2 Week Post-Op - Dietitian Frustration

[Stefanie S.]

Sat in a LONG class today with numerous RNY and Sleeve patients, and 2 brand new DS patients. I had my sleeve 3 years ago, and my DS 2 weeks ago. Even though I asked a few times how the advice given would be different for my situation (primarily being a DS), I was told the rules were the same. Here's what I was told:

Vitamins
Take 2 adult multivitamins with minerals each day.
Calcium citrate 3-4 times/day (500-600 mg each time).
Vitamin A: 10,000 IU
Vitamin D: 2,000 IU
Vitamin K: 300 mcg

Labs
First one done at 6 months, then yearly.

Diet
Goal: 60-80 g protein/day
Eat NO or very low fat
If using low-fat mayo, etc., only 1 T
If eating a fat, only once per day
If experiencing very slow weight loss, avoid fats.
Substitute Greek yogurt for sour cream
Do not drink 30 minutes before or after eating

I brought up the need for healthy fats for our brains and the fact that DSers malabsorb up to 80% of fat intake. I said I had been studying information online. Ready for the answer? "If you want to spend all day in the bathroom, then sure, eat fat. (said with a smile... and then Don't believe what you read online. Do what we are telling you in class. Actually, I need to get the sources from you so we can shut down the false information being spread online."

I never gave her any sources, and I didn't say anything else. But I tuned out after that... So far insurance has denied paying for my surgery, so I'm going to be frustrated if I have to end up paying for today's appointments, as the class felt 90% irrelevant to me

 

[Spiky Bugger]

So...ignore that and don't go to any more meetings.

Why?

Because the RnY and DS are such different surgeries that advice given for BOTH has to be wrong for one.

 

[galaxygrrl]

If insurance is not going to pay for the class, I would not go. The low fat, low fat is not accurate. I don't have a definitive answer on this. This forum and the rest of the Internet says well, don't worry about fatwith a DS. I had Dr Rabkin say to me, you need to be careful over time, but you get a free pass for the first 12 to 18 months. I had the full DS at one time though.

So, I would listen to what has worked for people with the DS. I eat a ton of fat and it's been OK.

What I have learned about the DS is YMMV, so, I would see of you can eat fats and lose weight. If you can, then, great. If you can't then, you'll just need to be more careful.

 

[Settledownnow]

I am really surprised about the information you were given and as well as the attitude. I can certainly see how hard it would be to be given conflicting information, and the truth of what is required will always show in your lab results and on the scale. While the no drinking 30-min prior and after sounds like a RNY rule the purpose here is so that you have enough room to eat the required protein. Eat full fat -- no low fat and no fake foods. The vits recommended are of course, very low.

I see a private practice dietitian (not affiliated with any hospital or surgeon) and she is a real gem. I saw her prior to surgery for insurance requirements and because she was so helpful I continued to see her every month or so. We focus on changing my eating habits, food prep/organization, and increasing activity level so that I do not fall back into old habits. We do not do measuring cups, lectures, or weigh-in's. I mention this because not all dietitians are nuts.

 

[southernlady]

Either stop going (esp if you are paying for it) or learn to smile and nod.

I tried asking the same question of my nut about the fat. Got the same type answer. When I mentioned fat malabsorption, I got the RCA dog look!

 

[Stefanie S.]

I see a private practice dietitian (not affiliated with any hospital or surgeon) and she is a real gem. I saw her prior to surgery for insurance requirements and because she was so helpful I continued to see her every month or so. We focus on changing my eating habits, food prep/organization, and increasing activity level so that I do not fall back into old habits. We do not do measuring cups, lectures, or weigh-in's. I mention this because not all dietitians are nuts.

That's a great idea. My insurance DOES pay for unlimited dietitian appointments. If I can find one in the Raleigh, NC area like what you have found, I'd definitely commit to that.

 

[Stefanie S.]

Either stop going (esp if you are paying for it) or learn to smile and nod.

I tried asking the same question of my nut about the fat. Got the same type answer. When I mentioned fat malabsorption, I got the RCA dog look!

It's so bizarre. This surgery has been around for a long time. I thought Duke would be on the cutting edge with their knowledge and advice. Sadly, I don't plan to attend any more of these sessions. And I'm even more grateful that @Larra recruited me to this site. Larra - I do believe you made a huge difference in my life - the quality of it as far as my surgery type and how to properly take care of myself afterwards. Thank you to all here!

 

[-Flo-]

I second that @Larra ! I don't know what I would have done if you didn't help me find this site and offer your wisdom about the DS. Thank you!

 

[Spiky Bugger]

That's a great idea. My insurance DOES pay for unlimited dietitian appointments. If I can find one in the Raleigh, NC area like what you have found, I'd definitely commit to that.

Just as a comparison, I saw my bariatric surgeon...one of the most experienced anywhere...and was reminded, for example, that breakfast should be bacon, eggs and sausage. And that tuna (I use LOTS of real mayo), cheese, tri-tip and ribeye steaks were great DS foods.

(Also, I mentioned that I was worried that I don't eat "enough" veggies because I have a particularly fussy gut, and was told not to worry because they provide too much fiber for me...not to mention, cause we didn't go there, that veggies contain oxalates which help my body make kidney stones, so who needs 'em, eh?)

 

[KathrynK]

They are getting advice from the surgeons. In May, 2016, Ranjan Sudan, MD gave a presentation for a bariatric masters session about nutritional deficiencies after DS. http://web.duke.edu/surgery/2016BariatricMasters/sudan_nutritional_complications_duodenal_switch.pdf
This is a quote from one of his slides

• Ensuring adequate protein consumption and decreasing carbohydrates and fat in diet is important

•  Reduction in fat will decrease number of stools and improve consistency

•  Reduction in carbohydrate will decrease flatus  Many patients will be lactose intolerant

Certainly, if you have diarrhea (or flatus) you might try to cut back on fats (or carbs). The nutrition staff (or Dr Sudan) may have misinterpreted it to mean that you should avoid fats and carbs without having the symptoms.

Dr Hess has been quoted as saying "fat is your friend" about the DS diet.

Is there an authoritative text that could be sent to Dr Sudan that would fill him in on the realities of the DS diet?

 

[Stefanie S.]

They are getting advice from the surgeons. In May, 2016, Ranjan Sudan, MD gave a presentation for a bariatric masters session about nutritional deficiencies after DS. http://web.duke.edu/surgery/2016BariatricMasters/sudan_nutritional_complications_duodenal_switch.pdf
This is a quote from one of his slides

• Ensuring adequate protein consumption and decreasing carbohydrates and fat in diet is important

•  Reduction in fat will decrease number of stools and improve consistency

•  Reduction in carbohydrate will decrease flatus  Many patients will be lactose intolerant

Certainly, if you have diarrhea (or flatus) you might try to cut back on fats (or carbs). The nutrition staff (or Dr Sudan) may have misinterpreted it to mean that you should avoid fats and carbs without having the symptoms.

Dr Hess has been quoted as saying "fat is your friend" about the DS diet.

Is there an authoritative text that could be sent to Dr Sudan that would fill him in on the realities of the DS diet?

Interesting! I would like to get my hands on some of those texts as well. I'll also research Dr. Hess more. Thanks Kathryn!

 

[Spiky Bugger]

Oh...and your vitamins...that's also bad advice, in that DS is a YMMV thing. Because of that, your labs tell you what vitamins you need.

And, depending on how YOUR body adapts, TWO multi-vitamins may end up providing you with not enough of what you DO need and TOO MUCH of something you don't need more of. Ergo, many of us avoid "cocktail" vitamins...like "ADEKs," a brand that provides a combo of vitamins A, D, E and K. I would rather take those individually, as I need them. In fact, yesterday, I got injections of A and D, so I can stop those individual vitamins, but continue my Vit K as a separate pill. ( I know I need that because my "clotting time" is just a tad too slow and has delayed unrelated surgical procedures.)

To me, a vet of 11+ years, what random doctors (even my PCP and other specialists) THINK I need means nothing if their opinions do not comport with what my lab results SHOW I need.

 

[KathrynK]

Oh...and your vitamins...that's also bad advice, in that DS is a YMMV thing. Because of that, your labs tell you what vitamins you need.

And, depending on how YOUR body adapts, TWO multi-vitamins may end up providing you with not enough of what you DO need and TOO MUCH of something you don't need more of. Ergo, many of us avoid "cocktail" vitamins...like "ADEKs," a brand that provides a combo of vitamins A, D, E and K. I would rather take those individually, as I need them. In fact, yesterday, I got injections of A and D, so I can stop those individual vitamins, but continue my Vit K as a separate pill. ( I know I need that because my "clotting time" is just a tad too slow and has delayed unrelated surgical procedures.)

To me, a vet of 11+ years, what random doctors (even myPCP and other specialists) THINK I need means nothing if this opinions do not comport with my labs results SHOW I need.

Dr Sudan recommends ADEKs made by Scandipharm
I don't think those are still available.
Further evidence an authoritative text on DS nutrition is needed.

 

[Spiky Bugger]

I second that @Larra ! I don't know what I would have done if you didn't help me find this site and offer your wisdom about the DS. Thank you!

You people need to stop feeding @Larra 's ego. She is TERRIBLE if you need someone to help you swear at stupid people...almost worthless.

 

[southernlady]

To me, a vet of 11+ years, what random doctors (even myPCP and other specialists) THINK I need means nothing if this opinions do not comport with my labs results SHOW I need.

THIS RIGHT HERE ^^^^^

Which is why we need to learn our own systems.

I fired a PCP who asked why I was using Cytomel T3, cause my labs were fine. My labs were fine cause I was taking it!!!!