Weight Loss Surgery - Gastric Bypass/Sleeve Gastrectomy: 3 Month Follow-Up

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Congratulations, you made it to 3 months! Hopefully you are losing weight and enjoying resolution of some of your previous health conditions. At this time you should be eating regularly textured solid foods and drinking calorie free carbonation free beverages in between your meals. Meal planning should be becoming habit, and you should be thinking about the total quality of your diet. Meal planning can be difficult and takes some time, so set aside 15-20 minutes each week to plan your menu for the week, create a grocery list, and stick to it, you will save money and will meet your weight loss goals. Make sure that you are getting in all of your food groups: 6 servings from the meat and meat substitute group, 2 servings from the milk or yogurt group, 2 servings of veggies, 2 of fruits, and only 2 servings of starch and up to 3 servings of fats. The farther you are from your surgery, the more likely you are to tolerate a wider variety of foods making the best choices more difficult! Keep in mind that if you still don’t have much of an appetite, this is a great time to work on eating only the best foods, so that if your appetite returns, you are in the proper habits. To plan your meals, focus on distributing the protein foods evenly throughout the day. For example, if you get 6 servings of meat, and you can eat 2 ounces at a time, you would have 3 small meals with 2 ounces each of a protein food. You still need to work in 2 servings of milk or yogurt, which usually pair nicely with your 2 servings of fruit. And don’t forget those veggies! The 2 servings of vegetable, or ½ cup cooked or 1 cup raw veg usually go nicely at lunch and dinnertime. So that leaves you with 2 chances to have a starch serving like high-fiber cereal in with that fruit and yogurt, or a slice of reduced calorie bread with your 2 proteins in the morning? Think about your meals like this so it ensures that you are getting the right types of foods. While sugar free ice cream or other frozen treats may be low in sugar and OK food, they don’t fit into this scheme of food groups, so this way the meal plan is eliminating some of those extra items for you. Keep in mind that a blue moon happens once every 2 and a half years, so those ‘once in a blue moon’ treats are probably happening too often! We all must strive for moderation, but keep the big picture in mind and think about your short and long term goals.

Ok, so that’s enough about your meal planning, lets talk about some long term effects of your new anatomy. While gastric bypass surgery does a great job aiding in rapid weight loss, sometimes it is at the cost of nutrient deficiencies. That’s why we stress from the beginning the importance of taking your vitamins for life. malabsorption helps you lose weight during the first 18 months after surgery. This malabsorption also puts you at risk for nutrient deficiencies leading to metabolic bone disease, neurological abnormalities and protein malnutrition. Lets review some of the more common deficiencies and the reasons why you can become deficient. Gastric bypass surgery creates a small pouch from the top part of your stomach and reduces the acid environment necessary to help convert some of the vitamins to an absorbable form. This is particularly important for vitamin B12, which is difficult to absorb in a post surgery pouch, hence our recommendation to take it in an absorbable form that can be absorbed in your mouth- liquid or sublingual which means, under the tongue. We recommend 500 micrograms for everyone, more or less depending on annual labwork. It takes years for a vitamin B12 deficiency to show up, but symptoms include fatigue, nervousness, tingling sensations, difficulty walking, tongue soreness, loss of appetite, constipation, anemia, memory loss and brain degeneration! Thiamin, another B vitamin, or vitamin B1 is essential for digestion and healthy nerve and muscle tissue. This is found in your daily multivitamin which must be taken for life. During the first few months after surgery, if you are vomiting often, this vitamin can be depleted quickly. Also, if you drink alcohol, you are at risk for thiamin deficiency. Thiamin deficiency is seen in patients before and after surgery, but symptoms include mental confusion, weakness, fatigue, swelling, reduced sensation, indigestion, constipation, and heart irregularity. Iron is a mineral in your body that is very important and if you do not get enough iron, your blood cannot carry oxygen through your body and you may feel tired and weak. Iron deficiency can occur after surgery because the part of your intestine that usually absorbs iron is bypassed, there are fewer receptors available to transport iron, you may not tolerate certain iron-rich foods, you have less stomach acid which is needed to absorb iron, and you may have monthly blood loss from menstruation. Some symptoms of iron deficiency are fatigue, weakness, pale appearance, restlessness, rapid heart rates, sore tongue, sores in mouth, and feeling cold. Additionally, if your iron deficiency is severe, you may crave ice or clay. You need to take a multivitamin daily which contains 18 milligrams of iron, but some people need additional supplements. Because iron can compete with substances in coffee or tea, take your multivitamin or iron supplements separate from coffee and tea, and also separately from calcium citrate supplements by about 2 hours. Speaking of calcium, why do you need to take so much of it after having gastric bypass? Like other minerals, calcium is usually absorbed in the first part of your small intestine which is bypassed after surgery. Calcium is important to build and maintain bones and teeth, and is required for blood clotting, nerve transmission, and muscle contraction. Calcium and vitamin D work together, and your calcium supplements will usually contain vitamin D. Preoperatively, most of our patients are vitamin D deficient, and receive appropriate supplementation. You can become vitamin D deficient after surgery as well and we check your vitamin D with every lab draw. Calcium deficiency is difficult to diagnose because there are not clear blood tests, but if you don’t have enough calcium in your blood, the body pulls from your calcium bank, your bones. Excessive bone loss can lead to fractures and bone disease and osteoporosis. The best way to evaluate bone density is with an annual DEXA scan. Calcium also requires an acidic environment to be properly absorbed, and remember, you don’t have that after surgery, so you must take supplements forever! Currently, the goal is to take 1500 to 2000 milligrams of calcium citrate with vitamin D in divided doses. Calcium citrate is the best absorbed version after surgery, not calcium carbonate. Another thing making calcium absorption difficult, is that you only absorb limited amounts of calcium at one time, about 500 to 600 milligrams at a time, so you must take your calcium supplements a few times per day, about 3-4. Typically Citracal or comparable pill form contains about 250 to 300 mg so the proper dosage is to take 2 pills at a time, 3 times a day so that you get about 6 pills/day. There are many new ways to take calcium- chewable lozenges, crystals that dissolve in water, liquid, and some chewy bites. Ask us for more information. Finally, there can be other micronutrient deficiencies like vitamins A, E and K, Zinc, Copper, Selenium and Folate. Be sure to take 2 multivitamins until you are 6 months out from surgery, the 1 per day for life, 500 micrograms of vitamin B12, and 1500-2000 mg calcium citrate with vitamin D. We check labwork every 6 months during the first 2 years, then annually, and will let you know if you need additional supplementation.

Your MUSC Bariatric Surgery Team wants you to be successful and stay in touch.  If you need an appointment, call us at (843) 792-7929 or visit us at www.muschealth.com/weightlosssurgery   

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