RickM

Some people stall earlier than others, particularly if they have lost weight with pre-op diets. Part of what is happening is that you have now used up your readily available stores of carbs and Protein, which burn at a rate of around 2000 calories per pound, and are now finally shifting to burning your fat, which burns at around 3600 calories per pound, so when you do start losing again, it will probably be at a somewhat slower rate scale weight loss, but now it will be fat. which is the whole idea here. Sometimes it takes a while for the word to get to your brain that you need to start tapping that fat savings account, and for it to give your body permission to do so - those are reserves to be saved for some serious famine and it can take some time for your brain to work out that you are serious about using that up! It's just one of the variations between all of us - some will stall for just a couple of days while others will stall for a couple weeks or more - it's hard to figure out sometimes. There will be more stalls along the way, too - it's just the natural progression that more resembles stairsteps than a ramp. As long as you are maintaining that large calorie deficit, you can't help but lose it.

Generally, you should follow your doctor's guidelines. That said, docs have a wide variety of programs and sometimes it's hard to figure out why. Some are very slow moving you from Clear liquids to thicker liquids to mushes to soft Proteins to more solids while others (like mine) start you on mushes and soft proteins in the hospital and never do a liquid only phase. Go figure. It seems to me that the docs with the extensive liquids programs are drawing from their RNY experience which may be overly conservative for the sleeve, which may be relatively new to them. My doc's practice has been doing sleeves, as part of the DS and stand alone, for around twenty years, so I figure they have a good handle on the care and feeding of the sleeve. I was having no problem with yogurts and puddings during the first week, though I was being conservative on amounts, experimenting with tolerances. There can be a wide variation in what we can tolerate when - my wife, who had a DS a few years ago, could barely drink her nominal stomach capacity in a sitting, which made Protein drinks particularyl nasty as they had to be so concentrated for her to get any usable amount of protein in, while liquids were flowing right through me from the hospital on out. My program has the general admonition of trying new things one at a time to judge your tolerance for them and if they don't feel right, try again in a couple of weeks. Again, despite the wide program variations out there, I would follow your doc's guidelines as closely as you can. It is certainly worth talking to them about it to see if you can quicken the progression some as you are well tolerating things - my doc was having me add veg to the diet at the 10 day follow up since I was getting in more than the requisite protein; they should have some flexibility built into their program to accommodate the variations in patient responses, but their experience level may not be ready to provide that variety yet, and if you have any problems down the line it will be assumed it was because you were "non compliant" rather than anything that they did. Good luck and be patient - I got sick of protein Jello and Soups fairly quickly, too, and have little interest in going back (though the yogurts and hi-pro puddings are still with me.)

You might also look into aversion therapy, since smoking is a combination of chemical addiction and behavior/habituation. Aversion is what the Schick-Schadel centers provided 20 years ago or so and used a minor shock (like from a 9V battery) to replace the pleasant sensations you get from smoking with unpleasant ones. My wife went through it (a few sessions within a week) and has been smoke free for the past 20+ years. I don't know who does this these days as Schick Shadel seems to be into alcohol and drug addiction treatment these days, but it's something worth checking out if the chemical/drug based solutions don't work.

The main thing is that if your multivitamin has a load of iron in it, then you want to space it out a couple of hours from any calcium supplements you are taking as they both compete for the same receptors

I can't understand the three meal a day restriction with our limited capacity - most docs allow a snack or two (or three) in between as long as they're healthy Snacks. We aren't supposed to get into grazing as that is a good way to torpedo our sleeve, but we do need to be able to work with this limitation that we have given ourselves. What is your problem with greek yogurt - taste, texture, stomach toleration? I'm not a fan of plain yogurts as they're just too tart and bitter for me, but the sweetened ones tend to be too sweet. I make my own blend of plain and sweetened vanilla that fits my taste. You can also add a little jam to flavor and sweeten it some. I usually have it with some berries, almonds and granola to add texture and other nutrients (and now a little wheat bran for some added Fiber.) I understand the taste problem with the Protein shakes and bars as many are downright unappetizing. I have settled (for now,) on the EAS protein powder as its taste is mild and I can add some unsweetened cocoa powder, SF hersheys syrup or instant Breakfast to it to build up the flavor and hide the protein taste. A SF instant breakfast can add 5g protein to your glass of milk - not as good as the dedicated protein powders, but better tasting than most of the, too. I make a protein enriched pudding using the SF instant puddings. The typical hi pro recipe calls for 2 scoops of protein powder along with the 2 cups of milk and pudding mix, but that still leaves a bit of the protein powder taste in it according to my taste buds; I substitute a cup of greek yogurt instead of one of those cups of milk and scoop of protein powder and that effectively masks the protein powder taste, though it does bring in a bit of tartness from the yogurt that you may or may not like. Sometimes ground meats don't settle well with us, particularly the drier/lower fat versions like chicken and turkey - my wife had a problem tolerating ground beef for a long time after her DS, and the surgeon suggested that filet often works better - and it did. Fatter meats at the early stage often work better than leaner ones as they are moister - dark meat chicken instead of light meat. Deli meats are often suggested as being well tolerated for the same reason. Meats are usually the slowest thing to go thru your stomach, so it's not surprising that you can only do 2 oz of the shrimp, but that's not a bad protein load for 2oz. - most of your meats are going to be in the same ball park. I'm not a coffee person, so I can't help you there, but the others are correct in that you have to be careful in heating the protein powders (whidh is why the instant puddings are usually used for this rather than the cooked ones. I believe that unjury says that you have to keep their powder under 130F, so you can't brew it with the coffee, but can usually add it after it is made and cooled a bit. Also, some protein powders mix better than others, so that is useful if you aren't frapping it in a blender - I find that the EAS powders mix better than the Unjury ones, which tend to clump a bit (at least with colder liquids). How do you handle cheese? String cheese is usually well tolerated and a common recommendation, and is 8g per stick. Most cheeses are in the 7-8g per ounce region. Good luck with it all, it can be tough at the beginning but it does get better

I was on basically the same plan - nothing special until the day before. There is a lot of variation in programs - intensive pre-op diets or none at all; extensive Clear Liquids to normal liquids to mush to soft to normal over weeks post op to mush and soft from the hospital on out; no carb trendiness to basic good nutrition with hi Protein. It's mostly based upon what experience the surgeon has and what has worked for him in the past. With the VSG being relatively new, much of it is based upon the surgeon's experience with other procedures, so I suspect that a lot of the intensive liquid post-op diet is a holdover from RNY practice. I was one who was on mush/puree/soft stuff in the hospital, so if their program says that garden burgers, egg noodles, mashed potatoes, tuna, rice & Beans, oatmeal, etc are fine in the first month, they have a lot more experience with sleeves, some 20 years worth, than I do - who am I to argue? If the doc doesn't feel that an intensive pre-op "liver shrinking" diet is necessary, and he's a liver specialist along with his bariatrics, I figure that he knows that aspect of it better than most (I also won't argue with him about his no alcohol for the 12-18 months prime weight loss period policy, either - he knows our livers better than most docs.)

I'm not particularly concerned or afraid of the intestinal or malabsorptive issues as my wife has had a DS for the past six years or so and we know many DSers who are 5-15 years out, so we are very familiar with all of the issues, major and minor. My objection to the RNY, and why it was never really considered, is that it goes to all the trouble of the intestinal rerouting, and it doesn't really buy you anything positive (compared to the VSG.) All the data available indicates that the weight loss and regain characters are similar but the RNY has a lot more issues. Beyond the more common incidence of dumping (which some surgeons promote as a benefit,) it doesn't significantly malabsorb calories, particularly long term, but does malabsorb minerals due to its bypassing of the duodenum where the bulk of the minerals are absorbed (the DS only bypasses part of the duodenum, so mineral malabsorption is usually not a bad.) The construction of the stomach pouch and connection to virgin intestine means NSAIDS are a permanent no-no, and while men don't typically have the iron issues that women do, the iron malabsorption is compounded by a typical slow blood loss at the pouch/intestine junction that rarely fully heals due to the exposure of stomach acid to tissues not designed for such exposure. Overall, lots of negatives without a real benefit compared to the VSG. The DS has somewhat different issues, though generally not as severe, but provides, on average, better overall performance, particularly on the regain front. The DS costs more, from an "issue" perspective, but you get something for that added cost. You don't get your money's worth with the RNY. There are probably some individuals for whom the RNY is the appropriate choice (aside from the surgeons promoting it) but they are few and far between now that the VSG has become mainstream.The RNY is rapidly becoming obsolete.

Perhaps there is a support group meeting that is closer to you, one from another surgeon maybe? The group I go to, which is a local meeting for the practice that's 6 hours away, attracts people from other practices including a couple of RNYers who don't like their doc's group or have time conflicts with it (my doc doesn't do RNY's) and the group leader is from another surgeon who is too far away. I don't see a lot of the coddling and agonizing over slow loss for obvious reasons, as Tiffy notes, in this group, though at this point much of this local group are long term post-ops 5-10+ years out, so their issues are somewhat different than initial post-ops. Much or their emphasis is on nutrition, supplements (which forms and subgroups are most useful and bioavailable, etc.) and Probiotics. The local group leader likes keeping up on the latest research on these topics, and the program director occasionally recruits him to present at the main practice meeting up in San Francisco. I've been going to it for about eight years now, first as pre-and post-op support for my wife and then for my own surgery. There's usually something worthwhile to pick up from it. It's also about an hour away, but is at a restaurant that serves decent fare (not one we would go to on our own, but acceptable) so it makes as worthwhile night out with my wife and semi-friends (as we've known most of them long enough!) I would certainly try to find a group that has a lot of other VSGers in it as one from a doc who mostly does bands or RNYs will probably not be as helpful.

Trader Joes, if they have invaded your area yet, has a good one that's uncured, 6g protein, 0.5g fat, 30 calories per 1 oz precooked slice. I haven't found anything in the supermarket brands that touches in for nutritional density.

The basic government guideline is 2400mg per day max, though there is no real minimum amount of sodium needed (at least until you get into serious endurance athletes who can lose too much sodium to sweat.) The typical American diet handily exceeds that amount, which is why it is such a concern amongst those who are concerned about what other people do. With our limited (by volume, if nothing else) diet, I am comfortably meeting that number, despite routinely having turkey sausage or bacon for breakfast. Something on the order of 1300mg per day or less is used for those who need to reduce their sodium intake for blood pressure or other medical reasons. The other side of the sodium coin is potassium, in which the typical American diet is usually deficient. Sodium and potassium work together to control Fluid flows thru the body, specifically in and out of our cells. Our legacy diet (when we were all hunting and gathering in the bush) typically had around five times as much potassium as sodium, and that tends to be what our bodies prefer. The modern western diet tends to be the reverse of that. Recommended potassium intake is 4700mg per day which I used to routinely hit pre-op, but am only getting in 30-40% with my limited volume post-op diet (fruits and veg are thegenerally the best dietary sources) so that is something that I am watching with my labs - potassium is difficult to supplement without prescription. The sodium intake is certainly something that should be watched with whatever tracking tool that you are using (you are tracking your intake, aren't you?) and this is as good of a time as we will ever have to get a handle on it before our doc (or cardiologist) sometime in the future tells us to cut out the sodium. Much of the sodium in our diets comes not from salt or what we think of as salty foods, but from the processing of much of the packaged foods we eat (as in MSG - monoSODIUMglutamate - and other preservatives), so that is part of the reasoning behind the movement to avoid packaged/processed foods. It has not been something that I have agonized over, but is one facet of my general move to a healthier diet - I was decent pre-op other than volume - and am seeking to improve that long term as part of getting into maintenance mode. Yesterday I was at 1600mg sodium, of which a third was those breakfast sausages (and was surprisingly at the 50% level on the potassium - maybe my efforts are working if things are improving without specifically thinking about them.) Good luck on your journey, and congrats on your friend's results with the band - it sounds like she should have some useful advice that is transferrable to us.

A typical day for me in the middle to end of the second month (and actually not much different today) is: Breakfast - 3 turkey sausage links (15g) or strips of turkey bacon (18g) AM Snack - 1/2 cup greek yogurt with raspberries and almonds (13g) lunch - salad including about 2 oz leftover meat (tri tip, filet, chicken, etc) and 10g lite cheese (20g) dinner - 3 oz light meat chicken w token veg (peppers, onions) w 1/2 oz lite mex cheese blend (must have been fajita night) (28g) Eve Snack - 1/2 cup hi pro SF pudding (ok, it has some Protein powder in it, and greek yogurt) (12 g) Total of 91g protein, 850 calories and two nominal servings of fruit/veg for that day, and coincidentally within the magical 40g carb limit that some impose upon themselves, though I don't control to carb count. I often do still have a Protein shake in the afternoon of heavier workouts, but that's more for workout recovery than meeting the protein bogey, but does mean that I can have a more veg intense dinner.

I think that the variation in advice stems from the differing experiences and backgrounds of our surgeons - some have noted their docs as not caring about the nutritional aspect of the plan, as they are the surgeon and that's the nut's job. My doc is one who is in the no alcohol at all for the 12-18 month (or whatever it takes) weight loss period camp (which also gets brought up in the psych eval - can you give up drinking for a year or more?), and that comes from his experience as a liver transplant surgeon, which he still does along with the bariatrics. Needless to say that he is a bit anal about liver health. His view is that being obese, our livers are in bad enough shape to begin with, add to that the load it has metabolizing all of the fat that we're losing, so you don't want to give it any more to handle in metabolizing alcohol. Other surgeons don't have that perspective, but may bring other experience to the table (hence, you find some docs heavily into the no carb trend while others stick with more classic balanced nutrition concepts.) I do find it curious, however, that my doc doesn't go in for the intensive "liver shrinking" pre-op diet that seems to be so important to some docs. These program variances may be disconcerting to some, but on the other hand, it does give us some choice in programs when choosing a surgeon.

It isn't an essential part of the process, but more of a preference on the part of your surgeon. The extensive pre-op diets that some docs impose doesn't really shrink the liver, but is said to help reduce the fatty/slimy coating that is often present on us fatty liver/obese patients. My doc doesn't do the major pre-op diet program, just the day before clear liquids bit, but then he also does liver transplants aside from his bariatric practice, so I guess he is used to dealing with livers in crappy condition. He said my liver was in good shape when he was in there (and I gained a little in the weeks leading up to surgery, for what that's worth!)

The saltines are often suggested as helping with stomach upset. As with your pharmachist's thoughts, I take meds that need to be with food just before the meal with water. I routinely take an omega horse capsule which really needs to be taken with food to avoid thier fishy recoil, and that works well for me.

We never had to do the weeks of liquids, but ground meats can be a problem for some. My wife had a problem tolerating ground beef for a long time, and our surgeon suggested ("prescribed" in our vernacular, now) filet as often being better tolerated than ground beef. After six years (for her, four months for me,) we still use the excuse of going to Outback as having to fill her "prescription." Likewise, the higher fat cuts are often better tolerated at first - dark meat chicken is moister than light meat, etc., though long term, of course, you want to stick to the leaner cuts as dictated by basic nutritional sanity.

I never had much problem with Protein, (they were telling me to add veg to my diet by day 10) though it does seem like you are having some overall eating problems. I understand the problem with tolerating the taste of Protein shakes, though there are many different kinds out there, and some taste better than others (and taste is such an individual thing.) - I find the EAS protein powders work for me as they have a relatively mild flavor that can be built on with additions (see below.) My wife had similar problems after her DS as she couldn't drink a lot either, so the protein powders had to be so concentrated that they were gagging. There are several possible things that you can do: Mix the powders with other things with stronger flavors - the Instant Breakfast suggested is a good start, but I boost the protein by mixing an envelope of Instant Breakfast with a scoop of Protein powder and 2 cups of milk for two servings - that significantly cuts the Protein shake taste; adding a little unsweetened cocoa to the mix deepens the chocolate taste with an insignificant calorie/carb addition. SF Hersheys syrup can be used for the same thing. Greek yogurt is a great protein source - 10-12g per half cup of plain, and can be sweetened to taste with your favorite sweetener, or even a bit of jam or SF syrup for flavor. I typically have it with some raspberries, granola, chopped almonds and wheat or oat bran to add flavor, texture, nutrition and Fiber. The SF instant puddings work well - I found that the classic hi-pro recipe of adding 2 scoops of protein powder to the 2 cups of milk and pudding mix still left a bit too strong protein powder flavor to it, so I substituted a cup of greek yogurt for 1 cup of milk and 1 scoop of the powder - that dropped the protein powder taste into the background, though added a bit of the yogurt tartness that some may not like. Peanut Butter is often suggested, and usually goes down well, though as with most plant based Proteins, it is an incomplete protein and should really be eaten with a complement like whole grain bread or crackers to complete the protein (which may not help you at this stage.) unjury makes a chicken soup flavored protein powder that you may tolerate, especially if you mix it with real chicken soup or maybe mashed potatoes. Good luck with it all - believe it or not, it does get better!

NSAID use is one of the classic reasons for getting a VSG or DS over an RNY. The main reason I have heard sited for RNY intolerance is that the portion of intestine that they join into the stomach pouch is not designed/evolved/created to be exposed to stomach acid, so that suture line never really heals fully so it doesn't like the added irritation of the NSAIDS.That's not an issue with the VSG, DS or bands.

My wife lost about 210 from her DS, and had another 14 removed with the lower body lift and didn't get a figur for the thigh lift.

Nexium was created as Prilosec was going off patent by slightly tweaking the molecule to make it different enough to patent (so it could be sold exclusively at elevated prices). It works in the same way as Prilosec and with rare exceptions, works as well as Prilosec/Omeprazole (except that it is the pretty purple pill...) If the cheaper, OTC Omeprazole works for you, Nexium provides no additional benefit.

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If you are not particularly a drinker or wine person, grape juice is supposed to provide the same health benefits, anti-oxidents, etc., as wine. Similar amounts (a 4-6oz glass) are fine for the same reason - limiting the excess sugars/calories while getting the proper amount of benefit and lessening the load on your liver during weight loss (some of us are on programs that avoid alcohol altogether during the weight loss period as our livers are already heavily taxed metabolizing the fat that we are losing - can you tell that my surgeon is also a liver specialist?) Addendum: any of the plant based foods with similar colors will have the same healful components - grapes, raspberries, blueberries, strawberries, etc.

San Francisco has a cluster of some of the best bariatric surgeons in the world - Drs. Rabkin, Jossert and Cirangle - all in different practices (though Jossert did train with the Rabkins years ago,) and all with extensive experience and long lists of satisfied patients. Many people travel extensively to be worked on by one of these guys (I came up from LA to Dr. Rabkin - my wife's DS was a self pay several years ago, though my VSG was insured). Check into them all, as they each have somewhat different programs, one of which may make fit you better than the others, and their self pay rates will vary some as well. None will be as cheap as going to Mexico, but they all give pretty extensive post-op support and follow up as part of the service. It's hard to go wrong with any of them. Good Luck

Everybody is somewhat different in what they can tolerate when. My doc''s program is pretty liberal (mushy/puree from the hospital, no big liquid only phase) with the admonition to experiment with small amounts of new foods, one at a time. If something doesn't settle well, try again in a couple of weeks.

It's not that unusual for those who don't have insurance coverage for WLS (or cosmetics/reconstruction, either.) There are many good doctors around the world, and most countries don't have the legal cost drag on their systems; the trick is finding them, and this is where sites like this one or obesityhelp are useful as part of that research. Many people go to Costa Rica or Brazil for cosmetic/reconstruction surgery where there are a number of renowned surgeons in that field. When my wife was going thru her DS journey 6-7 years ago, Spain was the major non-US alternative for that, and Dr. Baltasar was (and still is) one of the top DS surgeons worldwide. Mexico wasn't really an option then - they were not as big in doing WLS procedures for US patients then, and I'm not sure if I would go to any of the docs there for a DS, though the simpler VSG seems to be fine. Ultimately we went to San Francisco and self paid with Dr. Rabkin for her DS - for us, the cost savings from going to Spain once all the travel and lodging costs were figured in wasn't worth the added risk and hassle of going overseas for a procedure such as hers. Mexico has lower travel costs and the stay requirements aren't usually as long as they were for the DS in Spain, so the case for a VSG is much more compelling now. Still, it pays to shop around as there is some comfort in staying domestic - from what I have seen, my doc's program (one of the best in the business, though we didn't self-pay this time as our insurance covered my VSG with him) in SF is only about 2/3 the cost of the Alabama program quoted here, but that's still a lot out of pocket, and you still have travel expenses, but it does show the variation in pricing.

If you dig through the Aetna website you can find their latest WLS policy bulletin on what is required - it's in reasonably plain English - or your surgeon's insurance coordinator may be able to lay their hands on one. When I went thru this earlier this year I needed either a 6 month Dr. supervised diet/exercise program or a 3 month program thru the surgeon (which my doc doesn't do.) I did the 6 month program with my PCP with a couple of visits with his associated nutritionist. I didn't get in monthly dr. visits as implied in the policy bulletin - scheduling issues made it more like 4 visits over the 6 months. I'm not sure about the 2 yr diet history (perhaps weight history is what they mean?), I didn't supply it specifically, but the data is in his records that were submitted. The pulmonary and cardiac clearances are requirements of your surgeon depending upon your medical history (I did neither); the support group meetings, pre-op classes and psych evaluation are likewise your surgeon's requirements, but are typical. Aetna is notoriously slow in approvals, but they shocked the insurance coordinator by approving within a week or so (though they are still dragging their feet on paying the surgeon's fees after 4 months) I didn't lose any notable weight during the 6 month period, but continued my long term stall (which is why I needed the surgery - hello!) I actually gained some in the time between approval and the surgery with the serial last suppers out while doing all the requisite pre-op med appointments.