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.
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)’
This morning I found myself browsing through back issues of Nutrition when I stumbled upon an interesting study, published in 2008: “Comparison of ferrous sulfate and ferrous glycinate for the treatment of iron deficiency anemia in gastrectomized patients.” Which brings me to one of my favorite topics. Journey Vitamins.
Photo Credit: Journey Vitamins
You’ll remember that Journey uses a special form of iron known as Ferrochel, which is ferrous bisglycinate, an iron glycinate chelate. On its website, Journey makes the following claim:
Clinical studies with Albion’s Ferrochel® have shown Ferrochel® improves hemoglobin and ferritin indices at lower dosages than ferrous sulfate or ferrous ascorbate; lower dosages mean fewer side effects and no interactions with other nutrients.
Well, many members of the community, such as Andrea at WLS Vitagarten, have requested copies of these clinical studies to no avail. The research we do have does not support the use of ferrous bisglycinate, especially not in weight loss surgery patients. This study is no exception.
Continue reading ‘Ferrous Glycinate Chelate and Gastrectomized Patients’
Last week, I attended a local support group meeting for the first time in a few months. Unfortunately, it was an exercise in futility that once again proves that expert advice can be anything but. This surgery is for life. As patients, it is our responsibility to educate ourselves. We have a vested interest in our health that our doctors simply do not share.
Photo Credit: Flickr User SuperFantastic
Continue reading ‘Sleeve Patients Can Stop Vitamins at Two Years Post-Op?!?’
Note: An updated version of this document can be found in PDF form here. Please download and share.
Many years ago, the gold standard for post-operative supplementation was Flintstones children’s chewable vitamins, as well as Tums for calcium. Unfortunately, this regimen was woefully incomplete. Without the proper supplements, people developed deficiencies. Not always immediately—the body has stores of many vitamins—but they did eventually appear. In some people, circumstances helped to accelerate nutrient depletion. My friend Andrea had babies. Greedy little (adorable) things that they were, those babies stole from her vitamin stores. Her Flintstones and Tums simply couldn’t keep up. Andrea got rickets.
These cautionary tales are everywhere in the weight loss surgery world. There are countless post-ops five, ten, or more years out who have dug themselves out from deficiencies that were caused, at least in part, by bad medical advice. Despite these stories and the giant strides that have been made in bariatric and nutritional research, the recommendations given by surgeons are still outdated.
So, at my 18-month lab workup, my iron levels quite frankly stunk. They had been steadily dropping since surgery, despite supplementation.
Welcome to another vitamin post. I’ve previously written a post called “All About Iron.” This is a continuation on that subject. In my “All About Iron” post, I touched on the subject of ferritin and iron storage. This post will go into more depth and explain why ferritin is so important for weight loss surgery patients.
The Ferritin Complex
Iron deficiency is one of the most common complications following roux-en-y gastric bypass. For this reason, the American Society of Metabolic and Bariatric Surgeons (ASMBS) recommends iron supplements for gastric bypass patients. In this post, you will find information on the body’s use of iron, as well as causes and concerns related to iron deficiency.
A comparison of anemic red blood cells and normal red blood cells.
Earlier this week, I posted some facts about complications after roux-en-y gastric bypass. Today, I want to tell you a little bit about my personal experience since surgery.
Down 107 pounds, but that's not the full story. Photo Credit: Rebecca Bell Wilson
