Bariatric surgery, malabsorption and GLPs

[FarmgirlRebel]

At 320 pounds I signed up for bariatric surgery in 2020, due to Covid, I had to wait and eventually had it done in 2021.

I had the Biliopancreatic Duodenal Switch aka DS. This means they removed a large section of my stomach and re-routed my intestines, leaving approx 150cm of my small intestines (typical length is 600-750cm) creating a malabsorption component that I have to manage for the rest of my life w/supplements (wish Tirz was a thing back then).

Here is the deal, taking a GLP like Tirz works well, too well for me. With my reduced stomach and malabsorption, it is difficult at best to get the calories in, even when I can hit a target of 1200 calories, I am probably absorbing only 2/3rds of that...with good nutritional food (which I do eat).

The weight is shedding off, not complaining, but I need to slow it down or I'm going to end up looking like one of those Hollywood wraiths creeping around the red carpet, only not quite as pretty.

I decided to start titrating down on Tirz (never went over 5mg) and onboarding Reta. I am currently on 4mg Tirz and 1mg Reta. Next month I'll drop 3mg Tirz and 1.5mg Reta and so forth. I am actually hoping for some food noise ...that will allow me to eat several small meals a day.

Any other bariatric patients or people who have dealt with this successfully?

I'm navigating new waters for me.

I weighed in at 223 December 1st, today I weigh 155 (with another 5-10lbs to go)

Pushing a 70lb loss in 5 months w/zero stalls...my husband gave me a wake up call this morning and said I was looking a bit frail. I am super active, but I don't go to the gym...think I'll change that come autumn and the riding season is done. It could be that he just hasn't seen me at this weight for 18 years.

 

[Grogu]

Wow. You were right in the time period when the American Society for Metabolic Bariatric Surgery was issuing new guidance that SADI-S is the preferred surgery the for super morbidly obese over the BPD/DS, which is such an aggressive intervention.

I think it's going to be very difficult to find folks in similar situation as yours since the BPD/DS is performed very infrequently (just 2% of all bariatric procedures). My BMI was likely much higher than yours was when I had a RNY bypass in 2003. Many years ago. I haven't experienced the fast weight loss that you have experienced on tirzepatide. But I don't think it's necessary to find someone that has had a BPD/DS or other gastric surgery with fast weight loss, you just need to find someone who has dealt with rapid weight loss on tirzepatide and how they handled the titration and stacking of reta.

 

[greatbriton1]

I didn't have that surgery I got a sleeve gastrectomy because GLP1s didn't exist back in 2017. I have been on reta because I have type 1 diabetes and the weight gain just keeps happening. Reta has been great, it doesn't kill food noise as well as tirz I've heard but they're both great for weight loss. I've seen a lot of people change over to reta from tirz and its a big experiment becuase there's no protocol for switching-- you just have to try until you hit a sweet spot. I will say that once people switch it does require a moderate dose to work, as in 1mg of reta won't do anything for people who already have been on another GLP I've seen people seem to hit a good spot around 4-6mg, your results will vary. I too am not a gym goer but I do walk every day and just do lots of physical chores so I hope I haven't lost too much muscle.

 

[FarmgirlRebel]

Wow. You were right in the time period when the American Society for Metabolic Bariatric Surgery was issuing new guidance that SADI-S is the preferred surgery the for super morbidly obese over the BPD/DS, which is such an aggressive intervention.

I think it's going to be very difficult to find folks in similar situation as yours since the BPD/DS is performed very infrequently (just 2% of all bariatric procedures). My BMI was likely much higher than yours was when I had a RNY bypass in 2003. Many years ago. I haven't experienced the fast weight loss that you have experienced on tirzepatide. But I don't think it's necessary to find someone that has had a BPD/DS or other gastric surgery with fast weight loss, you just need to find someone who has dealt with rapid weight loss on tirzepatide and how they handled the titration and stacking of reta.

So true...I cannot even be sure my hyper responsiveness is due to the malabsorption component, it could be I'm just super sensitive to Tirz. But I suspect a combo of the two.

So far, Reta has caused me no issues while onboarding it...sticking with the 4/1 ratio for a few more weeks then titrate to 3/1.5 and see how it goes.

 

[FarmgirlRebel]

I didn't have that surgery I got a sleeve gastrectomy because GLP1s didn't exist back in 2017. I have been on reta because I have type 1 diabetes and the weight gain just keeps happening. Reta has been great, it doesn't kill food noise as well as tirz I've heard but they're both great for weight loss. I've seen a lot of people change over to reta from tirz and its a big experiment becuase there's no protocol for switching-- you just have to try until you hit a sweet spot. I will say that once people switch it does require a moderate dose to work, as in 1mg of reta won't do anything for people who already have been on another GLP I've seen people seem to hit a good spot around 4-6mg, your results will vary. I too am not a gym goer but I do walk every day and just do lots of physical chores so I hope I haven't lost too much muscle.

I am so close to maintenance right now, I am super hopeful that Reta will be my way to maintain w/o losing more weight. It will be interesting to see where I land on Reta for my dosage.

 

[RubbaDubba1]

At 320 pounds I signed up for bariatric surgery in 2020, due to Covid, I had to wait and eventually had it done in 2021.

I had the Biliopancreatic Duodenal Switch aka DS. This means they removed a large section of my stomach and re-routed my intestines, leaving approx 150cm of my small intestines (typical length is 600-750cm) creating a malabsorption component that I have to manage for the rest of my life w/supplements (wish Tirz was a thing back then).

Here is the deal, taking a GLP like Tirz works well, too well for me. With my reduced stomach and malabsorption, it is difficult at best to get the calories in, even when I can hit a target of 1200 calories, I am probably absorbing only 2/3rds of that...with good nutritional food (which I do eat).

The weight is shedding off, not complaining, but I need to slow it down or I'm going to end up looking like one of those Hollywood wraiths creeping around the red carpet, only not quite as pretty.

I decided to start titrating down on Tirz (never went over 5mg) and onboarding Reta. I am currently on 4mg Tirz and 1mg Reta. Next month I'll drop 3mg Tirz and 1.5mg Reta and so forth. I am actually hoping for some food noise ...that will allow me to eat several small meals a day.

Any other bariatric patients or people who have dealt with this successfully?

I'm navigating new waters for me.

I weighed in at 223 December 1st, today I weigh 155 (with another 5-10lbs to go)

Pushing a 70lb loss in 5 months w/zero stalls...my husband gave me a wake up call this morning and said I was looking a bit frail. I am super active, but I don't go to the gym...think I'll change that come autumn and the riding season is done. It could be that he just hasn't seen me at this weight for 18 years.

Unga Munga, I get it sister. I had my sleeve back in 2009, my mom had a DS so I'm familiar with it. My mom was on Zepbound for several months and she did lose some weight with it, but the side affects between 5mg and 7.5mg really jumped up for her and she wasn't keen on getting Tirz from me. So she just ended up stopping as it wasn't covered any more this year, but may try one of the pills once they're approved in July. To her credit, she has kept the 25lbs off this year. She would like another 25lbs as well, as would I at her age and condition.

I've been trying to dial this combo in for myself lately, last couple times I've done Tirz/Reta I only needed like 1mg of each and it worked well for maintenance. I'm 8 weeks post shoulder surgery and just now getting into some strength training, but the weight regain is very real. I was holding the line at 190lbs with just a couple mg of Reta, then I had a couple rough weeks, the dog was sick blah blah etc. Then 200 popped up on the scale, I went up to 4mg then added 1mg of Tirz and just starting to see some movement back to 195lbs this morning. Now I just started some Tesamorelin 1mg/Ipamorelin 250mcg 2 weeks ago, so I know there is some water retention there and that will fluctuate. I wanna get back to 180lbs, but my diet was crap for 3 weeks till I added the Tirz back in as the Reta just lets you eat You'll just start having snack attacks on more Reta and not even realize it. I always dosed, 3.5 days apart and tried to stay on those doses for 4 weeks to see how it went, before I changed something and see how it worked. That's the beauty of Grey market vial, you just dial up what you need to figure it out. You got the right idea, a little change at a time and do that for a few weeks.

Congratz on the weight loss and almost being at goal

 

[woundcarping]

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

Why switch to Reta?

 

[FarmgirlRebel]

Why switch to Reta?

Only because Tirz completely shuts down my appetite...I probably should never have gone above 2.5 but I did...even at 2.5 it was a complete shutdown. I'm hoping that Reta will let some of that food noise back in so I can eat more, but still with less quantity.

At least this is the game plan...who knows though, my body will let me know if it is a good plan or just try to microdose Tirz.

 

[Grogu]

So true...I cannot even be sure my hyper responsiveness is due to the malabsorption component, it could be I'm just super sensitive to Tirz. But I suspect a combo of the two.

So far, Reta has caused me no issues while onboarding it...sticking with the 4/1 ratio for a few more weeks then titrate to 3/1.5 and see how it goes.

I agree, you’re probably both super sensitive to tirzepatide and still experiencing malabsorption due to your surgery. It was a very aggressive surgery.

I guess in my mind there is such scant research on glp-1 use in the post-bariatric surgery population that we’re kind of left to our own devices. I don’t even think about my surgery anymore when considering treatment. I just follow what others do in similar situations on glp-1s.

As crazy as this may sound, since tirzepatide has you so close to goal, why mess with it. Get to goal and then start experimenting?

 

[FarmgirlRebel]

I agree, you’re probably both super sensitive to tirzepatide and still experiencing malabsorption due to your surgery. It was a very aggressive surgery.

I guess in my mind there is such scant research on glp-1 use in the post-bariatric surgery population that we’re kind of left to our own devices. I don’t even think about my surgery anymore when considering treatment. I just follow what others do in similar situations on glp-1s.

As crazy as this may sound, since tirzepatide has you so close to goal, why mess with it. Get to goal and then start experimenting?

I'm tracking that way...I will just stick with this ratio, as I am still losing, I should be at goal by June or the middle of the month.

I don't think about my surgery much either, except the supplement side of things. Landed myself in ICU once with Wernicke's encephalopathy as I do not absorb thiamine well despite eating protein etc...always make sure I am taking Thiamine now, lol...don't want to do that again.

 

[RCpilot]

i had bariatric surgery in 2010, a vertical sleeve gastrectomy.....be careful, i got my moneys worth for abot 5 years then started getting lazy and married and bad eating habbits....i went from 29 max, to 170 min, to 309 in 2024..im now at 245 ...just take your vitamins and eat clean, dont skimp on protein

 

[HereKittyKitty]

I only think about my VSG in relation to GLP/GIP in terms of what I'm eating to make sure I'm meeting my macros. I aim for real food instead of highly processed high protein "snacks". I definitely use them as I need them.

As close as you are to your goal, is now the time to switch? Maybe just lessen your Tz dosing?

Flintstone's Complete have been the best multivitamin solution for me. Bariatric vitamins left me nauseated.

 

[domin8brix]

I had a sleeve 5 years ago. I love the silence from tirz. But for maintenance, I would probably go down on tirz vs switching for now. Reta is stronger in other ways and I’m concerned you’re going to lose more vs maintain.

 

[FarmgirlRebel]

I only think about my VSG in relation to GLP/GIP in terms of what I'm eating to make sure I'm meeting my macros. I aim for real food instead of highly processed high protein "snacks". I definitely use them as I need them.

As close as you are to your goal, is now the time to switch? Maybe just lessen your Tz dosing?

Flintstone's Complete have been the best multivitamin solution for me. Bariatric vitamins left me nauseated.

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.

 

[domin8brix]

I think the iron in most of them is what gets you. I haven’t tried the Flintstones one just bec my surgeon says it’s not enough vitamin content.

But I have to take mine with food. I use the Procare Health Bariatric + Probiotic one. And sometimes their one a day which has a weird orange coating that is gross. I love their calcium chews and chocolate bars, too. I’ve tried a few others but keep going back to this one.

 

[HereKittyKitty]

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.

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#.

 

[FarmgirlRebel]

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#.

I here you on that chalky taste...ish!

What did you switch from before starting Tirz? The last 10lbs are supposed to be the toughest to get off.

So far my appetite has not improved on Tirz 4mg. I will drop again next week and see how it goes. It's kind of a PITA as I get those stupid Zepbound single shot pens and I have to transfer out of the pens, into a sterile vial and then start splitting. I shouldn't complain, it's covered by insurance 100% and there are so many people who cannot get covered at all.

 

[HereKittyKitty]

I was on Sema for a bit, did well on it, my employer stopped covering it for weight loss, I dosed eow for 3 months, took another month to find grey. Started back at lowest dose. Over 4 months, lost 6#. 4 of those pounds I lost after stacking with low dose cagri that last month (December).

A couple of months later I see study confirming higher doses of it bear results. Disappointing to happen so soon after switching but I was committed to Tirz at that point. And now I'm so far down the hoarding hole that it may outlast me. LOL

My cousin is doing what you're doing. She stocked up before retiring. Her last pens expire this year. She's worried about efficacy. I've tempered her anxiety about the cost to continue once the pens are exhausted, at least.

 

[Pocket]

Also had the sleeve gastrectomy back in 2018. Lost a bunch of weight, but then got divorced, super depressed, and packed a bunch (not all but a bunch) of the weight back on. Started tirz weeks ago to help get rid of the food noise and started working out to try and maintain muscle and well....exercise is good for you. lol. I'm well behind you on the journey so I don't have much data for you to go off of, but happy to help if/where I can and see what does and doesn't work for people in our situation.

As to multivitamins, I get multivitamin + fish oil gel caps from Bulk Supplements. Love them. They aren't huge like a lot of multivitamins are, they don't smell or taste fishy like some other fish oil supplements do, and they aren't horribly priced on Amazon.