A Plateau

Weight loss after gastric bypass or Lap Band surgery is reaching a plateau. How to deal with that?

First things first. Do not get frustrated. Frustration is a negative emotion that will take you to nowhere. It's never too late to get back to basics.

Here are some tips that may help you every time (yes, plateaus are not a once in a life-time event):

1. Sit back and reassess the situation. Have you reached a healthy weight goal. You do not expect to keep losing weight endlessly. The aim is not to reach the weight that you simply desire. The goal is to achieve the weight that brings to you the best health benefits. If you underwent weight loss surgery (bariatric surgery), your clinic had probably made a calculation as to the average target weight for you. Have you reached that goal? if so, any additional weight loss is just a bonus, as long as you stay healthy.

2. Remember that on average, individuals do regain some weight after reaching the lowest weight. This is OK and healthy, and may represent a normal variation or re-setting of your stable weight, rather than a new trend with increasing weight. Also it may indicate adding up muscle mass if you are exercising. So, if you are doing everything right, and you regain a little bit then plateau again, you have probably reached where you need to be.

3. Regardless whether you reached the weight you ought to be or not, re-evaluate your performance. Eating habits (portion control, watching the quality of the food) and physical activity, get back to basics. Refresh your memory about what you have learned before as part of your weight loss program.

4. If you are lagging behind in some of the basics, maybe you need to sit down and write a diary of your eating and physical activity habits. Writing a log is a very powerful tool, since it makes you accountable to yourself. You may be amazed when you see the reality in your own handwriting somewhat different from what you thought you were doing.

5. Increasing physical activity is particularly useful for getting you out of a plateau. Take every opportunity in your everyday life to spend some extra calories. They add up by the end of the day. Increasing physical activity has tremendous benefits to your state of mind, emotional well-being, physical efficiency, muscle mass preservation, and loss of fat tissue.

6. If you suspect that your motivation is cooling off, remind yourself of the the reasons why a healthy weight is important for you, and make that list handy.

7. Get involved with support group meetings. They are proven to help with long-term outcomes.

8. If after all, you find certain things are presenting an obstacle to achieving the realistic goals that you set, have an honest critique yourself. Write down the reasons that you think are contributing to your situation. Keep the list handy and sleep on it. Review it another day, and see if you can do something about it, or if you need professional help.

Stay Healthy!

Kidney Stones, Obesity and Bariatric Surgery

The most common type of kidney stones in the general population, and bariatric surgery is no exception, is "calcium oxalate" stones. Historically, calcium oxalate kidney stones formation was a complication of the obsolete jejuno-ileal bypass (JI Bypass) of the 1970s. The risk for kidney stones, kidney failure, and liver disease led to the abandonment of that surgery more than 20 years ago.

A Mayo Clinic retrospective study showed that by 12 months after gastric bypass, the mean urinary oxalate and calcium oxalate supersaturation were both increased in a group of patients who did not have a history of forming stones.

Notice that, even without surgery, recent data have suggested an increased prevalence of stones with diabetes and obesity. Insulin resistance may lower urinary citrate and increase urinary calcium. Obesity may increase oxalates in urine.

It is safe to say that bariatric surgery can increase the risk of forming kidney stones, and certain recommendations need to be followed. Water and fluid intake, calcium citrate supplements and a low fat diet, go a long way. Remember: Oxalate is not good. Citrate is good. Calcium is good in the intestine but not good in the urine. Sodium is not good. Too much fat in the stool is not good. Here are more details.

Water and fluid intake: Drinking plenty of water is one of the most important measures to help preventing kidney stones. At least 10 glasses (cups) of water (80 ounces = two and a half liters) is recommended. In the presence of a history of kidney stones, even more is required. Lemonade (made from real lemons or a frozen concentrate), is good because it increases the citrates in the urine, which helps preventing kidney stones. Citrate is good; it inhibits the formation and growth of calcium crystals. But grapefruit Juice is not so good in this situation. A number of studies reported an increased risk for kidney stones from drinking grapefruit juice.

Low fat diet: The amount of oxalate in the urine increases with the amount of fat in the stool (fecal fat). After JI bypass the overall fat absorption was reported to be only 15%. So, the amount of fat passing into the stool, because of not being absorbed, is huge, and hence the higher likelihood of developing kidney stones. After purely restrictive surgeries (adjustable gastric band or vertical banded gastroplasty), fat absorption is normal, that is 97%. Biliopancreatic diversion +/- duodenal switch caused only 19% fat absorption. After gastric bypass, it was intermediate (67%) although the study group was very small. Probably the effect is less with proximal than distal bypass.

Restricting foods rich in oxalates: These include chocolate, cocoa, spinach and other dark green leafy items, most nuts, soy products, most berries, beets, beans, and tea. Because oxalates are so common in otherwise healthy food items, it is very difficult to completely eliminate them from a daily healthy diet. You can diminish the effect of oxalate rich foods by accompanying them with dietary sources of calcium to lower oxalate absorption, and by drinking additional fluids along the day.

Dietary calcium and calcium supplements: Calcium in the diet binds with oxalates in the gastrointestinal tract. So, less oxalates will be absorbed in the intestine, and less will be available by the kidney to form stones. Calcium supplements seem to have the same protective effect, but they have to be taken with meals. Calcium citrate is preferred because it helps to increase urinary citrate excretion.

Notice that vitamin C can convert to oxalate. Therefore, vitamin C supplements should be limited to less than 1000 mg/d.

Sodium: Sodium is not your friend. Lowering sodium intake lowers calcium in urine, since calcium excretion is linked to sodium excretion. So, less sodium makes less calcium available in the urine to form stones.

Protein: Animal protein was shown to lower citrate excretion in urine and to increase calcium and uric acid excretion. It is unknown if the malabsorption accompanying gastric bypass (which is why patients are asked to take more proteins), would weaken that bad effect. Also, a study showed that urinary calcium, oxalate, magnesium, citrate, and phosphorus did not differ between a diet of plant protein and beef protein.

Medications: Thiazide diuretics (example, hydrochlorothiazide "HCTZ" ): have been proven to be effective in reducing calcium in urine and stone recurrence. These "water pills" help decreasing the calcium in urine, and lowering the chance of developing kidney stones. Usually patients also receive potassium supplementation, which, in this case, could be potassium citrate to provided more citrate.

Oxalobacter formigenes: This organism relies completely on oxalate as its source of energy . This colonic bacterium could be a promising treatment for oxaluria.


References:

Asplin JR, Coe FL. Hyperoxaluria in kidney stone formers treated with modern bariatric surgery. J Urol. 2007 Feb;177(2):565-9. PMID: 17222634 (Abstract)

Lieske JC, Kumar R, Collazo-Clavell ML. Nephrolithiasis After Bariatric Surgery for Obesity. Semin Nephrol. 2008 Mar;28(2):163-173. PMID: 18359397 (Abstract)

Finkielstein VA, Goldfarb DS.Strategies for preventing calcium oxalate stones.CMAJ. 2006 May 9;174(10):1407-9. PMID: 16682705 (Full Text)

Nelson WK, Houghton SG, Milliner DS, Lieske JC, Sarr MG. Enteric hyperoxaluria, nephrolithiasis, and oxalate nephropathy: potentially serious and unappreciated complications of Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2005 Sep-Oct;1(5):481-5. PMID: 16925274 (Abstract)

Duncan SH, Richardson AJ, Kaul P, Holmes RP, Allison MJ, Stewart CS. Oxalobacter formigenes and its potential role in human health. Appl Environ Microbiol. 2002 Aug;68(8):3841-7. PMID: 12147479 (Full Text)

Lieske JC, Goldfarb DS, De Simone C, Regnier C. Use of a probiotic to decrease enteric hyperoxaluria.Kidney Int. 2005 Sep;68(3):1244-9. PMID: 16105057 (Abstract)

Is it really important to do the follow-up visits after bariatric surgery?

After weight loss surgery (let's say gastric bypass or Lap Band), the majority of patients will initially lose some of their excess weight very well. In fact, they may do so well that they take for granted their weight loss trend, and some become less and less compliant with their follow-ups. Does it make a difference? Should patients do their follow-ups with their bariatric surgery programs, in addition to the usual check-ups with their own family doctors? We always felt that patients benefit tremendously from being committed to their long-term follow-ups. Is there any evidecne that long-term follow-ups make any difference? A study is published in the Nov-Dec 2007 issue of the journal "Surgery for Obesity and Related Diseases" titled "Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass". It is another addition to a mounting evidence. The authors, (Gould JC, Beverstein G, Reinhardt S, Garren MJ) from the University of Wisconsin School of Medicine, Madison, Wisconsin, looked into the data of patients with 3-4 years of follow-up data after laparoscopic gastric bypass. The patients were divided into 3 groups:

Group 1 patients: had attended every scheduled postoperative appointment
Group 2 patients had attended every appointment for 1 year, then were lost to follow-up
Group 3 patients had been lost to follow-up before 1 year.

Although the excess weight loss (EWL) did not differ at 1 year of follow-up, a significant difference in the EWL was observed at 3-4 years (74% for Group 1; 61% for Group 2; 56% for Group 3). The authors found that the most common explanation for missed follow-up appointments was a lack of insurance coverage. They concluded that on-going, multidisciplinary care is likely a critical component in maintaining the benefit after surgery.


Source Article:
Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surg Obes Relat Dis. 2007 Nov-Dec;3(6):627-30. PMID: 17950045 (Abstract)

Other References:

Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg. 2004 Apr;14(4):514-9. PMID: 15130229 (Abstract)

Harper J, Madan AK, Ternovits CA, Tichansky DS. What happens to patients who do not follow-up after bariatric surgery? Am Surg. 2007 Feb;73(2):181-4. PMID: 17305299 (Abstract)

"Surgery for Obesity and Related Diseases" (SOARD) is the official journal of the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Brazilian Society for Bariatric Surgery (SBCBM - Sociedade Brasileira de Cirurgia Bariátrica e Metabólica).

"Obesity surgery" is the official journal of several international societies including, among many others, the International Federation for the Surgery of Obesity (IFSO) , the Obesity Surgery Society of Australia and New Zealand and the French Society for Obesity Surgery (Société Française de Chirurgie de l'Obésité)

Urinary Incontinence & Weight Loss Surgery

We saw some great data about the improvement or resolution of diabetes type 2, hypertension, high cholesterol and sleep apnea after bariatric surgery.

We also read the report about the improvement in fibromyalgia symptoms. Stress urinary continence, however, is not widely talked about. It is the condition in which patients may lose control on their bladder when they sneeze, lift something heavy, laugh or cough. We know that this is common with obesity. Do we have research to back-up the common knowledge that stress urinary incontinence may improve or resolve after bariatric surgery? Well, a recent study from the Weight Management and Metabolic Health Center, University of South Florida, Health Sciences Center, Tampa, Florida by Kurubam et al, that was published in the October 2007 issue of the journal "Surgery for Obesity and Related Diseases"

They, prospectively, collected data from 201 candidates for bariatric surgery. They found that 32% of the patients reported urinary incontinence. Of those 65 patients, 45 underwent bariatric surgery. Of the 38 patients who had complete postoperative follow-up for at least 6 months, 50% enjoyed resolution of urinary incontinence while 37% had reported residual slight-to-moderate incontinence. Residual severe urinary incontinence was reported by 13%. In general, patients reported improvement within 4 months or after losing 50 lb. While the findings of this study are certainly very encouraging, the authors concluded that their findings warrant additional investigation with urodynamic studies.

Reference:

Kurubam D R, Almahmeed T, Martinez F, Torrella TA, Haines K, Nelson LG, Gallagher SF, Murr MM. Bariatric surgery improves urinary incontinence in morbidly obese individuals. Surg Obes Relat Dis. 2007 Oct 17; [PMID: 17950043]

Alcohol after Gastric Bypass

A glass of wine or two. A beer. A little mixed drink. Would that be OK after a gastric bypass? Well, early after the surgery, while the stomach is healing, you really want to avoid the irritant effect of alcohol. You want your pouch to heal well. So, the answer, as far as we know, is "no". But, what about drinking, let's say 6 months, a year, or more after the surgery? A very interesting study confirmed the previous opinion, that is, alcohol levels go higher after gastric bypass than people who had no such surgery. In a study published in the September issue of the journal "Surgery for Obesity and Related Diseases" (SOARD), researchers from Stanford School of Medicine, Stanford, California, concluded that the gastric bypass patients had a greater peak alcohol level and a longer time for the alcohol level to come back down to zero than the individuals who did not have gastric bypass. A particularly interesting finding was that the gastric bypass patients did not feel that alcohol influenced them any more than the no-surgery group. Could that explain why there are reports of post-gastric bypass patients who were cited for driving under the influence (DUI) after a small social alcoholic drink? Maybe. But also remember that there are other complications related to alcohol intake. Liver disease from alcohol is well-known. To develop alcoholic liver disease on top of the known obesity-related liver disease can be particularly dangerous. Alcohol is not good for peptic ulcers, either. Alcohol calories are empty calories, which is not what gastric bypass patients want to ingest. Also alcohol drinking has been linked to vitamin B1 deficiency. Severe vitamin B1 deficiency can lead to serious nerve damage, that is, Wernicke’s encephalopathy. So far, we do not have a perfectly scientific answer to the question: Is it OK to drink, in moderation, if you are not driving, several months or years after gastric bypass? We just do not have the final answer, and prefer to err on the cautious side. Better be safe than sorry.

References:
Klockhoff H, Naslund I, Jones AW. Faster absorption of ethanol and higher peak concentration in women after gastric bypass surgery.Br J Clin Pharmacol. 2002 Dec;54(6):587-91.

Hagedorn JC, Encarnacion B, Brat GA, Morton JM. Does gastric bypass alter alcohol metabolism? SOARD. 2007 Sept;3(5):543-8. (Note: This is the study quoted above)

Life Expectancy - again

A very good article reporting and commenting on the 2 studies from the August 23 issue of the New England Journal of Medicine (NEJM), appeared in the Independant Weekly of Lafayette, Louisiana. It is titled "Life Expectancy - New studies show bariatric surgery patients are living longer." By following this Link, you can access the article. This "Bariatrics Lounge" blog reported on the NEJM article on August 22, so our readers were among the first to be informed. You can go back to that blog entry by clicking this Link.

Just to be thinner?

I read a statement like "It's sad what some put themselves (or their kids) through, in order to be thin." Of course, referring to going through bariatric surgeries like Lap Band, gastric bypass, etc. This statement shows a major misconception as to what bariatric surgery is all about. The name "weight loss surgery" is correct in that bariatric surgery is designed to lead to weight loss. That is true. But the above statement implies that the entire reason for the weight loss is for a "thin" image. Here comes the misunderstanding. Although many patients like being thinner, which is a bonus result of the surgery, the real reason to have the surgery is for health purposes. Morbid obesity leads to three categories of major problems: (1) Life expectancy may be shortened (2) Co-morbidities may get worse, and certainly would not be cured (please, see note below) (3) Quality of life may deteriorate. Those are the real reasons why someone should consider bariatric surgery. Patients do not come and say, "I need weight loss surgery because I want to be thinner." They say things like "I want to get my [type 2] diabetes cured", "I want to be able to play with the kids", "I have many in my family who died from heart disease, and I am still young and would like to prevent that", "my orthopedic surgeon wanted me to lose weight before he replaces my bad knees", "I have sleep apnea, and my doctor said if I lose weight, I may be able to come off the CPAP machine." You've got the picture. So, my counterstatement to the first line here would be "It's sad what some put themselves (or their kids) through, by not controlling their weight and allowing an unhealthy life style to continue." And, as an aside, yes, weight loss will also lead to being thinner. Remember, bariatric surgery is not for everyone who has a problem with weight or obesity. In well-selected patients, the risk of bariatric surgery is, statistically, less than the risk of morbid obesity itself. It is an option if non-surgical weight loss fails to achieve a sustained healthy weight.



Note: "Co-morbidities" is the term given to describe medical problems that are either caused by, or made worse by, obesity.

Plastic Surgery after Massive Weight Loss

This posting is in response to a request to comment on cosmetic surgery for excess skin in the abdomen and other places, after weight loss surgery.

Body contouring, body lift, body shaping or body reshaping are alternative terms used to describe a group of plastic surgery procedures performed after massive weight loss, to manage hanging excess skin. Patients have to have reached a stable plateau weight before any such plastic surgery procedures. The person should have lost at least 100 pounds or achieved the target or maximum weight loss, had a stable weight for a good length of time after the weight loss surgery, and be in good health and not planning on becoming pregnant. Good candidates for a body lift should also have no medical problems that prevent them from going under general anesthesia for major surgery, and should not smoke. Smoking decreases blood flow to the tissues and, therefore, may slow healing.

Plastic surgery procedures after weight loss surgery include the following:

1. Panniculectomy: This is excising the "pannus", which is the excess hanging skin that is present below the belly-button.

2. Abdominoplasty (Tummy Tuck): Includes dissection and preservation of the umbilicus itself, and a more extensive skin mobilization and more aggressive skin removal than panniculectomy. A complete abdominoplasty also includes tightening of the abdominal wall muscles. Abdominoplasty and incisional hernia repair can be combined into a single procedure.

3. Arm lift or brachioplasty.

4. Breast lift or mastopexy.

5. Lower body lift is a combination of an abdominoplasty, plus a thigh and buttock lift. It requires a large incision around the belt line to lift the lower body.

6. Liposuction uses small, narrow tubes to remove fat and is often used in combination with other lifting procedures to help achieve better contouring in various parts of the body.

Combining multiple "lifts" entails longer operative time, and more potential blood loss, but is very appealing to many patients, from the stand-point of time off work and out-of-pocket costs. Combined procedures are avoided if there is active smoking history or medical problems that make a longer operation a particularly risky undertaking.

Insurance coverage varies from carrier to carrier, and a carrier may have different plans with different provisions. Almost all insurance carriers specify that coverage of aesthetic (cosmetic) surgery is excluded. Definition of medical necessity, that is essential for coverage, is variable.

Possible complications after body-contouring surgery include seroma (collection of thin serous or serosnaguineous fluid), hematoma (collection of blood), wound separation (usually minor), swelling and scarring. All patients will have scars, and basically the surgery trades excess skin for scars. For a small number of patients, scars can be excessively thick or inflamed. Before going for body contouring surgery, any nutritional deficiencies (as protein malnutrition, anemia, loss of muscle mass, and osteopenia/osteoporsis) need to be addressed and corrected.

Body contouring is considered major surgery. The outcome of body shaping is generally extremely satisfying to patients. It may take several months to see the final results of the procedure.

Does fibromyalgia improve after weight loss surgery?

Well, there are not too many studies that specifically address this issue. Of course the medical literature is full of evidence that musculoskeletal painful conditions in weight-bearing joints do improve with weight loss surgery in the vast majority of patients. However, when it comes to non-weight-bearing joints, and to fibromyalgia in particular, such information is scarce.

However, a study from the University Hospitals of Cleveland that was published in January 2007 did, indeed address that issue. (1)

Fibromyalgia syndrome (FMS) is one of the most common musculoskeletal diseases. Patients have fatigue, chronic diffuse musculoskeletal pains, poor sleep, and stiffness. There is no blood test to diagnose fibromyalgia. To make a diagnosis of FMS, widespread pain symptoms must exist for at least 3 months. The diagnosis is confirmed by finding at least 11 of 18 specific areas of point tenderness. Almost 9:1 patients are females.

In the study from Cleveland, FMS decreased by an impressive 90% after bariatric surgery. As for upper extremity pain, that is, of course,non-weight-bearing, 79% of patients had pain before surgery, compared to 40% after bariatric surgery.

References:

(1) Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW. Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond). 2007 Jan;31(1):114-20.