New Study – Gastric Bypass Increases Risk for New-Onset Alcohol Abuse (Now You Tell Us?)

I recently came across this article.   It’s from a presentation at the 2011 Obesity Conference in Orlando, Florida about the phenomena of new-onset alcohol abuse after gastric bypass surgery

I actually did appreciate this article, because this was one of the few articles that did not just summarily dismiss this as a psychological transfer issue.   The fact that new-onset alcohol abuse is in fact an extreme behavioral change seems to have finally caught the attention of some scientists.  They have begun to investigate this and ask some important questions – such as when the onset began? how quickly the abuse progresses? whether or not there was a history of alcohol abuse prior to surgery?  the average age of the person when the abuse sets it, etc.,

Some of the questions I would still would like to know are, did all of these people have the Roux-en-Y, or do these findings hold true for Duodenal Switch and Sleeve Gastrectomy?

Here is the text from the article from Medscape by Steven Fox:

Gastric Bypass Increases Risk for New-Onset Alcohol Abuse

Steven Fox

October 10, 2011 (Orlando, Florida) — Roux-en-Y gastric bypass (RYGB) surgery is associated with an increased risk of developing new-onset alcohol abuse, according to findings presented here from a study of 340 patients who underwent the procedure in Boston, Massachusetts.

The poster was presented at Obesity 2011: The Obesity Society’s 29th Annual Scientific Meeting.

“Our data underscore the need for asking patients during their preop evaluation about their use of alcohol, and again when following up after surgery,” presenter Stephanie Sogg, PhD, told Medscape Medical News. Dr. Sogg is a clinical staff psychologist at the Massachusetts General Hospital Weight Center in Boston.

Dr. Sogg said that several years ago she began hearing from patients that not only was alcohol having a far greater effect on them after surgery than before, but also that some were developing full-blown alcoholism after surgery — even if they had never had a previous problem with drinking.

And what was most intriguing, Dr. Sogg said, was that many of the people who were becoming alcoholics were middle-aged. That is long after most people begin to have alcohol-related problems. Data from the National Institute on Alcohol Abuse and Alcoholism indicate that the mean age of onset of alcohol abuse is 22 years.

“Although there’s not much in the literature on the subject of alcohol abuse following Roux-en-Y surgery, there’s quite a lot of discussion among weight loss specialists — anecdotal evidence — that this is a problem,” she said.

To find out more about a possible link, Dr. Sogg and her colleagues conducted telephone interviews with 340 patients who had undergone RYGB surgery at Massachusetts General Hospital in Boston. All procedures had been carried out at least 18 months before the survey.

About three quarters of the patients were female, and 91% were white. Mean age at the time of surgery was 46 years, and the mean time since surgery was 57 months.

Surveyors asked patients to quantify their preoperative and postoperative alcohol intake. Patients were also asked about how alcohol affected them both before and after surgery.

“We decided to ask about quantity and frequency rather than specific symptoms of alcohol abuse,” Dr. Sogg said. “That’s because we felt patients would be more comfortable reporting quantitative data rather than answering more subjective questions about their drinking.”

More than two thirds of participants said they were affected more by alcohol after surgery than before, she said.

Problem drinking was defined as consuming at least 3 drinks per day on at least 4 days per week, or having 5 or more drinks on at least 2 days per month.

“We found a significant increase in risk of new-onset postsurgical alcohol abuse among these patients,” Dr. Sogg said.

They defined “remote” problem drinking as problem drinking that had ceased more than 6 months before surgery. If patients were having drinking problems within the 6 months before surgery, that was defined as “immediate” problem drinking, Dr. Sogg explained.

About 21% of participants reported having drinking problems at some point before surgery. In all, 15% reported a remote history and 6.5% reported having an immediate problem.

Approximately 9% of participants reported a period of problem drinking after their surgery. Problem drinking after surgery was associated with younger age (P = .040), longer time since surgery (P = .001), and a higher baseline body mass index (P = .049).

“Drinking problems within 6 months prior to surgery strongly predicted problem drinking after surgery,” Dr. Sogg said. The odds ratio was 6.59 (P = .0005).

However, a remote history of problem drinking was not associated with having drinking problems after surgery (odds ratio, 1.01; P = .99), she noted.

Of particular note, Dr. Sogg said, was that 7% of patients surveyed reported new-onset problem drinking after RYGB.

However, no clinical or demographic variables were identified as predictors of new-onset drinking problems.

“In the population as a whole about 90% of alcohol problems develop before the mid-30s,” Dr. Sogg said. “The mean age of our sample was 46. So it’s troubling to find how relatively common new-onset alcohol problems were in this population of patients.”

Another observation Dr. Sogg said she has made over the years — but didn’t include in the present study — is how quickly drinking problems seem to progress in post-surgery patients. “Alcohol abuse is usually a gradual-onset problem, but in many of our patients who develop drinking problems, it seems to rapidly ramp up, escalating very quickly.”

On the basis of her study results, Dr. Sogg said clinicians need to increase their focus on the potential of alcohol-related RYGB complications. “That means better patient education, better screening, and better efforts at prevention, both before and after surgery,” she said.

“I think what this study clearly tells us is that alcohol can be a problem after surgery for some of these patients. And we especially need to watch people who had problems with drinking up to the time of surgery,” said Leslie Heinberg, PhD, director of behavioral sciences at the Bariatric and Metabolic Institute, Cleveland Clinic, Ohio, in an interview with Medscape Medical News.

She emphasized, however, that patients in the study who reported a remote history of alcohol problems before surgery were not at increased risk for postoperative drinking problems.

Dr. Heinberg, who is also associate professor at the Cleveland Clinic Lerner College of Medicine, said that in their program she and her colleagues are very careful to counsel all their patients about the physiologic changes that take place during surgery and how those changes will make patients permanently more susceptible to alcohol.

“We make sure they understand that if increased susceptibility is something that’s likely to create problems for them, they might want to reconsider having the surgery,” she said.

Dr. Sogg and Dr. Heinberg have disclosed no relevant financial relationships.

Obesity 2011: The Obesity Society 29th Annual Scientific Meeting; Abstract #21-OR. Presented October 5, 2011

Peripheral Neuropathy After Gastric Bypass Surgery

Peripheral Neuropathy has been increasingly on my radar, with respect to side effects related to nutrient deficiencies in gastric bypass patients.   This started for me a couple of years ago when my real good friend contacted me out of the blue.  He had gastric bypass surgery less than a year after I did from the same surgeon.   He emailed me out of concern to let me know he had been diagnosed with something called peripheral neuropathy.     How he figured this out was he was shopping in the local home improvement store and then all of a sudden experienced this extreme pain in his legs, to the point he didn’t think he would be able to make it out of the store.

What I soon learned was that peripheral neuropathy is a very serious and painful condition of the peripheral nervous system which is responsible for transmitting information from the brain and spinal cord to the rest of your body.    The Mayo Clinic found that as many as 16% of gastric bypass patients are developing nerve damage from problems associated with peripheral neuropathy.

The pain from neuropathy has been described as cutting, stabbing, crushing, burning, shooting, gnawing, or grinding, usually occurring on the extremities (arms and legs) .   Other symptoms of neuropathy include extreme numbness, paralysis, tingling, and burning.   In some cases, even just the weight of the bed sheet on the leg can trigger a pain event.    To heal or regrow nerves is a very slow and painful process.  This is definitely one of those cases – where an ounce of prevention is worth more than a pound of cure….

Think of peripheral nerves as the highways that transfer information back and forth from your extremities to the central nervous system (i.e., your big toe to your brain).    Information moves along the peripheral nerve electrically (which uses calcium, potassium and sodium as ions) and between other nerves (using neurotransmitters such as acetylcholine).  The nerve is protected by a sheath, which wraps around it and protects the fibers and keeps it from making abnormal transmissions.    When there is a breakdown anywhere in this process you can end up with a neuropathy.

There are many things that can cause neuropathies so it is often difficult to pinpoint the exact cause.   With that said, it is usually broken down to the following three causes:

•  Acquired Neuropathies – caused by environmental factors such as toxins, trauma, illness , infection, alcoholism,  as well as poor nutrition and vitamin/nutrient deficiency
• Hereditary Neuropathies
• Idiopathic Neuropathies – unknown causes

In gastric bypass patients (or gastric bypass patients who have become alcoholics), the most obvious cause of acquired neuropathies is vitamin and nutrient deficiency.    Fortunately, peripheral neuropathies caused by nutrient deficiencies can be halted – even reversed – with vitamin/nutrient therapy.  The typical nutrient deficiencies associated with peripheral neuropathy are B1 (thiamine), B-12, copper or, strangely enough, an excess of B6 (pyridoxine).

Some of the nutrients that can then in turn be beneficial in alleviating the symptoms of peripheral neuropathy (if caused by vitamin/nutrient deficiency) are:

• B-12 via injection (methylcobalamin or cyanocobalamin: methylcobalamin is the more absorbable of the two forms of B-12, so that may be the preferred form when recovering from peripheral neuropathy)
• Vitamin B1 (thiamine)
• Copper
• Vitamin C
• Multi-Mineral Supplement (that includes copper)
• Co-Q10
• Alpha Lipoic Acid

Intravenous MicroNutrient Therapy for Gastric Bypass Patients

When people who read my blog email me, they typically ask what they can do immediately to improve their nutrient deficiency. One of the procedures that I do that helps me maintain healthy nutrient levels is Intravenous MicroNutrient Therapy (IMNT). The most known of these is called the Myer’s Cocktail which was first created by Dr. John Myers, a Maryland physician who developed this process to treat his patients for a variety of conditions.  Dr. Alan Gaby, President of the American Holistic Medical Association, took over Dr. Myers patients after his death and has helped to popularize this treatment.

The contents of the basic Myer’s cocktail is magnesium, calcium, B12, B6, B5, B-complex, and Vitamin C.  My doctor customizes my treatment by adding selenium, zinc and a multi-trace mineral to the cocktail.   The cocktail can be administered via IV drip or IV push. I get the IV push. The procedure costs me $45 per treatment.

I started out with the first IMNT and then did another treatment one week later.  Now I go every 2-4 weeks depending on how I feel. When I received the first treatment she cautioned that I may notice a vitamin taste in my mouth during the procedure, but I felt nothing. However, during the next treatment a week later I could taste the vitamins almost immediately. My doctor explained that this was a sign that I was much more deficient the first time than the second.

The procedure can be a bit uncomfortable at times, but not painful. The injection must be done slowly. If it injected too quickly there is an uncomfortable pressure at the injection site. The needle is placed into the vein. The needle is connected to this very large syringe full of the nutrient solution by a long thin piece of tubing. The contents are then slowly injected. Like I wrote earlier, depending on your level of deficiency, you may or may not get this vitamin taste in your mouth right away. There is also a very warm flushing that comes over you caused by the magnesium sulfate solution (but goes away after the treatment is complete). The entire process takes 15-20 minutes. It is recommended that you arrive for this treatment very well hydrated.  I didn’t feel much improvement right away, but the next morning I was very peppy and in a great mood.

There aren’t very many studies regarding this process and gastric bypass patients. Most of the information I found was regarding patients that have been struggling with cancer related issues or fibromyalgia.

I have found this therapy a welcome adjunct to my daily supplement regimen. I feel this therapy provides me with that “cushion” of nutrients to cover for those days when I haven’t taken my supplements. I would also recommend this therapy as a jumpstart for those gastric bypass patients who have identified that they are experiencing extreme symptoms of nutrient deficiency and don’t want to wait for the daily oral supplements to take effect.

How Nutrient Deficiency is Conducive to Creating Addiction?

I get the following question quite a bit “How do you think that malabsorption causes alcoholism/addiction?”, so I thought I’d make that the topic of today’s blog.

The malabsorptive component of many types of gastric bypass surgery can cause nutrient deficiency and as a recent study has shown, amino acid deficiency (caused by malabsorption of proteins).

This deficiency or deficiencies can lead to some very uncomfortable feelings including anxiety, rapid heartbeat, restlessness, fatigue, confusion, irritability (and others – see list below). Often our first instinct, when these feeling comes is to assuage them with food – our “old friend”. In the past, we may have found this to be a reliable method of providing immediate relief – albeit with a weighty side effect. We would often get a boost in serotonin or glucose or whatever and temporarily feel better. Now, post-gastric bypass surgery, we may find our old friend may or may not provide the relief that it used to.

Now we come to what I call the “double whammy” component – the way alcohol is now metabolized by the gastric bypass patient. A normal stomach has an enzyme called alcohol dehydrogenase that is responsible for metabolizing alcohol. After surgery, the new “little” stomach no longer has access to very much of this enzyme. The result is you get drunk faster and stay drunker longer.

A study by John Morton showed gastric bypass patients having progressively increased blood alcohol content as well as length of time to sober.    For example, Pre-operatively Blood alcohol was 0.024, at 3 months 0.059 and at 6 months 0.088.   Respectively, time to sober up was 49 minutes,  61 minutes and 88 minutes.   No explanation was offered as to the progessive nature of the findings.

So, let’s just say you are experiencing this uncomfortable feeling, and you decide to have a drink to “take the edge off”. It’s never been a problem before so it never occurs to you it will now. All of a sudden you get swift and immediate relief (dopamine floods your pleasure centers), unlike anything you ever got with snacking.   Your brain puts two and two together and very quickly starts telling you, you “need” this.

However, many gastric bypass patients weren’t drinkers at all and never turn to alcohol. Some decide to go to their doctor – makes sense right? Some medications that are often prescribed for these “uncomfortable feelings” are anti-depressants (Prozac, Zoloft, Effexor, Cymbalta, LexaPro, Celexa, Paxil …), anti-anxiety medications or benzodiazapenes (Xanax, Ativan, Valium, Klonipin), and/or sleep medications (Ambien, Lunesta, Sonata, Rozerem).  Benzodiazapenes are very addictive and in this situation, if you are masking a nutritional deficiency that will only get worse if uncorrected, it is easy to see how someone could quickly become addicted. Like alcohol, this drug will also supply quick and immediate (though temporary relief) and again the brain will realize this drug makes you feel better and want more.

Prescription pain medications are also something that may be readily available to the gastric bypass patient. In addition to the original gastric bypass surgery, the patient may have had other revision type surgeries such as hernia repair or a tummy tuck or gall bladder or something unrelated. For whatever reason, if experiencing this “dis-ease” (I call it), and then the patient takes an opiate pain medication (LorTab, Vicodin, Oxycontin, Percocet, Hydrocodone) and gets immediate relief, the brain puts it together and decides that “this is a really good thing” – it doesn’t think about the side effects – it just knows how much relief is being provided.

So the way this sets the gastric bypass patient up for addiction is by creating a scenario where the malabsorption changes the brain/body chemistry such that the person feels so “wrong” – that when whatever drug that person chooses provides that “right” feeling (be it alcohol “the double whammy”, prescription medication, gambling, shopping, sex), the brain re-wires itself to want more and more of whatever made it feel so “right”. So, I don’t think you can say this surgery makes you an addict, but perhaps, you can say it is conducive to optimizing the ideal circumstances where addiction can occur.

I think it’s important to avoid the nutritional deficiency in the first place, for many, many reasons – this being merely one. If you do notice those first “inklings” realize that is your body/brain telling you something.   Try to find out if you have any nutrient deficiencies if possible and nourish your body with the appropriate food and/or supplements. If you have already developed an addiction, seek help and professional assistance.
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Website with list of nutrients and associated symptoms
http://bariatricfusion.com/nutritionaldeficiency.php
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Amino Acids are Important for Brain Function!

“Two Roads Diverge: Weight Loss Interventions and Circulating Amino Acids” by Robert E. Gerszten and Thomas J. Wang

This is the recent study (published April 26 in Science Translational Medicine) that was done to try and explain the fascinating phenomena why gastric bypass patients with type II diabetes see such quick improvement, if not cure of their diabetes. The investigators found that the bypass patients had much lower levels of amino acids known as branched-chain amino acids, and the amino acids phenylalanine and tyrosine.

The medical community appears to be quite excited by this find, as it appears to provide some valuable insight into the cause or perhaps cure for type II diabetes. However, as a gastric bypass patient myself, I have other concerns. What does this reduction in amino acids do to brain function?

Amino acids (the building blocks of proteins) are very important in the correct functioning of the brain. A generalized deficiency in them can lead to symptoms such as apathy, concentration difficulties, loss of interest, insomnia, mood swings, anxiety, depression, self mutilation and aggression.

Amino Acids function as neurotransmitters – the chemicals that carry information from one nerve cell to another. Certain amino acids are necessary for the brain to receive and send messages. Amino acids also enable vitamins and minerals to perform their jobs properly. Even if vitamins and minerals are absorbed and assimilated by the body, they cannot be effective unless the necessary amino acids are present. For example, low levels of the amino acid tyrosine may lead to iron deficiency.

According to Dr. Sunil Bhoyrul, a bariatric surgeon at Scripps Memorial Hospital in La Jolla, Calif, gastric bypass surgery is not without risks. It can cause malabsorption of nutrients. Indeed, the reason for the decrease in blood amino acid levels in the patients after surgery may be malabsorption of protein.

“It really shows the double-edge sword of malabsorption,” Bhoyrul said. “It might be a good explanation for why you get a better resolution of diabetes. But it also may be the cause of protein malabsorption,” Bhoyrul said.

Amino Acids can either excite or calm your brain. Tryptophan or Taurine can provide a calming effect where Tyrosine can provide an exciting or energizing effect. Here are just a couple of important qualities of just four amino acids (there are 20):

Tryptophan is an essential amino acid that is necessary for the production of vitamin B3 (niacin). It is used by the brain to produce serotonin, a necessary neurotransmitter that transfers nerve impulses from one cell to another and is responsible for normal sleep. Consequently, tryptophan helps to combat depression and insomnia and to stabilize moods. It helps to control hyperactivity in children, alleviates stress, is good for the heart, aids in weight control by reducing appetite, and enhances the release of growth hormone. It is good for migraine headaches, and may reduce some of the effects of nicotine. A sufficient amount of vitamin B6 (pyridoxine) is necessary for the formation of tryptophan, which, in turn, is required for the formation of serotonin.

Tyrosine is a precursor of the neurotransmitters norepinephrine and dopamine, which regulate mood, among other things. Tyrosine acts as a mood elevator; a lack of adequate amounts of tyrosine leads to a deficiency of norepinephrine in the brain, which in turn can result in depression. It suppresses the appetite and helps to reduce body fat. It aids in the functions of the adrenal, thyroid, and pituitary glands. It is also involved in the metabolism of the amino acid phenylalanine.

Taurine
is a building block of all the other amino acids as well as a key component of bile, which is needed for the digestion of fats, the absorption of fat-soluble vitamins, and the control of serum cholesterol levels. Taurine can be useful for people with atherosclerosis, edema, heart disorders, hypertension, or hypoglycaemia.

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Amino Acids: How They Affect the Brain and Nervous SystemOct 18th, 2009 by CarolineCollard

Supplementation to Prevent Addiction after Gastric Bypass Surgery

I was inspired to write today’s blog, as I was corresponding back and forth via email with someone explaining to them how I thought taking my supplement regime could potentially have prevented problems with anxiety, nutrient defiency, and addiction after Roux-en-Y Gastric Bypass Surgery.

What I’m afraid may be happening in more cases than they know is that sometime around 18-24 months, the body’s stores of reserve nutrients have been depleted and the body begins to experience malnutrition for one or more nutrients due to the malabsorption factor. I think this, in turn, may cause neurological problems and health problems that result in behavioral changes that can include anxiety, rapid heartbeat, aggression, insomnia, confusion, etc. Whether this would be caused from deficiencies in calcium, Vitamin D, magnesium, niacin, B-12, iron, whatever, or a combination, who knows?

This surmising is not unlike iron deficiency causing Pica which causes people to crave eating strange things such as ice or clay, or pellagra (the B3 deficiency) which can cause mental confusion, insomnia, and aggression, or beriberi (now they have a version called bariatric beriberi). In trying to self-medicate those symptoms, and with the double-whammy of the the way Roux-en-Y affects the way alcohol is metabolized (you are intoxicated faster and take longer to get sober), I think alcohol could be even more addictive than it would have otherwise been with a pre-surgery stomach. I’ve been told by others as well, in their words, “It feels different – I feel different”.

That’s why I would have taken the supplements from Day 1, if I had known then what I know now – To have prevented that early onset of nutrient deficiency. It is the potential for neurological problems associated with nutrient deficiency that I believe puts people at risk, and also impairs their judgment, combined with the increased effect alcohol has on WLS patients, that I believe is the root cause in the huge increase in the number of people developing addiction after WLS.

Magnesium Deficiency Causes Personality Change and WLS Patients are at Risk

I just read the article by the WLS advocate, Kaye Bailey, titled “Magnesium Deficiency Causes Personality Change and WLS Patients are at Risk” and I decided to make that the topic of this blog.

In that article she described a distinct personality change in herself – feeling that she’d lost her mind. Here is an excerpt:
“Have you ever felt like you were completely losing your mind? Like the world was swallowing you up and little things were out of your control and unmanageable? Like you were confused, tired, out of sorts and simply wanted to collapse?”

She later quotes from Dr. Bernard Jensen’s Guide to Body Chemistry & Nutrition”:

“I want to point out here that the classical deficiency symptoms for magnesium include neuromuscular signs, such as tremors, weakness, muscle spasms and irregular heartbeat; gastrointestinal signs such as nausea and vomiting; and personality changes that display confusion, apprehensiveness and depression. In the “old days” people with magnesium deficiency were often (mistakenly) taken to mental institutions because they acted so radically different that they literally seemed to be mentally ill.”

I had Roux-en-Y gastric bypass surgery in March of 2000. Approximately 18-24 months after surgery – after the “honeymoon period”, symptoms such as anxiety – a feeling like something wasn’t right but I didn’t know what it was overcame me.   As time went by these symptoms got worse, and I had no idea why. I began to start snacking – “grazing” if you will, to take this “edge” off.   I call it, feeling “like a shark in shallow waters” – kind of that feeling when you stare at the pantry or fridge – know you want or need something, but don’t know what it is.

More time went by with no relief. Symptoms had progressed to these feelings of panic where my heart would just begin to race – frequently on my drive home from work – what I would come to call “panic attacks”. For no apparent reason at all (or so it seemed) my heart would just start racing. It also became difficult for me to concentrate and focus. I was no longer able to follow an hour long TV program, read a novel, then could no longer follow a half-hour program, had difficulty balancing my checkbook (and I had it set up in Excel – which I had designed and programmed myself before). My favorite was (and remains) the Daily Show with Jon Stewart, and I knew something was really wrong when I couldn’t follow an entire show.   By this time, I also had developed swelling on my calves and small bruises all over that were unexplained.

Years went by with little relief and another trip to the ER, this time with a resting heartrate of 165 bpm.  By simple serendipity I followed up with a family doctor who also happened to have had Roux-en-Y gastric bypass surgery. It took him all of sixty seconds of hearing my story and looking at my medical history (he actually did read it) – and told me that I was likely deficient in magnesium (called hypomagnesaemia).   Added to the research I had already begun to do, it made a lot of sense.

We went over the supplements I was already taking – added some that he thought I should add including the magnesium. I then began researching and reading about magnesium and was astonished I hadn’t heard of this before.  I started taking magnesium oxide but quickly learned that it was only about 4% absorbable in a normal stomach. I’ve since switched to magnesium taurate and I also squirt magnesium oil on my skin for transdermal absorption. Some of the other forms of magnesium can give you a little condition well – let’s just say you spend a lot of time in the bathroom.

I haven’t had a single “panic attack” since!

If you are interested in additional information regarding magnesium, there is a great book called “The Magnesium Miracle” by Dr. Carolyn Dean. It explains that a serum blood test for magnesium really won’t tell you very much about your overall magnesium levels, as only 1% of the body’s magnesium is in the blood and 40% is in the tissues. The EXAtest is one of the magnesium testing methods the book discusses and it is a test that gives information about the levels of magnesium in the heart and muscle cells. The book also goes into great detail explaining the effect magnesium deficiency has on cardiovascular health, diabetes and obesity, PCOS, Osteoporosis and kidney stones as well as cholesterol and high blood pressure. There are many other great sources of information out there as well, this just happens to be one of the books I’ve read.

I’ve since discovered, this hasn’t just happened to me. On the gastric bypass surgery and obesity online forums – there were numerous postings of people who had discovered they were magnesium deficient – and chronicled how they were able manage it and whether magnesium supplementation improved their symptoms.

I’ve included the links to the sources I’ve used :

http://dearpharmacist.com/?p=1598

http://ezinearticles.com/?Magnesium-Deficiency-Causes-Personality-Change-and-WLS-Patients-are-at-Risk&id=42918

Vitamin D Supplements weren’t Sufficient for Gastric Bypass Patients

Another new Research study from the University of Maine by graduate student Joanna Fichthorn Rosebush titled “THE EFFICACY OF THREE DIFFERENT VITAMIN D SUPPLEMENTATION PROTOCOLS AFTER THE ROUX-EN-Y GASTRIC BYPASS PROCEDURE” concluded that while there didn’t appear to be a difference in the efficacy between those receiving supplementation with vitamin D2 versus vitamin D3, they all were less effective than expected.

Twelve-months after surgery, 72% of subjects taking 50,000 IU D2 weekly had optimal vitamin D status. Fifty percent of subjects taking 2800 IU D3 daily and 50% of the subjects taking 1200 IU D3 daily had optimal vitamin D levels. That means 28% – 50% were not!

In another study published in the February 2008 issue of Obesity Surgery: “VITAMIN D AND THE BARIATRIC SURGICAL PATIENT: A REVIEW” this was the conclusion: Both secondary hyperparathyroidism and bone loss were common, particularly when the obesity surgery included a malabsorptive component. Standard postsurgical supplementation with vitamin D and calcium have not been adequate to suppress secondary hyperparathyroidism or to restore 25-hydroxy vitamin D status.

The reason this is so startling is that these patients were taking high doses of the vitamin and on a frequent and monitored basis. As I’ve posted before, Vitamin D is not a vitamin most doctors tell their patients to supplement with. I received some blowback from my prior “Flintstones” postings from those who were just fine. But based on this study, anywhere from 28%-50% can still be deficient even with supplementation. What does that say for all of those patients who aren’t supplementing with Vitamin D – and studies show as many as 30% don’t even take a multi-vitamin – I bet it’s even higher for Vitamin D because they just don’t know?

I have been taking 5,000 – 6,000 IU of vitamin D3 per day and my levels were only 46. I would have thought they would be higher considering the supplements I was taking.

What does Vitamin D do and what are the symptoms of deficiency? I think that is the biggest problem – that most doctors aren’t familiar enough with symptoms of nutrient deficiencies and do not associate behavioral changes with nutritional deficiencies – in addition to which there may not be simple laboratory testing methods available.

Deficiency in vitamin D can cause cognitive impairment, impairs the body’s ability to appropriately utilize the calcium that many patients do take compliantly, impairs the immune response systom, is associated with increased cardiovascular problems, high blood pressure and increased risk of cancer. How can it affect so many areas? Because other nutrients (vitamins and minerals) are dependent on it to do their job – it’s the limiting factor. So when looking at symptoms of vitamin D deficiency you also need to look at symptoms of calcium deficiency, parathyroid impairment, pancreatic impairment, etc.

Vitamin D is one of the fat-soluble vitamins and you can obtain it from only a handful of natural dietary sources (fatty fishes), fortified dietary sources (milk, yogurt, cereals) and your body can generate it in the presence of sunshine. Supplements use either vitamin D2 (ergocalciferol) or D3 (cholecalciferol). Most medical professionals are recommending the D3 form, but this study seemed to indicate not much difference between the two. Most fortified foods use the D2 form as it is the cheaper form.

When they test your blood for vitamin D, they test mean serum 25(OH)D concentrations. There was been much debate in the medical community of late as to what is an optimum level for health, versus the minimum to keep adverse health effects away. Normal values according to the lab are considered between 33-49 ng/ml and optimum levels are 50-65 ng/ml. I am still only in the normal range. I would rather be in the optimum.

Here is an exerpt from the following website: “Obese individuals who have undergone gastric bypass surgery may become vitamin D deficient over time without a sufficient intake of this nutrient from food or supplements, since part of the upper small intestine where vitamin D is absorbed is bypassed and vitamin D mobilized into the serum from fat stores may not compensate over time”.

http://www.endotext.org/parathyroid/parathyroid3/parathyroidframe3.htm

You can find the studies I referenced here:

http://www.umaine.edu/graduate/research/efficacy-three-different
http://www.ncbi.nlm.nih.gov/pubmed/19017827?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/18176832?dopt=Abstract

Rate of Suicide Increases after Gastric Bypass Surgery

The Archives of Surgery has published in the 2007 October issue the following article: “Death Rates and Causes of Death After Bariatric Surgery for Pennsylvania Residents, 1995 to 2004″. They examined the results of 16,683 patients and found that there were 16 confirmed suicides (4%) and 14 drug overdoses (3%) that were not attributed to suicide. To put that in perspective, the The US Vital Statistics rates of death due to suicide
for white women are approximately 7 per 100,000 and for white men are 25 per 100,000 among the population for a comparable age range. These are alarming numbers. Here is a direct comment from their paper:

“It is very likely that suicide deaths were also underestimated because some of the deaths were listed as drug overdoses rather than suicide on the death certificate. The large number of deaths due to suicide and drug overdose, in excess of what we expected, is also a cause for concern.”

In another study published in the New England Journal of Medicine, “Long-Term Mortality after Gastric Bypass Surgery” they followed the outcomes of 9,949 patients and even though mortality from health related problems had declined. This study showed 21 documented suicides (7.29%), 25 other non-disease caused and 15 poisoning of undetermined intent. Even though the authors of this study did recognize the extraordinary increase in suicide, the conclusion drawn was that it was psychological, and related to unresolved psychological trauma.

Two studies strongly indicate that after gastric bypass surgery, the rate of suicide is significantly higher than in the control group. And as I’ve posted earlier there are studies that show this surgery is also capable of causing malnutrition from the malabsorption. I wish they had indicated in the suicide group what type of surgery that had, whether it was the Lap-Band or a bypass type of surgery. I think once they start breaking this out, it will become obvious that it is not the psychological issue they claim.

There appears to be the assumption that obese and morbidly obese and therefore people who have chosen to have WLS have higher instances of mental illnesses than the general population.   Is there the data to actually support that?

If you want to read the study yourself you can at:
http://www.nejm.org/doi/pdf/10.1056/NEJMoa066603
http://archsurg.ama-assn.org/cgi/reprint/142/10/923

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I rewrote some of this blog based on feedback from this forum . I will always welcome well intentioned criticism and critique and am open to learning as much as I can on a subject where there is so much yet to learn. After re-reading the blog entry, I did agree that parts were poorly written and did not reflect what I was trying to convey. It did appear that I was saying gastric bypass surgery caused suicide. That was and is not my contention. I recognize that human behavior is incredibly complex. When there are two separte studies both showing a marked increase in suicide, I believe it would be irresponsible of the medical community to simply ignore it. I do believe this calls for further investigation to see if the malabsortion component could have played a part, and if so, what, or aggravated a prior condition. Or perhaps it calls for the current recommended post-operative care modality to be re-examined? Whatever the findings call for.

A Flintstone a day Ain’t Enought

The American Journal of Clinical Nutrition has published the article “Nutritional Deficiencies after Roux-en-Y Gastric Bypass for Morbid Obesity Often Cannot be Prevented by Standard Multivitamin Supplementation”. One of the startling finds in their study to me was that only 33% of the participants were compliant in taking their vitamins at all. Their study found that at three months 34% of the study participants needed at least one supplement, by 6 months the number had increased to 59% and by month 24 the number was up to 98%. The conclusions of the study were
(1) A single multivitamin is insufficient post-Roux-en-Y gastric bypass to prevent deficiencies. In fact 60% were deficient within six months and virtually all participants were deficient within 24 months.
(2) The vitamin D and calcium deficiency prevalence corresponds with the length of the Roux-en-Y limb.
(3) Proper and adequate post-operative supplementation may become burdensome and expensive and challenge patient compliance.

I have to say that I was thrilled to see that there was a study done on this subject. I still get emails that doctors are telling their patients a Flintstone a day is enough. This study shows that you absolutely need to commit to much more than that. I wish they had gone into what those deficiencies are and what the signs and symptoms are, but I guess that can be for a later study. I don’t think that many doctors and patients know what the symptoms of deficiencies of iron, calcium, magnesium, thiamine, etc., are and how they can present, such as ice craving, agitation, heart racing or “panic attack”…. I friend of mind developed peripheral neuropathy. He also broke his leg one Christmas. After six weeks in a cast, expecting to get his cast off, he went back to the doctor, they X-rayed his leg and there had been absolutely no recalcification of the break. And he had been taking his Calcium Citrate as directed.   They ended up having to double the dose and healing time .

If anyone would like to read this study for themselves it is located at: http://www.ajcn.org/content/87/5/1128.full.pdf

I just got the blood work back from my doctor and my cholesterol was 143, HDL was 58, my LDL was 70 and my Triglycerides were 76. Excellent – so far so good!   Like I said earlier.    D was only 46 and expected it would be higher.

I was astonished to see in this study that only 33% take their vitamins!

My daily regimen:

High Potency Multi Vitamin – 6 x per day (2 softgels are a “serving”)
Magnesium Taurate – 125 mg 5 x per day (plus I spray magnesium oil on my skin for transdermal absorption) – I have never had a “so called panic attack since I started taking magnesium”
Omega-3 Fish Oil – 3 TBS per day (Carlson) – Barlean’s is supposed to awesome though (comes in Pina Colada)
Vitamin D3 – 2 5,000 IU per day
Calcium Citrate – 2,000 mg (4 TBS Nature’s Blend Blueberry)
Vitamin A – 10,000 IU 2 x per day
Vitamin E – 400 IU 1 x per day
Multi-Mineral Capsule – 1x per day
B12 – injection 1cc per month
Niacin (non-Flush) – 500 mg 2x per day  (may stop taking with cholesterol numbers)
Tyrosine – 500 mg – 3 x in the morning
Taurine – 1500 mg – evening (as needed)
1 protein shake/bar per day