RickM

I categorize them as things I don't keep around and have never used as they are unnecessary. If one has Celiac or other gluten intolerance, then they may have a role, otherwise I normally use basic whole wheat flour when it's needed. It's good that you mention baking, as that's probably good to stay away from for a while as most baked products, irrespective what flour is used, are pretty low in nutritional density (low nutrition, high calories). For incidental use as in thickening sauces, etc., it wouldn't make any significant difference what flour is used, even if one is into counting carbs and the like.

The general consensus of hospital nurses is to wait at least until your get home - they don't want to see it. Beyond that, it's when you feel up to it and interested. An orgasm isn't going to do any harm to your new sleeve - it's how you get there that matters to your comfort, so probably no swinging from the rafters for a while. But something slow and gentle that doesn't cause any discomfort - go for it when you feel like it. Your bf should be perfectly capable of taking care of himself until you do.

If you have Celiac or other gluten intolerance it would be an issue. I've never heard of bread, wheat or gluten being incompatible with the sleeve - lots of people and some surgeons are into the low carb thing which generally means avoiding bread products, but nothing inherent with the VSG. I make sandwiches on occasion when i need a roadfood meal and did at times when losing for energy management purposes, and it has never been an issue. In short, if its an ingredient of a veggie or meat substitute patty, I don't see any problem with it.

Cynically, we can say that they require the diet as a roadblock to approval, betting that it will weed out some of the less serious prospects. This does seem to work to some extent, as there are some who go straight to Mexico rather than jump through the insurance hoops. There doesn't seem to be much correlation between pre-op weight loss and long term success (note the number of people who can easily lose weight on a diet, but can't keep it off), but having some education and classwork ahead of time does have merit, helping to keep expectations more realistic. Usually, your initial weight when you start the effort is what counts, but insurance companies vary in their policies, so it is best to check with the insurer, or the surgeon's insurance coordinator. Your previous weight loss effort may count - some companies accept such a program within the past year or two with appropriate documentation. I was required a six month long medically supervised program, implicitly but not specifically with monthly check-ins but scheduling between me and the doc resulted in it being only about every six weeks, and that was acceptable. YMMV. Philosophically, unless one is in the very high BMI ranks, my preference for these pre-op insurance diets is to use the time to work on developing the long term habits that will serve well long into maintenance rather than maximizing short term weight loss. In my case, though weight loss was incidental with no specific goals in mind other than improving dietary and life habits, I still lost about a third of my excess weight, put off surgery (success for the insurance company!) and maintained that loss for several years until going ahead with the VSG to finish the job. 6-7 years after that and still maintaining it.

I think that more believe that they are keeping it a secret than actually are. The instances of successful massive weight loss by diet and exercise alone are so rare that most intuitively know that something else is involved. If it isn't WLS, then it's something more serious like cancer or other major life threatening disease.

The best time is when you will do it. As noted, with all of the conflicting research of varying quality, it's hard to tell what time is better, if any at all, or if that view will change over time. Further, what research there is on exercise is rarely focused on us - the obese and recovering obese, so there is another variable that throws everything into question. Exercising at a sub-optimal time is better than not exercising at the optimal time. This is somewhat similar to my advice on protein drinks - while whey isolate is generally considered to be the most available and absorbable form, the one that you will drink is better than the best thing out there that you won't drink (with the possible exception of Genepro, which only seems to be good for making expensive urine.)

They're not really my thing except as a component of various dishes, so I never had them then, but they were on my doc's first month menu. If they fit into whatever dietary progression that your doc uses, give it a try; our basic rule of thumb is to try new foods one at a time, testing for tolerance. If they work, fine; if not, try again in a couple of weeks.

I wouldn't go whole hog on a liquid diet if you don't required to - they are unnecessary for the liver shrinking thing as you only need a low carb, calorie restricted diet get whatever benefit there is to obtain. The purely liquid aspect that some doctors impose is usually done to get their patients used to an overly long post-op liquid diet. The docs in a couple of practices that I have worked with specifically don't want their patients fasting for weeks before surgery, but want them as strong as possible going into the procedure. These liquid pre-op diets appear to be more common than they really are through a concept known as "adverse selection" which is common to many internet forums. It is simply a skewed perception due to the fact that most of those who have something to complain about (like having to be on an unnecessary liquid diet) will complain online about it, while those who have nothing to complain about are pretty quiet. If one were to survey the general bariatric population, one would find a relative minority have to do a liquid pre-op diet, while most have some kind of calorie/carb restricted diet, or none at all.

Ah, the big straw debate - one of the great urban legends of the WLS world. First, what does your doc say about it, as they should be your primary source for advice on such things. Beyond that, docs vary on their advice between "never again" (although rarely, usually it's just an initial thing, tho some docs don't bother to say that) to "if it doesn't bother you, then it doesn't bother me - if it's uncomfortable, don't do it." It seems like that big issue with some (it's sometimes hard to find a reason for some of these "rules") is that drawing air into your stomach by sucking the last bit out of the glass may be uncomfortable. Personal note - I was having sips of water from a straw in the hospital. YMMV

It happens all the time - it is why most surgeons recommend being on two types of birth control until you get down to a stable weight to avoid the conflict between the low calories promoting weight loss and having to feed the growing little one inside.

Perhaps your PCP doesn't know what labs are appropriate, as DS labs will differ some from RNY or VSG labs? Or is he constrained by being in an insurance network (such as Kaiser or other ***) that needs to approve his work? These are the labs that my wife gets done every year from our PCP (she is a 2005 DS) - http://www.paclap.com/downloads/annualdslaborders.pdf We have had no problem getting these done with our PCP, or getting insurance coverage for them. While it is helpful to have a bariatric surgeon's insight as to what levels are appropriate with your DS, what variances from "normal" levels are acceptable or desirable, they aren't essential. Good luck on working this out.... By chance, are you a Dr. Baltasar patient? He was high on our list before deciding to self pay semi-locally.

I find the consistency of the Quest bars to be an asset; since they don't have any coatings or layers, it doesn't matter if they get warm sitting in the car (indeed, some people microwave them for a few seconds) so they work well as emergency rations.

Most CLIF bars aren't that suitable for us as they are targeted to a different audience. My nephew, who is an RD in training, uses them sometimes before workouts as their nutritional profile of protein, carbohydrates and fat fits that use, but isn't ideal for keeping calories low as we need. The Quest bars are pretty good as they are low in sugar, and what carbohydrates they have are mostly fiber, which we tend to need post-op. Pure Protein bars are similar in numbers, though with less fiber and more dependence upon sugar alcohols, which some people have problems with (and others don't). Generally, I don't use the bars much except when convenience is needed (I keep a couple in the car and in my gym bag if I need something when I'm out and about) as there are better choices of real food when at home. But as a convenience food, they aren't all that bad, and early out we often have to compromise on ideals to get in what we need.

Our plan combined what most have as their first 2,3 or 4 phases (liquids, purees, mushes and soft proteins) into a single initial phase for the first month, progressing as individual tolerances dictate, with everything else added in after that according to tolerance. We had things like yogurt and scrambled eggs on the hospital menu along with the usual liquids - some can handle more than others depending upon inflammation, etc. The pureed lettuce they served put us off pureeing anything after that! Their general finding has been that patients do better as they move toward real food, but pace was largely dictated by individual need rather than a strict calendar. Thankfuily, it also negated the need for extensive liquid dieting pre-op to get used to the post-op world. It's all a big YMMV thing.

My doc was adding veg to my diet at 10 days out as my protein intake was sufficient (90+ per day) though still a little short of my goal of 100-110 to maintain my then current lean mass. It's a big YMMV thing. On the main topic, I ignored carb counts, only seeking the best nutrition for the non-protein segment of my diet at the time irrespective macro counts. I started into the bariatric game 14-15 years ago when my wife was getting seriously into it (she was number one on the runway with her higher weight and more significant comorbidities,) which was still in the transition between yesterday's low fat fad and today's low carb fad. For the sake of the insurance mandated 6 month diet thing, we decided to go long term and work on improving overall nutrition rather than any miracle weight loss diets, and let the loss fall where it may - long term sustainability is much more important than any short term weight loss. I wound up losing about a third of my excess weight in six months or so and decided just to go into a holding pattern while we worked on getting my wife onto the table, ultimately going self-pay a year or two later. I kept tweaking my diet, making some progress here and there but little additional net loss, though did maintain that original loss for several years. Once our insurance started covering the sleeve, and it was apparent I was not going to sustainably lose significantly more, I signed up for the sleeve. As I had already effectively worked into a WLS maintenance lifestyle with my wife, there was no reason to make substantial dietary changes other than what was needed to support the calorie restriction. As popular as it was (and still is,) I couldn't afford the prospective side effects of low carb dieting, so I kept things as balanced as reasonably possible within the protein and calorie limits; thankfully, our doc had never jumped onto the low carb bandwagon, either (low sugar, simple carbohydrate and junk food - absolutely, but no arbitrary carb limits.) That worked fine, and still does 6-7 years later, though about 1000 calories higher. Establishing good fundamental habits beat miracle diets every time.

There is a liquid form of calcium citrate available (Solgar and a couple of other brands that I have seen) that may work for you. My wife used to make it into her smoothies that had a lot of her supplements. Her current thing is to simply dissolve the pills into her smoothie which costs less, but the liquids worked well. There are a few flavors (orange, strawberry, blueberry, IIRC) so they can be mixed into something compatible in flavor.

If your insurance doesn't have any restrictions on the number of WLS per lifetime (some limit to one WLS per lifetime) then the usual insurance rules generally apply - BMI of 40 and above, or 35 with comorbidities. So, that's the good news - if you were covered before and have regained to that point, then you should be covered again. The bad news that you probably don't want to hear is that it won't likely do you much good in the long term, unless there was something seriously defective with your first procedure that needs to be corrected. Changing to a bypass may get you back on track again for a while, but ultimately you will be in the same position as the two procedures are very similar in overall strength or outcome. Think of your WLS as more of a "do-over" than a metabolic reset - it gives you the chance to get things in order to live sustainably and maintain your weight, but it doesn't do it for you. While I don't agree with everything this doc says, he is one of the few that acknowledges that our meal capacity will increase over time (to around half of our pre-op capacity), and has a viable prescription for living with that fact. His numbers are consistent with my experience over the years. Also, that sleeve/pouch size has little to do with long term capacity or success - my wife has a huge sleeve on VSG terms (from her DS, which typically uses a sleeve of about twice the size of a stand alone VSG sleeve,) and our meal sizes are pretty much the same several years out. It is very much a matter of food choices and habits rather than absolute restriction minimizing how much we eat. A good part of the game here is matching the right procedure with the patient - think in terms of the WLS procedures having somewhat different personalities, and you have to find the right "fit", just as you do with friends and associates. The RNY isn't any mover powerful overall than the VSG, but may be a better fit for you. Or it may not - research and talk to as many people with the bypass as you can to see if it is right for you, as one of its' drawbacks is that it is very difficult to revise to something else if it doesn't fit. With either procedure, it would not be uncommon for women of average and below height to maintain in the 1000-1200 calorie range long term. If you are having problems at 12-1500 calories now, a bypass or resleeve isn't going to help much if you can't find a way to maintain at whatever level your metabolism dictates. The DS does offer a better metabolic kick long term and may be your best option if you can't make the long term diet/lifestyle adjustments to make the VSG work; its' caloric malabsorption is long term vs the bypass which sees its caloric malabsorption dissipate after a year or two.. But it requires more serious commitment to supplementing and follow up lab work for life (that's part of its' "personality" that you have to live with. But I have seen many be successful over 10-20 years with it, often eating a less than "ideal" diet.

Likewise, I suspect that he is giving you a (ultra) stretch goal to see how well you can do when motivated. If he seriously expects you to lose that much that quickly, he is clueless about the obesity problem and I would say goodbye and find another surgeon - there are plenty of them who don't play such games and their patients can be just as successful, if not more so.

This is something that you need to run by your surgical team, as pre-op diets come in all shapes and sizes (or none at all) for all kinds of different reasons. Only they can say whether that fits with their intent.

Beyond basic minimum protein levels, I ignored macros. There are all kinds of fad diets out there that promote magical macro numbers or ratios, but the main thing that most promote are poor eating habits: "I can't have that fish - it's too much fat", or "I can't have that apple, it's too many carbs..." I simply kept my protein at an appropriate level for my body type and aimed to get the best overall nutrition that I could with the remainder of my caloric budget. Overall, that wound up being an approximate caloric split between fats and carbohydrates, but that was incidental rather than a specific goal.

The duodenal switch typically uses a larger sleeve - they started using the smaller sleeve when they started doing stand alone VSGs. My wife's DS sleeve stomach was roughly twice the size of mine at surgery time (4oz vs. 2.5 oz) but our nominal meal capacity now, many years out, is roughly the same. Others may find that a larger sleeve will allow for excessively large meals down the line - depends on the individual, depends on the surgeon and how they make their sleeve. From what I have seen over the years in a DS centric practice, the DS doesn't seem to have as significant of a problem with reflux as the basic smaller sleeve does, so I think that there is some merit to the idea.

It sounds like a junk food - high calorie, low/no nutrition; it may be keto/paleo "compliant" but still a junk food - think paleo Twinkie, and do you really want to get in the habit of eating these? Protein, particularly meats and other firm proteins, tend to be the most satisfying longer term for hunger, and cravings are usually best controlled either nutritionaly (you're craving foods with nutrients that you are short on) or by limiting foods that trigger cravings, whether they be carbohydrate or fat based. Your classic junk carbs like chips, cookies and other sugary things fit that description, but many are also triggered by fat based foods like nuts or cheeses. It's an individual thing that you need to figure out for yourself - what triggers one person may have no effect on you, and vice versa.

It is tough, even for those of us who weren't obliged to do a strictly liquid diet and could do soft things, we're still doing a lot of liquidy things because that's what's tolerated initially, Though I could do some yogurt and eggs, I still got awful tired of soups and protein jello and couldn't stand the thought of them for a couple of years.

My wife had a similar problem with ground beef for a while, and the surgeon noted that it is not an unusual tolerance issue, and suggested that good quality steak like filet is often better tolerated. He was right - the best Rx we have ever gotten from an MD, and one we still fill often! I think that part of the problem is that even though ground beef "seems" soft and easy to digest because it is ground (pre-chewed?) it is often poor quality meat when bought commercially, and you never quite know what is in it. I suspect that if you grind up a good quality steak and cook that, then it would probably be better tolerated.

Protein drinks are the staple early out; I would avoid that Genepro stuff as it neatly fits into the "too good to be true" miracle supplement scam category (and nobody really knows what it is.) Whey protein, preferably whey isolate, is the well accepted, best absorbed form. I also had greek yogurt, eggs, and some sloppy tuna salad, though those may not be permitted on some diets the first week or two - check with your program directions.