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Month: July 2014

Protein Malnutrition Protein Part 2

July 31, 2014 1:25 pm

Protein energy malnutrition (PEM) or Protein Malnutrition is a problem that can effect a few after weight loss surgery (WLS) and Duodenal Switch (DS). In our previous blog post on protein  we discussed  the types of essential and non-essential Amino Acids and  possible sources. We also discussed  how to choose the best bioavailable protein and to vary protein sources to achieve adequate protein levels.  There are cases even with adequate protein intake that can result in PEM due to inadequate protein absorption. The early signs of low protein may be low energy, muscle weakness, moodiness, inability to sleep well, joint pain, changes in hair and nails and carb craving. It is imperative after WLS that you maintain your protein levels throughout your lifetime. The minimum protein intake is 80-100 grams per day after WLS.  There is no leeway where protein is concerned.  It is important in almost ever function in the body.

There are two types of protein energy malnutrition,  Kwashiorkor and Marasmus:

Kwashiorkor is a lack of protein intake with adequate or slightly lower caloric intake.  It’s symptoms are edema (swelling in legs, ankles, feet) enlarged abdomen, irritability, anorexia, hair discoloration and loss, muscle weakness, changes in psychomotor function, mental lethargy, ulcerations, brittle nails, rash or discoloration of the skin, bradycardia (slow heart rate), non-tender parotid enlargement, enlarged liver with fatty infiltrates that are similar to alcohol liver disease.  The edema is caused by osmotic imbalance in the intestinal system causing swelling of the gut.  Protein, primarily albumin is responsible for the colloidal pressure within the circulatory and tissue systems.  The lack of protein within the circulatory systems cause fluids to “leak” into tissues causing edema. Gastro-intestinal symptoms can include nausea, vomiting, dehydration, diarrhea and increases in appetite.  People who have pathological bacteria or parasites and/or after WLS diarrhea can precipitate lower levels of protein. If left untreated can lead to protein malnutrition.

Marasmus is characterized by a lack of protein and caloric intake.  The symptoms are an emaciated appearance with edema. There is no liver changes as in Kwashiorkor.  This is a starvation mode and can be difficult to treat and can progress to a point of no return.

Catabolysis is the bodies response to lack of protein and or nutrition.  This biologic process breaks down muscle and fat to maintain bodily functions. Catabolysis is the body’s last resort to keep it alive.  It is a starving body eating itself to keep vital organs alive.

Laboratory Studies are needed to determine the level of malnutrition and treatment routes.  These studies include:

Protein is an extremely important nutrient within our bodies and is considered the workhorse in cells and organs.  They are responsible for catalysts, messenger duties, structural, immunoprotectors, transporters, buffers, fluid balancers and many other roles. Protein has a hand in synthesizing other proteins, regulates protein turnover, enzyme activity, neurotransmission, gene transcription, transport of other nutrients, messenger and signals for growth hormone and insulin, structure, storage for other nutrients and immunity.

The muscular system is the most obvious structural protein in our bodies, 40% of the total body protein, as is hair, fingernails and cells. Our organs also require protein in order to function appropriately. However, protein’s role in red blood cell formation, size and health is extremely important.  If you don’t have adequate protein levels your body can not make red blood cells. Transferrin is a protein that carries iron to receptors.  Ferritin is an intercellular protein that stores iron until it is needed. Glycine is a protein for heme synthesis. B12 is also transported via a protein for red blood cell production. Protein is also important in blood clotting and plasma.

Cardiovascular health is also reliant on protein for structure and function. Also, proteins can have a protective effect at the mitochondrial level.

Kidney function relies on protein to regulate the acid base balance and ammonia disposal. The kidneys are also the site of amino acid production.

Protein is also important in bone health as a carrier for Vitamin K and calcium binding, tissue repair, healing and growth. Proteoglycans play a role in extracellular structures such as skin, bone, and cartilage. Also related to the skeletal system are glycoproteins, which also aid in building connective tissue, collagen, elastin and bone matrix.

Central Nervous system relies on proteins for neurotransmission, hormone production and other functions.  Protein deficients can lead to neurologic problems such as altered behavior and mental function among other manifestations. The neuorpeptides have actions on transmission functions, mood and behavior. They can also effect a wide range of functions such as blood pressure, body temperature, pain sensation, and learning ability.

Immonoproteins are the group of proteins that provide immune protection such as immunoglobulins and antibodies.

Protein also have storage roles for copper, iron and zinc called metalloproteins. Copper and zinc are considered neurotransmitters, important for iron metabolism, and connective tissue formation in heart, blood vessels and skeletal.

There are situation where your protein needs will increase. In cases of wounds, burns, surgery, stress, sepsis or other illnesses, protein requirements increase. Also age, pregnancy, lactating and increased exercise increases protein needs.

Protein Energy Malnutrition is protein deficit that can and should be avoided after WLS.  PEM, if left untreated, can lead to organ failure and death. Protein is crucial in almost every function of the body and without adequate levels there will be symptoms and side effects. Please take care to maintain your protein levels throughout your life.  We have discussed several of protein’s function, however, there are many more.

Probiotics, C. diff & Enteric Hyperoxaluria

July 26, 2014 3:21 pm

Probiotics have an important place in the supplement regime of a pre and post weight loss surgical (WLS) patient.  It seems some DS/WLS patients may be predisposed to pathogenic bacteria overgrowth. One primary reason resulting from the alteration of the gut. Most people are dis-biotic to begin with due to western diet, etc.  Weight loss surgical patients have colons which are simply far more nutrient rich than a non DS gut. The malabsorption greatly exacerbates the issue. Bacteria readily bloom under the advantageous conditions presented to them. The WLS patients’ gut is prime real estate, ripe for colonization with little or no competition from an established microbiome, pathogens can soon dominate. When we have antibiotic therapy the gut can be rapidly exposed to the very persistent C. diff spores.
 
There have been several questions regarding Clostridium difficult (C. Diff) and other bacterial overgrowth in the intestines.  It is a gram-positive spore forming bacteria that is opportunistic.  It is a small part of the normal colonic bacteria but can overgrow in people who have had antibiotic treatment. It is often spread very easily in hospitals, rehab centers or doctors’ offices. The spores live on objects for long periods of time and are not destroyed by hand sanitizers. The mode of infection is usually oral ingestion and hand washing and inflection control mechanisms can inhibit its spread. C.diff’s acid resistance nature makes it easy for the spores to travel into the intestines.
 
People at risk may have been on fluoroquinolones, cephalosporins, carbapenems, and clindamycin antibiotic therapy due to the destruction of the normal colonic bacterial groups. Also, daily use of medication to suppress gastric acid production is a risk factor. The low acid state does not destroy the C. diff spores.
 
The symptoms are flu like symptoms with moderate to severe diarrhea, abdominal pain, gas and bloating with or without fever.  Complications of C. diff can lead to dehydration and colitis.  Stool sampling is the usual definitive test.
 
Treatment for C.diff is Flaygyl, Vancomycin, or Fidaxomicin, Probiotics, hydration and possible electrolyte replacement.
 
Probiotics are also important in the general health of the colon.  Research has shown in recent years that intestinal health can lead to improved immune function, diarrhea symptoms, improved symptoms and inflamation from Irritable Bowel Syndrome and Crohn’s Disease. Probiotic therapy is also showing great signs for treatment of H. Pylori infection, which can cause gastritis and ulceration. The Probiotic bacteria can also aid in the conversion of Vitamin K1 to Vitamin K2 although, the intestines are not the only point of Vitamin K conversion. Probiotic bacteria can improve lactose digestion in the lactose intolerant population. Probiotic use has also shown a positive effect on the weight loss, Vitamin B12 absorption and normalization of intestinal flora after RNY.  Although this is not specifically DS research, we can potentially extrapolate the outcomes to DS. There is further research into Probiotic benefits in oral health, UTI and vaginal health, effect of LDL and total cholesterol absorption and bile salts hydrolase.
 

Calcium Oxalate Kidney Stones:

One DS specific advantage to adding a probiotic regime is the possible decrease in enteric hyperoxaluria, calcium oxalate kidney stones. Enteric hyperoxaluria is the mechanism of malabsorbed fatty acids in the colon binding with calcium thereby allowing oxalate to be absorbed into the blood stream.  Also there is the theory that the unapposed bile salts may change the epithelial cells allowing oxalate absorption. “This increases the chance for oxalate kidney stone formation. Enteric hyperoxaluria is caused by jejunoileal bypass, as well as the modern bariatric procedure Roux en Y bypass. Patients with inflammatory bowel disease, pancreatic insufficiency, and intestinal resection for any reason are also at risk.” John Leske, M.D., Mayo Clinic. The fat blocking drug Zetia has also been linked to enteric hyperoxaluria. These research articles suggests that the use of Oxadrop ® probiotics, along with a low fat, low oxalate diet and increased hydration and increase calcium intake with meals, deceased the amount of oxalate absorption. Oxadrop® contains the bacteria Lactobacillus acidophilus, Lactobacillus brevis, Streptococcus thermophilus, and Bifidobacteria infantis. They suggest that the probiotic should be taken with meals and hypothesize that the probiotic bacteria possibly bind with oxalate, therefore deceasing oxalate absorption in the colon and also improve colon cells health. This is an area that needs additional study.

Another research study suggests that Oxalobacter formigenes may reduce the risk of Calcium Oxalate Kidney Stones.  The study was a relatively small sample size but reports a 70% decrease in stone reoccurrence.

 

There are several forms of Probiotics and the following list is not meant to be inclusive. When starting a Probiotic regime there may be increased loose stool, gas and or bloating until the normal intestinal flora are re-established. In order for the beneficial flora to repopulate the intestines the pathological flora need to be eliminated. This can take time but the benefits of adding a Probiotic far outweigh the short term negative side effects. Please consult with your physician regarding any contraindications for starting probiotic therapy including allergies, medication interactions, etc.
 
1.    Saccharomyces boulardii has demonstrated the ability to restore normal gut flora after antibiotic therapy. It is the primary constituent in Florastor and can be used at same time as antibiotic therapy. It is important to note that people with central lines, ie; PICC, central venous catheters or implantable ports should NOT take this probiotic. There have been rare cases of Fungemia reported with patients taking Saccharomyces boulardii and having central lines.  
 
2.    VSL #3 is a high-potency probiotic containing 8 diffeent strains of live lactic acid bacteria. The 8 strains are:
                a.    Bifidobacterium breve*
                b.    Bifidobacterium longum
                c.    Bifidobacterium infantis*
                d.    Lactobacillus acidophilus*
                e.    Lactobacillus plantarum
                f.     Lactobacillus paracasei
                g.    Lactobacillus bulgaricus
                h.    Streptococcus thermophile*
*Four of the strains in VSL#3 are found in the Oxadrop probiotic to possibly reduce oxalate absorption

3. Align contains Bifidobacteria infantis 

In conclusion, adding probiotics to the pre and post DS supplement regime can have benefits of improved weight loss, immune function, decreasing loose stools and possibly decreasing oxalate kidney stone formation. There are many types of probiotics on the market. 
 In the U.S., probiotics are sold as a dietary supplement and are not held to the same standard that the medication are. There is no guarantee that the types of bacteria listed on a label are effective for the condition you’re taking them for. Health benefits are strain-specific, and not all strains are necessarily useful. It is beneficial to work with your physician to decide which probiotic may be the best choice for you.  

A special thank you to Dr. David Caya, D.C. for his input into this post.

Injectable Vitamin D Information and Research Articles

July 11, 2014 1:06 am

Injectable Vitamin D may be needed in some cases of Vitamin D deficiency or inability to increase Vitamin D level with oral supplements. Vitamin D is a fat soluble vitamin.  It plays an important role in bone metabolism and structure. It has also been found to affect the immune regulation, control off- inflammatory reactions, and also be involved in a number of broad cellular functions throughout the body.  Until a few years ago, very little attention was given to vitamin D levels. More recently, we have realized that due to a number of factors, there is a tendency for vitamin D deficiency to be present in the U.S. adult population. This finding is even more pronounced and severe in overweight patients.

The recommended dose for vitamin D supplements is much larger today than it was a few years ago. For example, it is not too uncommon to recommend an average dose of a 50,000 (IU) international unit of vitamin D by mouth on a daily basis after the duodenal switch operation.

Since vitamin D is a fat soluble vitamin, it is important that the appropriate type be utilized. Dry formulation of vitamin D is needed to ensure adequate absorption. There are a number of manufacturers that produce these. When searching for Dry Vitamin D the type a patient should be looking for is “Dry” D3-50. Some larger supplement manufacturer’s carry these products. The links to these manufacturers is located here.  The “Dry” type of Vitamin D should NOT be taken with fatty or oily foods.  Also to optimizes absorption they should be taken either 30 minutes prior to eating food or 30 minutes after eating.

If you are deficient in Vitamin D after trying “Dry” or water miscible Vitamin D then intramuscular Vitamin D injections might be an effective way to normalize your Vitamin D levels. Vitamin D can be formulated and purchased from any compounding  pharmacies that are equipped and experienced in the interpretation of injectable vitamins and minerals.  Your primary care WILL need to contact the compounding pharmacy of their choose for the recommendations and be willing to make the injections available to you. UNLESS you have been told to stop taking your daily “Dry” Vitamin D tablet supplement you should continue taking it after the injection.

We are supplying the following so that your PCP will understand the research behind injectable Vitamin D and to hopefully ensure that every patient is armed with this knowledge. Vitamin D deficiencies are becoming more common place in society due to the use of sunscreen and sun shielding clothing and hats,  not only Duodenal Switch patients.

This is a research paper out of Finland that discusses injectable Vitamin D for the aged. The information can translate to anyone who finds themselves in a Vitamin  D deficit state. https://www.gwern.net/docs/nootropics/1992-heikinheimo.pdf

This research paper is out of Australia where despite then sun drenched climate they are experiencing a large amount of people with Vitamin D deficiencies due to sunscreen, veiling, malabsorption, etc.
https://www.direct-ms.org/pdf/VitDGenScience/Vit%20D%20deficiency%20Australia%20art%20and%20ed.pdf

Below find the order sheet with the Injectable Vitamin D concentration listed. The common dosing for the vitamin D is 600,000 IU, deep IM every 6 months till the levels are normalized. The patient then can take the oral supplements only.

Finally, this is an except from an another Australian research paper describing the use of Megadoses of injectable Vitamin D in patients after Biliopancreatic Diversion which has a malabsorptive component similar to Duodenal Switch.

What size is my Bougie?

July 10, 2014 6:57 pm

Examples of Bougie
Examples of Bougie

A Bougie is a flexible plastic tube that comes in different sizes. It can be used to calibrate the size of the stomach during the duodenal switch or Sleeve gastrectomy. It is also used to dilate strictures of the esophagus or the stomach.

I am commonly asked what size is the  bougie that I use. My usual answer is that it is equivalent to a 38 or so, and that the size does not matter.

Many surgeons do not use these types dilators, but rather alternative tubes that function as a sizer and a suction tube to eliminates the need for multiple tube insertions and removals.

The July 2014 publication of Obesity Surgery had and article by Spivak et.al. titled “Laparsocopic Sleeve Gastrectomy Using 42-French Versus 32-French Bougie: The First-Year Outcome.” In conclusion they reported that using 42 vs 32 French Bougie does not influence the weight loss of resolution of the combed condition in the first year.

There also other studies that support the position of erring on the side a larger sizer, a 40-French, to decrease the leak rate without having an impact on the excess weight loss at 3 years time.

The take home massage is that the size of the stomach after the sleeve does not predict the outcome of the weight loss surgery independently. There are multiple factors in play such as age, amount of excess weight, diet adherence and exercise.

July 2, 2014 Group Meeting Recap

July 03, 2014 7:11 am

First and foremost, We apologize for the confusion and last minute change with the webinar.  It was set to go and logged in then the internet dropped the group meeting.  The meeting site automatically marked the meeting as over.  We sent out e-mails with the new URL for the group meeting but it took time.  Thank you for your patience with this new platform.  Although far reaching, it comes with downsides and hopefully we can make this a long term way to reach our patients.  Lesson learned, don’t rely on wireless internet access for webinars.  The Anemia slides will be added to our website dssurgery.com soon.

Ferritin is a protein that acts like your savings account.  It’s like a holding tank. When you have a blood loss your body goes to Ferritin stores for iron to increase red blood cell production. Iron is like money in your pocket.  For small and daily building of red blood cells. Transferrin is a protein transport that carries the iron.  Copper is also needed to transport iron. Iron can be readily available but will not be utilized unless your protein levels are adequate.  The protein level on laboratory studies needs to be at least 6 gm/dL & Albumin 3.2 gm/dL for adequate iron utilization.  Vitamin B12 also is needed for iron utilization.

Iron metabolism in the DS patient is limited due to several factors.  In unaltered anatomy Iron enters the stomach where it is exposed to acid and changes into a form which allows it to be absorbed.  Then it enters the duodenum which is the chief area of the small intestines where iron absorption takes place.  There is possibly a second minor site of absorption near the end of the ileum.  However,  after the DS there is a small portion of the duodenum that is left after the pyloric value for iron absorption.  Below is a list of iron rich foods.  Also remember to take Vitamin C with your iron supplements and when eating plant based iron rich foods add a food that is high in Vitamin C.

There was a brief discussion regarding Calcium oxalate kidney stones.  That talk can be found on our website.  Treatment is limiting oxalate containing foods and to increase calcium supplements to 3,000mg daily but to take half with food and the other half without food.  Also Vitamin K2 can also decrease kidney stones.

Fissures where also briefly discussed.  Fissures are most likely caused by the unopposed bile salts entering the colon after DS.  Bile is alkaline and causes irritation to the mucosa.  Treatment is liberal use of barrier type creams/ointments, controlling loose stools by watching if certain food items cause them or by using fiber with half the liquid mixed with it.  The fiber with less liquid acts as a sponge to give more form to the stool.

We had anemia themed snacks at the live group meeting.  Pate, Southwest ground Bison, and a Mayan Pumpkin seed dip. Here is the information on the nutritional value of Bison versus other meats.  It is higher in iron and Vitamin B12 and lower in fat and cholesterol.

Iron Content of Common Foods

This chart shows the amount of total iron in food. Iron from most animal sources (heme iron) usually is more readily absorbed than iron from plant sources of food (non-heme iron). Include a source of vitamin C or heme iron to improve the absorption of non-heme iron.
Sources of Predominantly Heme Iron

FOOD
IRON (MILLIGRAMS)
Beef liver, braised (3 oz)
5.8
Lean sirloin, broiled (3 oz)
2.9
Lean ground beef, broiled (3 oz)
1.8
Skinless chicken breast, roasted dark meat (3 oz)
1.1
Skinless chicken breast, roasted white meat (3 oz)
0.9
Pork, lean, roasted (3 oz)
0.9
Salmon, canned with bone (3 oz)
0.7

Sources of Non-Heme Iron

FOOD
IRON (MILLIGRAMS)
Fortified breakfast cereal (1 cup)*
4.5 – 18
Pumpkin seeds (1 oz)
4.2
Blackstrap molasses (1 Tablespoon)
3.5
Soybean nuts (1/2 cup)
3.5
Bran (1/2 cup)
3.0
Spinach, boiled (1/2 cup)
3.2
Red kidney beans, cooked (1/2 cup)
2.6
Prune juice (3/4 cup)
2.3
Lima beans, cooked (1/2 cup)
2.2
Tofu, firm (1/2 cup)
2.0
Enriched rice, cooked (1/2 cup)
1.4
Pretzels (1 oz)
1.2
Whole-wheat bread (1 slice)
0.9
Green beans, cooked (1/2 cup)
0.8
White bread, made with enriched flour (1 slice)
0.8
Egg yolk, large (1)
0.6
Peanut butter, chunky (2 tablespoons)
0.6
Apricots, dried (3)
0.6
Zucchini, cooked (1/2 cup)
0.3
Cranberry juice (3/4 cup)
0.3
Unenriched rice, cooked (1/2 cup)
0.2
Grapes (1/3 cup)
0.1
Egg white, large (1)
*The amount varies. Read the Nutrition Facts panel on food labels.
From: The American Dietetic Association’s COMPLETE FOOD & NUTRITION GUIDE, 2nd ed. 2002.
USDA National Nutrient Database