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:
- Lipids
- CBC (complete blood count)
- CMP (comprehensive metabolic panel) includes liver and kidney function tests, Calcium and electrolytes
- Albumin Normal is greater than 3.5 gdL (transports nutrients such as calcium, zinc and Vitamin B6)
- Prealbumin (transthyretin) transports retinol (Vitamin A)
- Total protein Normal is greater than 6.3 gdL
- Iron tests such as serum iron, TIBC, and ferritin
- Vitamins and trace minerals such as B12 and folate, vitamin A, vitamin D, vitamin K, B vitamins, calcium, and magnesium
- Ova and Parasite stool testing
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
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.
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
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)
|
From: The American Dietetic Association’s COMPLETE FOOD & NUTRITION GUIDE, 2nd ed. 2002.
USDA National Nutrient Database