Question:
Anyone experience genuinely unexplained weight regain?
Dear Colleagues, I have a patient who is 2 years post op. She had transected Roux en Y. Her beginning weight was 341. She lost exactly 100 pounds. In the last 6 months she has gained 45 pounds. We met at length to discuss the unsatisfactory initial weight loss and then to discuss the regain. The patient is quite frantic. She is a well spoken, well educated and presumably well balanced woman. According to the patient there is no way she is consuming enough calories in a day to have had an initial unsatisfactory loss and the consequent weight gain. She has been scoped and it has been verified that her surgery remains intact with no excessive stretching of the pouch or fistula. We advised her to keep a food diary of everything that she ate or drank including water and even chewing gum. There is no reason to believe this patient would be less than honest. She presents with a genuine desire to follow a healthy nutrition program. She exercises approximately 2 hours per day. She is blind (the result of a brain aneurysm at age 15) and participates in the swim team for 2 hours per day - 2 days a week in practice. The other days she does recumbent bike, arm bike, treadmill and weights. Her trainer has substantiated her exercise regimen. The patient has low protein levels in spite of supplementing 60 grams of protein per day - Occasionally she will supplement 100 grams per day during heaving swim training. This equals a maximum of 600 calories a day in protein supplementation. A typical day's meal would be: 1 Apple for breakfast 1/2 turkey sandwich on pita bread with fat free cheese - no mayo or condiments Protein bar for break - 145 calories Dinner - 1 apple or orange This makes her total daily calorie intake around 1300 or less - certainly no more. She is also experiencing swollen ankles, excessive thirstiness (though her sugars are currently in the normal range) an enlarged heart (no course of treatment however) and PCOS. Realizing the amount of exercise the patient participates in it would facilitate heavier muscle mass - there is no way this patient should weigh almost 300 pounds. Speaking as a Roux en Y patient myself, and also as the coordinator of a large program - I am keenly aware that there are times when patients are not honest about their food consumption. However, it seems that it would not be completely unreasonable to believe that a select few patients could do all the right things and still not experience adequate loss and even experience weight gain - possibly due to other underlying health factors. Oddly - after meeting with the above referenced patient I had another patient call me today with almost identical complaints and health symptoms. Out of well over 2000 patients I have only had these two credible patients present with these complications and frustrations. Any input, direction or advice is tremendously appreciated. Wishing you all a healthy and prosperous New Year, Rona — ronascott (posted on December 27, 2004)
December 27, 2004
Well we all probably know skinny people who can seemingly eat anything..
Have a couple friends like that. Lucky ones:)The low miles per calorie
folks... <P> Theres probably the super efficent ones too... Unlucky
high MPG er MPC. Eat little burn even less:(
<P> Theres always a chance of outright deception wether concious or
not. Studies of calorie controlled, constantly obeserved people show some
loose and some gain eating the exact same number of calories...
<P> There might be a good study in this. Have the patient paired with
observers for a month or two to document their calorie intake down to the
last calorie. It might add to the knowledge of obesity and definetely rule
out cheating... My heart goes out to the person and if a solution is found
please let us know. Has she had a basal metabolism study to find out how
many caloreies she is burning?
— bob-haller
December 27, 2004
studies have frequently documented that people tend to consume at least 20
% more than they report and in a controlled environment lose weight eating
what they report that they did before. However there is also the possiblity
that she needs a revision to a more distal proecedure, or a duodenal
switch. we are not all exactly the same, and the same procedure doesn't
work for everybody. I can honestly say I would not report to my doctor
the cookies I ate over Christmas.
— **willow**
December 27, 2004
Has either one of your patients had their thyroid (TSH, T3, T4) levels
checked? If hypothyroid, this could cause some weigh regain. A
lymphoscintigraphy (sp?) could determine if either patient has an impaired
lymphatic system, which could cause significant edema and weight gain. As
someone who suffers from both hypothyroid/Hashimoto's disease and primary
lymphedema, I could see where either of these issues could come into play.
However, I am not a medical professional, so these are only my opinions and
my experiences. I, too, have had an RNY 25 months ago and, because of the
lymphedema, deal with serious fluid weight flucuations (3-6 lbs) on a daily
basis. I hope that you will be able to find an answer for these patients.
It can be frustrating when solutions just don't jump out at you. Hope you
have a wonderful New Year, Melissa
— M. Groth
December 27, 2004
Um, okay. You said she had PCOS? That, in and of itself, would explain her
unsatisfactory weight loss and regain if she hasn't been medicated. Since
she has already been diagnosed as having PCOS (a precursor of diabetes) and
she has excessive thirst (which is a clear-cut symptom of diabetes), it is
time to make sure she hasn't developed diabetes. If she is not receiving
the appropriate meds for PCOS and/or diabetes, she WILL NOT LOSE WEIGHT.
period.
— sweetmana
December 27, 2004
I had a similiar problem at about seven months post op. I had unexplained
weight gain. I gained seven pounds. I was doing all the right things. I
was diagnosed with PCOS. My Testosterone and DHEA levels were high. I
began seeing an Endocrinologist who tested me for everything. I am not
insulin resistant or Diabetic, but she prescribed Metformin. It quickly
brought my hormone levels down. It took about nine months for them to be
in the normal range. I was able to start losing weight again. I feel that
It has been much more difficult for me to lose weight, but at least I
finally have an answer. I must exercise six days a week, take my
medication and carefully watch what I eat. I can easily gain the weight
back. I have lost a total of 192lbs, and still losing. It can be done.
— Allison M.
December 28, 2004
She's not eating enough protein 1) because she is so active she needs more
than normal 2) she needs to eat more protein than 600 grams, she is right
on the borderline with protein. If she eats more protein her weight will
go down. Right now she is starvation mode so her body will not let go of
anything. Have her up her protein thru more yogurt, cottage cheese etc.
She will see it start to drop once she does that.
— lstinson
December 28, 2004
Hi Rona- Here's a long shot, but a suggestion nontheless. You said she is
blind - is there someone else preparing her food and not being as careful
about recording what goes into her meals?
— Yolanda J.
December 30, 2004
It sounds as if this woman has more than some simple thing going on here
but I know for myself I've lost fairly slowly and if I don't diligently
watch CARBS then I can gain or maintain and i'm only 8 months out from RNY.
Hope she finds some answers
— FaithMills
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