Oops...I did it again!

Ever feel like you're king/queen of stupid? That's how I'm feeling this morning. I swear, I'm a bright girl. Ask anybody. I went to school, managed to get decent grades in difficult classes (when I applied myself) and even went on to get one of those highly sought after bachelor's degrees that people proudly display on their walls as proof of their intellectual elitism.

Yet, sometimes, I do the stupidest things. Like most people, I don't typically go around bragging about my stupid behavior. Instead, I favor smacking myself in the head in private and vowing to use my head as more than a hat rack in the future.

But last night's senseless act can't be kept private for many reasons. First off, writing is therapy, and maybe if I commit this one to print where it can confront me in the future, I won't be so stupid again. Second, I know there are others out there in my shoes who are guilty of my same stupidity. I am posting today to give them hope. I'm sure that like misery, stupidity also loves company.

I have reactive hypoglycemia, a somewhat uncommon form of low blood sugar that is now known to be a side effect of certain malabsorptive surgical weight loss procedures. I say "now known" because reactive hypoglycemia didn't have a name or much attention untill 2007 when bariatric researchers started studying patients who had a very odd reaction to consuming certain foods.

Instead of causing their blood sugar to skyrocket, simple carbs and sugars (even natural ones like in fresh fruit and juices) caused their blood sugar to plummet. In the world of blood sugar, 80 to 100 is good; 50 to 79 is when even normal people start feeling shaky or grumpy and need to find something to eat quick; under 50 signals danger with big, red flashing lights. Scientist dubbed this condition "reactive hypoglycemia" to group the patients whose blood sugar fell in reaction to the very foods that should have elevated it.

So, see, I'm special...unique...everything my mommy said I was when growing up. She just apparently left out the other qualifiers to indicate my natural inclination toward senseless behavior.

I rode the reactive hypoglycemia roller coaster for about a year after my emergency intestinal surgery in 2007. Those knotted innards were either slowing nutrient absorption enough to allow my body to react normally to complex carbs and sugars (simple sugars and carbs were always my enemy) or the reactive hypoglycemia was triggered by the trauma of that health crisis. No matter what, 2007 was a nightmare year for me. I didn't understand the rhyme or reason of what my body was doing, and not one of my "expert" docs could help me figure it out.

Then I moved to Merced and met a physician's assistant to whom I owe my life. Not only did she know about and understand reactive hypoglycemia, she taught me to manage it. She even gave me a glucometer to help me monitor my sugar levels at home. It was a newfound freedom to be able to equate my symptoms with one of the glucose zones I listed above. It also helped me figure out my body's rhythm. For example:

On a typical day, I wake up with a blood sugar level of 100. Then I eat breakfast and it drops to 80. If that breakfast is high in protein, I stay at 80 till my next meal. If it is not -- or if it includes sugars like toast, jam, juice or their ilk -- then it drops to 70 and sometimes 60 within 30 minutes. And I find myself forced to eat regardless of hunger just to achieve balance.

In the last 18 months or so, I've learned a lot about my body. I've learned that my hypoglycemic episodes are triggered by stress in addition to food, which means I sometimes suffer severe low episodes during stressful times (like when a deadline looms at work or I'm confronted by a personal crisis) even if I'm eating like I should.

Enough back story, let's talk about last night.

Last night, I had dinner with friends. I'm usually really good when eating in social situations. The conversation and activity provide enough of a distraction to give me time to step back and make wise eating choices. My worst moments are when eating in a rush. We had a family-style dinner that featured lots of chicken, veggies, noodles and rice.

Typically I would serve myself tablespoon-size portions of noodles and rice with four times the amount of chicken and some veggies so that the protein and fiber in my meal could slow the absorption of the carbohydrates. I might feel a little fatigued after that -- what many refer to as "food coma" -- but I would be otherwise fine.

However, I'm four months pregnant. And pregnancy has added nuances to managing my hypoglycemia: I find meat less appealing than usual and I have to share my available blood sugar with the baby growing inside of me. The good news is that the baby will always get what he/she needs. The bad news is that there is not always enough left over for me.

So last night, I go to serve myself what I know I should eat only to realize the chicken is unappetizing to me. I have a mental battle with myself (eat it anyway; no, if you eat that, you're going to throw up in front of everyone, eat it or you'll get sick, don't eat it or you'll get sick...and so on). I tried to compromise by serving myself two small chunks of chicken with a heap of veggies and sauce in hopes I could disguise the texture.

My plan seemed to work. I got through dinner, making sure to eat enough to satisfy me without overeating. After the meal, we sat and socialized for 30 to 40 minutes. I felt that faint feeling of fatigue that told me I would need a protein boost when I got home, but the conversation wasn't lulling to the point that it was clear we'd leave anytime soon. One friend ordered a sweetened beverage. It sounded good, and for a moment, I thought it would give me a needed boost till I could get home.

This beverage is one I've had before and I know that if I order it before my meal, I can sip it super-slowly while eating and suffer no ill effects. I've never tried order it as "dessert" before. I've surely never tried drinking it by itself without some type of protein to balance it out -- and I've never been dumb enough to drink almost half of it in the span of 15 to 20 minutes.

But last night, I was apparently struck stupid and did just that.

By the time I got home, I was feeling queasy. I had a long list of work to do and couldn't be bothered to listen to my body so I drank a glass of water. Thirty minutes later, I was soaked in sweat: That's the first symptom that I'm in the danger zone. I went to the bedroom and tried to undress myself but didn't have the dexterity needed to accomplish the task. I manage to send Brian (who had just gotten home) a text: "C me." When he got to the bedroom, I was lying in the fetal position and tugging at my clothes. He helped me out of them and instantly knew the problem.

True hypoglycemic episodes cause sweating, shivering, shaking, brain fog, impaired speech and hallucinations. And I was in the throes of every symptom at that time. I didn't realize he left but he returned with string cheese and a glass of water. He started prepping my glucometer to test my sugar for a benchmark. I was at 30.

I had trouble wrapping my brain around the situation but I knew that something was missing. In the danger zone, you need 15g of pure sugar -- fruit juice, honey, candy, even cake frosting -- to give your body an immediate boost before consuming something equal in protein and carbs (like cheese) to balance the sugar levels and head toward normal.

I tried to think of what was in the house he could give me, but it was hard to think and harder to articulate. Finally, I muttered something about chocolate and he brought me a small piece -- less than an ounce. I grunted and stuck it in my mouth. It was a good choice because it melted without much chewing. Next was the cheese. Chewing was very difficult. I was having trouble getting my brain to cooperate with my body, but I was managing.

Brian helped me test again. 50. Getting better. Lucidity should have come at any moment, but I found myself still slipping in and out. I was trying to think of my trigger. I remembered my after-dinner drink. Stupid, stupid, stupid. I asked for another cheese stick.

Then I had a brief hallucination of dying and winner the 2009 Darwin Awards for doing society a favor by chlorinating the gene pool. Just my luck.

I tried to stay conscious while Brian soothed me with a cool cloth, but something didn't feel right. I had him help me test again. 40. Brian said 30 minutes had passed since it all started. Crap. Sliding backward...why was that happening?

Struggling to remember my doctor's instructions, I couldn't decide whether to have Brian seek medical help or try to eat more sugar. The backslide didn't last long, the fog lifted a little, and I remembered the final part of my doctor's advice: "As soon as you're stable enough to walk under your own power, get to the kitchen and eat something else...ideally, protein and carb.

I couldn't fathom eating more cheese or touching any meat so I settled on a little nectarine with a few spoons of heavy whipping cream. Small amount of protein, small amount of carb. Besides, I'd rather dump from the dairy in the cream than feel like I felt.

That did the trick, and it wasn't long before recovery fatigue set in. For me, episodes like this are followed by extreme fatigue. My body likes sleep while it heals itself. I can easily sleep 12 hours after an experience like this. Usually, it's a dead sleep. Sometimes, though, it's filled with vivid dreams. Last night was a vivid seven hours of dreams. I woke up as exhausted as when I lied down. I immediately went to the kitchen for more fruit -- just in case -- which I will shortly follow with another cheese stick. Today will have to be a good eating day so I can build up my body's glucose stores.

It's a stiff lesson. It's probably been a year since my last episode of this level of severity. Writing it all out is hard, because nobody likes to admit to being senseless. But it's also necessary. I know what I did last night is standard behavior for others with the same affliction as me. They feel out of control, maybe even desperate. Some may not even understand why their bodies do what they do. They need to read stories like this to know they aren't alone -- and that there is hope.

For me, it drives home the same message I've been telling myself since 2007: I am not anatomically normal, and I probably never will be. But, like most things, this can be managed. I just have to take care to do so. The best news ever, though, is at least I don't have to worry about my stupidity affecting my child -- unless stupidity is genetic. If that's the case, let's hope the baby has Brian's intellect.

Tales From the Dark Side, Part II

In following up to yesterday’s post, I want to address my answer to the question, “Given the chance, would you have RNY again?”

WLS blogger Melting Mama, has a nine-minute YouTube video that explains why she wouldn’t. If you haven’t already, please watch the video (at the top of yesterday’s entry) before reading this. It’s not that MM wouldn’t have WLS, it’s just that given the choice, she would have picked an alternate procedure.

MM’s WLS journey is similar to mine in that we both went under the knife when we were in our 20s, both were over 300 pounds at the time, both had RNY and both now suffer from anemia and hypoglycemia as a direct result of that surgical procedure.

Yet now, more than three years later – four for her – we have very different views on what path we’d take if we could go back in time.

Why?

Because of one very key difference: MM was a very healthy 20-something who just happened to tip the scales at more than 300 pounds. I, on the other hand, was slowly dying in a 27-year-old fortress of fat. That’s the difference that makes our post-op experiences worlds apart.

Here’s my laundry list of pre-op concerns:

1. Chronic joint and back pain (I popped Darvocet and ibuprofen like candy);
2. High blood pressure (filled my first prescription for the condition at 21);
3. Debilitating migraines;
4. Infertility;
5. Chronic swelling;
6. Difficulty breathing;
7. Lack of mobility;

At 27, I felt like I was 80. I worked so hard to pretend the above conditions weren’t a problem and that I was “healthy” despite my weight, that I was exhausted by the end of the day. I had been morbidly obese since childhood, and my body was ready to collapse under its own weight.

After a long talk with a compassionate, yet direct, medical provider, I realized that I was on the cusp; my obesity was just beginning to catch up with me. I could continue down the path I was on and face increasingly severe co-morbidities or I could do something drastic to lose weight in an attempt to drastically reverse my course.

I chose the latter, and I haven’t had a single regret since.

Even when writhing in pain from a life-threatening bowel obstruction, I said with confidence that I would do it all over again because one day of life in a normal-size body is sweeter to me than any number in my pre-operative form.

But let’s get two things clear:

1. I DO NOT feel that way, because I’m “thin.” Go back and read my early posts – from before I had surgery – and you will see that I was terrified of being thin. It was a foreign concept to me at the time, something I could not wrap my brain around.
2. Surgery wasn't a cure-all for me. I still suffer from some of my pre-operative health concerns; they are just easier to manage at this size.
   

At the end of the day, my life is truly better now than it was in 2004 when I started my journey.

In my opinion, MM is not a whiner. Every word she says is true. We just have a different perspective on our situations. MM is right on the money when she calls WLS a trade-off. You give up obesity in exchange for other concerns or issues. In her case, the juice isn't worth the squeeze. In mine, it is.

She may not have had a bowel obstruction, but her hypoglycemia and nutritional deficiencies are much more severe than mine; I don’t suffer seizures nor do I need round-the-clock glucose monitoring. I also think that I’ve gotten more diligent after-care than she has – even when that bowel obstruction went misdiagnosed for six freaking months.

And I will say one thing very plainly: Reactive hypoglycemia is a nightmare.

MM says it best with the succinct comment, “Yeah, I look good. But what does that matter if I’m dead?”

If I ever came close to regretting bariatric surgery, it was when I became hypoglycemic. It’s difficult to articulate what it’s like other than to say it feels like your body is your enemy. Between that and the anemia presenting themselves at the same time, I felt like I was at the brink of insanity. The emotional and physical toll of hypoglycemic episodes were debilitating for me until brought them under control with the help of a caring, knowledgeable doctor a few months ago.

This last year has really been tough. I won’t lie. But in my situation, morbid obesity was still tougher.

Tales From the Dark Side, Part I

This video, courtesy of WLS blogger Melting Mama, is a must-see for anyone considering bariatric surgery. The picture she paints is grim reality that more pre-ops need to be exposed to. It’s a nine-minute video but it’s worth the time.

It’s been almost 3½ years since I had gastric-bypass – roughly about six months after Melting Mama. Our stories are similar in many ways: we were both over 300 pounds before WLS, we both were under 30, we both had roux-en-Y procedures, and we both suffer from anemia and hypoglycemia as a result of our surgical procedures.

Despite those similarities, though, we have different perspectives on our surgeries. Melting Mama would not have RNY all over again; I would.

I don’t want to steal the video’s thunder but it addresses the biggest issue I have with the popularity of surgical weight loss: LACK OF EDUCATION.

I remember my WLS orientation like it was yesterday. After six months of waiting, I was finally at Kaiser SSF to get more information on bariatric surgery. Like Melting Mama, I wanted the LapBand; it was less-invasive than gastric bypass, had no malabsorption and led to more gradual weight loss. I was also talked out of it when the surgeon at orientation informed me it was not covered by Kaiser and then gave me his laundry list of reasons why it was a bad idea anyway.

Beside that, there was one thing that struck me as odd about orientation – my fellow pre-ops didn’t seem to have a clue about bariatric surgery or what they were getting themselves into.

At this point, I had spent months poring over articles and research about WLS. I had interviewed people who had various procedures at various times. I talked to people with life-threatening complications and ones whose post-op journey was smooth sailing. I was armed and dangerous with more knowledge than my own physician when I marched into his office and asked to be considered for Kaiser’s program.

My cohorts at orientation, however, seemed to know little more than RNY made Al Roker and Carnie Wilson lose lots of weight and that they looked thin and beautiful. I remember one man who was downright outraged when he was told he’d have to limit his intake of sugar.

“But Al Roker says he can eat whatever he wants; he just eats less.”

It was hard not to roll my eyes.

I sat through three similar group classes before making a big decision: I would document my journey in writing and share it with the world.

Up to that point, I had intended to keep my surgery private. Like many of my friends, I was merely going to have “abdominal surgery” and let people think I was having my gall bladder removed or whatever. I didn’t want to make myself a spectacle. I didn’t want to open myself up to negative comments. I wasn’t even going to tell my family.

But the reactions and comments of the pre-ops I encountered in my journey showed me there was a dearth of reliable information on the subject of WLS that was easy to access. It also showed me that when it comes to losing weight, few people read the fine print. They are so intoxicated by the idea of being thin, they don’t pay any attention to the price they may have to pay. In short, they hear what they want.

So, my mission was simple: I would write a column dedicated to the subject with the goal of educating those who wanted or needed bariatric surgery and the general public. I wanted people to understand the seriousness of the decision, the dangers of the surgery and the fact that it requires a complete change in attitude and habits. I figured that since I had already done all the research, I could make it easier on others who followed in my footsteps to be as educated as I was when it came time to go under the knife.

Sadly, I overestimated my peers. Since I started this journey in 2004, I have only come across a handful of pre-ops truly willing to weigh the pros and cons of surgery. Even more sad are the number of post-ops who actually go on to make the changes necessary for success.

Annual Lab Results: The Human Pin Cushion Speaks

It's that time of year again. You post-ops all know what time I'm referring to. The time when we head to the doctor a leave with a handy-dandy lab request form in hand that has more boxes marked on it than unmarked, leaving us to wonder whether it would have just been easier for the doctor to write a note saying, "Check for everything but ... "

My lab results weren't that great last year. Both my blood sugar and iron levels were low. But with my employer changing insurance providers and then me taking a new job that offered other types of insurance plans, I had a hard time keeping track of things.

I met my PCP last week and instantly liked him. Merced may have a shortage of physicians, but so far, I think the ones we do have are top notch. He ordered a full course of lab tests for me and referred me to a nutritionist to discuss my hypoglycemia.

At the lab, I struggled not fall asleep as the technician drew eight vials of blood. I made a bee-line from the lab to a food source when it was all said and done.

My results came in early this week. I wish I could say I was surprised by them, but they only served to confirm what I already knew: I'm a bit out of whack.

First the good news: My cholesterol is 167. My risk level for cholesterol-related heart disease is 0.67. Average risk is 2.34-4.13. My doc is very happy. The nutritionist says I can eat all the cheese I want. Must be why I like her so much ;-)

Now for the not-so-good news: I have mytocytic anemia, most commonly referred to as iron-deficiency anemia. Most common, most easy to treat. The main concern is that I've been supplementing daily yet my iron levels are half of what they were a year ago, and my organs are not getting the oxygen they need. This is why I'm so tired and why I can't sustain physical activity for very long.

Here are my results for perspective:
Ferritin -- 1 (normal is 10-154)
Total Iron -- 22 (normal is 40-175)
Hemoglobin --- 10 (normal is 12-15)

Thought my ferritin level is in the toilet, the nutritionist I saw today said she doesn't recommend infusion therapy unless total iron is 10 or less, or hemoglobin is 7 or less. It's her opinion (she's also a family practitioner) that I can afford to try a higher dose of oral therapy for six weeks to see if that improves my levels. If it doesn't, then she'll combine oral therapy with weekly injections. Transfusion will be her last course of action. We will continue to monitor my iron levels every six weeks until I get in the normal range.

I've been taking 20mg of chewable iron daily. She's prescribing a new type of iron supplement that's supposed to be really good for women in general, but has also shown great results in bariatric patients. It's called Repliva. It's set up like birth control pills, where you take one active pill a day for 21 days and then an inactive pill for 7 days. Apparently, the body absorbs iron better when it gets a little break in between supplement cycles. Repliva is said to be more bioavailable than other forms of iron, because it contains B12, Vitamin C and Succinic Acid, which all act as binders to improve absorption. So, in theory, my body will absorb all 150mg of my daily dose. It's available by prescription only, and there is a chance that my insurance company won't cover it. But if it's not covered, I will figure something out. I can't afford not to supplement my iron intake. I'm not the type of person to cut corners when it comes to my health.

I really like my nutritionist. She gave me a glucometer so I can test my blood sugar levels daily and also gave me a plan of action on how to better control my hypoglycemia. I feel like she really took her time explaining reactive hypoglycemia to me and giving me additional tools to manage it. For instance, she told me that reactive hypoglycemia is much more common in the morning, which explains why I have such issues after breakfast that can lead to me ping-ponging all day to achieve balance. The solution may be as easy as eating only protein for breakfast. Following the same logic, that would mean that if I do want to indulge in a carbohydrate, dinner is the best time to do so.

Aside from logging my meals and testing regularly to find patterns, my immediate goal is to figure out how much carbohydrate my body can handle at one time and then ensuring I get a steady dose of that level throughout the day. This should alleviate my problems with fluid retention and bloating. I'm starting with 100 grams of carbs a day, split equally (20g) through my five meals. She prepared me for the need to juggle as my glucose monitoring reveals a pattern. For example, she said I might find that I have to limit my morning meals to only 10 grams of carbs but can boost my afternoon and evening meals to 30 grams.

Long story short, she did a lot to make me feel that all is not lost. That my hypoglycemia can be managed. And though it will take patience and discipline, I feel like she's willing to partner with me in figuring out my specific needs.

The highs and lows of blood sugar

Melting Mama posted an article to her blog this week about the relationship between gastric bypass and low blood sugar. The article was of particular interest to me, because I was diagnosed with hypoglycemia a few weeks ago. Since then, life has been a constant balancing act as I figure out the best way to keep my blood sugar level throughout the day.

Before the diagnosis, I thought I was losing my mind. I was lethargic, spacey, dizzy, easily confused and could not focus on the simplest tasks. It would take every bit of willpower I had to stay awake at work and on the drive home. As soon as I'd walk in the door, I head straight to bed and crash. Often, I'd sleep for the entire night only to spend an hour the next morning willing myself out of bed.

After a month of dealing with this, just about any diagnosis would have been welcome. But once I heard the news, then reality set in. Not only is this most likely a permanent condition that will require constant diligence, I had trouble wrapping my brain around my body's new dietary needs.

Here I had spent two years following the gospel of three meals a day (no snacks), few to no carbs, protein drinks vs. protein bars (drinks are lower in calories), and absolutely no sugar. I had finally gotten the rules down pat and didn't have to think about them anymore.

But hypoglycemia carrries its own set of rules: Eating every three to four hours keeps blood sugar most level; protein elevates blood sugar but fiber helps level and maintain it so complex cars are a good thing; protein bars are better than protein drinks because they don't cause a rapid change in blood sugar; and in low moments, sugar can be the difference between maintaining consciousness and passing out.

I had a brief moment of bitterness upon hearing my surgeon's bariatric coordinator rattle off this advice to me. I felt like the rug had been pulled from beneath me. Eating four to five times a day worried me. What if I gained all my weight back? Carbs a good thing? What if eating them led me to feel hungrier or caused me to binge? Eat sugar? Seriously? What planet was this and what did the pod people do to my doctor?

After getting off the phone, I did a little Web research and talked to other post-ops who also had hypoglycemia. I made myself a shopping list and other notes based on their advice. Though my doctor wanted me to eat three full meals a day and two protein-rich snacks, most post-ops I talked to said their blood sugar levels were best maintained by eating four or five equal-sized mini-meals each day. All the post-ops I spoke to said cheese and peanut butter were their best friends. Some kept glucose pills handy; others didn't. All recommended I keep a stash of yucky-tasting crackers that I could grab when at a low point but that wouldn't be tempting to me otherwise.

Next, experimentation came into play. Cheese was definitely my best friend, but peanut butter wasn't as helpful. I keep a jar of it at the office just in case I get desperate, but I'm more apt to select a protein bar instead. My body feels best if I eat at least three whole-food meals each day.

For me, bars are definitely better than drinks. My favorite bars are Think Thin cruncy peanut butter (available at Trader Joe's) and Oh Yeah! chocolate-mint wafers (available online and at the Vitamin Shoppe). A half-serving is all I need to keep my blood sugar level. Both Think Thin and Oh Yeah! chew down very well so as not to overfill my pouch, but the Oh Yeah! bars are more convenient because they come with two wafers in each pack -- instant portion control.

Liquid protein is a toss-up for me. AchievOne sends my blood sugar soaring through the roof and then crashing down, but I can mitigate that if I eat an ounce of cheese after finishing my drink. Nectar-brand drinks don't cause any wackiness at all.

Carbs are a necessity for me, but I'm still learning how to effectively use them. My typical breakfast is high-fiber cereal mixed with flax seeds and Fage 0% Greek-style yogurt. Cheese and crackers is not as helpful and ends up being more of a trigger food. Salads are a good way to incorporate complex carbohydrates with my protein. I eat salad almost every day now.

As I said before, it's a balancing act. It's a challenge but it's not impossible. and if anything, at least it prevents me from getting bored.