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:
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)’
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’
Allergan, the makers of the Lap-Band, has been in the news lately. They recommended to the FDA that the Lap-Band be approved for use in patients with a BMI as low as 30 kg/m2. The FDA panel voted to recommend the Lap-Band for use in these patients. The vote was 8-2.
Currently, the Lap-Band is approved for use in patients with a BMI of 40 kg/m2, or 35 kg/m2 with co-morbidities. The new recommendations would allow use in patients with a BMI of 35 kg/m2, without co-morbidities, or of 30 kg/m2, with co-morbidities.
