In March 2020, the Federal Food and Drug Administration updated the food labeling requirements. Therefore clarifying the information. This was to simplify and improve the information provided to the consumer.

Added-Sugars-New-Nutrition-Facts-Label_1

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.

A Parathyroid scan or Sestamibi scan may be needed if the typical weight loss surgical reasons for elevated PTH levels have been addressed. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with overactive parathyroid and is absorbed by the overactive parathyroid gland. If the parathyroid is normal it will not absorb the agent. The scan below shows the uptake of the agent.

Calcium, Vitamin D and Parathyroid hormone are routinely measured on yearly follow up for most post weight loss surgical (WLS) patients. Elevated parathyroid hormone (PTH) may be caused by Vitamin D deficiency or calcium deficiency (most common in post WLS) or by over active parathyroid gland(s). In the latter case, if one of the four glands is overactive then this is knows as a parathyroid Adenoma. If all 4 are over active and are secreting too much PTH, this is known as hyperplasia. Ultrasound of the neck, may identify an enraged parathyroid gland (adenoma) which is located behind the thyroid gland. Given the large area where the parathyroid gland may be located, additional tests are needed to not only identify the location of the gland(s) but also to distinguish between single gland (adenoma) or multiple glands (hyperplasia) cause for the elevated PTH. It is important to investigate all avenues and testing in parathyroid hormone elevation and in some cases, not to rely on one test for your diagnosis. It is also imperative that weight loss surgical patients take their supplements routinely and consistently and have their laboratory studies followed at least yearly.

• 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):

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.

During the hot summer months and even year around, hydration can be

difficult for weight loss surgical patients due to limited amount of intake and bypassed small intestines.  Staying hydrated can be a full time activity that takes consistency and diligence.  There are many commercial products in both liquid and powder form (mix with fluids) that can provide hydration and electrolytes.  We have a previous webinar on the subject of Fluids and Electrolytes and their importance and role in bodily functions. Please read the labels of some of the powder products available as several are high in Vitamin B6, which if taken in high doses of a long period of time can cause toxicity issues for some people.  It is also best to look at your other supplements for the amount of Vitamin B6 also. Here is a previous blog on Vitamin B6 toxicity.

There are also many infused water recipes that you can make yourself.  It is usually best to add a vegetable or fruit to an herb and a citrus.  If you would like, stevia can be added to sweeten infused waters or leave it unsweetened for a more savory flavor. You can also freeze these and make popsicles or ice cubes.

There are many combination that you can become creative with. Some great combinations for infused waters are:

• Lemon, rosemary, celery

  

• Lemon, blueberry, mint
• Lemon, cucumber, basil
• Lemon, raspberry, mint
• Apple, cinnamon stick, parsley
• Lime, raspberry, parsley

Using a natural type salt can also give you additional electrolytes as well as a salt substitutes that also have potassium.  You can add these to your foods or water.  There are also some beverages available that offer hydration, electrolytes and probiotics.

We have also found a few drinks, drink mixes and water enhancers that are sweetened with Stevia that are great for on the go.  Stur, Crystal Light Pure, Real Lemon and Bai are just a few.

The recommended daily fluid intake is a minimum of 64 ounces of fluids daily after weight loss .  You may have higher fluid intake requirements based on increased fluids lost through drainage, liquid stools, time of year (summer months), fever, illness, vomiting, exercise, or increased sweating. Any type of fluids, preferable low carb fluids count toward your daily goal. If you vomit that fluid should not be counted toward your daily goal. Staying hydrated will take continuous sipping.

If you have any of the following symptoms it is time to call your surgeon/physician.  It is extremely difficult to overcome dehydration once you get into the cycle of dehydration causing nausea causing more dehydration. Intravenous hydration is the best way to overcome dehydration at this point. Untreated dehydration increases chances of heart arrhythmias, heart attack, blood clots, brain swelling, kidney failure, seizures, heat injury, coma and death.

• Nausea
• Increased thirst
• Dry mouth and swollen tongue
• Weakness
• Tiredness
• Sleepiness
• General malaise
• Dizziness
• Lightheadedness
• Low blood pressure
• High heart rate
• Palpitations (feeling that the heart is jumping or pounding)
• Confusion
• Sluggishness
• Fainting
• Inability to sweat
• Decreased urine output
• Dark urine color may indicate dehydration. If urine is concentrated and deeply yellow or amber, you may be dehydrated. (not necessarily true if taking vitamins, vitamins make urine darker)
• Increased or constant vomiting for more than a day
• Fever over 101°F
• Diarrhea for more than 2 days
• Weight loss
• Decreased urine production
• Confusion
• Weakness
• Lack of tear production

Take the person to the hospital’s emergency department or call 911 if any these situations occur:

• Fever higher than 103°F
• Confusion
• Sluggishness (lethargy)
• Headache
• Seizures
• Difficulty breathing
• Chest or abdominal pains
• Pain in calf or leg
• Fainting
• No urine in the last 8 hours

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.