San Franscisco meeting notes

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SF GROUP MEETING

October 14, 2009

POST-OP MEETING:

Dana led the post-op session. Barb is not here because she broke her kneecap.

She hopes to be here for November's meeting.

Q: One patient's AST and ALT liver function lab results went up, which she knows

indicates high alcohol consumption. She stopped drinking entirely for five weeks

and the test results went up again. Should she be concerned?

A: AST and ALT are measures of liver enzymes. High liver enzymes mean something

is bothering your liver, but not necessarily alcohol. It could also be too much

Tylenol. Some people experience elevated liver enzymes during rapid weight loss.

Dana recommend continued monitoring.

Q: Does Advil affect the liver?

A: No.

Q: What about Darvocet?

A: Darvocet can contain 500 or 650 mg per tablet of Tylenol, so could contribute

to liver issues.

Taking more than 3,000 mg Tylenol per 24-hour period can damage your liver.

Q: One patient's PTH has been trending up slowly over time. How high does your

PTH have to get before you really should worry about it?

A: If you're not taking enough calcium or your Vitamin D levels are low, you

won't absorb adequate calcium and your body will elevate your PTH (parathyroid

hormone), a signal to pull calcium from the bones to elevate the calcium in the

blood levels. Ideally, your PTH should be in the 20s or 30s. The 60s is

considered high normal and is okay. If it is in the 70s, you should have a bone

density scan.

If someone has good Vitamin D levels but still has an elevated PTH, it may mean

there is something going on with the parathyroid gland itself and is worth

checking on.

Q: Are there symptoms of elevated PTH?

A: Not until it's affecting bone density and you fall and break a bone. If you

do have bone loss, many doctors will prescribe Fosomax or similar medications.

However, those medications require a good foundation of calcium and vitamin D in

order to work properly. Some research suggests that taking it without that

foundation can worsen the situation.

If you had a VG or no weight loss surgery, you can take any form of vitamin D.

But if you had a DS, anything in a gel cap or oil based will go through without

much absorption. Some people will absorb some but not all in this form. PacLap

recommends taking a water soluble or dry form of all supplements. Water soluble

means it will dissolve in water. Dry forms can come in capsules. It's not the

capsule itself; it's whether it's got oil – fish oil, vitamin E – that will

likely be malabsorbed.

Q: Why then recommend fish oil for low HDL?

A: DS patients might absorb some fish oil, but Dana recommends taking a dry

formulation called Vectomega, which is available online. DS patients can't

necessarily evaluate cholesterol levels in the same way as general population. A

low HDL is an independent risk factor for heart disease, even if one's total

cholesterol values or cholesterol ratio is okay. There's no data to indicate

that DS patients need to worry about low HDL. A cardiologist said you'd want to

treat low HDL with niacin if you have a history of coronary artery disease.

Primary care doctors can run tests for C-Reactive Protein (CRP), which is a

marker for vessel inflammation. It's not a perfect test, but it indicates a

propensity for related problems.

The body can only absorb about 600 mg of calcium at a time, so there is no

reason to take more than two pills at a time. You won't absorb the excess; it

will pass out in your stool. Bariatric Advantage sells a calcium chewy bit in

flavors; it's the right form of calcium (calcium citrate) and it's tasty.

Citracal has 330 mg per pill; two pills at a time constitute one dose.

One patient increased her dose from two pills three times a day to three pills

three times a day and saw improvement in her calcium levels.

Each individual absorbs calcium differently, so some may benefit from taking

more at a time, but PacLap assumes that patients can absorb 600 mg at a time if

we take a 600 mg dose.

Q: Is there a vitamin deficiency that causes tachycardia?

A: Low levels of potassium and calcium (and maybe magnesium) can cause a

quickened heart rate, as can serious anemia.

A patient has had an elevated resting heart rate for a few weeks. Dana

recommended that she see a cardiologist (not just her primary care doctor).

Dana quizzed the group:

You've had the DS and you're going in for surgery, say a colonoscopy where you

expect polyps will be cut, a tummy tuck, anything. What prescription do you need

to get two weeks before hand?

A: DS patients need to take prescription Vitamin K for two weeks prior to any

surgery. It has to be prescription level to get a high enough dose to be

effective. Vitamin K is a fat-soluble vitamin, so DS patients are likely to be

low. Vitamin K is involved in blood clotting, so it is very important to take it

before having surgery. If you're taking a blood thinner like Coumadin (aka

Warfarin), it complicates the situation and should be discussed with the

surgeon. If you ever need emergent surgery, you can have Vitamin K injections

immediately prior to surgery. You have to be your own advocate regarding Vitamin

K; this is something that most general surgeons and primary care doctors may not

be aware of.

Q: Does PacLap recommend taking ADEKs on a daily basis?

A: In general, yes, but there are not many water-soluble forms available.

Aquadeks are available but many people don't tolerate this supplement easily.

Most ADEKs do not provide DS patients with adequate supplementation for A and/or

D, so it might be better to take separate dry forms of each vitamin. It can also

be cheaper to buy them separately.

Q: Are potassium and Vitamin K the same?

A: No, the chemical symbol for potassium is K, but it is NOT the same as Vitamin

K.

Q: Are there training classes for primary care doctors?

A: Not really, but PacLap sends your primary care doctor information from your

follow-up appointments.

Q: Why can't DS patients take time-release medications?

A: DS patients typically do not have issues with malabsorption of medications.

However, extended release formulations work by slowly releasing the medication

as the pills travel through your intestines. Because of the shortened intestinal

tract, DS patients will not absorb enough and the pill will pass without being

fully absorbed. Some prescriptions are " sustained " rather than " slow " release;

these pills stay whole in your stomach, and then release all of the medication

as soon as the pill reaches the small intestines. This form is okay to take.

Some medicines are carried in mineral oil; DS patients generally will absorb all

the medication if not all the oil.

Q: Why has the bowel preparation before surgery changed?

A: Some people experienced kidney failure with the Fleet preparation, so PacLap

has switched to Go Lightly. You have to drink more, but it is safer. For some,

this is the worst part of the surgery. Keeping the liquid cold helps some people

tolerate it.

Q: What is A/G ratio?

Dana thinks it's related to liver enzymes. We need to ask Dr. Rabkin.

(Note from Lori: Per www.labtestsonline. org, the A/G ratio, or Albumin/Globulin

ratio, is related to tests of total protein levels. Total protein can reflect

general nutritional status and may be used to screen for and help diagnose

kidney disease, liver disease, and many other conditions. Low total protein

levels can suggest a liver disorder, kidney disorder, or a disorder in which

protein is not digested or absorbed properly. High levels may be seen with

chronic inflammation, infections such as viral hepatitis, or bone marrow

disorders. The A/G ratio is the calculated ratio of albumin to globulins. The

ratio is normally slightly over 1. A change in the A/G ratio may provide your

doctor with a clue as to the cause of a change in protein levels.)

Eating beef, cheese (fats) will not cause significant weight gain in a DS

patient. However, the enzyme amylase is secreted in the mouth and breaks down

sweets and carbs early in the digestive tract. Eating sweets and simple carbs

will cause weight gain. Sweets, carbs and lactose also tend to give you stinky

gas.

Tall men have the easiest time losing; short women have the hardest time.

Q: What element of milk causes lactose intolerance?

A: It's the milk sugar that causes the diarrhea and gas. Whey protein is usually

not a problem for DS patients, though some people do react to it. Egg white

protein is usually tolerated. Fat free milk has the most sugar; half and half

has the least sugar. One patient uses goat milk; soy milk also works well for

many people. Soy milk has a lot of sugar.

Hard cheeses are very low in lactose and are generally tolerated; soft cheeses

have more lactose and can be problematic.

Not everyone has problems with lactose intolerance, and it is temporary for many

people who do experience it.

When you're recently out of surgery, don't experiment with too many different

foods within any one day; be gentle with your stomach.

Hard-boiled eggs are great for many people.

It's the whey component in cottage cheese rather than the curds that contains

the lactose. You can put cottage cheese in a strainer and rinse it in water to

remove the lactose.

Linking into the Yahoo group online is very important, especially for new

post-ops.

If you can give a new post-op one piece of advice, what would it be?

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