RickM

Talk to your prescribing physician, and your pharmacist, to see what alternatives there are. Even ones that are less than ideal may get you through the initial couple (or few, as needed) weeks until you can take pills normally. Perhaps non-ER version and/or lower doses taken more frequently can do the job for a short time. With the sleeve, we usually don't need to resort to liquid, chewable or crushed medications, but some people will wind up with enough inflammation in the stomach to make it necessary, and some pills (typically calcium citrate and some multivitamins) are too large to take for a while. Good luck in finding a solution

Some capacity increase over time is normal - by this docs' experience, typically to about half of your pre-op capacity, which is enough restriction to provide for good weight control, but also enough to let things get our of hand if you eat the wrong things. I like this guy in that he acknowledges this characteristic of our WLS, and also provides a prescription of how to counter it, and it does have some merit (I do something like that, in that my diet is fairly veg heavy, though I don't buy into everything he says.) Yes, have your docs check things out in the event that there have been some odd evolutions with your sleeve. Take these "reset" diets with many kilos of salt - they are fundamentally fad diets that work on the premise that we lost a lot of weight early on when on a liquid diet, so therefor we should go back to a liquid diet to lose lots of weight again. Reality check - our early weight loss had nothing to do with a liquid diet, but simply that we physically couldn't eat much, and those of us who were never on a liquid diet still lost lots of weight early on. A basic meat and green veg diet will do all that is needed to "reset" things and restart some weight loss. Good luck in getting this worked out

This is highly dependent upon ones metabolism. A blanket recommendation of say, 1000 calories, or 1000-1200 calories is great for a guy burning 2500 calories or more per day, but for a short woman who may ultimately be maintaining at 1000-1200 calories per day, that's a recipe for very slow to non-existent weight loss. The common recommendation of 6-800 calories is good, and will cover 95+% of patients, but may be overkill for many. Considering that it's a lot easier to add than to cut back once one gets used to a specific level, erring on the low side isn't a bad idea, unless one has a pretty good idea of what their metabolism is (real world, not online calculators of what it should be.) As a guy who was maintaining weight pre-op at around 26-2700 calories per day, I found 1100 a comfortable and sustainable level that also resulted in quite rapid loss. Keep in mind that your overall metabolism will drop some as your weight comes off - it takes fewer calories to move 200 lb around than 300 lb, etc.

There are a lot of books out there that cater to those who want, or need, to follow a particular popular diet but also want to enjoy athletic pursuits that may be inhibited by deficiencies inherent in such diets. They make the initial assumption that the diet is primary and physiological performance is secondary - how do I overcome the limitations imposed by the diet - and are typically aimed toward the weekend warrior who wants to stay faithful to their chosen diet rather than the serious amateur or pro athlete who needs to maximize their performance. We are an adaptable species so we can get by with a lot of limitations, so we can make compromises. Philosophically, I would rather optimize the nutrition to help the body work its best, even if my demands aren't that of a serious athlete, rather than compromise physiological performance for the sake of the current, and changing, hypothesis of the "ideal" weight loss diet; particularly since for most in the WLS realm, dietary style is an insignificant factor to weight loss success. It makes little difference what kind of diet one is on, you're going to lose a ton of weight that first year after surgery - may as well go for the long term and nurture the habits that you need to sustain yourself and control your weight over the long term rather than worrying about which diet is today's vision of the optimal weight loss diet for the masses.

The problem with depending upon the latest diet fads is that they tend to ignore history, as in all those people from the 90's who successfully navigated their WLS, even when low fat diets were the "in" thing, not to mention that there is little in the diet world that hasn't been tried before and found wanting - that's why the diet industry cycles between diets (what's old is new again!) and why the obesity crisis continues unchecked despite the major pendulum swing toward low carb these past couple decades. It sorta makes one conclude that things are a lot more complex than macro nutrient elimination or the hormone of the day (insulin, leptin, cholesterol, etc.) Keep the faith, and it will keep you all the way until low fat diets are back "in" again.

If you want to burn your body's stored fat, you need a caloric deficit; it makes little difference what your diet is composed of, so you may as well make it a fundamentally healthy diet rather than one of these high deficiency diets that eliminates whole food or macronutrient groups. If you swap carbohydrates for fats, as is popular in many of today's fad diets, you simply burn your ingested fat rather than ingested carbohydrate before getting to using your fat stores - either way, you still need a caloric deficit to do that job. People do often stall when starting or changing up a workout routine due to hydration issues - you need more water to counter increased demand from the exercise, along with the water used in muscle repair. People also often stall when they increase their carbohydrate proportion (within an existing caloric budget) when they are on a low carb diet and their body is running short of glycogen, which fuels our short term exertion and needs water to keep it in solution; those who aren't on a low carb diet but similarly increase their carbohydrate proportion don't see this effect, or not as significantly, as their glycogen is already at or near its normal capacity. This is the same reason that most need to overshoot their goal weight to make up for that snap back regain that happens when they normalize their diet moving into maintenance - they need to account for that previously lost water weight that came with their low carb diet coming back to them. (Note that this is not a reason to avoid a low carb diet if that is appropriate for one's needs, but simply a manifestation of that diet that needs to be accounted for, rather than buying into the mythology.)

There's really no need for it, even during the weight loss period. We concentrate on protein early out because that is essential and there is no replacement - no supplements other than protein drinks until we can get by on real food. But even early out, our diets aren't really high protein, but rather "just right" protein to meet our needs; it's only high protein relative to everything else that we can, for a time, get from pills. Protein consumption later on, in maintenance and beyond, doesn't need to be any higher, but other things will be higher to go along with it, as our calorie needs increase from loss to maintenance. For an average or shorter than average woman, 60g per day of protein is usually considered to be plenty (if not more than plenty.) The only real exception to this is for those who get into body building and need extra protein for added muscle growth. The low carb part has never really been part of the "bariatric" diet, but is simply a carry over from the currently popular fad diets in the weight loss industry. Classic bariatric diets are simply protein first and then whatever else fits after; they are by default low carb and low fat, so no effort needs to be put into that aspect of an eating plan. Carbohydrates don't lead to any more weight gain long term than fats or protein does, rather it is the excess of any or all of them that leads to weight gain. It is only current diet mythology that preaches that low carb is needed to lose or maintain weight (because they still have lots of low carb diet products to sell....)

For the sake of the surgery, they are typically looking for, as above, signs of damage from GERD (acid reflux), gastritis, esophagitis or Barrett's esophagus (precursors to cancer of the esophagus), H. Pylori infection or ulcers - things that directly impact the surgery or choice of procedure - or any masses or polyps that may be cancerous or pre-cancerous (which are really nice to find early, if you are going to find them!)

Generally, no, you don't need or want to increase your calories; maybe for those who get into serious exercise routines (as in marathon training level.) While what you are doing is intense for you, on the overall scale of things, it is still considered to be "moderate" and you should be able to work within your existing caloric budget. You might, at some point, need to increase your carbohydrate allotment if you feel like you are running out of gas, (particularly before a workout,) but that can be done within your normal calorie level, and avoids the problem of "eating back" the calories that you burn.

The first question is whether you need it - the sleeve based procedures generally don't while the bypass does. If one is low on it pre-op, then some form of it is appropriate - tablets usually work fine with the sleeve, or the sublinguals if preferred; shots usually aren't needed with the sleeve. Our program doesn't call for B12 supplements with the VSG or DS unless needed by a specific patient. My levels are always on high end of the normal range without any supplements.

My wife and I have dinner with him periodically in our support group, which is largely composed of Dr. K and Dr. Rabkin veterans, mostly 10-20 years out. I can't comment much on his program currently, but as above, he would be our choice for being here in SoCal, and from travelling from out of state, either are quite good and it would come down to whichever is more convenient for travelling.

Look up the vagus nerve - that sucker branches out to most of the abdominal organs and helps control most of our involuntary functions including digestion and initial satiety from stomach stretch. It also branches off to the larynx and sinuses along the way from the brain. With our reduced stomach size things are more sensitive now, along with the wires getting a bit crossed in the process, so we can now get some odd signals that we never got before.

I wouldn't expect that it would be needed if you're doing one of those liquid diets for a couple weeks beforehand - I expect that you will be fasting after midnight before surgery and maybe clear liquids only the day before and that should have things adequately emptied out. We did a bowel prep with clear liquids the day before (which was mostly a holdover from their DS practice) but we didn't have any pre-op diet before then.

A couple of basic points about diabetes and WLS that I have learned over the years. 1 - the VSG and RNY are, on average, about 85% effective in driving T2 diabetes into remission, (some practices will show somewhat better or poorer results with one procedure or the other, but the overall average is in that ballpark) so there will be an unlucky 15% or so that will still struggle with it. The DS does a better job overall, with remission rates in the 98-99% range, but it is not as widely performed. That is the bad news; the better news is that 2 - the longer one has been diagnosed and under treatment for diabetes, the longer it often takes after WLS for remission to occur. Again, a generalization, as some will leave the hospital free of meds and insulin, but others will lag but catch up. My wife had been diabetic for about 20 years and just short of being on insulin, and it took her the better part of a year to be off all of the meds for it, and that was with the stronger DS on her side. Patience is a virtue in this case; give it time and work with your docs on it, and it should work out for you - the odds are still on your side.

Teaching nutrition and sustainable weight control is great, and I really hope that they are doing that - not just the "diet of the day". Compliance is a factor as well, and that is, I believe, one of the issues that this study can point to - those that are non-compliant with the pre-op program will likely have compliance problems post-op. This can be a good tool in identifying potential problems. Compliance is an issue, and can can point to the need for either additional psych or nutritional therapy or counseling. depending upon where the compliance problem is. If the diet is overly restrictive, that's a problem, but a good RD should be able to tailor a diet around a patient's preferences and aversions. This is not to say that they should allow a 1200 calorie Twinkie diet, but there are a lot of healthy ways to craft a low calorie diet - a Mediterranean diet, as good as it may be, won't work with our family, for instance, due to its' inherent fishiness, but that's ok because there are other approaches that work well, too. It can also point to metabolic problems - as others have noted, some do better on a 1200 calorie diets than others. Some, particularly shorter women who inherently have less muscle mass to drive their metabolism, will ultimately be maintaining at 1200 calories (and sometimes less) which can make sustainable maintenance a problem for many - they can't keep it that low and the weight creeps back up again. This factor can help drive a decision as to which procedure may be most appropriate for a particular patient - the DS, for instance, is a stronger metabolic tool and typically has better regain resistance than the VSG or RNY, so is often a better choice for those with significant metabolic problems or a long history of yo-yo dieting. There isn't a one-size-fits-all solution. On the flip side, over the years that I have been involved in this, I haven't seen much evidence that pre-op diets have much of an influence over long term success in weight control (as in 5-10 years out and beyond.) Many programs include pre-op diets of some kind, while many others don't, and many patients will struggle with regain problems after a couple or years or so, and observationally at least, it is real hard to pre-op dieting or lack thereof as being a factor. I am familiar with several programs that don't do any such dieting yet they have very good long term results. It would be real hard to craft a study to evaluate this while isolating the multitude of confounders, In short, there is a lot of benefit to good nutritional counseling and education as part of a good WLS program, and helping patients learn new and better lifestyle habits, but I remain skeptical of the value of imposed pre-op dieting in regard to long term success.

I'm not so sure that they are drawing a valid conclusion from their study (or at least the headline isn't.) By giving their population a common diet (1200 calories, etc.) and dividing them into those who lost more than 8%EW and those who lost less than 8%, they are effectively grouping their patients into those who lose weight more or less easily (implicitly by differing metabolic rates), and it doesn't seem like a profound conclusion that those who lose more easily pre-op will lose more easily post-op. Further evidence of this is that their male patients did better than their female patients, which also isn't overly profound as men typically have higher metabolic rates than women, so they do tend to lose more on a given diet plan. The implied headline conclusion that dieting and losing weight pre-op leads to better post-op loss really doesn't follow. For that, you need to look at two randomly chosen groups, one of which follows some prescribed diet program and the other that does nothing special, and then look at the post-op results. Another question not answered is whether the imposed diet provides any long term benefit toward maintaining a healthy weight once the weight is lost I'm not saying that there are not benefits to getting one's head together and establishing good habits ahead of time, but that imposing yet another diet on people who have an established pattern of failing at diets is of questionable value. I had to do the common six month insurance program, but the focus was on developing good dietary and lifestyle habits rather than any particular weight loss goals, and the loss followed with the improved habits - which flowed through the post-op period and into the long term maintenance period. Learning long term weight control is much more valuable than a dubious improvement in short term loss rate.

Pre-op diets vary from nothing at all other than the day or night before surgery to months of liquids, and varying rationale are given for them, mostly either to "shrink" the liver or otherwise improve its condition prior to surgery, or to "get one ready" for post op regimens. The liver shrinking thing is debated amongst the surgeons, as to how much improvement can actually be accomplished with a week or two of dieting, how necessary such changes are depending upon surgeons' background and experiences. I find the "get used to post op" a weak argument in that in the immediate post op times there isn't much that one feels like eating other than the soft/mushy/liquidy stuff for a while, though some programs have progression rates that are very much slower than others, so possibly those guys might need that transition (or it may make it worse.) In any case, it is best to follow your program's guidelines. If they have a long and involved pre-op regimen, do it, as you want the surgeon as comfortable as possible when he is rooting around in your insides. If they have no pre-op diet, or a very short or simple one, don't worry about it as something longer or more involved is not needed for their program; the most successful programs that I have run across, both from the perspective of good long term results and low complication rates don't involve any pre-op diets other than the usual day before thing.

It only takes a few hours for the stomach to be empty for surgery, which is why most surgeries, including GI procedures, have one stop eating after midnight or some such time, sometimes they may restrict one to clear liquids for a few hours before that, but otherwise it is similar to what one needs to do for an EGD. The shrinking the liver thing is something that is debated amongst the surgeons, as to how much improvement can actually be achieved with a week or two of dieting, but to the extent that it is therapeutic, it is the low carb/keto thing that has the beneficial effect; the liquid only diet that some programs impose is of questionable value in that regard as many programs don't impose any diet at all other than the standard day or night before thing. A couple surgeons I know specifically don't want their patients fasting for weeks ahead of time as they want them as strong and healthy as possible going into surgery - a lot of different philosophies and experiences out there that lead to these varying practices. There may be other reasons for the different pre-op protocols (other than, hopefully, "that's the way we've always done it") so it's best to follow your surgeon't plan even if it isn't fully explained

It is normal to be able to sip that much, but also normal to have trouble getting much in, all depending upon how much inflammation one has in the stomach post-op. I could sip through a bowl of broth (6-8 oz maybe?) and a juice box in a sitting (say, half an hour) in the hospital while in the same phase, and later, my wife could barely get through her nominal stomach size of about 4 oz; both were within normal expectations according to our surgeon. Our target for early drinking was a one ounce shot glass per five minutes if we could do it; some programs talk in terms of an ounce per fifteen minutes. If you have a lot of inflammation, drinking is like waiting for the water to drain through a pinched soda straw, so it can take quite a while to get any reasonable amount down; if there isn't much inflammation, it's like the water draining through a normal soda straw - it goes through fairly quickly. If you aren't feeling any distress and it isn't coming back up, you are doing fine.

I was looking for a healthy body composition, looking to get my body fat% into the mid teens - average to lean side of average for guys (mid twenties for the gals) and targeted the scale weight that corresponded to that range; BMI is irrelevant for individuals as it is mostly used for population studies. I started out with the gross assumption that I would only lose body fat (not realistic, but a start) and adjusted goal weight as I got closer and saw how my body comp was shaking out.

You can find more out about your insurance requirements by finding their policy bulletin on WLS, which should be on their website somewhere. There are many BCBS organizations around the country (at least one for each state, and it may not be the state that you live in, if the employer sponsoring the insurance is based in a different state. The bulletin should spell out precisely what they require to qualify for WLS, so you can get a jump on the program, and probably find more questions to ask when you go for your first appointment. The will usually have an insurance coordinator in the office (who may or may not be your case manager) but they will know the in's and out's of the different companies and their policies, and can read the language ("insurancese"). Some companies require some months (3-6 typically) of dieting and weigh ins before approval while others don't. Likewise, some surgeons or programs have a lot of hoops to jump through (classes, pre-op diets, exercise consults, etc) while others have very little. It's all a "learning experience". Good luck,

The hiatal hernia is usually no big deal, as they usually fix that when they do your surgery. Polyps likewise aren't usually a show stopper, they usually remove them during the EGD and send them out for biopsy to see if anything nasty is in there - the same as they do with a colonoscopy. The gastritis may be a concern that they want to investigate or treat before surgery, or possibly change the surgery type if they deem appropriate. After a couple of weeks, they should have gotten back to you if they want to do something else, so it wouldn't be unreasonable to call them on it.

We had to do one, as their practice is DS oriented, so there are similar concerns about having the intestines cleared out. And yes, it is basically the same thing as for a colonoscopy. Thankfully, we didn't have to play any of the liquid pre-op diet games that some practices impose, which to me was a much better trade off.

A lot of these things might be termed "advanced class" in that you have to learn how to use them, and use them at appropriate times, and not necessarily a "never again" thing. My wife, 13 years out on her WLS, has a smoothie every day - very high nutrition and a good way to bury some of her needed supplements, but in no way is it a low calorie or weight loss drink - nor does she need it to be at this time. It's all a matter of context.

You'r welcomed. While the BP coffee, and the keto movement in general may be debatable, the liquid calories are one of the Cardinal no-no's of WLS, (or at least a big red flag,) no matter how healthy and nutritious that liquid may be. Some surgeons are even really down on the protein shakes because of them being liquid calories, though most are accepting of them for their necessity during the immediate to intermediate post op times to ensure adequate protein intake.