RickM

From the purely gastric surgery perspective, all that's really needed is for the stomach to be empty at time of surgery, so the minimum that we normally see is liquids only, sometimes clear, the day before (and occasionally we see someone reporting just the 'nothing after midnight' thing.) Anything that goes beyond that, as in additional days or weeks of low carb dieting or liquids only is an individual choice of the surgeons to address whatever other concerns they may have.

By what measure(s) is #1 decided? By volume, McDonald's is the #1 restaurant in North America. Are you equating the two? Overall, the sniping between promoters on this thread isn't doing the overall business of medical tourism any good at all.

I fail to be amazed at the variety of pre-op diets anymore, as docs do all kinds of things for all kinds of stated and unstated reasons. Likely, ketosis was far from his intention, as it is hardly a major success factor in WLS, as much as one may read about it in internet forums. For us, ketosis (or at least the objectionable symptoms) was merely an accidental thing that happened because the diet was overly low in carbohydrates for a while, but that didn't make any difference to the weight loss performance of the program. But that does sound a bit scant in protein for something leading up to (any) surgery.

Certainly - programs vary all over the map - though I never used the pre-made ones, just the powdered mixes. We were started on a soft diet, so weren't restricted to just liquids, though they were certainly a big part of things initially.

They will sample anything that looks a bit odd - polyps can happen in the stomach as well as in the colon (which is what they commonly remove and biopsy during a colonoscopy), anyplace where it looks like an ulcer may be forming, there can be localized changes to the lining that can be pre-cancerous. It's generally nothing to worry about, but if there is something going on it's better to know about it early rather than later.

My wife had a DS 12 years ago and I had a VSG 6 years ago. She started out at a mid 60's BMI and I was a near 50. During her pre-op period of trying to get insurance to cooperate (it was still "investigational" then) and we did the semi-typical insurance 6 month diet/exercise program, I lost around 50lb - about 1/3 of my excess weight - and subsequently kept it off for a number of years (settling out around a 40-41 BMI. Once we got her on the table, and into the losing phase, I felt I was too low to go for the DS, and still had some prospect of maybe losing some more on my own. Ultimately, I maintained what I had lost and when our insurance started covering the VSG, I went for it. Had I regained what I had lost, as often/usually happens, I would have gone for the DS as that would have shown me that I needed its better regain resistance. A few things that I have picked up over the years in DS-land: A 2-step DS is a good option for those who are too ill to withstand the longer 1-step procedure. As a "plan B" option in the event of regain it is less satisfactory. Discussing this with our surgeon, his experience has been that the second step works best if it is done before any substantial regain is experienced - the weight loss after revision is usually less than what would have been experienced with a "virgin" DS. There is a general characterization that is sometimes used that "the sleeve loses your weight, while the switch keeps it off." That may not be entirely correct, but it's probably an 80/20 thing. Another consideration is that the DS is usually performed with a larger version of the sleeve than the VSG, so the restriction is a little less than the VSG, offset for weight loss purposes by the malabsorption. This also means that reflux problems that are a not unusual problem with the VSG is less common with the DS. These above considerations really tend to push one toward an either/or decision, rather than a more casual approach of "I'll go with the VSG and the DS is always there if that doesn't work out." We often see threads here about VSG vs. RNY or DS, and it is common for thsoe who decided on the VSG to state that they didn't want their guts rearranged, etc., which is a fair perspective - who does? But we all got comfortable with the idea of removing 80% of our stomach, which many consider a radical step. Fact of the matter is that some people need a malabsorbing procedure to get that job done. In my mind, the more one is inclined toward yo-yo weight patterns and increasing weight over time, the more appropriate the DS becomes over the VSG (and RNY, for that matter.) Indeed, some who fit that pattern do succeed long term with the VSG, but it's more of a long shot; OTOH, I see several 10-15 year DSers every month at our support group who continue to maintain well (and wake up every morning with one!)

It depends upon what your diet requires. For many diets, that wouldn't be a cheat at all, but for others it would be. My guess is that by asking, it isn't on your plan so I wouldn't do it without asking (the doc's staff) first.

I hear you on that - I was/am too. Fortunately we travelled for surgery so I had some good shoreline and forest trails for walking for the first couple of weeks. But yeah, I officially pushed things a bit by going in to the gym at three weeks, but mostly did it as a means of maintaining the habit and took it real easy. I could have walked around the block more as easily as walking on the treadmill. And when I was able to get back in the pool again, it was mostly just paddling around, getting things stretched out again before slowly working up to pace again. I had a much harder time after plastics, which puts you down for a lot longer.

Walking immediately and some cardio in 3-4 weeks and lifting beyond 10lb after 6 is fairly typical advice; my doc didn't want any ab or core work for 12 weeks, which arguably is not conservative enough. I started back to some basic resistance exercise at 3 weeks since the pool was out for another week for me (still had a weeping incision to close) but kept it light, about half of what I had been doing and only with the machines to isolate the core. It was mostly just a range of motion thing to keep everything moving some. One of the things that I have picked up from the physical therapists going through orthopedics is that the connective tissues - the tendons and ligaments holding the muscles together, and would also include the fascias like the abdominal wall, don't get the blood supply that the muscles get, so they don't heal as quickly. This means that we may feel strong enough to lift more than we really can, so caution is the watchword. Incisional hernias are fairly common after abdominal surgery, even lap, and even something like a sharp sneeze or cough can open one (this is why we are often advised to hole a small pillow against our abdomen when we cough post op.) The good news is that such hernias can be a way to subsidize the cost of plastics later on! An abdominal binder might be useful for a while when you start - talk to your surgeon about your plans and what his experience has been.

It could well be the low carb count - such lethargy is a hallmark of low carb dieting (one of the reasons that I never went that direction - I couldn't afford the side effects.) The keto enthusiasts insist that you are supposed to be able to burn fat to get that energy, unfortunately, our bodies don't read those diet books so don't always know what they are "supposed" to do. Talk to your surgeon about your needs and what can be changed if his program isn't working out for you - you may be doing more work than your surgeon was anticipating in providing those instructions. Timing can be an important consideration if you have specific workout times when you do your walking and run into your problem. A small snack an hour or so ahead of time, composed of something relatively high in complex carbohydrates, moderate in protein and low to moderate in fat can provide the longer enduring energy needed to extend things some - this is what I worked out with my RD when I was running into a wall about an hour into my swimming at about 4 months out and hit the spot just right. I did not increase my calories for the energy, but just reallocated what I was already consuming. If your walking is more spread out during the day, it may take a more generalized increase in complex carbohydrates or fats, or a bit more of both, during the day to meet those needs. Another thought is that it could be a bit of anemia - have you had labs checked lately. Iron is the traditional problem but B12 is sometimes a problem - some programs recommend B12 supplements as a matter of course and some don't, and some people are more sensitive to it than others as well. Also, double check your hydration, as you may think that you have been well hydrated, but if you just increased your exercise levels a month ago and didn't increase your hydration to compensate, you may not be doing as well as you think.

It sounds like the RD you were working with was just dispensing the standard diet sheet handed down from upon high by the surgeon or hospital, much as pharmacists spend much of their time simply counting pills per a computer order rather than getting to dispense the advice that they have the education and training to do. A good RD given a bit of freedom will work with the patient to affect the desired result within the tastes and tolerances of the patient. You are right though, that it seems that many pre-op programs seem to be devised to test a patient's tolerance and compliance. Another thought is whether "liver shrinking" was a major intent of the diet, or some other rationale. A lot of surgeons aren't overly concerned with that.

There are an awful lot of "may"s and "could"s in there. The problem that we have is that the science that we currently see comes from the same sources that also told us how essential low fat and low dietary cholesterol was. The science then was just as good as it is today, but ultimately what we see are small elements of a much larger whole - there was nothing fundamentally wrong with the science on fats and cholesterol in the limited cases that were studied, but it ultimately didn't translate as a big a deal in the general case. Likewise, as the pendulum has swung back to the low carb regime (as it has done several times over the past century - lather, rinse, repeat...) there is a lot of work that applies to similarly limited cases - particularly diabetics and the insulin resistent who have always benefited from such diets even when they weren't "in" - that has questionable application in the general case. Looking from the top down of how these diets work in the long term - 1 year, 2 years, 5 years, etc., they don't show any better success rate than any other diet over the years - about 5% success in the absence of WLS. With WLS, there isn't much objective work out there to suggest that one diet works better than any other. Go with whatever diet one likes - if one has a specific morbidity that requires specific limitations, then go with them, whether they be limits on carbohydrates in general or sugars specifically, fats, dietary cholesterol, gluten, fiber, protein, nuts, dairy, etc. - there is a lot to be gained from good dietary science (see your local RD!) but if one is looking for a one-size-fits-all magic bullet, keep looking - or keep jumping on whatever is trendy. You need to find something that you can stick with for the rest of your life that will help you control your weight and hopefully provide adequate nutrition to minimize the need for pills.

Yes. There are legions of people out there who have tried and failed at Atkins diets over the years who need to be convinced that there is something new to spend their money on. Plus, there's a new generation of dieters to whom Atkins is just too "old school", so a new name and a new scientific gloss and you get a new diet. That's marketing at its' best. Much like some restaurants that will inject steam into their day old dinner rolls to make them "fresh baked". Same thing.

You certainly want to keep an eye on your calories as you move on from losing into maintenance and beyond. We often see people come through these forums who proudly proclaim that they do "full fat everything", which works well early on when capacity is minimal but then the struggle with regain later if they let their calories get away from them. From a practical perspective, the clinical use for a high fat/low carbohydrate diet is for non-WLS gastrectomy patients (from cancer or gastroparesis, typically) who need to minimize their weight loss and ultimately gain back lost weight, so there is weight gain built into the diet that you need to counter.

It is hard to tell from the vernacular - traditional/modified/etc. - what exactly you had as surgeons can use such general terms rather loosely. If indeed you had a BPD/DS, that is quite distinct from the SIPS/SADI/"loop DS" which is a very different procedure where some use a DS label for marketing purposes. The "traditional" BPD/DS can be "modified" in different ways - primarily in varying limb lengths and proportions, and the common channel length, but still be a BPD/DS as defined by the CPT codes that insurance companies and Medicare use for billing purposes. The SIPS/SADI is a different structure that resembles a DS in that it uses a sleeve gastrectomy and alters the intestinal tract, but to a different fundamental configuration. It is neither better nor worse than the traditional DS (time will tell on that, given its' newness) but it will have different characteristics in its nutritional absorption and potential side effects. Calling it a DS is somewhat deceptive (that's marketing for you!) and is akin to calling a RNY gastric bypass a "DS with a pouch instead of a sleeve." My suggestion would be to have the surgeon explain exactly what he did and how it differs from a "traditional" DS, and to get a copy of the surgical report from him or the hospital. This last point is very important for all with these intestine altering procedures (or any bariatric, for that matter) so that if any problems crop up later in life - including an accident putting you in the ER for emergency surgery - the responsible surgeon at that time can have some idea of what your altered anatomy looks like. Some patients I know keep a reduced and laminated copy in their purse for just such an eventuality.

Either way, really - whatever is most convenient for you. If you consider that in these early mushy and soft phases most foods are close to the density of water (which scientifically is the measurement standard as 1oz volume = 1 oz weight) then it doesn't really matter. I find weighing to be much more convenient as one isn't continually cleaning measuring cups and spoons; even when cooking I rarely use measuring cups as the European method of weighing things is a lot easier.

They wouldn't be here on a WLS forum if they lost it on such a diet and didn't have surgery. Many people try those diets (and every other kind) as a "one last try", fail at it and have the surgery, as all of those diets have a 95% failure rate in the absence of WLS. With the help of WLS, such diets are more successful, but most any diet works the first 6-12 months post op; the important factor is learning how to control one's weight in the long term, which most of those diets don't help. Those who I know who have been most successful at this (as in maintaining substantial weight loss for 10, 15, 20 or more years didn't do it by succumbing to quickie fad diets, but by taking advantage of that year or so long window post-op to establish the healthy dietary habits that work forever.

First and foremost is to not get fat in the first place, and second would be to get better parents - it's primarily a genetic thing. There are lots of potions and creams out there that purport to tighten loose skin, and some might actually do something in minor cases. The problem is, beyond the nature of the industry for cosmetics, nutritional supplements and other miracle cures, is that it is very difficult to validate the claims with any kind of double blind control testing. With all the personal variables involved, it's virtually impossible to get two groups of effectively identical people together to test the value of these products (assuming the manufacturers were so inclined, which they rarely are.) So, yes, we will find people who used this or that product and report a certain result. The problem is that they have no idea whether that product did anything at all versus having done nothing. Give it your best shot, use what seems to be the best product, and see how it goes. Losing more slowly has some merit, though the major difference would be in losing your weight over five years versus six months. The difference between getting to goal in ten months versus eight months would be insignificant. Some are naturally slower losers than others due to their metabolism; however, the danger in trying to lose more slowly by consuming more while losing is that you may never get all the weight off that you want to get off. Our overall metabolism (resting plus activities) will trend lower as we lose since we have progressively less weight to move around (the main exception being those who seriously ramp up their exercise as they progress - as in marathon training levels,) We go into weight maintenance when our consumption meets that declining metabolic burn, so we can end up short on our loss if we consume too much.

With a VSG? Probably nothing as B12 concerns are mostly an RNY thing that many docs carry over to their VSG patients; it isn't even in my doc's protocol for VSG or DS patients. If you aren't feeling overly lethargic, you are probably fine as the main upshot of low B12 is a form of anemia. Go ahead and start taking it until you get your first round of labs done and see what your levels are.

You're also hanging on to more muscle mass than most, and working it too. But, yeah, 150 isn't overly excessive if the calories are in line with one's weight loss needs (that's 600 calories so well within most weight loss needs), though some with kidney problems may complain (particulary their doctors!) but those limitations should be from MD instructions as appropriate. I target 105-110g to maintain my 150ish lb of lean mass; 140-150 if I was inclined to be building muscle mass, or for heavy duty surgical recoverly (like from plastics.)

Too much protein, fat, carbohydrate, or any combination thereof, will turn to fat. Over the long term, it comes down to your caloric deficit - how much more are you burning than you are consuming - that ultimately comes out of your stored fat. You need a certain minimum amount of protein on average for you body to function properly, and if you don't get enough it will take it out of your muscle mass - there is no other place for the body to get the amino acids that it needs other than the protein that we consume. Fats and carbohydrates are fairly interchangeable and the body will convert either to get the sugars and lipids that it needs, though it can also go for protein if one or the other is too short in supply (that's right - too little carbohydrate can cause the body to divert your protein for those needs, contrary to what some popular diet books may preach; your body doesn't read those books and does what it darned well pleases.) The typically quoted protein levels that most docs use (usually 60-80 for women and 80-100 for men) is adequate for the body's needs with enough overkill to minimize loss of muscle mass as we lose weight; those who are particularly muscular for their size may need a little more. Generally, a little bit of excess protein is better than too little, and that is usually accounted for in these dietary recommendations. As BigVif indicates, some bloodwork will give your doc a clue as to which way things are going. Many people overconsume protein in an effort to keep carbs low, as that's what some currently popular diets preach, so you are in good (though not necessarily the healthiest) company. An alternate strategy that you might consider is to substitute more vegetables (and maybe a bit of fruit as well) for some of that excess protein as that can help fill in some of that excess capacity that we develop over time, as such low calorie/high nutrition food can be very handy in maintaining long term weight control once we get to our goal weight - start good habits early.

Why do you want to do a liquid diet if there is no reason to do one? It doesn't promote any more weight loss than a normal diet of similar calories, nor does it "shrink the liver" any better than a solid diet of similar macro composition. Given that you will probably be on a liquid, or more liquid intense, diet post of for a while and protein is usually a big emphasis, it would be useful to experiment with the different protein shakes on the market to see which ones you like, or at least tolerate. But don't stock up too much on a preferred one as tastes may change post op (or they might not - YMMV) BTW - what's a "mini-sleeve"? How much more mini, or simple, can a sleeve get?

As long as you are getting adequate water and protein, it makes no difference at all what composition your food takes on - liquids, soft and mushy or firmer and more real foods. That can make a difference to how your new stomach tolerates things as it heals and inflammation subsides, but that is a very individual thing. Most will typically stall or at least slow down somewhere in the 2-3 week range - that is completely normal and has its physiological roots in your starting a major weight loss program with a large caloric deficit. This happens just the same to those who start out on soft foods as to those who start on liquids and transition later. Initially, you are living off of your short term energy supply of glycogen, which involves a fair amount of water weight loss. After that has exhausted and your body gets the idea that you are serious about this caloric deficit thing, it starts drawing on your longer term energy stores of fat which burns more slowly, so you will experience a bit of a slow down in loss rate. But this is what you are really here to do - burn stored fat (and you don't need a "ketogenic" diet or any other fadish things to do it - just a caloric deficit. Enjoy the ride.

I can't speak to specifics on the MGB, but when my wife and I first started looking seriously at WLS some fourteen years ago, it was an offbeat procedure looking to gain respect and legitmacy. Since then, both the DS and the VSG have gained general acceptance by the ASMBS, the insurance industry and Medicare as routine, mainstream bariatric procedures, while the MGB remains on the fringes. I would focus your research on understanding why this is. Usually the reason lies with some combination of effectiveness and complications. No one goes into this planning to need a revision (excepting the few cases where two step procedures are planned from the outset,), but having a viable "plan B" isn't a bad idea, and some procedures are more flexible in this regard than others.

Mine is pretty much the same as it was before, corrected for the lower weight that I'm dragging around all day. Before surgery, I was stable in the 26-2800 calorie range and now, 100 lb lower, I'm stable in the 2000-2200 range. I ran in the 1100 calorie range while losing and started ramping up the calories to slow things down toward maintenance after six months. One can probably conclude that my resting metabolism is similar to what went before, while the active burn has decreased some due to the lost weight. I suspect that you will also be a fairly quick loser without having to go to extremely low calorie levels given your numbers and your discussion in the other thread that I have lost track of. Do you know what your approx metabolism is currently, where are you stable or losing/gaining? The ones who really struggle are coming into this, usually from fairly high (relatively speaking) weight and already have significant metabolic problems, as in 1200 calories or so, and have little choice but to go significantly lower (or go with a DS, that really kicks the metabolism up.) If the weight loss significantly helps your ortho problems as you hope, your overall burn should pick up some if you can return to some of your former activities. BTW, did you go with Dr. Billy as you were considering, or someone else (semi-neighbor here, in the Valley, though our doc shares a support group in Ventura with another surgeon)?