The ultimate cash prize is going to go to the person who is able to capture the effects, but not the risks, of bariatric surgery, in a device or pill. Sure, Roca Labs may claim to have done it, but there are scientists working on devices that will mimic portions of bariatric surgeries, without the risks and invasiveness inherent to major surgery.
One device already available in Europe and parts of South America and set to begin multi-center clinical trials in the US is the EndoBarrier. The device is a two-foot long “sleeve” that lines the upper portion of the intestine, just below the stomach, mimicking the intestinal bypass of the Roux-en-Y gastric bypass. The EndoBarrier is manufactured by GI Dynamics and costs $5,000.
The device’s results are promising, especially for diabetes. The EndoBarrier was reported to improve the metabolic function of diabetics on par with Roux-en-Y gastric bypass. At 46%, excess weight loss at one year did not meet that of bypass patients, but it was close to Lap-Band patients.
Despite its promise, the EndoBarrier is not a permanent solution for weight loss or for diabetes management. The device is only designed to remain inside the patient for one year. As soon as it is removed, its benefits will cease. Weight will be regained, and diabetes will return. However, I could see this being beneficial for patients who need to lose to be healthy enough for bariatric surgery.
Source:
So, back in November, I got a headache. A migraine, actually, on November 25th. Ordinarily, that wouldn’t be that big of a deal. People get headaches, even migraines. They go away. Except this one hasn’t.
That’s right.
It’s April now, and I still have the same headache that started back in November. Now, it isn’t always a migraine, but some days it is. What I can always count on, though, is that it’s there.
I have a diagnosis now to add to my ever-growing list: migraines with chronic daily headaches. This is something that I had never experienced until seventeen months out from surgery. Before my Roux-en-Y, I had very infrequent migraines, often going years in between episodes, and some tension headaches. Now? Life’s a little different.
So, I was intrigued to see the publicity surrounding a study in the journal Neurology. The study’s authors found that the frequency, severity, and disability of migraines all improved six months after bariatric surgery. Their conclusion was that this was a result of weight loss, even though the majority of participants were still classified as obese.
It’s tricky to assign causation to the migraine mechanism. Migraines are not well-understood. We know they are linked to abnormal brain activity and that they can be triggered by certain environmental factors. But is it the weight loss after bariatric surgery that caused the improvement, or was it another factor? Many women report that their migraines improve during pregnancy, likely due to the changes in hormone levels. In the early months follow weight loss surgery, fat cells are releasing stored hormones, and hormone levels are fluctuating. This is another possible mechanism for the effect that is ignored by the authors of the study. All too often, the easy answer of weight loss is used, almost automatically. But, at six months out from surgery, the average BMI was still 34.6, just shy of morbidly obese.
I would also very strongly hesitate before recommending that anyone pursue weight loss surgery with the hopes of improving their headaches. While you may see improvement, there is not guarantee that you will, and treating your headaches may become harder after bariatric surgery. Because of my RNY, I can no longer just pop an Aleve for my headache, and Tylenol does nothing for my pain—I am limited to prescription medications. Lap-Banders and RNYers will not be able to take NSAIDs for headaches. Patients with malabsorptive procedures (RNY and DS) may process and absorb medications differently after surgery.
I am hopeful that some people see improvement in their headaches after surgery I wish I could be one of them. I’d also like to know what the data look like at 12, 18, 24 months out. If the weight loss is responsible, headaches should continue to improve and stabilize with weight. If hormones are contributing, they would start to worsen once out of the rapid weight loss phase.
Do you have migraines? Have they changed, one way or the other, since surgery?
Sources:
Two years ago today, I took off my requisite green, put on a hospital gown, and underwent Roux-en-Y gastric bypass. Two years ago, I was sick, sicker than a twenty-one year old should be. I had non-alcoholic steatohepatitis, or fatty liver disease. I had high cholesterol, high triglycerides, and my blood pressure had begun to creep above the normal limits. At my highest, I weighed over 285 pounds. I’m not sure how much because I began to avoid scales after I saw that number. My asthma was out of control. I was using my rescue inhaler on a regular basis, including many nights as I was lying in bed. I had upper airway resistance syndrome, a mild form of sleep apnea. I was struggling to breathe in my sleep, snoring and gasping for breath. I also had GERD, and the reflux was starting to wake me up at night.
All wired up for my pre-op sleep study, which revealed I had UARS.
So, I made the decision to pursue bariatric surgery. I actually made that decision in spring 2008, three years ago. I began reading the ObesityHelp message boards. Compulsively. I wanted to find all the information I could. My parents and I attended our first information session, with Dr. David Provost, who was practicing at UT Southwestern. My mother, a physician assistant, had heard good things about him. We walked away shocked. But not by the doctor. Instead, it was the other patients, the ones who were stunned that they would no longer be able to drink Hi-C. The ones who were more interested in abdominoplasty and liposuction than in losing the weight with bariatric surgery. We were shocked. But, we were also reassured by Dr. Provost. My decision was made. Bariatric surgery was something I wanted to pursue. Dr. Provost was my surgeon.
Me, pre-op, in Mexico. January 2007. This was taken near my highest weight. The hike up to see the monarchs was grueling.
I began traveling the long road towards insurance approval. I scheduled appointments with my primary care physician to complete the six months of supervised weight loss required by my insurance company. I gave it my best effort. As usual, I lost a bit of weight, only to find that weight again, with friends along for the ride. I had lost weight before, up to fifty pounds, but it always came back. Bariatric surgery offered the chance to change that.
Pre-Op, September 2007.
While completing the insurance requirements, I continued to research. Not only did I read books and web forums, I also read scientific studies. I saw the odds of weight loss and regain with weight loss surgery, as compared to conventional weight loss methods. I saw that even with bariatric surgery, there was a high rate of failure, but it was nowhere near the almost guaranteed failure of conventional weight loss methods. I learned that pregnancy was very possible, and safe, after weight loss surgery. I was not sacrificing my future to lose weight.
Four months into my insurance-mandated weight loss program, I received a letter in the mail. Dr. Provost was leaving UT Southwestern for a private hospital in Denton, one that was not on my insurance plan. I had to find a new surgeon. A suggestion from my gastroenterologist sent me to Dr. Joe Cribbins, a bariatric surgeon at the hospital by my house. I went to another seminar, sat through the routine questions, and had a consult with Dr. Cribbins following the intro session. He agreed with my selection of the Roux-en-Y gastric bypass. Under my insurance coverage, my choice was between the RNY and the Lap-Band, but I did not like the long-term stats of the band.
I completed the insurance requirements and submitted to my insurance company for approval. That approval came in late November 2008. Because I was a full-time student at the time, we scheduled my surgery for spring break. March 17, 2009.
My official pre-op photo, taken the night before surgery. March 16, 2009. 267 pounds.
Now, at two years post-op, my life has changed. This morning, the scale said 183, which is six pounds higher than my lowest weight of 177. My BMI is 24.8, so I’m in the normal weight category, but just barely. Several of my pre-op health conditions have been resolved. I no longer have GERD, fatty liver disease, UARS, high cholesterol, or high triglycerides. My blood pressure is normal.
Taken seven months after surgery. October 2009.
Christmas 2009, taken with my nephew. Around 180 pounds.
But that’s not to say I’m healthy. I still suffer from the depression and anxiety I had before surgery. And the malabsorption from my gastric bypass makes treating those conditions even trickier. My depression is finally back to being under control, but for almost a year, it wasn’t. I’m dealing with iron deficiency. My ferritin is still a 12, though that’s up from a 6 a few months ago. I was diagnosed with migraines with chronic daily headaches two months ago, and I’ve had a headache since November 25, 2010. I wake up with a headache, and I go to sleep with a headache. Every. Single. Day. While I no longer have fatty liver disease, my liver function tests are elevated. They returned to normal with weight loss, but the stress of my new array of medications is taking its toll on my liver. So I’m in a place where I cannot take pain medicine for my headaches. I cannot even take Tylenol. I cannot take the preventative medication that was helping with my migraines, Topamax. Not only is it processed through the liver, with a known risk of hepatotoxicity, but it also was making me acidotic. My CO2 level dropped below the normal limits. There’s no evidence that the headaches are in any way related to my gastric bypass. But the RNY has certainly made treating them more complicated. I do not have the option of simply popping an anti-inflammatory. Advil and other NSAIDs are off the table.
April 2010. Over a year post-op. Photo Credit: Rebecca Bell Wilson
At two years out, the only thing I can say for sure is that I am skinnier. I am not slowly dying of obesity-related conditions. Whether I’m healthier today is up for debate. I do not regret having weight loss surgery; to do so would not be productive. I do wish I had had the option of a vertical sleeve gastrectomy (VSG), a restrictive-only procedure that my insurance company started covering in the last year. But that wasn’t an option when I had my surgery. I’ve been successful. I’ve lost my excess weight. I’m “normal.” The RNY did it’s job. It helped me get the weight off.
November 2010. Houston OH Conference. Photo Credit: Beth Sheldon-Badore
But I’m still ambivalent. I wonder where I would be if I hadn’t had surgery. Would I have managed to lose the weight through conventional methods? The scientific research, as well as my own pre-op experience, says that is unlikely. I would likely be 300 pounds by now, and I would be killing my liver, even more so than my prescription medications are today. I would not be able to keep up with the kids I teach at work. Nor would I be able to chase my nephew around. Instead, I would struggle to breath. I would walk slowly. I would still shop at Lane Bryant.
So, life is different. I cannot say for sure that it is better, but it certainly is different. Ask me again next year.
The American Heart Association issued a statement in Circulation: Journal of the American Heart Association stating the benefits of bariatric surgery for severely obese patients. This was the first statement by the AHA to focus solely on bariatric surgery and cardiac risk factors. However, it was not a full endorsement of weight loss surgery.
In the past, the AHA has presented bariatric surgery as a strong option to be considered based on the individual patient’s medical profile. In this statement, he AHA examined the serious health consequences of morbid obesity and the disappointing success found with conventional weight loss methods. The statement panel examined the current literature, which led them to conclude that, when indicated, bariatric surgery can lead to significant weight loss, as well as improvements in the comorbid conditions of morbid obesity, including diabetes, liver disease, high blood pressure, high cholesterol, and sleep apnea. Moreover, weight loss surgery can cause improvements in cardiovascular dysfunction. Finally, the statement panel also found that recent studies show bariatric surgery can prolong life in the severely obese.
According to the statement, such benefits can overcome the risks that accompany bariatric surgery, such as death and long-term post-surgical lifestyle implications.
A new device, known as Abiliti, has entered the bariatric surgery arena. It will soon be available in Germany, Spain, and the U.K., with the first implantations scheduled to take place later this week.
Photo Credit: Intrapace
Calcium is the most abundant mineral in the human body. Almost 99% of the body’s calcium is stored within the bones and teeth. The remaining 1% is found in the blood and soft tissues.
Photo Credit: faria! (Flickr)
Functions
Calcium plays several important roles within the body, including providing structure, cell signaling, serving as a cofactor for enzymes and proteins, blood clotting, and allowing membrane permeability.
Structure
Calcium plays a role in the mineralization of bone. It is a major structural element of both the bones and the teeth. The mineral component of bone consists mainly of hydroxyapatite crystals, which contain large amounts of calcium and phosphate.
Cell signaling
Calcium helps mediate the constriction and relaxation of blood vessels, nerve impulse transmission, muscle contraction, and the secretion of hormones like insulin.
Blood clotting
Calcium ions must be bound in order to activate the seven vitamin K-dependent clotting factors in the coagulation cascade, which stops bleeding through clot formation.
Digestion & Absorption
Calcium is absorbed only in its ionized (Ca2+) form. As a result, it must first be released from the salts in which it is contained (e.g., calcium citrate, calcium carbonate) before it can be absorbed. Under ordinary circumstances, this is accomplished in about one hour at a mildly acidic pH.
There are two main transport processes that are responsible for the absorption of calcium:
1) The first process operates primarily in the duodenum and proximal jejunum. It is saturable and requires energy. This process involves a calcium-binding protein, and it is regulated by calcitriol, the active form of vitamin D. This transport system is stimulated by low-calcium diets and in conditions of growth.
2) The second process occurs throughout the small intestine, but is most prominent in the jejunum and ileum. This process is passive and nonsaturable. Absorption via this mechanism increases when the net calcium intake increases.
Blood Calcium Levels
The level of calcium in your blood is tightly controlled so as to maintain normal physiological functioning. Calcium is so vital to everyday functions that your body will demineralize bone in order to keep blood calcium levels within normal limits.
Calcium, parathyroid hormone (PTH), and vitamin D work together to maintain blood calcium levels. When blood calcium levels begin to drop, the parathyroid glands increase their production of parathyroid hormone (PTH). PTH, in turn, increases the reabsorption of calcium by the kidneys and stimulates the kidneys to convert vitamin D to its active form, calcitriol.
Calcitriol accelerates the absorption of calcium in the small intestine. Working together with PTH, it also stimulates the release of calcium from bone by activating osteoclasts, which are bone resorbing cells. The two also increase the reabsorption of calcium in the kidneys.
Once the blood calcium levels return to normal levels, the parathyroid glands stop secreting PTH, causing the kidneys to return to excreting excess calcium in the urine.
Labwork
Because blood calcium levels are so closely regulated by the body, a blood calcium level is an ineffective marker of calcium status. However, taken together with PTH and vitamin D, you can begin to determine your true calcium status.
An elevated PTH level can indicate that your body is leeching calcium from your bones, especially if paired with a low vitamin D level. This can occur even if your blood calcium levels are normal.
Calcium status is one of the best example of why a basic CBC and CMP are not enough for bariatric patients. While a CMP includes a blood calcium level, your body has mechanisms for protecting the level of calcium circulating in your blood by drawing on its stores—your bones. Only through more extensive testing can you reveal the full picture.
Interactions with Other Nutrients
Vitamin D helps to optimize calcium absorption.
Calcium inhibits the absorption of iron. The effect is stronger with nonheme iron, but also occurs with heme iron, though with higher doses of calcium.
Remember to check the serving size on calcium citrate supplements!
ASMBS Recommendations
Roux-en-Y Gastric Bypass: 1500-2000 mg/day
Duodenal Switch: 1800-2400 mg/day
Adjustable Gastric Band: 1500 mg/day
Vertical Sleeve Gastrectomy: 1500 mg/day
- Choose a brand that contains calcium citrate and vitamin D3. (Calcium carbonate is not well absorbed in individuals with decreased stomach acid. Calcium citrate is absorbed better by everyone, regardless of surgery status.)
- Begin with a chewable or liquid supplement, then progress to a whole tablet or capsule as tolerated.
- Split into 500-600 mg doses. Your body can only absorb 500-600 mg of calcium at a time.
- Be mindful of the serving size on the supplement label. The serving size for calcium is typically two tablets or capsules.
- Space doses evenly throughout the day.
- Do not combine calcium with iron-containing supplements. Calcium inhibits the absorption of iron. Separate calcium and iron-containing supplements by at least two hours.
Sources:
Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surgery for Obesity and Related Diseases 2008;4:S73-S108.
Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. Belmont: Wadsworth, 2000.
The American Society of Metabolic and Bariatric Surgeons published nutrition recommendations for weight loss surgery patients in 2008. You can download and read the recommendations for yourself here. This document is extremely helpful. It includes information on diet progression, vitamin recommendations, and information on complications and micronutrient deficiencies. I’d highly recommend reading it for yourself.
In the meantime, I’ll include the recommendations for vitamin supplementation. The ASMBS recommendations are a good place to start with supplementation, but know that you may need to alter your vitamin regimen based on your personal labwork.
Continue reading ‘ASMBS Vitamin Recommendations (Reformatted)’
The weight loss surgery world is a strange little place sometimes. I think some of its oddities derive from the nature of the procedure itself. I mean, most medical procedures are over and done when the patient leaves the operating room, but that’s where bariatric surgery starts.
You’ll remember that back in December, an FDA advisory panel recommended the lap band for less obese individuals–people with a BMI over 35 or between 30 and 35 with comorbidities. Now, the Food and Drug Administration is due to issue its decision on approving the device for this weight class. Last week, an editorial appeared in The New York Times that made some interesting points. Beth (aka Melting Mama) posted it on her Facebook, and I thought it was worth sharing.
Continue reading ‘The FDA & the Lap-Band for the Less Obese’
Another very successful product review here at The Bypassed Life. I picked up some Isopure Smoothies at Vitamin Shoppe the other day when I saw them for buy one, get one, and I think I’m in love!
\Little Bottles of Love (and Protein)
