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.

From the "duh" files...

SAN DIEGO -- Though I appreciate the time and effort taken in researching obesity and bariatric procedures and outcomes, some studies make me shake my head in wonder.

For instance, comparing the success rate of bariatric surgery to commercial weight loss programs seems ridiculous. After all, does anybody really think counting POINTS! can hold a candle to rerouting one's digestive tract to reduce capacity and nutrient absorption? That doesn't even seem logical to me, much less a wise use of funding.

Here are two of what I'd call "duh" studies that were presented at the convention this week:

* Bariatric surgery makes people more sensitive to alcohol -- I don't think any of us with gastric bypass needed Stanford researchers to tell us that our rerouted intestinal tract makes us cheap dates when it comes to running a bar tab.
Dr. John Morton, assistant professor of surgery and senior author of the study, was quoted in today's Science Daily as saying, "I've heard the anecdotes of a patient who will drink one glass of wine and get a DUI, but I wanted to know if there is really a difference before and after the surgery."
Dr. Morton later says in the article that most patients aren't aware of this and that Oprah has done the field a favor by pointing it out on her show about the dangers of cross-addiction. I don't know about the rest of the post-ops in the world, but I discovered that fact the first time I tried wine after surgery. I didn't need Oprah or a study to enlighten me. Furthermore, I had been warned by other post-ops about the phenomena long before I ever had surgery, so I don't think it's as big of a mystery as Dr. Morton professes.

* Binge eating and a sweet tooth lead to gastric-band failures -- Just to make sure we're all on the same page here, a team of Swiss researchers reported that those post-ops who binged on food or indulged in sweets experienced a higher incidence of band failure than those who did not. The conclusion? The best candidates for banding are highly motivated patients who don't binge or eat sweets. Wouldn't you say the same thing for any type of bariatric procedure?

The dark side of WLS

In the 18 months that I have been writing about my decision to have bariatric surgery and my subsequent journey toward a healthy weight, I've tried to paint a clear picture of my overall experience.

But there have been some topics I've steered clear from for fear that they are too unpleasant for general consumption. The fact is that bariatric surgery is not all peaches and roses. No two patients have the same experience, because every body reacts to the anatomical changes in a different way. Some post-ops feel as if they've never had surgery, because their experience is that unremarkable. Other post-ops experience side effects so embarassing they fear leaving the house. And it's those side effects that are the topic of today's post.

Gas
There are two types of gas that bariatric patients suffer from: pouch gas and intestinal gas. Pouch gas is the easiest to deal with. Any over-the-counter gas aid with simethicone will dispel pouch gas and ease the pressure and pain.

Intestinal gas is the most painful and problematic. No over-the-counter gas aids work well in the intestinal tract. However, Digestive Advantage markets an over-the-counter pill that prevents gas in the intestines. The once-daily pill must be taken daily to work, and takes a few days to become effective, but it drastically reduces the amount of intestinal gas one experiences.

The final issue with gas is that a few patients -- particularly those who have duodenal switch -- experience flatulence with such a pungent odor that it alienates them from the world outside. They don't want to be alone with themselves, much less with anyone else. This problem can be particularly traumatizing in some patients who find their world even smaller after weight-loss surgery than it was when they were morbidly obese. For these post-ops, Devrom can be a godsend. Devrom is an internal deodorant that works to neutralize the odor in gas and excrement. It's not pretty to talk about, but it's a tool that provides post-ops in this uncomfortable situation with some measure of freedom.

Constipation
Constipation is a common problem after bariatric surgery. Decreased consumption of food and fluids, combined with protein supplements, make for a situation where things don't move. Constipation may seem like no big deal, but if it goes on too long, it can lead to hemmorhoids, fistulas and obstructed bowels -- all of which are painful and can be dangerous. The best way to prevent constipation after gastric-bypass is to consume at least 64 ounces of water a day. Other post-ops advocate taking stool softeners and/or fiber supplements daily to add some bulk to the intestines and to encourage everything to keep moving. Those are great preventive measures, but what does one do if constipation is already a problem? Milk of Magnesia and Smooth Move tea are excellent solutions. They are non-stimulant laxatives that help solve the problem of constipation in relatively short order.

Diarrhea
Though more rare than constipation, diarrhea can also be a side effect of bariatric surgery. Aside from the social discomfort of dealing with diarrhea, constant loose bowels can also cause dehydration. Depending on how long it's been since the patient had gastric-bypass, there are a few solutions. Eating bananas can firm up bowel movements. For patients at least one year out, high-fiber cereals can add much needed bulk. Another option is to use fiber supplements. Fiber supplementation is a good solution, but it takes time to kick in.