citracal - $10 per 180 or 90 doses, so $10 per daily dose for 90 days, call it $20 for typical early VSG twice a day dosing for 90 days. First couple months you prob can't swallow those horse pills, so look up Bariatric Advantage chewables, or similar brand, Alternative is some brands (Celebrate, IIRC) make a petite half dose pill that works well for many - figure twice the price of the Target pills, or$40 for 2 doses per day for 90 days. B12 - never took it (more of an RNY thing, tho some are naturally short on it.) Iron - maybe - Solgar Iron Bisglycinate 25mg, prob $25 per 180 capsules or 6 months worth Protein - Optimum Nutrition 100% whey isolate - $40-50 per 55 serving tub (on sale now for $30) - figure 2 servings per day for the first month, 1 per day after that, YMMV ballpark est $140-ish total for the first 3 months.

Yes, ask your surgeon's team to see how that would fit in at this point. Picking the toppings off of pizza and leaving the crust behind is a classic WLS solution, progression dependent. Soft cheeses like mozzarella were fine the first week in our program (individual tolerance depending...) but not sure how that fits with your program, or how the baked on cheese fits, compared to the raw cheese.

I ignored carb and fat counts. If you have a suitable amount of protein and your calories are low enough to promote the desired weight loss, you will by default be on a low carb and low fat diet. Let the numbers fall where they may (in retrospect, looking at my past data, my carbohydrates and fats were, on average, split about even calorically. That was not a specific goal, but just the way things shook out looking after the nutritional side of things.

Most people are into overkill, lol. There does seem to be some over-emphasis on protein in the bariatric world because early on that is what we need most - we can get by without most vitamins and minerals (pills do good for that, for a while at least), our bodies will make the sugars and carbohydrates that it need (though it may not like it) and we already have all the fat that we need, but protein can't be converted from anything else. There are some "high protein" diets in the weight loss diet world but they are just another alternative to all the other low carb and low fat diets that don't work any better, but some get into them, particularly those who don't like their vegetables, Our needs vary, largely based upon how much lean body mass we have (largely musculature and organs) so that a taller man needs more protein than a shorter woman. Figures, methods and opinions on figuring out how much protein we need vary, but generally fall into the same ballpark. I use a method based upon maintenance of lean mass as being sensible and gives results that fall within most sane guidelines - my 150 or so lb of lean mass needs around 105g per day, as a 5 ft woman (presumably....) your lean mass will likely be around 75-80 lb, so about half of my needs, or a little over 50g - call it 60 to be on the safe side. Most bariatric programs recommend around 60-80g for women and 80-100g for men as a baseline. If one is seriously intent on increasing muscle mass (and most importantly - doing the work to do so - protein needs can go up by 50% or more. Likewise, recovering from major trauma such as major surgery or big time burns can require a 50% or so boost in protein to promote healing. The matter that most bariatric programs are where they are on protein recommendations, and have been there for years, indicates that the surgery that we are undergoing is not all that major from an overall healing or trauma perspective; plastics or reconstruction surgery is much more traumatic to the body and they usually recommend higher protein levels for those.

Lot's of people try such things, but without the surgery it is no more successful than any other diet - maybe a 5% success rate at best - it is the surgery that does the trick, not the diet (though that is a part of it.) Diet after WLS is mostly a long term learning process to help you with weight control in the long term, as the diet after surgery during the loss phase makes little difference.

nope, you're not going to stretch it with a couple of cheetos (though those are something you really shouldn't be having now, whatever phase you are in, but we all know that, lol.) A lot of us are on a soft diet from the outset, so it shouldn't be a problem, but do try to follow your surgeon's program, as there may be other reasons for their progression rates.

It sounds like you are doing the right thing to wean off of them, but that your body isn't ready to, as if whatever underlying problem has not been resolved. This certainly isn't normal. Typically we hear of VSG patients having problems with acid reflux and heartburn that sometimes can't be resolved, so an RNY revision is sometimes done, though reflux can hit the bypass too sometimes, though fairly rarely. The asnastomis between the pouch and intestine is sensitive and the typical location for ulcer problems - the intestine where the pouch joins isn't resistant to stomach acid like the duodenum is, hence the sensitivity. I would think that the endoscopy would have shown any problems there. That leaves the remnant stomach and upper bypassed limb as a possible problem area. The remnant stomach is where most of your acid production typically occurs, but that is usually neutralized by bile that's introduced into the duodenum. so perhaps there is something wrong there that is creating an imbalance. Unfortunately, that doesn't show up in an endoscopy with your bypass anatomy. You mention that you are following your surgeon's instructions on taper off the PPI, so I assume that he is in the loop on this problem and should be able to suggest the next step. Does the omeprazole resolve the problem when you are on it, and this is just a problem when trying to taper off of it, or is this a continuing problem even with the omeprazole? Perhaps whatever quirk there is in your body isn't ready to give it up, as desirable as it may be to do so. If you haven't found her already, maybe you can reach out to this gal who is having significant ulcer problems with her bypass - there may be some insight from her problem that can shed some light onto yours. This is a puzzle, and as my PCP likes to say, you don't want to be an "interesting" patient - great for the MD's to have an interesting problem to solve, not so great for the patient. Perhaps this is your turn. Been there, done that myself on the interesting patient thing, with a different problem. Good luck in getting this resolved.

The various reset diets seem to be of dubious value in that they work from the premise that we since we lost like gangbusters right after surgery when we were (mostly) on a liquid diet, that if we go back to a liquid diet we should lose like gangbusters again. Reality check here is that those of us who were never on a liquid diet also lost like gangbusters right after surgery - so it isn't the liquid part that is doing anything. The approach that seems to work better for most is just to go back to a basic meat and green veg diet to clean out whatever crap that has crept back into your the diet and to reset your mind.

It is hard to say how much you may be "hyper" as in a metabolic problem above and beyond just being a fat guy like the rest of us have been, but it is quite common with all of the weight that we carry. As with James, that usually disappears as the weight comes off. I haven't used anti-persperants for years and even after a moderately hard workout in the gym it's no problem (was a bit of sweating a couple weeks ago when the AC as off in the weight room, though!) I suspect that this next winter you will probably be cold, as you still have the cardiovascular system of a 445 pounder when you are 345 and falling, and the following winter will be worse, though that does seem to even out some after a few years of adaptation.

It is best to consider it to be irreversible as one typically needs some form of WLS to get or keep the weight off, so revisions are the norm in that case, but in the rare cases where something is drastically wrong as I believe is the case with the OP, it can certainly be put back to semi-normal again. When the bypass is revised to a DS, that is the first step before the reunited stomach is sleeved and the intestines are reconfigured.

I have seen this referenced a couple of times before as a potential revision configuration, and it is distinct from a RNY conversion. With the RNY, they make a pouch with the tissue at the top of your stomach around the esophagus (whether from a normal or sleeved stomach) and join the bottom of that pouch to a limb of intestine typically 40-60cm downstream of the stomach, leaving the remainder of the stomach in place. What they are proposing in this variant is leaving the sleeved stomach intact, but making a hole in the side and joining that to a limb of intestine. So you wind up with two outlets to the stomach - one as normal through the pyloric valve at the bottom, and through the side into this "bypass loop". The sleeve has some predisposition toward GERD by virtue that the volume of the stomach is reduced much more than the acid producing potential, and in some people the body never fully adapts to that change. The second factor influencing this problem is that the sleeve is considered to be a "high pressure" system in that when the pyloric valve at the bottom closes to allow digestion, any gas produced in the stomach has no where to go other than back up (the normal stomach will stretch a lot more to accommodate this) while an RNY is a "low pressure" system in that the pyloric valve has been bypassed along with the rest of the stomach, so any gas buildup in the pouch can vent down into the intestines (part of why RNY folks can be "gassier". With this proposed configuration, any gas can be vented out this second outlet so it doesn't tend to force things back up, so there is some promise there, and since the duodenum is not entirely bypassed like on the RNY, there should be less of the nutritional deficiencies that are seen with the bypass. A couple of concerns that I would have (as a non-expert, non MD) - one is the long term prospects for the configuration. The bit of cursory research on this that I could do online indicated that one of the main uses of this procedure is to bypass blockages in the bottom of the stomach from tumors and similar that for one reason or another are inoperable (like from late stage cancers.) Given the relatively low life expectancy of such patients, are there other longer term uses for this procedure that provide experience that would give one confidence that this will work for you in the long term? The other potential problem that I see is that one of the weaknesses of the RNY is a propensity toward marginal ulcers, mostly around the anastomosis between the pouch and intestine because the part of the intestine that the pouch is now emptying into is not resistant to stomach acid like the duodenum (upper end of small intestine immediately downstream of the natural stomach), so that joint is easily irritated (this is the origin of the "no NSAID" rule for the bypass.) Now, this proposed configuration will have a similar anastomosis with similar sensitivities to acid, but with the sleeved stomach that is producing more acid than the typical RNY pouch - is this asking for trouble, or are there offsetting factors that address this issue? Always like seeing new things here, I remain cautiously curious...

That's a lot saner than those diets that allow only protein drinks and broth. If one has to do one of these per-op diets, they can be a lot worse! Enjoy.

The consensus that I have seen is more in the 80/20 range for weight loss - the experts still don't really know why, it just is.... - and that it is most particularly useful as a maintenance tool for long term health. I have seen a number of people go through with minimal exercise until the get around goal weight and then pick it up. Our program did emphasize it, particularly strength and resistance work to help maintain as much lean mass as possible to keep the metabolism up, though as with most things that are "good for us" the best is what you will do consistently rather than some ideal that you hate and will stop doing.

Unless you have already tried them, I wouldn't buy a months worth and then have them sitting in the garage for the next five years when you find you don't like them. Taste is a subjective thing, so someone else's preference may not be your own, and vice versa. We tried the PP drinks when my wife had her WLS years ago and have generally left RTD protein drinks behind after that - I prefer to use the powders as I can manipulate the taste more readily and can still bottle one up to have on the go if I need to. Looking at the ingredients, they are using a whey concentrate, which is cheaper and less well absorbed than the preferred whey isolate (but if the product that you like and will use is a whey concentrate or blend, go with what you will use rather than the ideal that you won't use.)

I wasn't speaking so much as personally, but as to how our ancestors lived, and how we as a species evolved to eat and process food. We see so many things that are today supposed to be bad for us (grains are bad, fruit is bad, fat is bad, carbohydrates are bad...) that were staples of our ancestors' lives that we need to take a step back and try to figure out if there is something inherently wrong about these foods (unlikely, given history) or something about how we are using or processing them today that may cause problems (much more likely).

The whole 30g protein limit never made sense to me from an evolutionary perspective. We used to go out and kill an antelope and gorge on it, then not have substantial protein for a few days, maybe grazing on some nuts and seeds along the way. I can buy that we may have a declining absorption with quantity - the first 30g is fully absorbed, the next 30g maybe 85% absorbed, the next 30g maybe 72%, etc.; that would make sense biologically. I can certainly buy into the idea that supplements that hit our system all at once have limits - it's a big difference between a pint of super miracle protein drink hitting all at once, and a pile of antelope that has to be digested and absorbed over time, We have discussed such things in our support group at times, with things like the classic iron/calcium conflict - makes sense when discussing supplements, but considering the number of foods and food combinations that have both iron and calcium in them, the time element for digestion and absorption comes into play.

After a couple of weeks for things like tuna or dark chicken. It's a big YMMV thing for us all. Dark meat poultry usually works better than white meat - the extra fat helps it go down easier. High quality steak like filet often works better than ground beef, which is usually cheaper tougher cuts ground up. Seafood is usually considered easier than beef or poultry and is often considered a 'soft food', though it's not really my thing. Having it in soup or a sauce (aka, 'meat lube') usually makes it go down easier. Good luck, and it does get better, even if one is on the slower side of progress.

You need to look at what your company's policy bulletin specifically says - it should be posted somewhere on their website or you can call them (and hope the rep tells you the right thing!) The policy bulletin is the legal requirement that you and they have to follow. Your surgeon's insurance coordinator may be able to help as they know the lingo and how to read the policies. Typically, these insurance diets are to be medically supervised, which can mean your surgeon, PCP or an RD (dietician), and sometimes a structured program like Weight Watchers is acceptable - you need to see what the policy bulletin states. I used my PCP for my diet and that went through fine.

IIRC, Viactiv is based upon calcium carbonate, which is not as well absorbed as the preferred calcium citrate. Citracal used to have a citrate chew but dropped the product, though I think it got picked up by one of the bariatric vitamin companies (possibly Bariatric Advantage) I think that they also make a chewable tablet as well - I bought too big of a bucket of them and was using them long after I could use the regular horse pill calcium tablet. Some vitamin makers (Celebrate is one, IIRC) produce a petite calcium citrate tablet that's half the dose and size of a normal tablet that works well for many.