Barbara C.

Send Message

Block

Add Friend

I am nearly 4 years post op and I honestly think that one of my keys to success is that I go in to see my surgeon/RNP for my follow up appointments no matter how I'm doing. What I mean, is that it's easy to go back in and see them when you are losing weight and want to celebrate your achievements, but it can be more challenging to go back when you feel like there isn't anything to celebrate, are worried that you might get bad news because you either weren't taking care of yourself by not taking your supplements, not exercising or may have experienced some regain. To be honest, I have all of those scenario's occur during the past couple of years, but I keep going and as I said, I think it's a key to my success. Not only my success in keeping the weight off, but also my success in taking care of myself because when I go in and I'm having a problem they are able to help me get back on track.

When I went in this time my weight was stable and while my pulse and BP where in 'normal' ranges they were somewhat high for me... I have fractured vertebrae in my back that are causing some significant pain and it's likely the reason for the escalated BP/pulse. We discussed pain management issues; I let her know that I was having issues with my oral pain meds not working well for me and that I'm certainly not drug seeking, but needed a better solution and that transdermal pain patches seem to help with pain medication delivery, bypassing the gut when managing the delivery of pain meds. We discussed treatment plans to manage my osteoporosis considering that I'm a RNY bariatric patient. I was focused on the serum ferritin number and she helpedme see the bigger picture. I have a somewhat unusual condition called Hemochromatosis and my serum ferritin was lower than most and I was concerned that it was becoming a problem, but she showed me that I have the iron stores and platelet counts that let them know that my body is doing just what it needs to do to produce plenty of iron to take care of my needs. I also have had some low D readings and she was able to talk to me about the course of action my PCP has recommended and she concurs with the direction we are taking. We also looked at things like my B12 readings and other details that are important to a bariatric patient. She sees my labs through a slightly different, more specialized view than my PCP does and I really appreciate her perspective and advice on what we are doing to keep me healthy.

I am often asked about hair loss in WLS patients, so I did a little research and found an article from the Obesity Action Coalition written by Jacqueline Jacques that describes how hair grows, the risk factors and treatments for hair loss.

I am including her conclusion and will provide a brief summary of the article.

Conclusion
Hair loss can be distressing to bariatric surgery patients and many will try nutrition themselves to see if they can prevent it. Unfortunately, there is little evidence that early hair loss is preventable because it is mostly likely caused by surgery and rapid weight-loss.

Later hair loss, however, can be indicative of a nutritional problem, especially iron deficiency, and may be a clinically useful sign. Educating patients about the potential for hair loss and possible underlying causes can help them to make informed choices and avoid wasting money on gimmicks that may have little real value.

Summary:
At any given time most of our hair is in a 'growth phase', but a small percentage is in a 'resting phase'. A number of stressors can cause a greater percentage of our hair to move into a resting phase and WLS patients are at particular risk because we have all had major surgery and experience rapid weight loss which are among the stressors that can impact having a larger percentage of our hair being in the resting phase. Also, if we are experiencing low values of ferritin, zinc or protein or have had more rapid than expected weight loss we may be at greater risk of hair loss.

While some think that supplementing with Biotin, topically or ingesting it; studies have not shown it to be effective in either stopping hair loss or improving regrowth.

 

I found an article on Metabolic Bone Disease from the Journal of Obesity. I am including the summary and highlighting the areas that I think are most important. If you want to read the complete article, click this link.

Bariatric surgery has proven to be an effective and life-saving measure that provides sustainable weight loss but it is not without risk of complications, to include metabolic bone disease (MBD).

There is a causal, multifactorial relationship between bariatric surgery and MBD and for that reason MBD remains an ever-present risk in bariatric surgery patients.  Patients presenting for bariatric surgery should be evaluated for MBD and receive appropriate presurgical interventions. Postsurgically, the importance of consuming adequate protein and the correct combination of vitamins and minerals cannot be overstated, remembering that no bariatric surgical procedure is risk-free when it comes to the development of metabolic bone disease.

As clinicians, we cannot assume that our morbidly obese patients are well nourished or that they have normal bone quality.  Dual-energy X-ray absorptiometry can be used to help assess bone status in the morbidly obese, however if the DXA table limitations prevent imaging the hips and spine, the nondominant forearm is a validated option for quantifying bone mineral density.  

Not all abnormal DXA results represent primary osteoporosis and in fact, in the bariatric population, secondary bone disease is the norm and when the diagnosis has been confirmed, treating the underlying cause of the secondary disease must take precedent.  DXA Z-scores, if abnormally low, suggest the presence of secondary MBD, however it is important to remember that secondary disease can be present even in the presence of normal scores.  Clues such as proximal weakness, a history of renal oxalate stones, chronic steatorrhea, and undersupplementation should serve to alert the clinician to the possible presence of metabolic bone disease.

In addition to the AACE/TOS/ASMBS guidelines, a baseline and one year postoperative DXAs are recommended. The use of calcium citrate and cholecalciferol (vitamin D3) are the recommended forms of these supplements, and in order to achieve and maintain normal serum levels, very high doses are often required in the bariatric postoperative patient.

Caution is advised when considering the use of certain medications to treat common problems in this patient population.  Cholestyramine or other bile acid sequestrants used to control diarrhea in this patient population increase the risk of exacerbating vitamin D malabsorption and osteomalacia, and may increase the risk of bowel obstruction. The use of bisphosphonates for presumed osteoporosis carries the risk of life-threatening hypocalcemia; efficacy has not been well established in this population, and the risk for ulceration from oral preparations at the surgical anastamosis has yet to be delineated.

Finally, there is emerging evidence that bariatric osteomalacia is a unique and increasingly common phenomenon in bariatric surgery patients that can have a subtle clinical presentation but potentially devastating consequences if left unrecognized.  Investigations into the underlying mechanism of the disease, the response to aggressive repletion, and effective preventive strategies are ongoing.  The treatment regimen at this point in time includes the use of cholecalciferol and calcium citrate with frequent monitoring and dose adjustments to attain and maintain normal lab parameters.

I am a little over 3.5 years post RNY and  I had my labs run again. While most of the news was good news, it did show that I'm not absorbing as much D as I need so I got another Rx for 8 weekly doses of 50K of D3. We'll retest after this course and see how it's going. We're also checking with my insurance to see about starting a regimen of ReClast or another injectable medication to help reverse the osteoporosis I've developed and hopefully get me back to the land of osteopinia if not back on solid ground. I have really been worrying that I had compromised my health with my decision to have RNY and have been beating myself up about it. My PCP said that I have to remember that while my RNY is likely a contributing factor in my fight with osteoporosis, that the meds I take for my depression, my family history and the fact that I hit menopause at the same time I had my RNY are all likely significant factors in my osteoporosis. He said that he felt that my osteoporosis is mild at this time and that he thinks we can reverse it with a combination of managing my supplementation, exercise, and alternating medications for osteoporosis with estrogen therapy. (We'll do a year of Reclast and when we take off a year to give my bones and body a break fromt he Reclast, we'll put me on estrogen therapy to try to maintain the bone stores, then switch back to the Reclast the following year, and so on...) He said that the relative trade-offs that my labs showed in healthy glucose, cholesteral, lipids, etc. are a testament to my good overall general health and that he thought that everything we do has tradeoffs. That said, he thinks my decision to have my WLS have served me well. That was comforting.

I visited the orthopedic Dr to address my back and the pain associated with the compression fractures I have in my back. My PCP originally Rx'd Hydrocodone and while they did seem to take the edge off of the pain, they also seemed to wear off very quickly and then I was hurt for several hours without any relief. My PCP then Rx'd Oxycontin which is a longer acting medication. Again, this seemed to help some, but also seemed to wear off long before the next dose was due. On top of that, I'm not a big fan of taking medications that are addictive, so to be honest I wasn't taking them quite as much as I should. This was leading to pain and not being able to sleep very well. The PCP had orginally Rx'd the pain management medications in response to my fractured wrist. When I went back to see him because my back was hurting, he Xray'd my back uncovering the compression fractures and suggested that I see a colleague that specializes in treating back injuries and managing the pain associated with them. She prescribed a Fentanyl patch. The patches last for 72 hours each, but it takes a while for the medication to build up in your system, so I'm just now beginning to 'enjoy' the pain relief. It's the first time in more than a month where my pain level has been below a 2 or 3 on the pain scale. I know that may not seem like a big deal, but it's been between a 2 and a 7 for over a month. Until last night, I hadn't slept for more than 3 to 5 hours a night and sleep deprivation can get mean after a while so I'm really grateful for the break. I'll be using the patch for the next month. After that, we'll see what happens. I'm hoping I won't be hurting anymore and won't need anything. I'm supposed to abstain from exercise until further notice. When I can exercise again, I'll work with a physical therapist to make sure I don't hurt myself again. I want to improve my balance, strength and aerobic endurance in hopes that it will improve my overall and skeletal health.

I'm working on trying to make sure that I not only get in my requisite calcium citrate and vitamin D, but also that I am eating a diet rich in vitamins and minerals such as calcium, magnesium, iron, etc...

I fell on the icy driveway about a month ago. My feet flew out from under me and up above my hips. When I hit the driveway, I actually felt like I was being 'dropped' onto the cement. At any rate, while my back really hurt, it was my wrist that was screaming at me. It has quit screaming, but my back is still really hurting. My dear husband was worried about me and asked me to have the Dr. check it. I saw my Dr. today and they did a couple of Xrays which show that I have at least one compression fracture in my spine. I also had a DexaScan done to test my bone denisty and they compared it to the one done 2 years ago. It shows deterioration of the bone mass and that I now have osteoporosis. I had osteopinia, the precursor to osteoporosis when the last DexaScan was done. My Dr. said it's common among 'petite' white women. I laughed and said I hadn't been petite for very long. He said it is likely due to my family history of osteoporosis; my grandmother, great aunt, mother and sister all had or have it. He also said that my excess weight may have 'protected' me before because of the 'load bearing exercise' associated with carrying that excess weight. Now, I no longer have that 'protection.' 

They don't know if and/or how much my RNY has to do with my osteoporosis considering my family history. None of my other family members have had a bypass, but have been affected. My sister was just about 46 when she was first diagnosed and that is about 7 to 8 years earlier than myself; again, she has never had a bypass. That said, I have to admit to being ever more vigilant about my calcium and vitamin D supplementation. I worry that I have brought this osteoporosis on myself, but realize that now all I can do is work with my Dr's to treat it and try to limit the long term damage. I'm now being referred to an orthopedic back specialist and was told to take it easy until I see her next week.

Remember that success is not found perfection, but in perseverance.

As I start yet another new year, I have to say that I'm approaching it differently than years past. I've learned that success is not about doing 'it' right all of the time, whatever 'it' happens to be, but it is perservering towards the goals that I've laid out. I've learned that I will stumble and fall, but that the imporant thing is that I will also get up and continue to try. For me, continuing to try is the difference between success and failure. I think it has been my key to success.

I find that I indulge a bit more during the holidays, but I've found a few ways to keep it 'under control' for me. I tend to do better regarding the extra treats if I make a deal with myself that I can have them, but only after I've had some protein first. This allows me to have my 'proverbial' cake and be able to eat too without significant repercussions. I also have found that while I don't generally log anymore unless I'm having an issue with my weight, that doing so during the holidays really helps me be very aware of what I'm putting in my mouth, the 'value' of it and to be honest, it's relative expense. This also helps me as I work to make sure I'm getting in the nutrients I need. When I'm working to be sure I have enough protein, I often will have to delay the simple carbs that abound during the holidays. This in turn stems the tide and I don't indulge quite as much.

To say that this has been a tumultuous year for my family is a major understatement. My husband lost his job in January of 09. In January 2010 we got a call indicating that my FIL who was the primary caregiver for my invalid MIL was ill and needed care. I flew to CA to care for him and we discovered he was dying of metastatic lung and liver cancer. He passed away in hospice in February. I stay in CA following my FILs passing to help care for my invalid MIL. My mother who had lived with me here in NC had returned to CA and there were significant strains between my siblings and myself that precluded my ability to see my mother often while I was in CA. My mother passed away in late March. I flew back to NC in April and this summer we lost the home we had in with my mother. The difficult move was made more difficult because of the actions of my siblings and that their actions further tainted what should have been a joyous occasion; the marriage of our second son. Things seemed to start to get better when my husband was able to get a contract job, but that position was unexpected cut short. We have no reserves left and now no income. He is looking everywhere for anything. So far, not much at all. 

All of this stress is really impacting us from every direction including eating... we are doing all that we can to try eat well, but that too is a struggle. I'm struggling to eat enough and keep my weight up. Ben is struggling to not over eat and keep his weight down. 

I need to find a way to manage this stress, but I'm not sure what to do or how to do it. I'm trying to reach out for support. I'm trying to actively identify those things that are good in my life. I'm trying to stay in the 'moment' because the future is so very frightening. I'm really struggling to take care of myself and I'm not doing as a good a job of it as I would like. I'm struggling to get in all of my supplements, eat enough protien, get enough complex carbs and limit the simple carbs. 

I, like many of us, tend to be very harsh with myself about how I look or how I'm 'doing.' I was leading a support group meeting this weekend and told them that I wish that we could be as compassionate and supportive of ourselves as we are with others. This afternoon as I was walking down my hallway, I saw the Norman Rockwell 'Do Unto Others as you would have them do  unto you.' While I hold steadfast that notion, I also think that we can and should turn it around, so that we are as kind, gentle, and supportive to ourselves as we are to our friends, families, neighbors, and even strangers. I think that as we are aware of the tasks at hand necessary to support our goals for good health, quality of life and appearance, we also need to be compassionate with ourselves, and give credit where credit is due.