Monthly Archives: June 2012

Alcohol Use Patient Agreement? Is this the prevention or merely protection from liability?

I was recently forwarded this from Dr. Wendy King, the principal on the new study, ” Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery” .      I was astonished to see that this type of release is now recommended before bariatric surgery.     It is alarming in that it appears to be a liability waiver.    I had RNY in 2000 and my ex-husband in 2001.    I would have been quite alarmed had I been presented with this and required to sign something of this nature before surgery.      What is even more strange is that this form is asking the patient to certify that they have been truthful in revealing their pre-surgical alcohol consumption when the most startling thing about the phenomena of “addiction transfer” is that the person rarely has a history of alcohol of drug problems before surgery.     One has to ask, what is the purpose of requiring patients to sign an agreement so very specific.    When I first started writing, bariatric surgeons insisted this surgery did not cause alcoholism or addiction.   If that were the case, why require a form such as this?    I am all for education and counselling the bariatric patient on all the various and sundry changes that will affect them post-operatively.   But is this the way to do it?   And I don’t see anything about say, taking your vitamins every day, getting sufficient protein every day, or any of the other things the patient should do after surgery…. just the alcohol.        I would love to hear what you all think about this .      Did you have to sign anything like this before you had surgery?    If you had been asked to sign something like this, what would you have thought?   Would it have changed anything?   Made you re-think anything?   I’d love to hear your thoughts on this, so please comment?

Re: {Insert Patient Name}
Medical Record #: ______________________________
Surgeon:  ____________________________________
Proposed surgery: ______________________________

Alcohol Use Patient Agreement
I, {patient’s name}, have reported the following alcohol and/or substance use to Dr. {Dr.’s name}:
__________________________________________
__________________________________________
My signature below indicates the following

1. I have been completely thorough and honest in my disclosure of my alcohol and substance use.
2. I understand that I will be permanently more susceptible to the effects of alcohol after surgery.
3. I understand that I should avoid alcohol for the first 3–6 months after surgery and that I should drink in extreme moderation afterward.
4. I understand that I am at higher risk for developing problematic use after surgery and that abstinence from alcohol is the best way to reduce this risk and other medical and psychological complications.
5. I agree that if my surgeon or another member of the surgery team (nurse, nutritionist, psychologist, etc.), have concerns about my alcohol and/or substance use, I will seek consultation and/or treatment as recommended.
6. I have had the opportunity to ask questions regarding alcohol and substance use.
Other:
Signature:
__________________ Date:_______________

 

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There is no empirical evidence to backup the idea of “addiction transfer”

Hello All,

Dr. Wendy King just published a new study on the prevalence of Alcohol Use Disorders Before and After Bariatric Surgery.   She is presenting this at the American Society of Metabolic and Bariatric Surgery in San Diego this week.   I emailed her to discuss this and to get her comments so we will see if she responds….stay posted everyone.

This is phenomenal news.   Ground-breaking for us in that she is one of the first in the bariatric community to speak out against the myth of “addiction transfer” and state plainly that there is no evidence to support it.   Rather the evidence supports the opposite.

Here is an excerpt from what she told Reuters:

“This idea of addiction transfer has been popular in the general media, but there is no empirical evidence to back it up,”

Here is the entire article and a link to her paper where you can download the pdf http://jama.jamanetwork.com/article.aspx?articleID=1185618:

NEW YORK (Reuters Health) – For some obese people, drinking problems may become a new burden following weight loss surgery, according to a new study out Monday.

Although the rate of alcohol abuse climbed only two percent after the procedures, researchers say this translates into more than 2,000 new cases of abuse every year in the U.S.

Two years following their surgery, patients described more symptoms of dependence — such as needing a drink in the morning or failing to meet normal expectations — and more alcohol-related harms, such as black-outs, feelings of guilt or injuring someone.

The jump in drinking problems was seen mainly among people who had gastric bypass surgery, which reduces the stomach to the size of a golf ball.

“This is something that we need to really pay attention to,” said Dr. Robin Blackstone, president of the American Society for Metabolic & Bariatric Surgery.

But, she added to Reuters Health, the findings aren’t surprising as alcohol sensitivity is known to go up after gastric bypass. That’s because the acid in the stomach usually makes some of the alcohol molecules less potent before they are absorbed.

“When you have a gastric bypass you disconnect most of the acid,” said Blackstone, who wasn’t involved in the new work. “We really don’t believe they should be using alcohol at all after the procedure.”

More than 220,000 Americans had some type of weight loss surgery in 2009, at a price of about $20,000 per patient, according to the American Society for Metabolic and Bariatric Surgery.

Surgery is considered the gold-standard treatment for morbid obesity, which plagues about 15 million Americans and is linked to a host of health problems, including diabetes and heart disease.

One previous study found seven percent of patients experienced complications from weight-loss surgery, but most were minor wound problems. Serious complications — such as massive bleeding or kidney failure — occurred in less than three percent of patients.

The new study, published in the Journal of the American Medical Association, highlights another potential risk of gastric bypass, said researcher Wendy King of the University of Pittsburgh. She presented her findings Monday at the annual meeting of the American Society for Metabolic & Bariatric Surgery in San Diego.

The results are based on nearly 2,000 patients at various U.S. centers.

Each underwent a weight loss procedure, including gastric bypass and gastric banding, in which a silicone band is placed around the top portion of the stomach to restrict food intake. They answered questions about their drinking habits before their surgery and again one and/or two years later. The researchers then rated the alcohol use on a scale developed by the World Health Organization to measure alcohol use disorders.

Before surgery, 7.6 percent of the patients had drinking problems. One year later, the number hadn’t changed much, but at two years, it had gone up to 9.6 percent.

More than half of the 167 patients who had drinking problems following their surgery had not been abusing alcohol prior to their surgery. Alcohol issues were particularly common in those who had gastric bypass, known as Roux-en-Y, and in younger men.

King said it’s unclear why people would develop drinking problems after weight-loss surgery, but it could be due to the increased alcohol sensitivity when people resume their normal drinking habits a couple years after surgery.

According to King, there is no reason to believe the procedures would replace one addiction for another.

“This idea of addiction transfer has been popular in the general media, but there is no empirical evidence to back it up,” she told Reuters Health, adding that binge eating before surgery was not linked to later drinking problems in her study.

Blackstone said the findings shouldn’t deter very obese people from having gastric bypass, which is typically preferred when people need to shed a lot of poundage. Younger, healthier people might consider other options such as a gastric band or sleeve, which haven’t been linked to alcohol problems.

“People who get weight-loss surgery are getting it because they are really unhealthy,” Blackstone said. “I think (this study) needs to be taken into account in terms of procedure choice, but the big picture of metabolic surgery is really about obesity.”

SOURCE: http://bit.ly/L92706 Journal of the American Medical Association, online June 18, 2012.

(c) Copyright Thomson Reuters 2012. Check for restrictions at: http://about.reuters.com/fulllegal.asp

 

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Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation

Note:   I just want to apologize to all for not posting sooner.  I’ve been studying for a test.  I will try and do better in the future – I have not forgotten you all, and I thank you for your patience.   I am also on FaceBook and Twitter now (@gerl_369)

http://www.ajcn.org/content/87/5/1128.full.pdf+html

Here is another interesting article out of Denmark that shows how nutrient deficiency progresses during the first two years after Roux-en-Y gastric bypass surgery.   Two years after surgery, 98% of patients require additional supplementation over and above the standard vitamin regime initially prescribed.

Some of the conclusions from the study show the lack of effectiveness of multi-vitamin therapy and it documents the rapidity of the onset of the deficiencies, with most deficiencies presenting at the 6th peri-operative month.   One of the more common recommendations of doctors to the gastric bypass patients is to double their multi-vitamins, but according to this study the effectiveness of that approach has not even been determined.   If one of something isn’t working, it doesn’t necessarily make sense that doubling it will.    The author’s recommendation is to develop a daily single-dose supplement and determine the most effective route of administration to encourage compliance and improve overall health outcome.

After two years, 80% of patients required additional B-12, 60% required additional calcium and iron and 45% required additional folic acid – on top of the multi-vitamin they’d been taking.   Smaller percentages were prescribed additional nutrients such as zinc, magnesium and B-vitamins.

This article is concerning in light of the finding that only about 35% of bariatric patients are compliant with their supplementation at all.    After two years, most patients are no longer under their bariatric surgeon’s care and are now being followed by their primary care practitioner who may, or may not, have significant experience with nutrient deficiency.

Bariatric patients should educate themselves on which laboratory tests are available to test for nutrient deficiencies, how indicative they are of actual tissue deficiency, what those optimum levels for their well-being should be, and associate those levels with a supplement regimen that adequately helps them maintain those levels.

One piece of information from this study that really caught my attention was the identification of the rapid onset of deficiency around the six month mark.   Most of the people that contact me regarding addiction transfer indicate that their problems did not start right after surgery, but rather during this 6-24 months post-operative period when this rapid onset of nutrient deficiency occurs.    There is still much to be studied and learned, but I for one would love it if they followed the recommendations of this paper and developed a one-shot effective supplement that was proven to be absorbable and effective.

If you have any questions, please email me at (lisanelson_2@yahoo.com, follow me on Twitter (@gerl_369) and FaceBook (It’s Not Addiction Transfer after Gastric Bypass Surgery)

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