RickM

Sliders aren't necessarily high calories/fat/carbs, but are simply foods that go through our stomachs easily and with little restriction. Many of the junk foods that we should avoid fall into that category - ice cream, chips, twinkies, crackers and the like. But many low calorie/high nutrition foods can also be sliders - peppers, onions, spinach, avocado (ok, not so low cal, but good nutrition when you can afford it), tomatoes and the like tend to go through me fairly easily (can you tell that I just made a salad?) and when added to some meat can increase the volume consumed with little caloric impact but a good addition to the daily nutrition. I would often have mixed meat and veg meals - stews, stir fries, salads, chili and the like once my Protein intake was fairly reliable and I could back away a bit from the "protein first" rule. "Slider" is a bit like color - it is neither good nor bad, it just is. Green leafy vegetables are generally good, while green fuzzy meat is not. The same with sliders, and that can be used to your advantage as you progress through this process - benefit from the good sliders while avoiding the crap sliders. The greek yogurt that is often recommended is a great slider for getting in additional protein when meats and other firm Proteins are too restricted.

Loss rates will be all over the map since there are so many variables involved, not least of which is amount of weight that needs to be lost (bigger, heavier people at the start will tend to lose more pounds per month even if the percent of excess weight lost is lower.) I lost about 60lb of the 100-ish that I had to lose in the first three months; others will lose slower and some will lose faster. YMMV. I have guy metabolism on my side (guys tend to lose more quickly than women) as well as established patterns of fairly high activity levels. I did a 5k walk at about 3 1/2 months (running is a no-go on my knees), but I had been doing them periodically for several years pre-op. What is probably more important for you is your condition at three months rather than any particular weight loss - any loss will be a big help, but you will be feeling so much better by that time that it won't matter that much if you are down 60lb or 30. It was around the three month mark that I noticed that fast walking was no longer providing me with the exercise intensity that it once did - a fast walk pace, about as quick as I could walk without breaking into a jog, somewhere a little above a 3mph pace, would previously get me into that peak cardio target zone of 80% max heart rate (130-140bpm for me) but after about 3 months I could barely break 100bpm at that pace. I really needed to get into the hills and do some climbing to get my heartrate up to that previous level. These days, at 17 months out, it takes some serious work in the pool to get it over 120. For the record, I lost about 30lb the first month, 15lb each of the next two months and 10 lb per month thereafter; your numbers will likely be different, but the profile of loss will should be similar, with your biggest loss in the first month tapering off after that. In the meantime, do your walk, walk, walking preop and postop as your doc instructs, and ramp it up as you feel up to it.

I suspect that a lot have cheated on it. The most important part of those pre-op diets (for those whose docs require them - many don't) is that they be low carb to help improve the physical condition of the liver when they are working around it doing your sleeve; your liver doesn't care whether you have been sucking liquids or eating meat and veg. I have yet to find a satisfactory rationale for liquid over solid diets pre-op.

This is very common - my doc's plan has early meats be things like tuna or chicken salad - soft and squishy blended into sauce. Early meats by themselves would be dark meat poultry (fatter & moister than light meat) and fatter, moister cuts of beef when getting to that point. Chicken breast and the like can be some of the more difficult meats early on.

The NSAID ban is mostly an RNY thing, carried over by RNY docs when they move into doing sleeves. NSAID use has long been one of the advantages of the DS (which uses a sleeved stomach as its basis) and now the stand alone sleeve over the RNY. There are specific structural issues with the RNY that contraindicates the use of NSAIDs and other stomach irritating medications that doesn't apply to the sleeve which is structured quite differently. This factor has been used many times in the successful appeal of insurance decisions favoring the RNY over the DS or sleeve. There are some systemic issues with the use of NSAIDs for the population in general that may be exacerbated by our smaller stomachs but those are generally mitigated by use of PPIs if the NSAIDs are going to be used routinely, but caution should be applied to this class of drugs for anyone needing to use them long term. Some sleeve docs will not recommend their use for some period of time after surgery out of healing concerns while others will recommend their use shortly after surgery for pain relief after the narcotic pain relievers are no longer appropriate. So we have yet another topic where there is little consensus amongst surgeons, though from my observation, the surgeons with the most specific sleeve experience have little problem with NSAID use for their sleeve/DS patients. YMMV

First, we are not on a high Protein diet, rather we are having enough protein to maintain ourselves, which is an amount that doesn't change much from what we should be doing pre-op, post-op, maintenance, surgery or no surgery. The 60-80 gm per day (sometimes up to 100gm for men) that we commonly see as the recommended amount is consistent with the govt. RDAs of 60 gm for basic maintenance of our lean body mass for the "average" person. Our tissues - muscles, skin, organs, etc. are continually regenerating themselves, and need protein to do it, and that's where these basic recommendations come from. The amount needed is roughly proportional to our lean body mass, so a lighter framed woman who may be 120 lb in "normal" or "ideal" weight may need around 60gm while a larger framed man of 180 lb normal weight may need 90-100gm. Men normally tend to be leaner than women, so a normal man would need a little more protein for maintenance than normal woman of the same weight ("normal" body fat % for men is in the mid teens, while for women it's in the mid twenties.) My lean mass in the mid 150lb range needs around 100-105gm of protein to maintain; if I were interested in seriously adding muscle mass, that could easily require 140-150gm. Like Pdx, I never really did low carb during the loss phase (I'm 17 months out, maintaining for the past 10,) as it didn't make sense for my activity levels, though I added some complex carb part way through the process to better fuel some workouts as they got longer. My overall philosophy was to work to keep as reasonable a balance as possible with the remaining calories beyond my basic protein intake. Also like Pdx, I am on injured reserve status (shoulder surgery for me) so exercise intensity is down, though overall activity levels are up some (new puppy helps...), so I am keeping stable on the same 2000 calories that I was using before I got into this rehab mode. Off to the pool, now, for some restricted workout....

I started working with small salads with some leftover meat around the end of the first month. I mostly use chopped spinach instead of lettuce to boost the nutrition a bit, and some misc. salad veg. Doc told me to add veg to my diet at day ten as my protein intake was more than adequate at that time (so make sure you are still getting in your protein when you add salad to the mix!)

Before subjecting myself to a bypass, if that is the recommended fix, I would consult with a surgeon who is more experienced with the sleeve and duodenal switch (DS simply by virtue that it has been done for a long time and uses the sleeve as its basis, so any surgeon who has been doing DSs for a while has also been doing sleeves for that time.) There are a lot of surgeons around who are comfortable with the bypass and just getting into the sleeve, so if they have any problems with the sleeve, their first instinct is to return to their comfort zone and do a bypass rather than fixing the sleeve as a more experienced sleeve surgeon would do. So, when one gets into complications such as this may be, it is doubly important to get second opinions to see what your options really are. http://www.dsfacts.c...h-surgeons.html The above is a list of well qualified DS surgeons around the world that may be handy if you need a second opinion from a doc who knows their way around a sleeve (and a few of them are also well qualified in revising RNYs to DSs, so if they can re-fabricate a sleeve out of an RNY pouch and the old remnant stomach that was set aside, they would likely have no problem un-twisting a sleeve - assuming that the twist didn't cut off the blood supply and kill off the tissue.) Good luck, complications of any description are never a fun thing,

I started with six meal/snacks a day and dropped it to five after a month or so when I could get enough protein and other nutrition in on just five, and there wasn't that much time between breakfast and lunch to make the extra snack worthwhile. Now, in maintenance, I have added that sixth feeding back in to get enough calories in for the day.

Cirangle's program fee isn't too patient friendly, particularly considering that it covers a lot of things that would be covered by insurance if they were billed separately. His program is a bit one-size-fits-all which is great if you fit his profile but a bit of a waste of his high program fee if you don't. Some docs charge a program fee, but it is usually a nominal few hundred dollars to cover thier support groups and the like. By all feedback from the online patient population he is a well qualified surgeon though I can't say what his reputation amongst his peers is (which can be quite different.) I went with Dr. Rabkin in SF who is another long experienced sleeve and DS guy (came up from SoCal for him,) He doesn't have any program fees, but he also isn't in network for any of the major insurance companies (I think that he buries the costs of what would be the "program fee" in the ordinary surgical fee, so doesn't have room for the forced discount for the insurance networks - you pay one way or another - though since I had already hit my max out of pocket limit for the year, the insurance paid his fee 100%.) The other SF doc that I would consider is Dr. Jossart who used to partner with Cirangle and did his early training with the Rabkins. A little further out in CA is Dr. Keshisian who operates out of the central valley and Glendale and is another of the top drawer DS/sleeve surgeons around. If you happen to have any liver issues along with your obesity problems, Rabkin is your go-to guy as he is also an experienced biliopancreatic transplant surgeon.

It really depends upon how your doc phases things in - I never had a liquid-only phase so I progressed quicker than those on slower progressing programs. Protein shake a day, protein loaded puddings and jello, unstrained soups, tuna in cream sauce, mashed potatoes, softer cheeses, boiled eggs etc. were my norms then. It all depends on what your doc's program allows and what you can tolerate at that point - I was getting sick of soups and jello by then and haven't had much of either since, a year and a half later, so I know where you are coming from!.

Certainly strained out should be no problem, and over time as you progress you can have more of it included. My doc's plan didn't have discrete clear and full liquids then mush then soft proteins but combined them all together in one step allowing progress as tolerated, so we made some homemade french onion soup and progressively added the more solid components. You should be able to do much the same thing as you keep to your doc's specified progression.

I would say that this is a definite yes - with qualifications. If you are one who will agonize over every little bump along the way - "I didn't lose anything yesterday" or, "I gained a pound yesterday but didn't eat anything..." then use it only weekly, or maybe even monthly. If, on the other hand, you can accept that it can be a bumpy set of stairs down the scale rather than a smooth slide, then a daily weighing can be useful, The next factor is getting into good habits for the long term, and in the long term once you have gotten to your goal weight and want to maintain it, it will become very important to weigh regularly - again weekly or monthly (more frequently when you are earlier on in maintenance and things are still settling out) - because you want to catch any regain quickly - typically within 5-10 lb where it's fairly easy to cut things back to basics and bring the weight back where you want it. Just as with "normal" people, the less one has to lose the easier it is to do so. Some may find it best to only weigh in during doctors' visits during the loss phase, but in maintenance you will probably want to do it a bit more frequently than that (particularly since doctors' visits should be less frequent then.) Another thing to consider is getting a body fat (or body composition) scale that reads your body fat % as well as your weight. These typically run $50-100 but are worthwhile in tracking what you are really interested in losing - the fat! They can help you better understand what is happening to you as you lose, and help to form better goals based upon your individual body composition rather than just scale weight and BMI My goals were based upon losing fat mass and getting to a healthy body composition rather than a simple weight on a BMI chart, and as a result, I am still a little "overweight" on the BMI chart but on the lean side from a body composition perspective because I still have a fairly significant lean muscle mass - driving myself to "normal" BMI would mean losing too much muscle mass which isn't healthy. (Conversly, one can be in the "normal" BMI range yet still be overly fat.) The body composition measurments are not as accurate as the basic weight measurments, but if measured regularly (daily works best for these measurements,) you get a good sense for the trend of your loss and whether you are losing too much muscle mass relative to fat. In short, get a scale at least for the long term monitoring benefit - keep that weight from coming back, and don't put the scale in the closet if you see a bit of regain!

My doc's plan allows for Peanut Butter immediately as a soft Protein (creamy style, of course - avoid the crunchy types for a while.) I didn't use it much after the initial 2-3 weeks when I could get in better protein rich foods as its' caloric content is a bit much to swallow in any quantity during the loss phase, I typically had some on a saltine cracker or two, as those are good at soaking up excess stomach acid and settling stomachs that are still getting used to their new life. It should be good whenever your plan gets you onto soft Proteins - soft cheeses, yogurts, etc., unless your doc's plan specifically says otherwise.

It's not a worry, as the anesthesiologist is there to keep you breathing and monitor everything while you are out - that's his job!

The whole wheat english muffin with PB is the best bet protein-wise, as the whole grain complements the Peanut Butter to make a complete protein; peanut butter by itself, as with most vegetable Proteins, is not a complete Protein, so whole grain bread or crackers are your best bet nutritionally. Like some others here, I never did the low carb thing, either, and never suffered on the weightloss front because of it. The other suggestions of bananas, carrots or celery are popular items that are also healthy, and even if they aren't protein complements, may be very good taste complements! If you are looking for good potassium sources, try the low sodium variety of V8 juice - an 11.5 oz can has around 1100mg of potassium in it, and is about as good a supplement that you can find without a prescription. (My wife also has potassium problems so we are always on the lookout for good sources.)

Not a worry there - you aren't going to hurt your sleeve (your body will tell you if you are doing too much.) There is a wide variation in how different people handle liquids and mushes which generally are not very restricted by the sleeve. I was able to drink remarkable amounts (sip, sip, sip) of broths and juices in the hospital while my wife at the early stage of her WLS could barely get in her nominal stomach capacity of liquids - the doc and program RN were not at all worried as these are just normal variations. I was getting in enough protein by my token shake per day, yogurt, protein loaded puddings and jello, and soft protein dishes that the doc was adding veg to the diet by day 10.

Yes, quite normal. They pump you full of fluids in the hospital and that shows up on the scale. I think I gained around 5 lb when I had my sleeve done last year, and it happened again this year when I had my shoulder repaired. It will come off in a couple of days and the weight will likely continue to come off until you hit the dreaded third week stall. Enjoy the ride, even if it gets a bit bumpy sometimes!

It really depends upon the specifics of the BCBS policy bulletins on WLS (and which BCBS you are covered by - there are dozens of them.) See if you can look up the bulletins on their website (they are usually there somewhere) or check with the insurance coordinator for your surgeon (if you are that far in choosing a surgeon) as they know how to translate insurance-ese.

Whey is generally the best as far as bioavailability, somewhere in the upper 90% range (and isolated whey, or whey protein isolate is more refined and better for those who are lactose intolerant as virtually all of the lactose has be removed) while so while soy proteins are in the 70% range, IIRC. I don't know where the hemp protein fits in as that's somewhat newer and trendier.

That is a good warning for us all. Since dietary cholesterol has been de-emphasized after the mania about it during the last low-fat phase of the fad diet cycle (we are in the low-carb phase now,) it has dropped off the radar for most but is still an important thing to keep track of. There are a lot of things that can get us into trouble nutritionally, and this helps to remind us to take more of a "whole diet" (for lack of a better term - maybe classically balanced diet) approach rather than the extreme deprivation of one particular demon nutrient.

Sodium usually isn't a big issue with us during the loss phase as we are eating such reduced amounts that compliance with the typical 2400 mg per day max RDA guideline comes almost automatically - but it is worth checking the levels with whatever tracking program you are using if you think you are having enough to be concerned about. Higher Sodium levels can work to retain Water and impede your loss some, so that is something to look into if you are stalling frequently. As important, if not more so than sodium is the companion Potassium intake which should be around 4700mg per day minimum and is a real tough target for us to hit, particularly for low carbers (and it isn't supplemented well with our usual supplements.) Your doc should be keeping track of your potassium levels with periodic blood tests as that is one that can get you into trouble.

Sliders can also be healthy low calorie fruits and veg (some of them at least,) which is useful for adding nutrition to your diet with minimal caloric impact. My capacity is about 3 oz of most meats, but if I cut that back to 2 oz, I can add in another 4-5 oz of various salad veg for similar satisfaction, and likewise with various veg and meat stews and stir fries. This works well once you are to the point where your protein intake is under control and fairly reliable and predictable.

Under your circumstances of a limited window of insurance coverage, then I would go ahead with the VSG and forget about the RNY, which would likely be no better for you from the weight loss and regain perspectives, and would certainly provide you with more limitations in the future. Getting that much weight off will be a challenge with either procedure, but is do-able. Should further surgical intervention be needed to get you down to normal weight, things will be much easier starting with the sleeve. A revision to an RNY is possible but makes little sense as its performance is little different from the sleeve, but a revision to a DS is fairly straightforward and would provide a useful improvement in performance should it be needed, while starting with an RNY now puts one into something of a surgical dead end should it need to be revised - a conversion to a DS from the RNY is a very complex procedure that puts one into the hands of one of only a handful of qualified surgeons.

Basically correct - I made the distinction in the post to reflect that most DS surgeons will make their sleeves somewhat larger when they do a DS than they do when they make a stand alone VSG, so the DS folks will have somewhat more stomach capacity than we do, but with the malabsorption to compensate calorically.