Bariatric surgery, malabsorption and GLPs

FarmgirlRebel

FarmgirlRebel

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I registered for bariatric surgery in 2020 at 320 pounds, but Covid pushed things back, so the procedure finally happened in 2021.

The operation I had was the Biliopancreatic Duodenal Switch, also called DS. A big portion of my stomach was taken out and my intestines were rearranged, which left me with roughly 150cm of small intestine (normal is 600-750cm). That creates a malabsorption issue I'll have to handle for life with supplements (I wish Tirz had existed back then).

So here's the situation: a GLP such as Tirz does work, but for me it works too strongly. Because my stomach is smaller and I malabsorb, getting enough calories in is hard at best. Even if I manage to reach 1200 calories, I'm likely only taking in about 2/3rds of them...and that's with decent nutritious food (which I do eat).

The pounds are coming off fast, and I'm not complaining, but I need to put the brakes on or I'll wind up resembling one of those Hollywood wraiths drifting along the red carpet, just not as attractive.

I chose to begin lowering Tirz (I never exceeded 5mg) and adding Reta. Right now I'm at 4mg Tirz and 1mg Reta. Next month I'll go down to 3mg Tirz and 1.5mg Reta, and keep going that way. Honestly, I'm hoping to get some food noise back...that way I can eat several small meals each day.

Are there other bariatric patients, or people who've managed this well?

This is uncharted territory for me.

On December 1st I weighed 223, and today I'm at 155 (with another 5-10lbs to lose)

That's close to a 70lb drop in 5 months with no stalls at all...my husband gave me a reality check this morning, saying I looked a little frail. I'm very active, though I don't go to a gym...I think I'll start that in autumn once riding season ends. Maybe he just hasn't seen me at this weight in 18 years.
 
Wow. You happened to be right in the window when the American Society for Metabolic Bariatric Surgery put out fresh guidance naming SADI-S as the preferred operation for the super morbidly obese, ahead of the BPD/DS, which is such an aggressive intervention.

Given that the BPD/DS is done so rarely (only 2% of all bariatric procedures), I figure locating people in a situation like yours is going to be really hard. When I had a RNY bypass back in 2003, my BMI was probably a lot higher than yours. That's many years ago now. On tirzepatide, I haven't had the fast weight loss you've had. Still, I don't believe you need to find somebody who's had a BPD/DS or another gastric surgery plus fast weight loss — what you need is somebody who has gone through rapid weight loss on tirzepatide and can speak to how they managed titration and stacking of reta.
 
In 2017 GLP1s weren't around, so instead of that procedure I ended up with a sleeve gastrectomy. Since I have type 1 diabetes and the pounds keep piling on, I've been using reta. Reta has worked really well for me; from what I hear it doesn't silence food noise quite as strongly as tirz, though both are excellent for dropping weight. Many folks I've seen have moved from tirz over to reta, and since no switching protocol exists, it's basically one big experiment--you keep adjusting until you land on a sweet spot. One thing I'll note: after making the change, a moderate dose seems necessary for it to do anything, meaning 1mg of reta is useless for someone who's already used another GLP. From what I've observed, people tend to find their good range near 4-6mg, though your mileage may vary. Like you, I'm no gym person, but I walk daily and handle plenty of physical chores, so hopefully I haven't shed too much muscle.
 
Grogu said:

Wow. You happened to be right in the window when the American Society for Metabolic Bariatric Surgery put out fresh guidance naming SADI-S as the preferred operation for the super morbidly obese, ahead of the BPD/DS, which is such an aggressive intervention.

Given that the BPD/DS is done so rarely (only 2% of all bariatric procedures), I figure locating people in a situation like yours is going to be really hard. When I had a RNY bypass back in 2003, my BMI was probably a lot higher than yours. That's many years ago now. On tirzepatide, I haven't had the fast weight loss you've had. Still, I don't believe you need to find somebody who's had a BPD/DS or another gastric surgery plus fast weight loss — what you need is somebody who has gone through rapid weight loss on tirzepatide and can speak to how they managed titration and stacking of reta.
Click to expand...
That's exactly right...whether my hyper-responsiveness comes from the malabsorption piece is something I can't confirm — maybe I'm simply very sensitive to Tirz. My guess, though, is that both factors are at play.

Up to now, onboarding Reta hasn't given me any trouble...I'll hold at the 4/1 ratio for another few weeks, then move up to 3/1.5 and check how that treats me.
 
greatbriton1 said:

In 2017 GLP1s weren't around, so instead of that procedure I ended up with a sleeve gastrectomy. Since I have type 1 diabetes and the pounds keep piling on, I've been using reta. Reta has worked really well for me; from what I hear it doesn't silence food noise quite as strongly as tirz, though both are excellent for dropping weight. Many folks I've seen have moved from tirz over to reta, and since no switching protocol exists, it's basically one big experiment--you keep adjusting until you land on a sweet spot. One thing I'll note: after making the change, a moderate dose seems necessary for it to do anything, meaning 1mg of reta is useless for someone who's already used another GLP. From what I've observed, people tend to find their good range near 4-6mg, though your mileage may vary. Like you, I'm no gym person, but I walk daily and handle plenty of physical chores, so hopefully I haven't shed too much muscle.
Click to expand...
Maintenance is nearly within reach for me at this point, and my hope is strong that Reta can serve as the tool that keeps me steady rather than pushing my weight down any further. Where my Reta dose ends up settling is something I'm curious to find out.
 
FarmgirlRebel said:

I registered for bariatric surgery in 2020 at 320 pounds, but Covid pushed things back, so the procedure finally happened in 2021.

The operation I had was the Biliopancreatic Duodenal Switch, also called DS. A big portion of my stomach was taken out and my intestines were rearranged, which left me with roughly 150cm of small intestine (normal is 600-750cm). That creates a malabsorption issue I'll have to handle for life with supplements (I wish Tirz had existed back then).

So here's the situation: a GLP such as Tirz does work, but for me it works too strongly. Because my stomach is smaller and I malabsorb, getting enough calories in is hard at best. Even if I manage to reach 1200 calories, I'm likely only taking in about 2/3rds of them...and that's with decent nutritious food (which I do eat).

The pounds are coming off fast, and I'm not complaining, but I need to put the brakes on or I'll wind up resembling one of those Hollywood wraiths drifting along the red carpet, just not as attractive.

I chose to begin lowering Tirz (I never exceeded 5mg) and adding Reta. Right now I'm at 4mg Tirz and 1mg Reta. Next month I'll go down to 3mg Tirz and 1.5mg Reta, and keep going that way. Honestly, I'm hoping to get some food noise back...that way I can eat several small meals each day.

Are there other bariatric patients, or people who've managed this well?

This is uncharted territory for me.

On December 1st I weighed 223, and today I'm at 155 (with another 5-10lbs to lose)

That's close to a 70lb drop in 5 months with no stalls at all...my husband gave me a reality check this morning, saying I looked a little frail. I'm very active, though I don't go to a gym...I think I'll start that in autumn once riding season ends. Maybe he just hasn't seen me at this weight in 18 years.
Click to expand...
Unga Munga, I hear you, sis. My sleeve was done in 2009, and since my mom went through a DS, I know that procedure well. She used Zepbound for a few months and did drop some weight on it, but when she moved from 5mg to 7.5mg the side effects spiked hard, and she didn't want to take Tirz from me. She stopped once it wasn't covered this year, though she might give one of the pills a shot when they get approved in July. Give her credit—she's kept 25lbs off this year. She'd like to lose another 25lbs, and honestly at her age and with her condition, so would I.

Lately I've been trying to fine-tune this combo for myself. The last few times I ran Tirz/Reta, only about 1mg of each was enough and it held me steady for maintenance. I'm 8 weeks out from shoulder surgery and only just starting strength training again, but the regain is no joke. I was staying at 190lbs on just a couple mg of Reta, then a few bad weeks hit—the dog got sick, blah blah—and next thing 200 showed up on the scale. I bumped to 4mg, added 1mg of Tirz, and this morning I'm finally seeing it move back toward 195lbs. I began Tesamorelin 1mg/Ipamorelin 250mcg 2 weeks ago, so I know water retention is in play and will shift around. My goal is 180lbs again, but my eating was garbage for 3 weeks until I put the Tirz back in—Reta alone just lets you eat 🍿🍰 You'll get snack attacks on higher Reta without even noticing. I always injected 3.5 days apart and tried to hold each dose for 4 weeks to judge it before tweaking anything and seeing what happened. That's what's great about Grey market vial—you just adjust what you need to sort it out. You've got the right approach: small change, then stick with it a few weeks.

Congratz on the weight loss and being so close to goal🙂
 
FarmgirlRebel said:


…I decided to start titrating down on Tire (never went over 5mg) and onboarding Reta…

Click to expand...
Click to expand...

What's the reason for making the change to Reta?
 
woundcarping said:

FarmgirlRebel said:


…I decided to start titrating down on Tire (never went over 5mg) and onboarding Reta…

Click to expand...
Click to expand...

What's the reason for making the change to Reta?
Click to expand...
The sole reason is that Tirz wipes out my hunger entirely...going above 2.5 was likely a mistake on my part, yet I did it...at 2.5 alone, everything shut down completely. My hope is that Reta brings back a bit of that food noise, allowing me to consume more, while keeping portions smaller.

That's the plan for now...though who really knows, my body will signal whether it works or if I should just microdose Tirz instead.
 
FarmgirlRebel said:

Grogu said:

Wow. You happened to be right in the window when the American Society for Metabolic Bariatric Surgery put out fresh guidance naming SADI-S as the preferred operation for the super morbidly obese, ahead of the BPD/DS, which is such an aggressive intervention.

Given that the BPD/DS is done so rarely (only 2% of all bariatric procedures), I figure locating people in a situation like yours is going to be really hard. When I had a RNY bypass back in 2003, my BMI was probably a lot higher than yours. That's many years ago now. On tirzepatide, I haven't had the fast weight loss you've had. Still, I don't believe you need to find somebody who's had a BPD/DS or another gastric surgery plus fast weight loss — what you need is somebody who has gone through rapid weight loss on tirzepatide and can speak to how they managed titration and stacking of reta.
Click to expand...
That's exactly right...whether my hyper-responsiveness comes from the malabsorption piece is something I can't confirm — maybe I'm simply very sensitive to Tirz. My guess, though, is that both factors are at play.

Up to now, onboarding Reta hasn't given me any trouble...I'll hold at the 4/1 ratio for another few weeks, then move up to 3/1.5 and check how that treats me.
Click to expand...

I’m with you — the two of you are likely extremely responsive to tirzepatide, and on top of that, your procedure probably still leaves you absorbing less than normal. That operation was pretty drastic.

From where I sit, there’s just so little data on how GLP-1s behave in people who’ve had bariatric surgery that each of us ends up figuring it out alone. These days my surgery doesn’t even cross my mind when I’m deciding on treatment. I simply copy what people in comparable circumstances do with GLP-1s.

Maybe this sounds odd, but if tirzepatide already has you this near your target, why change anything? Reach goal first, and only then begin trying other things?
 
Grogu said:

FarmgirlRebel said:

Grogu said:

Wow. You happened to be right in the window when the American Society for Metabolic Bariatric Surgery put out fresh guidance naming SADI-S as the preferred operation for the super morbidly obese, ahead of the BPD/DS, which is such an aggressive intervention.

Given that the BPD/DS is done so rarely (only 2% of all bariatric procedures), I figure locating people in a situation like yours is going to be really hard. When I had a RNY bypass back in 2003, my BMI was probably a lot higher than yours. That's many years ago now. On tirzepatide, I haven't had the fast weight loss you've had. Still, I don't believe you need to find somebody who's had a BPD/DS or another gastric surgery plus fast weight loss — what you need is somebody who has gone through rapid weight loss on tirzepatide and can speak to how they managed titration and stacking of reta.
Click to expand...
That's exactly right...whether my hyper-responsiveness comes from the malabsorption piece is something I can't confirm — maybe I'm simply very sensitive to Tirz. My guess, though, is that both factors are at play.

Up to now, onboarding Reta hasn't given me any trouble...I'll hold at the 4/1 ratio for another few weeks, then move up to 3/1.5 and check how that treats me.
Click to expand...

I’m with you — the two of you are likely extremely responsive to tirzepatide, and on top of that, your procedure probably still leaves you absorbing less than normal. That operation was pretty drastic.

From where I sit, there’s just so little data on how GLP-1s behave in people who’ve had bariatric surgery that each of us ends up figuring it out alone. These days my surgery doesn’t even cross my mind when I’m deciding on treatment. I simply copy what people in comparable circumstances do with GLP-1s.

Maybe this sounds odd, but if tirzepatide already has you this near your target, why change anything? Reach goal first, and only then begin trying other things?
Click to expand...
That's how I'm keeping an eye on it too...I'll keep this ratio as-is since the weight is still coming off, and I ought to hit goal by June, or maybe mid-month.

My surgery rarely crosses my mind these days, other than when it comes to supplements. I ended up in ICU one time with Wernicke's encephalopathy because thiamine just doesn't absorb well in my body even though I eat protein and so on...these days I always make sure Thiamine is part of my routine, lol...not something I'd want to go through a second time.
 
Back in 2010 I went through bariatric surgery — a vertical sleeve gastrectomy. A word of warning: things went well for roughly 5 years, then I grew complacent, got married, and picked up poor eating patterns. My weight went from a high of 29, down to a low of 170, and then up to 309 in 2024. Right now I'm at 245. Keep up with your vitamins, stick to clean eating, and don't cut corners on protein.
 
When it comes to GLP/GIP, my VSG only crosses my mind regarding food choices, so that my macros are covered. My preference is whole foods over the heavily processed, protein-packed "snacks". I take them whenever I feel the need.

Given how near you are to your target, should you really be making a switch at this point? What about simply reducing your Tz dose?

For me, Flintstone's Complete has worked better than anything else as a multivitamin. Bariatric vitamins made me feel sick.
 
My sleeve was done 5 years back. The quiet that tirz gives me is something I really value. If it came to maintenance, though, my choice for the moment would likely be lowering my tirz dose rather than making a switch. Reta packs more strength in other respects, and that makes me worry you'd end up dropping more weight instead of holding steady.
 
HereKittyKitty said:

When it comes to GLP/GIP, my VSG only crosses my mind regarding food choices, so that my macros are covered. My preference is whole foods over the heavily processed, protein-packed "snacks". I take them whenever I feel the need.

Given how near you are to your target, should you really be making a switch at this point? What about simply reducing your Tz dose?

For me, Flintstone's Complete has worked better than anything else as a multivitamin. Bariatric vitamins made me feel sick.
Click to expand...
For a long stretch I took Flinstones, though not long ago I made the change to Centrum Silver, and so far it seems to be working well for me...the tricky thing about vitamins, though, is that when something isn't working, the effects can take quite a while to show up. That said, every one of my labs looks great.

I'm down to 4mg of Tirz...these days I divide it into separate doses.
 
The iron in the majority of them is likely the culprit, in my opinion. As for the Flintstones one, I haven't given it a shot, simply because my surgeon told me the vitamin content isn't sufficient.

Taking mine alongside food is a must, though. The one I go with is Procare Health Bariatric + Probiotic. On occasion I'll use their one a day, which comes with a strange orange coating that I find disgusting. Their calcium chews and chocolate bars are things I really like as well. A handful of other options have been tested by me, but this is the one I keep coming back to.
 
FarmgirlRebel said:


I was doing Flinstones for ages, but recently switched to Centrum Silver and I seem to be doing just fine on it...but the problem with vitamins, if you aren't doing fine on something, it takes a long time for it to manifest. But, all my bloodwork is looking awesome.

I have reduced Tirz to 4mg...splitting the doses now.

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Those Flintstones are unbearable to me — way too chalky. I might reach out to my team and ask their opinion on vitamins now that I'm more than 5 yrs past surgery.

Great to hear your labs came back so well! Mine are perfect too.

Keep us posted on how 4mg treats you. I'm considering bumping up to 7.5mg to shed these last 10lbs or so. Getting there is painfully slow. Since January, when I made the switch to Tirz, I've dropped only 13#.
 
HereKittyKitty said:


I can't stand the Flintstones. They're so chalky. Maybe I will drop my team a note to see what they say about vitamins 5+ yrs out from surgery.

Glad your blood work is so good! Mine is perfect.

Let us know how you make out on 4mg. I am thinking of going up to 7.5mg to knock off these last 10lbs or so. It's excruciatingly slow to get there. Since January, when I switched to Tirz, I've only lost 13#.

Click to expand...
Click to expand...
Yeah, that chalky flavor is rough...sort of!

Before you began Tirz, what were you taking? Those final 10lbs are said to be the hardest to shed.

As of now, on Tirz 4mg, my appetite hasn't gotten any better. Next week I'll lower it again and see how that goes. It's a bit of a PITA since I receive those annoying Zepbound single shot pens, and I have to move the contents out of the pens, into a sterile vial, and then begin splitting. I shouldn't complain, it's covered by insurance 100% and there are so many people who cannot get covered at all.
 
I spent some time on Sema and it worked well for me. Then my employer dropped coverage for weight loss, so for 3 months I injected every other week, and it took another month before I located grey. Restarted from the lowest dose. Across 4 months I dropped 6#, and 4 of those pounds came off during December, the final month, after I stacked a low dose of cagri on top.

A few months afterward, I come across a study backing up that larger doses of it produce results. Annoying that this surfaced so soon after I'd made the switch, but by then I was set on Tirz. These days I'm buried so deep in stockpiling that the supply might outlive me. LOL

My cousin is following the same path you are. Before she retired she loaded up. 🤣 The last of her pens expire this year. Efficacy is what worries her. At least I've calmed her nerves about what it'll cost to keep going once those pens run out.
 
I had a sleeve gastrectomy done in 2018 as well. I dropped a significant amount of weight, but following that I went through a divorce, fell into a deep depression, and regained a good chunk (not every pound, but a good chunk) of what I had lost. A few weeks ago I began tirz to quiet the food noise, and I've also started exercising in an effort to hold onto muscle, plus... working out is beneficial. lol. Since I'm much earlier in this journey than you are, there isn't much data I can offer, but I'm glad to assist however I can and to observe what helps and what doesn't for those of us in this same situation.

When it comes to multivitamins, I buy multivitamin + fish oil gel caps from Bulk Supplements. I really like them. Unlike many multivitamins, they aren't enormous, they lack the fishy smell and taste that other fish oil products have, and on Amazon the price isn't terrible.
 
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