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By Charles Bankhead, Staff Writer, MedPage Today
Published: June 26, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

DALLAS, June 26 — Patients who undergo gastric bypass surgery often have undiagnosed glucose abnormalities that can lead to bad eating habits and regained weight, a small clinical study suggests.

Almost 80% of the patients had glucose abnormalities, including hyperglycemia, hypoglycemia, or both, Mitchell Roslin, MD, of Lenox Hill Hospital in New York, reported here at the American Society of Metabolic and Bariatric Surgery meeting. Patients were alarmed by the weight regain, but at the same time, they often had a ravenous appetite soon after a meal, accompanied by an almost uncontrollable urge to eat.” Our hypothesis is that . . . patients may have an enhanced insulin response,” said Dr. Roslin. “They have rapid emptying of the pouch that leads to reactive hypoglycemia. The combination of an empty pouch and low blood sugar leads to hunger.” The findings have led him to question whether gastric bypass surgery should remain the gold standard procedure for treating obesity, he added. At the very least, surgeons should consider the possible need to include a valve in gastric bypass.

The study evolved from clinical observations during patients’ periodic postoperative visits. A growing number of patients complained of weight regain and loss of restriction. The complaints often had a common ring.” Patients were saying that one or two hours after eating, they were ravenously hungry,” said Dr. Roslin. “It sounded a lot like hypoglycemia to me.” To investigate the origin of the symptoms, Dr. Roslin and colleagues studied 63 patients who had undergone gastric bypass procedures. All the patients had a 100-g glucose tolerance test, wherein the maximum/minimum glucose ratio was assessed one to two hours after the glucose challenge.The investigators defined reactive hypoglycemia as a glucose value <60 mg/ dL, or a decrease of 100 mg/dL or more within two hours and no glucose value exceeding 200 mg/dL. They defined hyperglycemia as any value >200 mg/dL and no value <80 mg/dL. Follow-up from surgery averaged about four years. The mean age of the group was 48.5, and 81% were women. The patients’ average preoperative weight was 138 kg, with an average body mass index of 49. One-third had preoperative diabetes. The percentage of excess BMI lost averaged 55%, and the patients had regained an average of 12 kg. Glucose tolerance tests showed six patients with hyperglycemia, including five who had normal fasting blood glucose levels. In addition, 35 patients had reactive hypoglycemia, while eight had hyper- and hypoglycemia. “The hyperglycemic cohort was characterized by a rapid rise to high sugar levels,” said Dr. Roslin. “The fact that most of these patients had normal fasting glucose means we need to be very careful of what we call cure or control of diabetes.” Reactive hypoglycemia manifested as a rapid upsurge of glucose levels that correlated with a rise in insulin and then a rapid decline during the second hour after the glucose challenge. Patients with both hyper- and hypoglycemia had even more pronounced swings in glucose and insulin levels, said Dr. Roslin.

The most dramatic rises and falls in blood glucose have been associated with small pouches and wide anastomoses, he added. The findings suggest a need to consider alterations in the standard gastric bypass procedure, such as use of valves, or possibly abandonment of the procedure in favor of another approach. “I believe that vertical-sleeve gastrectomy and duodenal switches that are not severely malabsorptive will be the best options in the future,” said Dr. Roslin.

Editorial: The about article was sent to me by Vicki Blackburn- Thank you Vicki. This was one of the many presentations that was made at the ASMBS meeting held in Dallas. I will be sharing other presentation in the future newsletters. This article describes what those if us that have been preforming duodenal switch operation have knows for years. This explains why the size of the pouch does not matter, that dumping does not protect against weight gain and why duodenal switch operation is far better option that the alternatives. As with other procedures the science will eventually shed light on all the facts. Dr. Roslin indicates the time is now to consider what should be the benchmark standard for weight loss.
Ara Keshishian MD, FACS

The term “probiotic” is getting much attention in professional circles as well as in the advertising media but is still poorly understood by many. The term describes beneficial bacteria that are added to our diet to help populate our digestive system with a healthy population of good bacteria. It is becoming ever clearer that a healthy population of bacteria is very important for our overall health. Our gut is the most intimate contact between the interior of our body and the outside world much as our skin is. The gut must remain permeable to nutrients which we absorb from foods yet impermeable to invading bacteria and viruses. The bacterial population of our gut plays important roles in both of those functions. It is also very important in the function of our overall immune function. I will leave that for another time. The purpose today is to discus the use and function of probiotic products.

The human gut is populated by tens of billions of bacteria of a yet to be discovered number of species. In excess of six hundred have already been isolated and identified. Some of these species are beneficial, some are harmful and some are a bit of both. Unfortunately modern society tends to have a negative impact on the health and balance of the members of the probiotic population. Chlorinated water, antibiotics both as medications and in our food and even our food choices can cause an imbalance in this population. When this balance is severely disrupted it is termed “Disbiosis”. A disbiotic gut is not a happy thing. We perceive this disbiosis as digestive symptoms of some sort. We may have gas and bloating, constipation or diarrhea, or even both or all of the above. One of the unfortunate aftereffects of having bariatric (weight loss) surgery is it can allow the gut to become disbiotic more easily.

In the DS gut food reaches the large intestine far more nutrient rich than in the “normal” gut. This provides the population of bacteria living there much more food. Given more food the population can flourish. If this population is out of balance it is even more sensitive to poor food choices thereby making the symptoms of this imbalance even worse. This is why the DS patient needs to make prudent food choices and may well enjoy great benefit from proper doses of high quality probiotic products containing the correct species.

The problem is that not all probiotic products are what they say they are and not all probiotic products have the same species. Add to that the fact that each gut is individual. We may need to do some experimentation to find the right combination of dose and product.

Some people have what I term a McDonald’s mentality. A Big Mac in one town is exactly the same as one from a different town or, as another example, a gallon of Shell unleaded gasoline is essentially the same as a gallon of gas from the Chevron station. This is not the case with probiotic products. Some products contain only one species and some contain thirteen or more. These various species, with one exception fall, into two large groups these are Lactobacillus species which predominate in the small intestine and Bifidobacterium species which predominate in the large intestine. The one exception is actually not a bacterium at all but rather a specific yeast. This yeast is very important and beneficial. It is called Saccharomyces boulardii. Some patients have reported good results with single species products such as Align (B. infantus), Culturelle (L. rhamnosus) or Floristor (S. boulardii). My feeling is that these products are overly expensive as they are heavily advertised and that cost is built into the price. They also tend to be rather low dose.

We also need to address the correct dosage. It is important to read the label. Minimum “therapeutic” dosage is thought to be 20 billion colony forming units (CFU’s). I personally am using 50 billion CFU’s per day as maintenance. I have taken as much as 200b CFU’s per day. I am also aware of research going on that also is looking at similarly high dosage.

I think a good product to start with is “Primal Defense Ultra”. Make sure it is the “Ultra” as it is the stronger blend. It is reasonably priced and contains a total of 13 species including the very important S. boulardii. For DS patients experiencing a disbiosis creating very foul flatus and stool. This species as an ingredient is very important. The S. boulardii has very specific activity against some of the nastiest bad guys in our gut such as Clostridium difficile, Candida albicans and even Entameba histolytica and Giardia lamblia which have been shown to enhance the effectiveness of conventional therapy for these conditions. In less severe cases the probiotics alone may be sufficient to correct the disbiosis but more severe cases antibiotic therapy may be indicated.

As stated previously the dosage needs to be sufficient. Three caps per day of Primal Defense Ultra (PDU) is a commonly used dose. This provides a total of 45b CFU’s with 12b of that total as S. boulardii. This was the dose used in a recent case study looking at DS patients with recurring frank C.diff treated with antibiotic and S. boulardii. Statistically very significant benefit was shown.

Also as stated previously every gut is different. Some may do well on small doses and some may need more. Every patient needs to find the dose that works for them. We need to start slowly and work up. Some increase in gas and bloating may occur. Once the disbiosis is improved patients can experiment with different blends. It is suggested that there be several species of both the lacto and bifido groups. The only allergic reaction I have heard of is one patient who developed a slight rash which subsided after lowering the dose. You can find this is most health food stores but it is a much better deal on line. Typically about 90 caps for $37 vs. 218 caps for about $50. General rule of thumb is that the refrigerated brands are superior to the less expensive freeze dried ones. But, many do well with the less expensive brands. Again, you need to experiment.

Also as stated prudent food choices are extremely important. Things like lean protein, complex carbohydrates and whole grains. Avoidance artificial sweeteners and simple sugars and white flour are all prudent decisions.

By: David Caya, DC