Obesity is related to as many as 400,000 deaths each year in the US and it has increasingly been recognized as a risk factor for several nutrient deficiencies. This may seem surprising given the likelihood of over consumption of calories, however these additional calories are not from nutritious sources. One of the main reason for these nutritional deficits is the greater availability of inexpensive foods that are rich in calories and are nutrient deficient. This has led some medical professional to conclude that there is a certain group of people who are overfed but undernourished.  Even with the epidemic of the obesity, there is significant nutritional deficiencies noted.

Obese subjects have increased blood volume, cardiac output, adiposity, lean mass and organ size all of which can influence volume of distribution, in addition, treatment for severe obesity involving surgical procedures can worsen these nutrient deficiencies and in some cases may cause new ones to develop.

This table shows the percentage of population below the estimated average requirement (EAR) by body weight status in adults more tan 19 years old, showing that almost 90 to 100 percent of people including normal weight (NW) are below the EAR of vitamin D and Vitamin E.

Nutritional deficiencies in obese patients may promote the development of chronic diseases including increased insulin resistance, pancreatic B-cell disfunction and diabetes, this is because specific micronutrients are involved in glucose metabolic pathways; There are other chronic diseases related to obesity that are being investigated such as decrease in focal grey matter volume and cognitive impairment or inadequate sleep due to low intake of antioxidant vitamins.

We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.

Flagyl is sometimes prescribed for excessive gas and diarrhea. It is an antibiotics that works well on certain bacteria that accumulates in the GI tract and contributes to the gas and the bloating. 

These bad bacteria flourish when patients consume significant and excessive fiber and carbohydrates (sugars, salad, pasta etc.) The FIRST line of defense against flatulence, bloating, and diarrhea should be eleminating the culprits in the diet.  This point can not be stressed enough.   Adding a daily dose of yogurt may improve symptoms due to yogurts probiotic benefits. To be beneficial, Yogurt should contain live bacteria cultures, not contain artificial sweeteners or have a high sugar content.

Artificial sweetness also area source of the excessive gas and should be avoided.

The Flagyl eliminates and reduces the bad bacteria. Along with a Probiotic and healthy dietary choices Flagyl can help to significantly improved or eliminate those symptoms of gas and diarrhea.

Before Flagyl is prescribed, it is important that the diet is critically examined to make sure that the carbohydrates and the fiber as source of gas and bloating is minimized or eliminated. Excessive use of medications that may be needed for other infections should be avoided.

Chronic diarrhea should be evaluated to rule out GI infection with C. diff bacteria or other bacteria or parasite.

Additional Information on C. Diff (Clostridium Difficile)  and probiotics.

• Magnesium citrate or Magnesium Oxide can cause loose stool, gas bloating for some. Check your supplement labels for these types of Magnesium.  Magnesium Citrate is very common in Calcium supplements.
  Magnesium Glycinate is a more absorbable form of magnesium. Magnesium Information here.
• Too high of dietary fat intake. Fat Intake after Duodenal Switch here.
• Lactose (Milk Sugars)
• Milk or Milk products
• Artificial Sweeteners (Splenda, Aspartame (Equal), Acesulfame potassium (also known as Acesulfame K)),
• Sugar Alcohols (Usually found in sugar free items. List: https://www.diabetes.org/food-and-fi…)
• Sugar
• RTD shakes (many are whey concentrate which contains lactose)
• Preservatives
• Nitrates/Nitrites
• Additives
• Fruit
• Gluten from Bread products
• Flour (breading)
• Refried Beans
• Seasonings these may contain hidden or unknown gluten, MSG, etc.
• Meats (example: Pork causes some DSrs gas issues),
• Blend Protein Powders/Drinks (not whey isolate only, milk protein concentrate contains lactose)
• Cruciferous vegetables
• Legumes (Beans/peas/lentils)
• Refined or processed oils
• MSG

Things that help with the odor:

Things to help with trapped gas:

Supplements (which may help):

We have found that a great way to start an exercise program is with resistance exercise bands. These type of exercise are easy on the joints, low impact and low cardio for people just starting an exercise program.  They are also very portal and can be done just about anywhere.  Resistance exercise bands can also work just about every area of the body. This is what makes them ideal for post surgical exercise when cleared by your surgeon.  You can help maintain and build muscle without overexertion.

As always when starting a new exercise program, go slowly with a few repetitions. If you get tired stop and start again slowly. If it starts to become uncomfortable stop, rest and come back to it another day.

Link to our other blog posts on the benefits of exercise.

Link to full article on Resistance Band Exercises:

https://greatist.com/fitness/resistance-band-exercises

Arm and Shoulder Resistance Exercises:  https://www.productivefitness.com/resistancetubing-backlegsbicepschestandtriceps.aspx
Leg Resistance Exercises:https://productivefitness.com/product/resistance-tubing-back-legs/

Let’s get back on track 2017 after the holiday season! The holidays were wonderful but if you find yourself with a few extra souvenirs don’t feel alone. The average American gains between 1-8 pounds during the holiday season and I am no exception. Let’s get back on track 2017 together.

Time to clear out the kitchen! Disposing of temptations and high trigger foods is the first step to getting back on track. If the food isn’t easily acquired then it is less likely to be consumed.

Stock up on high protein and whole, unprocessed foods that are low carbohydrate and nutrient dense. When quality foods are easily available we are more likely to stay on track with the types of foods we should be eating. Simple sugars/carbohydrates are the biggest culprit of holiday weight gain. We need to go back to the basics of hydration, high protein, low carbohydrate/sugar, vitamin/mineral supplements and exercise. Simple sugars and carbohydrates are easy for our bodies to use and absorb and cutting them back can jump start your weight loss. Each individual needs to identify the daily carbohydrate intake that works for them. Some people stay under 50 grams of carbohydrates daily. You may also need to look at your protein and fat intake. All excess nutrients absorbed have the potential to turn into fat mass and inhibit weight loss. Metabolism video.

Hydration is an important ways to start getting back on track. Water is essential to life functions. The brain is 85% water, blood is 80% and muscle is about 70% water. Hydration aids in digestion, eliminating waste, byproducts and toxins. It also can decrease the feeling of hunger. Lack of hydration can increase fatigue which can lead to craving high carbohydrate foods to increase energy.

Protein’s importance in almost every bodily function and muscle mass can not be ignored. High quality complete Protein sustains muscle mass during weight loss, aids immunity, antioxidant function, and enhances leptin and insulin function. Filling up on protein first will help with carbohydrate carvings and give a sustained satisfied feeling. A prior blog post gives additional information on the importance of protein and the effects of protein malnutrition. WLS makes daily protein intake important but especially after Duodenal Switch, protein is a necessity of daily life.

Vitamins, minerals and supplements will ensure the body has the nutrients it needs to function adequately and can keep cravings at bay. Deficiencies in vitamins and minerals can cause cravings for foods. Vitamin and minerals are essential to muscle function, red blood cell production, bone health, and numerous other physiologic functions. We may all slack off on our supplements occasionally but now is the time to get back into the habit of daily vitamins and mineral supplements. A daily vitamin, mineral, and supplement routine is a lifetime commitment after Duodenal Switch or any WLS. Here is a list of commonly used supplements.

Exercise can increase weight loss, overall well being, mental well being, mood, alertness, improve digestion, improve sleep, and increases energy levels. Exercise does not have to be a daunting task. Simply adding 15-30 minutes of activity can give added benefits. Yoga, walking, dancing, lifting weights, hiking, and sports activities can be included or added to more traditional forms of exercise. There are many free online videos for all types of exercise available.

Finding a new hobby can keep both your hands and mind busy, curbing the unconscious eating of foods that are high in sugar and carbohydrates. Adult coloring books, drawing, painting, knitting, crocheting, sewing, dance lessons, gardening, learning to play an instrument and many others are great ways to use your time and expand your quality of life and brain function. New hobbies can also help establish new coping skills.  Our previous post on Coping Skills After Bariatric Surgery can be found here.  There are a whole host of online videos for “how to” on new hobbies.

Teaming up with others can also help increase weight loss and compliance. Support from friends, family and other groups will assist you. There is a whole gamut of support group online and in person. If you have fallen out of the habit of attending our support group or webinars get back to them. You can find our schedule and announcements regarding webinars here. Our Central Valley Bariatric Facebook page also gives daily inspirational messages, protein recipes and articles and any new information or research available. There is also our Duodenal Switch Facebook Group. Anything that increases accountability is a benefit and motivates us to stay on track.

Experiment with new recipes and flavors that are bariatric friendly and within your dietary needs.  There are so many options for quick and easy meals.  We have several recipes on our page for all stages following weight loss surgery and Duodenal Switch. However, there are endless option on the internet in Paleo, low carb, and high protein type recipes.

In the spirit of new starts and getting back on track 2017, we are having a giveaway with the basics to get back into the swing of things. This year we are looking for before and after weight loss surgical journeys.  Share your weight loss journey! Don’t be shy, your journey can inspire others and/or motivate yourself. To enter the Back on Track 2017 Giveaway, please submit your weight loss surgical journey with before and after pictures to contact@dssurgery.com or you can also post your before and after pictures on our Facebook page. You will also need to sign a release for the use of your story on our website. We will draw 2 names from those that enter by announcing it on our FaceBook page or by e-mail on January 31, 2017. You must submit your mailing information to contact@dssurgery.com in order to claim the prize.

Please check with your physician before starting a new supplement and follow laboratory studies for adjustments in supplements. Vitamin information here. Mineral information here.

Introduction

Society has long ignored the scientific causes of obesity and formed their perceptions based on personal attitudes. There are a number of  factors that have been identified that contribute to the epidemic of obesity. Unfortunately, there continues to be a public perception of obesity being a “personality” disorder. Quite frequently patients are told “…just eat right and exercise, and everything will be fine.” We all know that is not the case. One of the poster presentations during the 2016 Obesity Week was on the subject of causes and perception of obesity. This topic is always an important talking point at these meetings and there seems to be some changes in viewpoint of the general population.

This was a large study conducted over a long time frame with a relatively decent population size.

The study showed a slow but steady improvement in the perception by the general population in recognizing the multifactorial nature of obesity with less personal blame on the patient. The pace of change in perception has been positive, however, there is a still large gap for improvement. There is hope for the future of a correlation of causes and perceptions of obesity.

Summary

We, as a healthcare providers and society, are making improvements in educating, awareness, and perception of obesity but we still have work to do.  In this changing healthcare environment, we can not let these gains in perception slip back to old patterns and biases. We need to maintain our diligence, education and our forward thinking to continue the positive and factual perception of obesity.

The question of “Is a pre operative diet and weight loss important?” No. This is the short answer. In a previous blog, “Weight Loss Before Weight Loss Surgery?” I have gone into further detail about why I don’t require a pre operative diet and weight loss program.

More recently there has been a concerted effort by a number of major health plans to require 3-6 months documented pre operative diet attempt prior to authorization for weight loss surgery. Furthermore, there are surgeons who would mandate a 10% weight loss as a precondition for the patient to have a weight loss surgery, laparoscopic sleeve gastrectomy for example. The overwhelming scientific literature fails to support any direct correlation between preoperative weight loss and the outcome of the weight loss surgery.

Some surgeons require preoperative weight loss as a way to reduce the size of the liver. I’ve personally have never met a liver I couldn’t work around unless it was severely diseased.

There is some literature to support this position. However, one has to critically look at all the studies. Almost all the studies have very specific population and procedures that are being looked at. Most often the recommendations had been made for adjustable gastric banding procedures. There are also some that are recommending the same for Lap Sleeve cases only siting the reduction of the liver size as a reason for the Very Low Energy Diet as a precondition to surgery. It is, however, important to remind ourselves that there is no long term studies whatsoever that show any relationship between the preoperative weight loss and the outcome of any weight loss surgery.

Recently there have been several patients who have asked me about increasing and maintaining their healthy gut micro-biome with yogurt.  Dr. Caya has generously shared his recipe for a multi-strain yogurt.  Below is a link to the starter he uses, however there are many starters on the market.  The best starters have multiple strains of healthy gut bacteria. Homemade yogurt may have higher bacteria and strain count due to less shelf life, etc than manufactured yogurt products. Additional blog information regarding probiotics can be found here.

General Probiotic & Gut Health information here

Starter: https://klaire.com/v106-10-probiotic-complex

Yogurt Recipe:

In a glass or stainless covered saucepan heat milk to 190 degrees, cover and remove from heat. Let stand for 10 min. Place covered saucepan in sink of cool water and let stand until milk is cooled to below 95 degrees.

When milk is cooled to desired temp thoroughly whisk in a rounded 1/4 tsp starter mix (or whatever the directions on starter indicate). Fill small glass jars with mixture and place (uncovered) in maker. Cover maker and switch on and let stand for about 8.5 hours. For best heat distribution make sure jars are in physical contact with each other and clustered toward the switch side of maker. At the end of the fermentation cycle remove, cover and refrigerate finished yogurt.

The consistency of the resulting yogurt might be slightly thinner than commercial products. There may be some whey (clear liquid) visible in the jars. Perfectly normal and nutritious. If thicker texture is desired straining off the whey will give the product a Greek Yogurt texture.

Needed equipment:

• Saucepan 2qt
• Food Thermometer
• Measuring spoon ¼ tsp
• Whisk
• Ladle
• Yogurt maker (Cuisene YM-80 is best buy)

Other brands of starter here & here.

Research on manufactured yogurt  here and article here.

Research on homemade from starter yogurt here.

Thank you Dr. Caya for sharing your recipe.
We are not affiliated with any of the products nor do we endorse any one type of product.

There is a new publication in the British Journal of Medicine that has raised questions about the benefits of Calcium supplements and  Calcium from food sources and Bone Mineral Density.

This article is a “meta analysis” of a number of studies. This means that the researches have taken number of other research articles and have “analyzed” and summarized the data.

I will start by saying that there is nothing in this article that suggest post weight loss surgical patients should stop taking their calcium supplements.

This article studied a number of other publications and looked at a number of variables that were common in those articles. The authors themselves outlined a number of limitation to the study. More importantly they recognized these limitation and their conclusion were limited to those that can be justified by the significant limitations  and variability amongst those articles.

Calcium, Magnesium, Vitamin D, and various supplements are recommended for Duodenal Switch and other weight loss surgical patients for the offsetting the malabsorption that is caused by weight loss procedures. There is nothing in this article that addressed decreased absorption of calcium. The reduced absorption maybe because of the sopanification of calcium with fat, decreased absorption because of the small bowel, or other reasons.

In Summary I recommend Calcium, Magnesium, Vitamin D, and other supplements to be taken on regular basis as it has been recommended to each patient based on the specific lab results.

When I perform the duodenal switch operation,  the common channel is a percentage of the total small bowel length and  I also account for the  patient’s metabolic rate. Two individuals with a BMI of 50, should not have the same common channel. If  we compare two patients, one of them is a 20 years old male who is 6’2″ and the second patient is a 60 year old female who is 5’4″, we can see how this applies. These two patients have very different metabolic needs and requirements. When the Duodenal Switch is performed in this fashion, the common channel based on a percentage of total small bowel length and metabolic needs, the patients post op diet works best when it is a well balanced, protein based diet. The basic principals are : Hydration (water), Protein and Everything else, low carb,  avoid artificial sweeteners, avoid carbonated drinks,  have frequent smaller meals and avoid processed food.  Listen to you body as to what it tolerates and what it doesn’t. This is what I recommend for my patients.

I am not aware of any scientific evidence that proves any benefit to excessive amounts of fat for DS patients who have had their length of the common and alimentary bowels based as a percentage of the total length.

My recommendation are to have a well balanced high protein diet. I do not recommend a  low fat diet, except in the healing phase after surgery.  However,  there is no reason to consume excessive amounts of fat long term.

High fat diet is used to facilitate bowel movements for some patients who have constipation. It may be prudent to try and identify what may be causing the constipation and correct or eliminate them before one resorts to a very high fat diet as a “treatment” for constipation after Duodenal Switch. The possible causes for constipation after duodenal switch may be metabolic-organic (where some patients have infrequent bowel movements before DS, hypothyroidism), length of the common and the Alimentary channels and medications (pain meds, narcotics, antidepressants).

In addition, Medium Chain Fatty Acids do not require bile salts to be absorbed and are directly absorbed into the Portal Vein in the liver. Medium Chain Fatty Acids are not malabsorbed post Duodenal Switch. Medium Chain Fatty Acids included Caproic acid, Caprylic acid, Capric acid, and Lauric acid. Commonly found in varying amounts within coconut oil and palm oil. MCT supplement is made with Medium Chain Fatty Acids.

In summary,  I recommend that Duodenal Switch patients who have had surgery with our practice have a high protein balanced diet. I do not recommend avoiding fat, or going on a low fat diet.  I am not sure if there a reason to consume excessive amount of fat, which may in fact have unexpected metabolic and nutrient consequences.

Every patient, as their weight stabilizes, will find what works and what does not work for them. Some patients will tolerate a higher fat intake and other will not be able to tolerate higher fat intake.