RickM

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.

From what I have seen on the various forums (I can't speak from personal experience as the pre-op diets aren't part of my doc's protocols,) some is better than none, and you will have about a week of low carb prep between your 2 day pre-op diet and whatever you do from now until then. Some docs who do the liver shrinking diet will vary the length of diet depending upon patient BMI, with some doing one week, others two or more, so it seems like there is some value in a shorter diet. As a note, I didn't lose anything pre-op (actually gained a bit with all of the "last suppers" associated with all of the pre-op tests and appointments,) and have never been particularly low carb though my diet has long been sane and healthy - just overly-portioned - and my liver was in fine shape at surgery time, (doc tends notice and mention such things as he is also a liver transplant surgeon in his "other life") so YMMV.

I have been wondering things along the same lines - maybe within their experience in their practice, they don't have such good success with the sleeve with higher BMI patients. I would take their advice seriously, which leaves you with the choice of having an RNY with them, or going elsewhere for a VSG (which would certainly be my preference - I never seriously considered the RNY or bands.) There are other surgeons who have had good success with the sleeve and higher BMI patients, though you may have to travel a little farther than you had planned - SF seems to be attract top-drawer bariatric surgeons. Though I'm not a big fan, Dr Cirangle seems to have developed his sleeves and program to work very well with higher BMI patients; Rabkin and Jossart are both well experienced and capable DS and sleeve surgeons there as well. There is also Dr. Keshisian, who operates out of both Delano and Glendale, and is another top flight DS and sleeve surgeon. While with the excitement, stress and hassles involved in getting this close to surgery, it may be well worth taking a step back and re-evaluating things as either an RNY or a substandard sleeve could lead to substantial disappointments down the road, possibly taking you down the path of a revision that may never had been necessary had the correct surgery been done in first place (and if you need to revise an RNY, then you will probably be going to either Drs. Rabkin or Keshisian, as they are two of maybe a half dozen surgeons in the US and Canada who are actually qualified to revise an RNY to a DS. Further, at your BMI, it is worth researching and considering the DS (if you haven't done so already) along with the VSG as it does classically work better for high BMI patients, and has better regain resistance than the other mainstream WLS procedures if regain or yo yo dieting has been in your past history. Good luck in your journey, whatever decision you make,

It is not so much shrinking of the liver that is desired, but a de-sliming or improving its texture by depleting it of as much of the glycogen (basically carbs) that it processes as possible. Typically you see docs that call for these diets to be a couple of weeks of low carbs - some do liquids only but there is no real rationale for that. So, if you want to do what you can, keep it low carb for the couple of weeks before your 2 day surgical diet - heavy on meats and veg while minimizing the fruits, sugars, breads, etc. It wouldn't hurt to experiment with the protein shakes early on, too, so that you don't get caught up with one that you can't stand when that's your primary protein source early on post-op.

The RNY pouch tends to be around an ounce in nominal capacity (give or take half an ounce or so, depending upon the surgeon and patient) while sleeves can be anywhere from two to six or so ounces, though our stand alone sleeves tend to be in the 2-3 ounce range while DS sleeves on the larger side since they are paired with the malabsorption component. My sleeve started at about 2.5 ounces at surgery, while my wife's DS sleeve was about 4 ounces. Some docs like to make tighter sleeves while others prefer somewhat larger ones (it is thought that smaller sleeves may yield better regain resistance, but be more prone to reflux problems than larger sleeves, but that is still somewhat speculative until more longer term data is collected.) Then there are patient variations - a doc may make the same size sleeve (with or without the same sized bougie) but a patient may have a larger stomach to start with that will end up being a longer sleeved stomach overall, so therefore larger capacity - same diameter tube but longer. The pictures that are often shown can be deceiving as they are usually only intended to represent what the procedure does rather than be accurate in their scale.

I think that what he is saying, is in agreement with the OP and probably you as well, is that if one can lose the weight that they need to lose, and keep it off, then you don't really need his services. What is the point of putting the patient through yet another little temporary diet/weight loss effort, just to prove that they can do it for a couple of months? It has already been proven, in the prospective patient's case, that they can't over the long term and need the added help of the surgery. Some docs need the extra help of the quickie "liver shrinking" diet while others do not, so you do see some variations in surgical plans for that reason. From what I have seen over the years, those docs who have been in the DS business for a long time (and by default, VSGs,) tend not to be overly reliant upon pre-op diets.

I recognize that now - the pre-op thing that some docs do usually is a low carb program so this is often unavoidable. Once you get through that and past surgery, then you get a bit more flexibility to tailor things for your needs rather than the surgeon's (depending upon how much of a low carb enthusiast your surgeon is in his post op program.)

That makes some sense then. Double check with the insurance documents or your surgeon's insurance coordinator to verify exactly what the insurance company requires and do what they say. I didn't lose any weight on the 6 month insurance roadblock and it was fine; I just had everything documented - food tracking and exercise logs and doctor's visits notes and it went on through. My philosophy on these longer term pre-op diets (like the 6 month insurance diets,) is to emphasize establishing or reinforcing good eating habits for the long term over temporary weight loss thru fad diets. Good luck in your journey....

Here is a good explanation of what's going on with these stalls - http://www.dsfacts.com/weight-loss-stall-or-plateau.html You are probably doing OK on calories, though the most popular plan is for 600-800 calories, and being a relative lightweight, you can probably afford a few more calories if they come your way (but it's probably not worth getting too worried about it at this point - more calories will come your way as you progress up the food chain. Hydration (water - sip,sip,sip) and Protein are your biggest concerns at this point.

As the token counterpoint to the discussion, you can avoid most of those nasty side effects by keeping your carbs up some - the extreme ketosis state is not essential to burning fat or losing weight (though by the Atkins hypothesis, it might increase the rate of loss to some degree.) I'm glad I never had to put up with it.

Is this diet an insurance company or surgeon's requirement? Insurance company diets are primarily a hoop to jump through intended to delay approval while surgeons have a variety of reasons and requirements. Some surgeons want to test patients' compliance with instructions (can you stay on the doc's liquid post-op diet while others at the same stage are having steak?) while others need added confidence when operating around fatty livers (though these so-called "liver shrinking" diets are usually only a couple of weeks or so of low carb dieting.) Some require a specific amount of weight loss while others don't. My doc is in agreement with the OP in that if the patients could lose it on their own, what is he needed for?

As with most questions of this sort, it really gets down to your doctor's plan and how he defines things. I had oatmeal the day after I got out of the hospital, but my doc's plan calls for purees/mushes and soft proteins, as tolerated, at that point (and everything else the following month) while other docs have more discrete stages - clear liquids, all liquids, purees, soft proteins, everything else, phased in over longer times. It basically gets down to your doc's experience with the sleeve and his comfort level with his patients' progression. Myself, I would say that you could try it and see how things go, but I am not your doc and don't know where he places oatmeal within his progression stages - it's really his call, and that's what you are paying him for.

Is there something in your history, other than your recent sleeve, that contraindicates the use of NSAIDs? Some surgeons like to avoid NSAIDs early on during the immediate healing phase, but long term there is no reason that NSAIDs can't be taken with the sleeve - indeed, thats one of the major benefits of the sleeve over the RNY, and NSAIDs requirements are often used to overturn insurance company decisions denying the VSG or DS in favor of the RNY (though many RNY focused surgeons who are relatively new to the sleeve are slow to understand or accept this.) If your NSAID restriction is from your sleeve surgeon, then certainly you should go to him for approval, as he may have some specific reasons for you not using them. If there is not something specific to you, politely ask him to do a bit more research on the subject, as most of the long experienced sleeve and DS (which uses the sleeve as its basis) surgeons have no problem with NSAID use post op - it's even in my patient binder for use once the prescribed narcotic pain relievers are exhausted (they have about twenty years of sleeve experience behind them, so I tend to trust their word on the care and feeding of a sleeve.) If there is some other issue with your history that precludes the use of NSAIDs, then your orthopedic or primary docs would be the place to go. While there is nothing about the sleeve that specifically addresses or improves joint conditions, as others have noted, things can improve markedly just by getting the weight off, so that just takes a little patience. So, good luck with it, and things should be improving as you progress,

There are a lot of the surgeons out there who do not require an extensive pre-op diet. Some will require one only for some patients, usually those with a higher starting BMI. My doc doesn't require any pre-op diet other than the usual day before thing.

The general consensus from docs and nurses that I have seen seems to be whenever you feel like it (though most hospital nurses prefer that you wait until you get home!)

I had mine done at St. Mary's by Dr. John Rabkin last May; all went very smooothly. My wife had her DS done there a few years ago by his older brother.

6-7 hours for LA to SF, though they do have a semi-local office and support group about an hour away.

It is very difficult early on to get a significant amount of fruits and veg into our diets, even for those of us who ignore the low carb diet fad and seek to get as balanced a diet as possible. I used the semi-slider property of a lot of veg by having small salads with some leftover meat, a few berries with my greek yogurt, meat/veg stir fries and stews, etc. I found that combinations of meats and veg allowed for a fair extra volume of veg to be added to a meal with a small sacrifice in meat quantity. For example, my capacity for firm meats like steak or chicken is about three ounces, but if I cut that back to two ounces, I could fit in 3-4 ounces of misc. salad veg - chopped spinach, tomato, avo,green onion, bell pepper, snow peas, etc. Similar math applies to stews and stir frys (at least to my sleeve!) I somewhat lucked out in that Protein was never a big problem for me (doc was adding veg to my diet at day 10,) so I had some flexibility in my diet and not stuck with a protein only diet. Even at that, it was difficult for me to get in more than 2-3 fruit/veg servings per day during the loss phase, though now I'm happier being able to get in 5-6 per day in maintenance. V8 is a good help in getting in some veg content. One suggestion on that would be to try their low sodium original variety as that has about a large a dose of potassium as anything that I have found (about 1100mg or 25% of RDA in a 11.5oz can) and potassium is very difficult to supplement to any usable degree without prescription - most everything else we can supplement and get by for the time when our diets are fairly restricted during out loss phase. In time, you will be able to consume more and add more fruit and veg to your diet, but early on, it's best to concentrate on losing as much as you can while your restriction is maximized. Many programs want to limit fruits early on due to their natural sugar content and many docs discourage juices as they are too close to drinking calories, so those are things to be cautious about. But kudos for wanting to expand into the healty fare and not just cheat on chips and twinkies! Good luck with your journey - a healthy balanced diet is very workable with the sleeve, even if somewhat modified for a while with our protein emphasis.

It's a variable depending upon the doc's program and how one tolerates different things. I was playing around with small salads after 3-4 weeks, using chopped spinach instead of lettuce for its' little better nutritional profile, along with tomato, avo, bell pepper, green onion, etc. along with a couple ounces of meat for protein.

Not drinking Protein is not a big deal, however not getting in the requisite amount is a big deal. Some docs encourage their patients to move from Protein drinks to real food as soon as practical while others don't care so much. I was able to move off of the drinks as a necessity fairly quickly, around three weeks or so, but still used them as a convenience and exercise recovery drink. What issues are you having with the drinks - taste/texture, keeping them down, etc.? My wife had a hard time using them when she went thru this several years ago, but was able to make do with other foods, though it was more of a struggle for her for a while than it was for me (just those variations between us all....) The protein powders can be mixed into other things to enhance their protein, so you aren't restricted to the Protein shake form - add it into SF puddings, yogurt, mashed potatoes, Soups, etc. Try different brands if taste/texture is the issue, as there is a wide variation between brands. Good luck with it, but do get in the protein that you need, one way or another.