Life again...

Jan 24, 2018

To everyone who have been so supportive of me during the last few months, thank you.  Your support has been, well, priceless-something I can never repay-thank you.

Alicia had back surgery on December 18th.  She did well and has recovered wonderfully.  She is still improving.  Her walking is about 95%, which is wonderful.  She is back to her happy, loving self.



Prior to my Grammy going into hospice, and Allie injuring her back, I had made arrangements to obtain a puppy from Alicia's breeder.  He will not be breeding for a while, and the house didn't feel just right.  Bullies are like Lay's-You can't have just one!  So, of course, he contacted me shortly after Allies surgery and wanted me to pick up the baby because he was in the middle of a move and he didn't want me to miss the fun time...  So, on New Years Eve, I brought home Violet Lily!

She has been well received by my two others, and she makes me laugh.  She has perked up the other two as well.

 

As far as myself, well, I put back on 35 pounds since September 5th.  It sucks, and I have only myself to blame.  But I'm not going to assign blame.  I lost my grandmother, and spent six weeks on my couch with my service dog who I had to watch constantly to make sure she didn't further injur her back, and go through surgery with her.  My food went completely off course  But today, I start tracking again, and it gets back ON course.  One day at a time...

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So Ready For The End Of 2017

Nov 30, 2017

It isn't even funny...  I can't even begin to remember what the beginning of the year was like, except my whirlwind 24 hour flight to Houston and back to pick up my handsome wee lad, Duncan:

Then, in July, I returned to working for my old company here in Tucson, and was given the option to work from home, and given quite a better salary to do so.  I am so grateful for my employer.  They have been so helpful to me, and understanding of the things I have been through over the years.

 

In September, my grandmother went into hospice. A most incredible woman.  She had home hospice because she was too well to go to a hospice center.  For a month, she "Held Court" in her hospital bed in her condomenium dining room.  All her daughters were by her side, and her last sibling came to visit.  I have to say I was closer to her than I was to my mother.  When I was a little girl, I used to tell her I wanted her to be my mommy.  One of the last things she consciously communicated to me was to remind me, and perhaps to relive the memboriy that was as precious to her as it was to me, that I had wanted her to be my mommy.  And me, I spent that last month getting all the kisses I could.  I was grateful for that.

 

So, thanksgiving day, my mom and I and our service dogs went to see Justice League.  We had a great time.  Then we went home.  Mom wanted a couple hours for a nap.  So around six, I loaded up the kids (My service dog, Allie, and Duncan) and we went to my parents place.  When we got there, Allie injured her back getting out of the car.  Now, she is barely walking.  Her back is very wobbly and she is walking on her back tip toes, or on the tops of her feet.  She can't feel if she is walking correctly on her feet.  I have taken her to a neurologist, and we are waiting to see if there is a little improvement, as she has had some in the 5 days following the injury.  I believe we will be having a CT next week to see if she has a herniated disc, and if so, to what extreme.  If not, what is causing this.  Is surgery in the cards? 
I just want life to be tolerable again  I want to enter 2018 with an abundance of gratitude.

I know it may seem foolish to some of you, but please keep my little girl, Alicia Rae, in your thoughts and prayers.  Send healing wishes and light that she may be able to return to her previous normal life.  She is not yet five years old, and she is my keeper, my medical service dog, and my child.

 

My fondest wishes, and greatest thanks,

Rachel

5 comments

Of Grief and Loss

Oct 26, 2017

When last I wrote, my grandmother was in hospice at home.  She was laughing with her daughters, granddaughters, great grandaughters, and even one great great grandaughter.  We were sharing memories, and making our final ones.  Sharing our love and compassion.

Around the beginning of October, grammy's pain began to worsen.  We had held out on the morphine because it made her loopy, and grammy was sharp as a tack.  Finally, we began using it, little by little, and the paranoia and confusion began to set in.

My mom and all my aunts had stayed by her side every day and every night.  I began taking weekends so that they may rest for the week days.  On the sixth of October when I arrived at her apartment, she was worse than I had ever seen her.

I'm a nurse, and she always trusted me in medical matters.  So when I came, I was able to get her relaxed enough to take her medication, and to fall asleep.  I kept her comfortable.  I medicated her every two hours, as was ordered by the doctor, from Friday evening until Sunday morning.  When I went to give her her medications at 0430, she had passed.  I was able to give her what she wanted.  She went to sleep, and she didn't wake up.  And I'm grateful she is no longer in pain.

I have so many emotions, but little ability to express them.  She was my biggest fan (well, her and my mom would have to fight over that one).  She was my matron of honor at my first wedding.  I loved her so much as a child that I used to ask her if she could be my mommy.  This was actually one of the last things she said to me before she couldn't recognize any of us anymore.  She was a rock.  She was a survivor.  She lost a son to SIDS, her high school sweetheart to suicide, and her 11 year old son just six months after that to a shotgun accident.  She raised four girls all on her own.  She devoted her heart and her services to spreading the word of Jehovah.  Believe or not, she had friends world-wide who live-streamed her memorial service on 14OCT17.

So, why this today?

Today, I am crying.  I feel such saddness, and a longing for her.  I am so appreciative to have had her in my life.  Stern and stubborn and unrelenting.  She asked me to become a Jehovahs Witness to meet her in paradise after the resurection.  I have a very hard time with that faith.  I can respect it, but I don't believe it can find a place in my heart.  I pray that God is everyones God.  With culture and social differences being our way of seeing 'Him'.  I want to see my grandmother again. 

Sorry.

I miss her.  And I guess today is a day for processing grief.  I'm a little angry today too.  But that has seemed to fade since the tears came.  I hope no one cares that I put this here.  FB is not a place to process this.  OH is not quite as public, and the post will fade shortly.  Thank you, everyone, for your support.

 

OH!  And she was getting after me till the end telling me not to go eating a bunch of cookies and gaining my weight back and getting fat again!!!!

4 comments

Life after surgery - Emotional loss

Sep 05, 2017

I have been on a journey, since 15OCT16, to lose a regain of 96 pounds.  Things have gone relatively well.  I had gotten down to 160.1 pounds on 13AUG17, and started going through a roller coaster.  I had a binge of Talenti, one to two quarts daily.  I was maintaining my training appointments, but my aerobic activity on off days has decreased to little to none.  I've not been making my daily step goal of 12K at all.  I got of the gelato merry-go-round, but still am not meeting my activity level.  My weight has been coming back down.

Last Friday, 1SEP17, my 95 year old grandmother had emergency surgery for blood clots.  It was found that her ascending aortic aneurysm, previously treated on three occasions through the years, has began to expand again-the culprit of the clots.  A small piece ofclot got loose during the surgery and disappeared into her pelvis.  Blood flow to a muscle in her right thigh was blocked, and that muscle is now dying.  Risks of throwing another clot, causing a stroke, pulmonary embolism, or her aortic aneurysm is high.  Hospice in her home is now beginning.  She can't go to an inpatient, she's too well.

I've been spending overnights with her, being the nurse in the family.  My food is downhill, not excessive by any means, but not as much protein as I need.  My training sessions cancelled so I can spend as much time possible with my grammy.  She is my last surviving grand parent.  This year, I turned the age she was when I was born.  We even talked about that.  She is sharp mentally, and had been up and walking, still living independantly up until this happened last week.  She has a sharp wit and an excellent sense of humor.  She is an incredible woman.

I am writing this because I have no place else to vent this to.  I write a little on the meal thread daily, to be accountable to the group, which keeps me mindful of my journey.  But after my posts it feels as though it is a lifetime before anyone else posts.  How do you follow someone stating "grammy is in hospice.  I'm ok with it.  Not tracking food.  Have a blessed day."?  I have cried little.  I know the mechanics of whats happening to her body, I'm a medical professional.  But I'm 47 and my grandmother is dying.  Last time this happened, it was sudden and I was 6.

I've been sober from alcohol for five years.  i'd be lying if I said I didn't want to drink, but I'm more likely to reach for gelato.  And I went to be with my family yesterday rather than do that.

This is an ongoing situation and I will probably add more later.  Just needed to get some of the emotion out.

3 comments

Some good words on hydration

Jul 17, 2017

1 comment

Nine Months Back On Track

Jun 19, 2017

Short Recap:  Had my surgery on 8AUG08.  Started the journey at 271 (highest weight measured) and got down to 144 by May09.  In 2015, was back up to 241 at one point.  On 15OCT16, restarted my journey at 235.

Its Now 19JUN17, 9 months after my re-commitment to my health, and my sleeve.  As of this morning, I weigh 171.7#, down 69.3# since 15OCT16.  My momentum has continued well.  I have added a little treat once a week at the suggestion of my trainer.  This keeps me from going whole hog when I do have something sweet and carby.  I had the experience of eating three brownies from Papa John's and waking with a horrible hangover the next day.  I don't drink alcohol, so it was definately the sugar/carbs.  It was not pleasant.

I have another 20 to 30# I want to lose before I start leveling off for maintenance.  I don't know how long it will take, but I'm in it to win it.

This is just a small testament that regain can be conquered.

3 comments

Six Months Back on Track

Mar 17, 2017

I just realized that it has been six months since I decided to get off my ass and get back on my bariatric diet.  Tired of carting around 91 pounds of the 97 I regained in the years after my surgery in 2008,  October 15, 2016 I had finally had it.  That day, I weighed in at 235.  This morning, 17MAR17, I weighed in at 193.4!  I wil be happy to lose another 35 pounds, but would be most pleased with another 45. 

My momentum is increasing.  I have been very vigilant about my protein and carbs.  Recently, I have increased my activity and have been endeavoring to get at least five miles of walking a day.  I have joined my first "Weekend Warrior" FitBit Challenge, and hope to do well.  I'm not particularly motivated to move naturally.  But, as I said, my momentum is rolling!

My trainer reminded me to have a little 'treat' every once in a while, so much as it won't push me over the edge.  My sugar free White Mocha (5 Sparrows Sugar Free White Chocolate Mocha with Stevia and Xylitol) has been something I was quite resistant to give up.  Today I will be enjoying my white mocha with my 5 Sparrows, WITHOUT protein, and also a piece of pizza (thin crust), as my 'treat'.  Then back on the wagon.

I have been having difficulty finding a good time to blog as I go along, but I guess six months is good.  It has become clear to me that it is going to take a lot of exercise at this point to continue to have continued good movement in losses, and that's what I like.

I'll check back in when I get into my skinny jeans I have from my last surgery!!!

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Bariatric Surgery Patients Requirements

Mar 04, 2017

 Bariatric Surgery Patients Requirements

Tips for Monitoring Post-Bariatric Surgery Nutritional Deficiency
David A. Johnson, MD | Disclosures
February 14, 2017


BARIATRIC SURGERY PATIENTS' SPECIAL REQUIREMENTS
Hello. I am Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another GI Common Concerns—Computer Consult.


I have seen a lot of blogging back and forth recently with questions about bariatric surgery and, in particular, what to do with these patients. This Computer Consult is meant to tell care providers, irrespective of specialty, to be on the alert when somebody tells you that they have had previous bariatric surgery.

This is now one of the most commonly performed surgeries, not only in the United States[1] but also emerging worldwide.[2] This is due to the obesity epidemic and the significant improvement that we see not only in weight reduction but also in the metabolic consequences, such as diabetes, hyperlipidemia, and cardiovascular risks, and even cancer risk.[3]

In my experience, one of the things that does not happen commonly enough is the routine monitoring of these patients. The Centers for Medicare & Medicaid Services now requires you to perform this operation to be a recognized Center of Excellence, and there are certain criteria that equate to this. There are many patients who have had these bariatric procedures who may perhaps just land in your lap. Therefore, you really need to understand that these patients need to be watched routinely.


I have been privileged enough to edit two issues of Gastroenterology Clinics in North America in 2005[4] and 2010,[5] which included work on bariatric surgery. In doing so, I have learned a lot from a lot of smart people, and want to highlight some of the things that are really critical for you to know when you see these patients in your practice.

MACRONUTRIENT DEFICIENCY
First, there clearly are elements of macronutrient deficiency. This is protein malnutrition. The worst case is those patients who come in with severe protein malnutrition.

It is important to recognize that the protein malnutrition is maybe a consequence of how they are eating, but also depends on what type of surgery they have had. The more extensive surgeries, such as biliary-pancreatic diversion surgery or more extended Roux-en-Y gastric bypass surgery, may result in more protein malabsorption. You can also see this with bacterial overgrowth.

Routine monitoring of albumin in these patients is pretty reasonable, but prealbumin is probably a better short-term assessment here and more variable in response to interventional nutritional efforts.

VITAMIN DEFICIENCIES
The topic of vitamin micronutrients is what I want to spend the bulk of the time on today.
These cannot be synthesized; you have to ingest them. There are fat- and water-soluble vitamins. The fat-soluble vitamins are A, D, E and K, which clearly can be malabsorbed and then manifest as particular disease states.

With the fat-soluble vitamins (eg, vitamin A, keratins), patients may have some common visual symptoms and also some elements of very nonspecific things, such as dry skin, dry hair, and pruritus. Recognize the sublime nature of these types of presentations, and that you really have to be on your toes when you start to assess this.

Vitamin D deficiency is very common after bariatric surgery, and something you have to monitor on a regular basis. In particular, we monitor 1,25-dihydroxyvitamin D. Isolated serum calcium measurements are not adequate to follow these people, who may have a long period where their calcium is actually normalized. Urinary calcium is a good way to measure this, but its excretion can be altered and accelerated by concomitant use of diuretics. If a patient is hypertensive or they are on diuretics for edema, urinary calcium may be increased as well. You really need to follow and monitor total 1,25- hydroxyvitamin D and 24-hour urinary calcium.

Vitamin E deficiency is relatively unusual. When patients present with this, they have very nonspecific features, including ataxia, neurologic symptoms, loss of sensory vibration, muscle weakness, and sometimes even hemolytic anemia. It is very unusual in this patient population, but again, something to be aware of.

Vitamin K is primarily absorbed in the jejunum and the ileum, which are not as extensively bypassable, although the jejunum is considerable depending on the length of the gastric bypass or, in particular, with biliary pancreatic diversion. Patients with vitamin K deficiency may have coagulation deficits. Recognize that vitamin K is very important not only in the development of prothrombin, but also factors 7, 9, and 10, as well as protein C and S. These are things that essentially are required for adequate coagulation. Again, such a deficiency is unusual in the bariatric surgery patient, but must be considered in the appropriate setting.

As far as the water-soluble vitamins, the one that I insist you cannot forget is thiamine. Remember: thiamine, thiamine, thiamine. Vitamin B1 deficiency is potentially a catastrophic complication; it relates to what we see in alcoholic patients with classic Wernicke encephalopathy, but this can be the same presentation in a bariatric surgery patient. There are patients with malabsorption, but there are also those with clinical small-intestinal bacterial overgrowth who are refractory to thiamine repletion and respond to antibiotics directed toward it.

The most accurate measurement of thiamine deficiency is the erythrocyte transketolase measurement. It may not be something that you can whip around in your lab very quickly, but it is the best bioassay. We routinely measure thiamine levels, although the key to remember is that it is whole-blood thiamine, not just serum thiamine. It may be still underrepresenting the thiamine stores, but if you are going to order a thiamine level in these people—and you routinely should—you need to remember whole-blood thiamine. Certainly, when patients present with problems, in particular significant nausea and vomiting, they need to be replete with thiamine.

Some of the other water-soluble vitamins, such as riboflavin and niacin, are very rare deficiencies in this population, but ones that can be very versatile in their manifestations. Patients with riboflavin deficiency may present with stomatitis, anemia, or some scaly dermatitis, whereas in niacin deficiency the classic presentation is pellagra rash. These are very unusual, but they may also involve neurologic; dermatologic; or even some gastrointestinal symptoms, particularly nausea and vomiting.

Folate deficiency is something that also needs to be considered, particularly in patients with a more extended bypass. Elevated folate levels may also tip you off to bacterial overgrowth, which is a consequence for some patients with bariatric surgery.

Vitamin B12 deficiency has been fairly well described as a nutritional deficiency post-bariatric surgery, given how commonly it can occur. This makes logical sense, because it relates to bypassing the parietal cell mass, which is the site of the R factor and the R intrinsic factor. In addition, you have a relative achlorhydria after bariatric surgery, so some of the oral B12 may not be subject to the de-conjugation process in facilitation for absorption. This is also something that may be complicated with bacterial overgrowth, which can accelerate the metabolism of B12 and allow B12 deficiency. Vitamin B12 needs to be monitored routinely in these patients.

TRACE ELEMENTS
Regarding trace elements, zinc is the one to remember. Zinc, as you know, has a prominent role as a cellular antioxidant. This is something that can cause various symptoms, including skin manifestations, alopecia, glossitis, nail dystrophic changes, classic rashes, and the acrodermatitis enteropathica that you see in severe zinc deficiency.

Iron absorption is obviously a problem, given that you bypass the proximal intestine, the primary area where it is absorbed. These are patients who may have a relative achlorhydria because the gastric pouch does not have much acid. This absorption of non-heme iron from plant sources and bypassing of this duodenum and proximal jejunum may compound the iron deficiency. It is incredibly common, in my experience, and furthermore compounded if patients have some type of gastric mucosal disruption or ulceration. Iron deficiency clearly needs to at least be thought of in this patient population.


Copper is a joint transport mechanism similar to zinc, and copper deficiency really may be a problem. If you are giving your patients liquid vitamin supplements, take note that these may be deficient in copper. This is something you need to watch clearly on a semi-annual or annual basis, in particular after 3 years. Copper deficiency can induce some hematologic and profound neurologic abnormalities.

Zinc, iron, and copper deficiencies must be considered and monitored routinely.

WHAT TO WATCH OUT FOR
My bottom line is that when somebody comes in post-bariatric surgery, you need to be thinking that every symptom that they report may be a nutritional metabolic consequence.

With something simple, such as anemia, contributing factors run the gamut from deficiencies of iron to vitamin A, vitamin E, folate, zinc, and copper.

I have also seen some profound neurologic deficits, peripheral neuropathy being the most common; these also can be caused by a variety of vitamin deficiencies, such as niacin, vitamin B12, vitamin E, and copper. Also, remember to consider thiamine deficiency, and if you order thiamine levels, assess whole-blood thiamine or the erythrocyte transketolase.

Visual disturbances are something you may not think of asking about, but this is why it's important to include in your checklist that you routinely probe these people about every symptom as it relates to neurologic, visual, and dermatologic manifestations. With visual symptoms, the classic cause is vitamin A deficiency, but thiamine and vitamin E deficiencies can also result in visual impairment.

With skin disorders, think about deficiencies in vitamin A, niacin, and zinc. These are very classically associated with skin disorders and dermatitis.

FINAL RECOMMENDATIONS
What do I recommend for my patients?


On the basis of the metabolic recommendations from the bariatric surgery societies and national guidelines,[6] it is routine to advise these patients to take a chewable vitamin. I ask my gastric bypass patients to take a chewable vitamin twice daily—not a gummy bear, not a routine swallowed vitamin. A chewable [vitamin] disperses the vitamin and allows for potentially better absorption, within a limited bioabsorptive space. Then I have these patients take 1.2 g of elemental calcium. I personally put them all on 800 IU of vitamin D. If you choose not to do that, you should be monitoring them on a regular basis.

This is a proactive routine that should be coordinated by the surgeon, but we should recognize that these surgeons are not always following these people routinely.

What are the national recommendations for monitoring these people?[6]

It depends on how long out they are from their surgery. In the first 3 months, they are almost always monitored by the surgeon. However, we tend to inherit these patients as they migrate out from the surgeon, and if they are not in a Center of Excellence where they may be monitored on a routine basis.

Postoperatively, we routinely suggest that these people should be followed every 6 months, in particular for the first 3 years, and then once a year thereafter.

The chemistry profile would include not only a complete blood cell count (CBC) but also lipids, ferritin, zinc, copper, magnesium, vitamin A, 1,25-dihydroxyvitamin D, folate, whole-blood thiamine, and vitamin B12, and then 24-hour urinary calcium. These are things that we do every 6 months for the first 3 years and then annually thereafter.

In conclusion, what I want you to remember is that this is a lifetime monitoring requirement. It is not being done enough, even though it is incredibly important. Patients need to be proactive if their doctor is not doing it. I do not care if you are a primary care doctor, a gastroenterologist, or whatever—make sure that these patients are on the chewable vitamin twice daily, that they are on the respective elemental calcium, and that they are monitored on a regular basis. It is a lifelong requirement, with catastrophic potential otherwise.

I hope this helps you in your next interface with these patients. Take every sign and symptom (eg, neurologic, visual, dermatologic), and keep monitoring. Look for such things as anemia or edema, or something as simple as hair loss. These are all important facets. Take every symptom and sign as potentially related to the gastric bypass and micro- and macronutrient deficiency.

 

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Back on Track

Jan 09, 2017

 As of today, I am down 27.6 pounds from 15OCT16.  I have been tracking every day.  I've been on here, accountable, every day.  I'll admit, there's been carb cravings here and there, but I haven't given in.  I do have one or two pieces of thin crust pizza per week, but it falls in my calories, and does not kick me out of ketosis.  I am keeping to about 1000 calories per day.  Yesterday, my mother gave me back my favorite pair of Rock & Republic jeans.  They're a size 30 juniors or misses, whatever.  Not for women with curves, like I still have now.  I wear 33 'easy curves' now.  BAH!  But I have a box of my post surgical 32 through 30's that are just waiting.  Another 20 pounds, I'll be opening it up!!

4 comments

Eight years plus

Nov 21, 2016

Life has happened, and I was not so good at maintenance...

I remarried someone who was not such a good choice for me, in not such a good time for me.  I did a lot of traveling, which involved good times and bad times.  It also involved a lot of eating and drinking.  From 2010, I went from an all time weight low of 145, slowly back up to 235 when I brought myself back on here on 15OCT16.  I talked to my surgeon about revision, and reached back out to this community for the support I really needed all along.

Since 15OCT16, I have lost 16.5 pounds.  Pretty good, actually.  My tool is working really well.  I'm not experiencing head hunger.  I've got enough energy to maintain some serious weight lifting. 

The journey is underway again, but this time with perspective, and hindsight.  Hopefully I can maintain contact with that knowledge, and let it work for me for years to come.

 

5 comments

About Me
Tucson, AZ
Location
27.4
BMI
VSG
Surgery
08/11/2008
Surgery Date
Apr 02, 2008
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