Gastric bypass surgery increases risk of kidney stones, study reports

Kidney stone risk increased by gastric bypass surgery

Dallas, TX

Patients who undergo gastric bypass surgery experience changes in their urine composition that increase their risk of developing kidney stones, research from UT Southwestern Medical Center investigators suggests.

A new study, published in the March issue of The Journal of Urology, found that some of these urinary changes place weight-loss surgery patients at higher risk for developing kidney stones than obese patients who do not undergo the procedure.

For the study, researchers collected urine samples from 38 study participants. There were 16 women and three men in each of two groups. One group had undergone Roux-en-Y gastric bypass (RYGB) surgery; the second group contained normal obese individuals. RYGB, which is one of the most commonly performed weight-loss procedures, involves the creation of a small gastric pouch and allows food to bypass part of the small intestine.

The researchers found that the excretion of a material called oxalate in urine was significantly greater in the participants who had the surgical procedure than those who did not (47 percent, compared with 10.5 percent, respectively). In addition, the amount of a chemical called citrate in the urine was low in many gastric bypass patients in comparison to the obese nonsurgical group (32 percent to 5 percent).

Oxalate is found in the majority of kidney stones, while citrate inhibits stone formation.

“Almost half of the patients who had undergone gastric bypass and did not have a history of kidney stones showed high urine oxalate and low urine citrate – factors that lead to kidney-stone formation,” said Dr. Naim Maalouf, assistant professor of internal medicine in the Charles and Jane Pak Center for Mineral Metabolism and Clinical Research and the study’s lead author.

The cause for stone formation after bariatric surgery is not entirely clear, but the study reinforces the message that weight-loss surgery patients and their physicians should be alert to the heightened risk, Dr. Maalouf said.

“These findings illustrate that the majority of patients are at risk for kidney-stone formation after RYGB,” Dr. Maalouf said. “This complication may not be well-recognized in part because it tends to occur months to years after the bypass surgery.”

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Better gastric bypass surgery outcomes linke to preoperative weight loss

Trenton, NJ

Preoperative weight loss is associated with fewer complications after gastric bypass surgery, according to the results of a record review reported in the December issue of Archives of Surgery.

"Despite the improved ability to accurately predict an increase in surgical risk, the optimal preoperative preparation of such high-risk bariatric surgery candidates remains controversial," write Peter N. Benotti, MD, from Saint Francis Medical Center in Trenton, New Jersey, and colleagues.

"Proposed risk-reducing strategies supported by varying degrees of evidence include staged surgical procedures, preoperative gastric balloon placement for weight loss, and preoperative medical weight reduction....Because the major determinant of postoperative length of stay is operative morbidity, we hypothesized that preoperative weight loss will reduce the frequency of surgical complications in patients who undergo bariatric surgery."

At a comprehensive, multidisciplinary obesity treatment center at a tertiary referral center serving central Pennsylvania, the investigators reviewed records of 881 patients undergoing open or laparoscopic gastric bypass surgery from May 31, 2002, through February 24, 2006. Before surgery, all patients underwent a 6-month multidisciplinary program with the goal of achieving a 10% preoperative weight loss. The primary endpoints of the study were loss of excess body weight and rates of total and major complications.

Loss of 5% or more excess body weight was achieved by 592 (67.2%) of the 881 patients and loss of more than 10% excess body weight by 423 patients (48.0%). Compared with patients undergoing laparoscopic gastric bypass surgery (n = 415), those referred for open gastric bypass (n = 466) were generally older (P < .001), had a higher body mass index (P < .001), and were more often men (P < .001). In addition, they had higher total complication rates (P < .001) and major complication rates (P = .03) vs patients undergoing laparoscopic gastric bypass surgery. Increased preoperative weight loss was associated with decreased rates of total complications (P = .004) and, most likely, decreased rates of major complications (P = .06), based on univariate analysis. In a multiple logistic regression model controlling for age, sex, baseline body mass index, and type of surgery, increased preoperative weight loss predicted reduced rates of total complications (P = .004) and major complications (P = .03). "Preoperative weight loss is associated with fewer complications after gastric bypass surgery," the study authors write. "We hope that these findings will be confirmed by prospective, controlled trials and that bariatric surgeons will consider this modality for preoperative risk reduction in selected patients who are deemed high risk for complications after surgery." Limitations of this study include retrospective design, lack of a control group, referral bias, and possible unmeasured confounding variables. In an accompanying invited critique, Patricia L. Turner, MD, from the University of Maryland Medical Center in Baltimore, recommends emphasizing an aggressive preoperative weight loss regimen. "Overall, this article presents the largest study thus far, to our knowledge, which may demonstrate a significant advantage to preoperative weight loss," Dr. Turner writes. "Moreover, the authors did not experience the attrition feared by some surgeons should they require preoperative weight loss of their patients. These findings suggest that consideration be given to incorporating either a suggestion of or the requirement for modest weight loss prior to bariatric surgery as a means of decreasing postoperative complications."

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Britain’s "most obese teen" is slim after gastric bypass surgery, says would rather be dead

Selby, North Yorks, England

At 19 years of age, Malissa Jones of Selby, North Yorks, England, sees herself as the unhappiest woman alive, whose future is extremely bleak unless she somehow comes up with £20,000 required to undergo cosmetic surgery. At 16, Malissa, Britain’s fattest teen, underwent gastric bypass after doctors told her she only had months to live, and thus became the first person in the world to undergo the surgery. She is now telling Closer magazine she’d rather be dead than live her life as she is now.

Malissa knows that the surgery saved her life, especially since she had her first suspected heart attack at the tender age of 15. Doctors told her at the time that, although risky and not usually done on under-18s, the procedure was the only hope she had to live longer than a few more months. At the time, Jones was diagnosed with angina, had her internal organs compressed, could not move and breathed at night with the help of an oxygen tank. She weighed 34 stone (215 kg) and ate 15,000 calories a day (with the daily recommended intake being of 2,000).

Now, two years later, Malissa has lost 20 stone (127 kg) and her life expectancy is increased. Still, she is depressed and is on medication because she is constantly so ill she can hardly get out of the bed. She says she’s been left with so much excess skin from her weight loss that she truly wishes she had never had the surgery at all – anything, even death, is better than looking like this. She doesn’t have the money to undergo surgery to remove the saggy skin and the NHS will not pay for it.

“I know it sounds ungrateful, but I preferred my body when I was fat. At least it was firm and curvy, not droopy and saggy. I had nice firm arms – now the skin just hangs and I have to cover them up because they look so awful. The NHS won’t remove the skin and I’ll never manage to save £20,000 to have it done privately. The surgery might have saved my life, but I wish I’d never had it done,” Jones says for Closer.

There is tinge of regret though at not having tried to lose the weight the healthy way, with diet and exercise, and especially at having let her problems become so serious. “Although my heart’s healthier and life expectancy is normal, some days I’m too ill to get out of bed. […] I hope people read this and realize gastric surgery isn’t a miracle cure. I wish I’d lost the weight through exercise and healthy eating. I know this operation was life-saving, but the complications I’m suffering now might still kill me. The truth is I feel I’m no better off than I was before,” she says for the same magazine.

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A prospective study of risk factors for nephrolithiasis after Roux-en-Y gastric bypass surgery (Abstract)

Roux-en-Y gastric bypass surgery has become an increasingly common form of weight management. Early retrospective reviews have suggested that new onset nephrolithiasis develops in some patients after undergoing Roux-en-Y gastric bypass. We present a prospective longitudinal study to assess risk factors for nephrolithiasis after Roux-en-Y gastric bypass.

A total of 45 morbidly obese patients scheduled to undergo Roux-en-Y gastric bypass surgery were enrolled in this prospective study between November 2006 and November 2007. Exclusion criteria included history of nephrolithiasis or inflammatory bowel disease. Serum uric acid, parathyroid hormone, calcium, albumin, and creatinine and 24-hour urine collections were obtained within 6 months before Roux-en-Y gastric bypass, and at 6 to 12 months postoperatively. A Wilcoxon signed-rank test was used to compare preoperative and postoperative serum laboratory values and 24-hour urine values. McNemar's test was used to determine if the percent of abnormal values underwent a statistically significant change after Roux-en-Y gastric bypass. For both statistical methods a p value was calculated for the change in each variable with p <0.05 considered statistically significant. Statistically significant changes included increased urinary oxalate and calcium oxalate supersaturation, and decreased urinary citrate and total urinary volume postoperatively. A statistically significant percentage of patients exhibited decreased urinary calcium, while a statistically significant percentage of patients experienced increased urinary oxalate and calcium oxalate supersaturation. Our prospective study demonstrated multiple factors that increase the relative risk of nephrolithiasis after Roux-en-Y gastric bypass. These changes may make stone formation after Roux-en-Y gastric bypass increasingly likely and pose an ongoing challenge in the realm of urology. Gastric Bypass Malpractice Lawsuit Attorneys

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Doctors embrace bariatric surgery as effective treatment for diabetes

Los Angeles, CA

Fifty international scientific and medical experts have issued a "consensus statement" declaring that bariatric surgery should be considered a treatment option for patients with Type 2 diabetes, even if they are not extremely obese.

The new guidelines, published today online in the Annals of Surgery, urge surgeons performing bariatric surgery and healthcare insurers reimbursing for such treatment to relax criteria, adopted in 1991, that have restricted such surgery to patients with a body-mass index of 35 or more.

Reviewing more than a decade's worth of studies on weight-loss surgery and diabetes, clinicians and researchers backing the document have concluded that the improved metabolic function that is typical in diabetic patients who undergo bariatric surgery is not merely an incidental effect of weight loss. "Surgery is a specific treatment for diabetes...the effect on diabetes is a direct consequence of the new anatomy created by surgery," said lead author Dr. Francesco Rubino, director of the gastrointestinal metabolic surgery program at New York-Presbyterian Hospital/Weill Cornell Medical College.

The implications, added Rubino in an interview, "are enormous." For starters, that finding should drive a broadening of the patient population offered the option of gastric bypass surgery or less invasive procedures that reduce the capacity of the gastrointestinal tract. Rubino said that patients with Type 2 diabetes that is poorly managed by diet, exercise and medicine should now routinely be assessed as surgery candidates.

Some of those will likely be far less overweight than the bulk of patients who have had the surgery for weight loss. Rubino cited the example of diabetic patients of Asian descent, who rarely reach a BMI of 35 but who might benefit from bariatric surgery.

For the more than 20 million Americans -- and counting -- thought to have Type 2 diabetes, bariatric surgery may offer more than just another treatment option. Research shows that for many patients, diabetes abates dramatically and permanently with surgery. That, said Rubino, makes the possibility of a "cure"--a prospect not discussed until very recently--real for many patients who have been told that "living with diabetes" is the best they can do.

Beyond that, said Rubino, clinicians caring for these patients will need to optimize their pre- and post-operative care to serve a new objective: that of improving metabolic function. Currently, many bariatric surgery patients continue on diabetes medicines after their operation when that might not be optimal or even necessary.

Finally, the consensus finding should guide the search for drugs that can better treat Type 2 diabetes. Those should focus on how metabolic function is changed by an alteration of the gut's anatomy, and whether drugs could be developed or adapted to work in the same way, Rubino said.

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Gastric bypass and diabetes: CNN Health Q&A

Q: Does roux-en-Y gastric bypass cure diabetes?

Expert Answer: (by Dr. Melina Jampolis)

Hi, Rick. I'm not a surgeon, so to answer your question more thoroughly, I consulted with a very well-respected bariatric surgeon in San Francisco, John Rabkin, M.D. He explained that the roux-en-Y gastric bypass (RGB) improves type 2 diabetes via at least three different mechanisms:

1. The surgery decreases caloric intake immediately after the procedure because food intake is restricted by the small volume of the created stomach pouch, which holds only 1 ounce. The decrease in food intake, particularly refined carbohydrates, which are not well-tolerated after this procedure, can help stabilize blood sugar levels and immediately improves control of diabetes.

2. The significant amount of weight loss that results from the surgery improves insulin resistance over time.

3. There are changes in hormones and caloric processing because the food ingested bypasses the segment of the small intestine closest to where it attaches to the stomach (the duodenum and proximal jejunum), but not quite as much as you mentioned (not one-third of the small intestine). Because of the anatomical changes resulting from the surgery, it appears that these hormonal changes are greater than would be seen with weight loss via diet and exercise, but no research has yet to compare the two directly and evaluate hormonal changes.

The overall outcome is complete resolution of type 2 diabetes in greater than 70 percent of patients with diabetes before the procedure.

Unfortunately, as many RGB patients regain weight over time, the durability of the cure isn't as high as with a newer procedure called the duodenal switch.

In this procedure, there is a much larger pouch created (4 to 5 ounces), and the complete stomach anatomy is preserved, which helps preserve more normal stomach function. In this procedure, the rearrangement of the intestines leads not only to some restriction of food, but also causes your body to absorb significantly fewer calories, which has a more lasting effect.

Rabkin, a leader in this procedure, reports that he has had a 96 percent cure of type 2 diabetes at one year after surgery, which has persisted for five and 10 years post -op and seems to be similarly durable out past 15 years post-op.

Hope this helps. I strongly recommend spending a considerable amount of time with your surgeon if you are considering either of these procedures, as both have important lifestyle-related issues that should be discussed to determine the best procedure for you for the long term.

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Probiotics may help gastric bypass patients

Hueytown, AL

Probiotics are sometimes prescribed by doctors to improve the body’s response to antibiotics by increasing levels of gut bacteria used by the body, but new research suggests they may play a complementary role in another treatment.

Researchers at Stanford University School of Medicine included probiotics as part of a regimen for patients who had recently undergone gastric bypass surgery.

They found that patients who used the "good bacteria" were more likely to lose weight than study subjects in the control group, and were also able to limit vitamin B12 deficiencies associated with the procedure.

Dr. John Morton, the study’s co-author, says that the research was initiated in response to obese patients who complained that it was difficult to eat properly after surgery because of the effects on the digestive tract.

"A lot of people aren’t aware that we all carry around a lot of bacteria in our intestines and that they’re extremely helpful in aiding digestion," he added. "And I thought, ‘Well, if we give these patients probiotics, then maybe we can improve these symptoms."

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Laparoscopic gastric bypass surgery helps man shed obesity

St. Louis, MO

Two years ago, Herb Simmons tipped the scales at 497 pounds.

"As the years snuck up on me I noticed it was getting harder to get around," he says. "I couldn't leave home in the morning without soaking my knees in Ben Gay."

He was suffering from sleep apnea, atrial fibrillation and hypertension. Getting from his car to his house was an exhausting, stop-and-go process because he'd rest every few feet to catch his breath. He needed an extra seat belt on airplanes and a chair without arms in restaurants.

Simmons says he didn't eat big meals, but admits to snacking on chips and slurping sugary colas every day. He says he's been on every diet known to man.


"I once lost 100 pounds on OPTIFAST and regained 200," he says. "I was a yo-yo dieter."

In 2007, he attended a bariatric seminar to learn more about Lap-Band surgery, a laparoscopic procedure to place a silicone band around the top of the stomach. The band reduces the amount of food the stomach can hold so patients eat less. Simmons made an appointment with one of the surgeons, Dr. Van L. Wagner, of Heart of America Bariatrics in Lemay. He was surprised when Wagner recommended gastric bypass instead.

Gastric bypass uses staples to make the stomach smaller, then reroutes food past part of the small intestine. Patients feel full sooner, and absorb fewer calories and nutrients.

With a Lap-Band, patients lose only between 50 and 70 pounds in the first year then often taper off on weight loss, Wagner says. With gastric bypass they almost always lose between 200 and 250 pounds in two years.

"Bypass is usually a better option for patients who are sicker, older and have higher weights," Wagner says. "And Herb was extreme on several of those things so banding would not have provided the weight loss he needed."

Wagner performed laparoscopic gastric bypass surgery on Simmons Sept. 19, 2007, at St. Alexius Hospital.

Gastric bypass comes with risks, including developing gallstones and nutritional deficiencies.

Simmons takes calcium and vitamin pills and drinks protein shakes to prevent malnutrition. Two weeks after surgery, he began walking, first up and down the sidewalk in front of his house, then on a quarter-mile track. At first he couldn't walk a lap without stopping to rest several times. Within a few months, he was walking two miles. Now, he walks three to five miles every afternoon and bicycles three to five miles every evening.

He also eats a lot less, especially high-fat, sugary foods.

"It can cause dumping syndrome, which makes you want to lock yourself in a room for hours," Simmons says. WebMD describes the syndrome as a shock-like state that lasts for 30 to 60 minutes after small, easily absorbed food particles are rapidly dumped into the digestive system. Symptoms include a clammy sweat, butterflies in the stomach, a pounding pulse, cramps and diarrhea.

Simmons says his triglyceride and cholesterol levels have plummeted, his sleep apnea has dissipated and his blood pressure medications are one-fourth the dose they were before surgery. His legs no longer swell and his knees feel fine.

He credits ongoing counseling by Wagner and St. Alexius' NewStart program for his success. Both offer emotional support, nutritional guidance and ongoing education.

Last month, Simmons celebrated the second anniversary of his surgery by walking 3.7 miles as part of the Walk From Obesity event in Creve Coeur.

"After my wedding anniversary, my surgery date is the second-most important anniversary for me," Simmons says.

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Gastric bypass surgery increased risk of iron deficiency

New York, NY

Weight loss surgery can help you lose weight, but it's also likely to leave you unable to absorb iron, a new study suggests: Iron deficiency is a common problem after stomach bypass surgery to treat severe obesity -- and standard iron supplements may not be enough to prevent it in some patients.

Researchers found that among 67 Chilean women who had undergone the most common form of weight-loss surgery, 39 percent developed low blood counts, also known as anemia, within 18 months of surgery. That anemia was most often due to a deficiency in iron, which the body needs to produce healthy red blood cells that carry oxygen.

In contrast, less than two percent of the women had been anemic before surgery, the researchers report in the American Journal of Clinical Nutrition.

It's well known that nutritional deficiencies are a risk after the type of surgery examined in the trial, known as Roux-en-Y gastric bypass, the most common and most effective form of weight- loss surgery for severe obesity.

The procedure involves stapling off the upper portion of the stomach to create a small pouch that restricts the amount of food a person can eat at one time. The surgeon also makes a bypass from the pouch that skirts around the rest of the stomach and a portion of the small intestine, limiting the body's absorption of nutrients.
The new findings suggest that impaired iron absorption, rather than reduced iron intake, is the major cause of long-term deficiency after gastric bypass, according to the researchers.

Tests done six months after surgery showed that, on average, women were absorbing just one-third of the iron from food that they had before surgery.

What's more, their absorption of iron from supplements showed nearly as great a decline. And many women became deficient in iron despite taking supplements after surgery, according to the researchers, led by Manuel Ruz of the University of Chile in Santiago. More "Gastric bypass surgery increased risk of iron deficiency"

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Gastric bypass surgery and anemia: Monitoring nurtitional deficiencies needed

Washington, D.C. (National Anemia Action Council)

In recent years, bariatric surgery has become a much more common procedure to treat morbidly obese patients in the United States, with the number of surgeries increasing more than 10-fold in the last decade.1 This growth has occurred in part due to the large number of obese and morbidly obese individuals in need of weight reduction and the relative success of the surgery at shedding excess weight and reducing obesity-related health conditions.

Yet, surgery often creates permanent alterations of the digestive tract, which can lead to a variety of nutritional consequences. Many bariatric patients develop new or worsen preexisting iron and vitamin deficiencies, with some patients becoming anemic in the months and years following the procedure. These patients may then be relying on you, their primary care providers, to monitor their nutritional health. This article explains why bariatric surgery patients are prone to developing nutritional deficiencies and what you can do help them avoid anemia.

Candidates for Bariatric Surgery

In 2008, about 220,000 bariatric surgeries were performed in the United States to help patients permanently reduce excess body weight.2 Only morbidly obese patients are eligible for the surgery, as determined by their body mass index (BMI) – calculated by weight relative to height (kg/m2). Patients with a BMI >40, or a BMI >35 in combination with comorbidities, are considered for bariatric surgery. Comorbidities may include type 2 diabetes, heart disease, hypertension and sleep apnea, among many others. Approximately 15 million people in the United States (about 5%) are considered morbidly obese and about one-third are considered obese, with a BMI >30.2,3

Prior to surgery, morbidly obese patients may have numerous chronic illnesses and health complications, including nutritional deficiencies and anemia. According to Dr. John W. Baker, President of the American Society for Metabolic & Bariatric Surgery (ASMBS), about 60% of his patients have low or deficient levels of vitamin B12 prior to surgery and about 20%, both male and female, had preoperative iron deficiency. This rate is consistent with current statistical data of nutritional deficiencies among bariatric surgery candidates.4

Although prevalent, the etiology of their preoperative anemia can be elusive, with some morbidly obese patients displaying evidence of both iron deficiency and chronic inflammation. In a considerable percentage of candidates, the cause of anemia may be undiagnosed. Dr. Baker advises that preoperative anemia should be treated prior to surgery either by the surgeon or by the patient’s primary doctor. Following bariatric surgery, the surgeon and the patient’s primary care doctor often communicate about continuing care of the patient to decide the roles and responsibilities of each physician in the postoperative period. This coordination is especially important for a patient with any preexisting anemia, which will need to be monitored closely.

The Surgery Itself

Bariatric surgery has a considerable impact on both a patient’s overall weight and many of the obesity-related conditions that affect quality of life. A meta-analysis of over 22,000 bariatric surgery patients revealed that patients lost on average 60% of their excess weight. In contrast, patients treated with conventional diet and exercise reported losing less than 10% of their excess weight for a sustained time period and exhibited only mild effects on reduction in obesity-related conditions.4

Studies have reported type 2 diabetes being resolved in 73-87% of patients following bariatric surgery, depending on the type of surgery.5,6 Risk of coronary heart disease was cut in half5 and sleep apnea was resolved in more than 85% of patients.7 Additionally, when compared to candidates who did not have surgery, patients improved their life expectancy 89% of the time8 and reduced their risk of premature death by 30-40%.9 Risk of death from diabetes, cancer, and from coronary artery disease was also reduced by 92%, 60%, and 56%, respectively.10

Speaking in regards to the effectiveness of bariatric surgery at treating concomitant conditions of obese patients, Dr. Baker said, “This is one of the most durable procedures we have for resolution of chronic diseases. What other procedure can improve hypertension, heart disease, diabetes, sleep apnea and high cholesterol?”

How bariatric surgery affects a patient is largely determined by the type of procedure and how it alters the mechanics of the digestive tract. Weight loss results from reduction in the capacity of the digestive tract and number of calories consumed (restrictive), alteration of the absorption of food (malabsorptive), or a combination of both approaches. Restrictive methods include vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB). Malabsorptive procedures with some restriction include biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD-DS). Restrictive procedures with some malabsorption include roux-en-Y gastric bypass (RYGB) and vertical banded gastric bypass.11

Following surgery, a patient’s body must get necessary nutrients from less food with a smaller, less effective digestive system. Although helpful in reducing their caloric intake and fat absorption, these physical and metabolic changes leave them susceptible to nutritional deficiencies and subsequent anemia. Depending on the form of bariatric surgery, alterations to the digestive tract which may lead to an increase in nutritional deficiencies and anemia include the:

* Lower intake of food and essential nutrients
* Decrease in the absorptive surface area in the digestive tract
* Decrease in available stomach acid to help break down food and nutrients
* Possible intolerance to some nutrient-rich foods, such as red meat

Nutritional Deficiencies Related to Anemia

Iron deficiency is the most common cause of anemia after bariatric surgery and can be found in 20-49% of patients. This is especially true after the RYGB procedure in menstruating women (51%) and in patients with super obesity (49-52%).12 Other deficiencies which can lead to anemia are less common, but do include vitamin B12 and folic acid, which are most common in patients who exhibited signs of the deficiency prior to surgery or who are not receiving adequate supplementation. For instance, vitamin B12 deficiencies can occur in older patients, patients taking H2 blockers or proton pump inhibitors (PPIs), or in roughly 12-33% of patients not receiving supplementation after the RYGB procedure.

Baker quoteAlthough these deficiencies are mostly related to the altered absorption in the digestive tract, all forms of bariatric surgery can contribute to lower serum levels or reduced stores of nutrients. Dr. Baker has observed that, “Even in patients who didn’t have a malabsorptive procedure, I still see them coming in with deficiencies at follow-up; often due to preoperative deficiencies or preexisting conditions.”

The ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient states that, “Taking daily micronutrient supplements and eating foods high in vitamins and minerals are important aspects of any successful weight loss program. For the morbidly obese, taking vitamin and mineral supplements is essential for appropriate micronutrient repletion both before and after bariatric surgery.” The surgeon will recommend the necessary vitamins during presurgical education and consultation. Concerning anemia-related nutrients, these recommendations include a multivitamin with at least 100% of daily value for vitamin B12, 18 mg of iron, and 400 μg of folic acid. Following surgery, an additional vitamin B12 supplement or oral iron supplement may be required if monitoring indicates low or deficient levels of these nutrients.12 Patients may also be taking a recommended 1200 mg of calcium citrate daily, but should not ingest it at the same time as an oral iron supplement because the two will compete for absorption.

Continuing Care Following Surgery

Surgical patients are typically enrolled in postoperative programs to help them adjust to their new lifestyle and reinforce compliance with recommended dietary restrictions and nutritional supplementation. All patients in these programs are instructed to take multivitamin supplements, usually with iron. Many physicians recommend life-long supplementation, with iron-deficient patients being treated initially with oral iron. Patients who cannot or will not take oral iron because of gastrointestinal side effects may need to receive the generally more tolerable ferrous fumarate oral preparation or parenteral iron supplementation.

Postoperative nutritional care puts a great deal of responsibility on the patient who may not realize the drastic nature of the procedure as it relates to nutrient absorption and the need to comply with supplementation and follow-up care. It can be difficult for patients to adhere to these programs with many of them dropping out 3-6 months after surgery. Dr. Annette von Drygalski, a hematologic fellow at the University of California-San Diego who has worked with many anemic patients following bariatric surgery, has witnessed this. She said, “Some patients may not be educated enough about the surgery and some may not even remember what procedure they had. And, because bariatric surgery is a relatively new field, some physicians may not be educated about the nutritional implications.” Patients may remain healthy for a short time and may attribute postoperative symptoms of fatigue to the procedure alone while deficiencies develop. Iron deficiency and other causes of anemia can manifest years later, potentially putting primary care physicians in a tough spot.

“Sometimes patients won’t follow-up with anybody until they finally develop a complication,” noted Dr. Baker. “We encourage our patients to identify their primary care physician so that lab work and recommendations can be shared. This way, physicians can identify patients who are not following up after the surgery.”

Monitoring Nutrition & Deficiencies

Patients are often enrolled in a postsurgical program operated by the surgical team. Programs of this nature normally require patients to attend follow-up visits at the first, third, sixth and 12th months to monitor their overall health and address any symptoms they may be experiencing. At a minimum, screening for nutritional deficiencies occurs at the 6-month and 12-month visits. Adjustments to a patient’s dietary supplementation levels, initially set by the surgeon, may occur at these visits, if necessary. Some patients prefer to have these visits coordinated with their primary doctors instead of with the surgical team. In this case, the primary doctor should continue to update the surgical team of the patient’s care and status, and the surgeon should remain available for consultation.

Information for Bariatric Surgery Patients

* Bariatric surgery is not harmless, it drastically alters your body
* There are lifelong dietary and nutritional considerations
* You may not absorb vitamins or iron as well from the food you eat
* It is important to follow vitamin and iron supplementation
* Do not take iron supplements with tea, cola, coffee, calcium citrate or levothyroxine
* Remember the type of surgery you had performed and be sure to tell your doctor

If you are working with a known bariatric surgery patient for the first time, even if you have not had prior consultation with their surgeon, Dr. Baker recommends inquiring about their dietary intake, types of foods they eat, their menstrual blood loss if they are female, and any symptoms of fatigue which could be related to anemia, in addition to monitoring their levels of iron, vitamin B12 and folate as described below. Notable things to watch for include excess tea, cola or coffee consumption, which may interfere with iron conversion to an absorbable form. If taking an iron supplement, it is necessary to wait at least two hours before drinking any tea, taking calcium supplements, or taking the synthetic thyroid hormone levothyroxine. If possible, communication with their surgeon about recommended supplementation and follow-up care should be pursued prior to subsequent visits.

The first step in screening for anemia is acquiring a complete blood count that includes red blood cell indices. If anemia is present – determined by a hemoglobin <12 g/dL in women and <13 g/dL in men – indices can point toward the appropriate further investigation.13 Patients with a microcytic, hypochromic anemia most likely have an iron deficiency. Vitamin B-12 deficiency produces macrocytic red blood cells. Remember that the cause of anemia may be multi-factorial, so indices are not the final answer. Some screening guidelines of anemia-related nutrients, taken in part from the ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient,12 are listed below.

Iron – Ferritin levels should be checked at six months, one year and annually at a minimum following bariatric surgery. A normal ferritin level for men is 15-200 ng/mL and for women is 12-150 ng/mL.12 Also check serum iron (normal range 60-170 mcg/dL), total iron binding capacity (normal range 240-450 mcg/dL) and transferrin saturation (normal range 20-50%). Note that normal ranges vary by lab, so be sure to check for their established levels.
Related Research Review

A recent research review of the study by Coupaye et al prospectively compared the prevalence of nutritional deficiencies after adjustable gastric banding and gastric bypass procedures. Read more about the study in Research Reviews:
Evaluation of Short-term Nutritional Regimens Following Bariatric Surgery

Vitamin B12 – Serum B12 levels should be checked at six months, one year and annually at a minimum following bariatric surgery. A normal vitamin B12 range is 200-900 pg/mL,14 but serum measurements may miss 25-30% of deficiency cases in lower normal ranges. If symptoms of a vitamin B12 deficiency are present (including fatigue, bright red/smooth tongue or tingling/numbness in hands and feet) and vitamin B12 levels are 200-250 pg/mL, MMA and tHcy measurements may help identify the cause.12

Folate – RBC folate should be checked at six months, one year and annually at a minimum following bariatric surgery. A normal RBC folate range is 280-791 ng/mL, with a deficiency present at <305 nmol/L and the presence of anemia <227 nmol/L.12 Serum folate more closely reflects recent dietary intake than actual folate status measured by RBC folate. Although relatively uncommon before and after bariatric surgery, folate deficiencies should be monitored, especially in women who may become pregnant.

The Lasting Effects

Bariatric surgery and the behavioral changes patients adopt have shown to be very effective reducing excess weight and the effects of obesity-related health conditions. However, the physical and metabolic alterations as a result of the procedure must be monitored by patients and their healthcare providers for the rest of their lives.

A dedication to following supplementation recommendations and monitoring nutrient levels should be incorporated into routine care which the patient can follow, the primary care physician can execute, and which allows the bariatric surgeon to remain informed and available for consultation.

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Risk of alcohol abuse increases after gastric bypas surgery

Sacramento, CA

On Friday's Live_Online at 11 a.m., we learned that an unintended consequence of gastric bypass surgery is the risk of alcohol abuse, said Laura Lagge, a certified alcohol and drug counselor with New Dawn Recovery in Citrus Heights.

Lagge told viewers she's seeing more women who turned to gastric bypass for their weight problem now struggling with alcohol abuse.

She said after the surgery, alcohol enters a person's system more quickly and the effects are stronger.

Lagge said, "If you are considering gastric bypass, tell your doctor truthfully about how much alcohol you currently drink." Once the surgery is done, patients must reduce the amount of food and beverages they consume or face serious health consequences, such as alcohol abuse.

Several high profiles DUI cases involving women, most recently the off-duty Sacramento County deputy who crashed into a Natomas Starbucks, prompted Friday's discussion on women and addiction.

Lagge added that alcoholism and addiction is a disease that "strikes all kinds of people, regardless of age, race, economic standing, gender or education."

"Having the disease does not mean you are immoral, weak or defective," and that recovery is a gradual process, like any other chronic disease, she said.

If you're wondering if you have a drug or alcohol problem, Lagge said consider the following questions:

1. Have you ever felt you should cut down or try to control your drinking or drug use?

2. Have you ever felt guilty or bad about your drinking or using drugs?

3. Do you ever take a morning eye-opener to steady your nerves or to get rid of a hangover? Do you use drugs or drink daily or weekly? Do you use prescription medications more often than prescribed?

4. Are alcohol or drugs sometimes more important that other things in your life, such as your family or your job?

5. Do you find yourself lying to your spouse, your kids, or your employer to cover up your drinking or using?

6. Have you ever switched from one type of drug to another to either prove you're not addicted or to help with withdrawal symptoms from another drug?

7. Have you had problems with your job, your relationship, finances, legal or your health due to your drinking or drug use?

8. Have friends or family members expressed concern for you about your drinking or drug use?

9. Have you gone to work or driven while intoxicated or in a drug-induced haze?

10. Have you been drunk or high more than four times in the past year? Do you sometimes stay drunk or high for days at a time?

11. Do you need more alcohol or drugs in order to do something (start the day, have sex, clean the house, socialize, for example) or to change how you feel?

12. Do you need more of the drug or alcohol in order to get the same effect?

13. Are you uncomfortable when you have to be somewhere where no alcohol or drugs will be available?

Lagge said if people answer yes to two or more of the above questions, "they are at the very least abusers and would benefit greatly from stopping."

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California woman seriously ill after gastric bypass surgery finds hope

Modesto, CA

Tests have shown that Sandi Krueger's golf-ball-sized pouch no longer breaks down the food she eats, but dumps it directly into her small intestine. Before the feeding tube, her attempts to eat caused nausea and she often had dumping syndrome, a reaction when certain foods pass too quickly into the intestine, resulting in sweating, rapid heart beat and weakness.

Her journey began in 2002 with a gastric bypass at Doctors Hospital of Manteca, which later closed its bariatric program. She had constant dumping and severe weight loss, had a falling out with her surgeon and went to the University of California at San Francisco for corrective surgery in 2004.

Her condition improved for several months and then her condition gradually deteriorated. She stopped working as a nursing assistant last year and then UCSF rejected her request for a reversal surgery.

Repairs are complex

She's made the 165-mile trip to Delano because Keshishian accepted her Medi-Cal coverage and he specializes in revising or reversing gastric bypasses. A reversal has some of the same risks as gastric bypass; in addition, the surgeon must deal with scar tissue that grows between the left side of the liver and upper part of the stomach.

"You have to peel the stomach away from the liver," Husted said. "It's tricky and can take a long time."

Many patients who aren't absorbing enough nutrients can improve with counseling and treatment, experts say.

Until her surgery is scheduled, Krueger will stay with the tube- feeding routine — 44 ounces of water mixed with a formula of protein, vitamins and other stuff costing the family $549 a month. With her husband drawing unemployment, it strains the family budget, but at least she feels healthy.

"It is nice to be a mom again," she said. "It feels like I have missed six years of my life."

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Obese student seeks charitable donations for gastric bypass surgery

Seattle, WA

A Seattle college student doesn't want to be the "biggest" man on campus and has started a Web site asking for donations to help him get gastric bypass surgery.

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Study identifies several risk factors linked to poor bariatric surgery utcomes

Cambridge, MA

Several risk factors may help identify factors linked to poor outcomes for bariatric surgery, according to the results of a prospective, multicenter, observational study reported in the July 30 issue of the New England Journal of Medicine.

"To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization," write David R. Flum, MD, from the University of Washington in Seattle, and colleagues from the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. "Concern about the safety of bariatric surgery has grown with its increasing popularity and has been heightened by periodic high-profile reports in the lay press of deaths after bariatric surgery and of the closure or threatened suspension of bariatric programs because of safety issues. Malpractice insurers have expressed concern about the increased risk they incur when they provide liability-insurance coverage to bariatric surgeons."

From 2005 through 2007, the investigators evaluated 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical US sites. For 4776 patients undergoing first-time bariatric surgery, the composite endpoint of 30-day major adverse outcomes included death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital.

Mean age of the study sample was 44.5 years, 21.1% were men, 10.9% were nonwhite, and more than half had at least 2 comorbid conditions. Median body-mass index (BMI), defined as weight in kilograms divided by the square of the height in meters, was 46.5 kg/m2.

The bariatric procedure performed was Roux-en-Y gastric bypass in 3412 patients (performed laparoscopically in 87.2% of these patients) and laparoscopic adjustable gastric banding in 1198 patients. The analysis excluded 166 patients who underwent other procedures. Among patients treated with Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding, 30-day mortality rate was 0.3%, and 1 or more major adverse outcomes occurred in 4.3% of patients.

Factors independently associated with an increased risk for the composite endpoint were a history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, and impaired functional status. Although extreme BMI values were significantly associated with increased risk for the composite endpoint, age, sex, race, ethnicity, and other comorbid conditions were not.

"The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics," the study authors write. "In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese."

Limitations of this study include possible lack of generalizability to the general community; limited size of certain patient subgroups, resulting in a type II error that did not identify a difference in safety among groups; comorbid conditions determined by patients' self-report; and inability to determine the case volume at the centers.

In an accompanying editorial, Malcolm K. Robinson, MD, from Harvard Medical School in Boston, Massachusetts, is hopeful that learning more about how bariatric surgery works may help develop even less invasive procedures.

"It is a sobering fact that some obese young adults may lose up to 20 years of life expectancy if they do not reduce their weight," Dr. Robinson writes. "One must treat obesity aggressively, though thoughtfully, and with an eye toward developing effective prevention and better therapies that ideally would eliminate the need for surgery altogether. But until we get to that point, the weight of the evidence indicates that bariatric surgery is safe, effective, and affordable."

The National Institute of Diabetes and Digestive and Kidney Diseases and the General Clinical Research Center supported the LABS study. Some of the study authors have disclosed various financial relationships with Covidien, legal firms representing cases involving bariatric surgery, Allergan, Pfizer, sanofi-aventis, Stryker, GlaxoSmithKline, Lilly Research, Legacy Health System, W.L. Gore and Associates, Ethicon Endo-Surgery, Johnson & Johnson, Tyco, and/or EnteroMedics.

Dr. Robinson has received consulting fees from Storz and has served as an expert witness in legal cases regarding standards of care in bariatric surgery.

N Engl J Med. 2009;361:445-454, 520-521.

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Studies underway to determine why obesity surgery thins bones

from Red Orbit

Experts say melting fat from obesity surgery somehow thins bones and even suggest that patients who undergo these procedures might have twice the average person's risk for a fracture, and are more likely to break a hand or foot, The Associated Press reported.

Further research is now under way to see if The Mayo Clinic's finding is significant. But specialists say uncovering long-term side effects from bariatric surgery and how to counter them takes on new urgency as more and more overweight people are electing to try it.

Dr. Shonni Joy Silverberg of Columbia University told last week's annual meeting of The Endocrine Society that these procedures are now being sold as a panacea.

"It is of heightened importance to find the answers to these questions," he said.

And perhaps the only positive thing you'll ever hear a doctor say about too much fat is that obesity actually is considered protective against bone-weakening osteoporosis.

Mayo bone-metabolism expert Dr. Jackie Clowes said overweight people are starting out better than most of us when it comes to staving off osteoporosis.

Therefore, researchers are working towards answering whether those who undergo the procedures really end up with worse bones, or just go through a transition period as their bones adjust to their new body size.

In the United States, some 15 million people are classified as extremely obese (100 pounds or more overweight). With rampant diabetes and other health problems, surgery is fast becoming the preferred treatment.

Options include stomach stapling called gastric bypass to less invasive stomach banding procedures, where patients tend to lose between 15 percent and 25 percent of their original weight — dramatically improving diabetes symptoms.

The American Society for Metabolic and Bariatric Surgery shows that more than 1.2 million U.S. patients have undergone the surgery in the past decade, 220,000 in the last year alone.

Now large National Institutes of Health studies on both adults and teens are underway to find more data on how patients fare many years after the surgeries.

However, doctors know that radical weight loss can speed bone turnover until the breakdown of old bone outpaces the formation of new bone.

A year after gastric bypass, adults' hip density drops as much as 10 percent, raising concern about a common fracture site of old age, according to more recent studies.

And while almost half of peak bone mass develops during adolescence, more research is needed to determine if teen bones react similarly.

The Mayo team is comparing the medical records of nearly 300 adults who've had bariatric surgery with similarly aged Minnesotans who haven't, to see if such changes translate into fractures.

Mayo's Dr. Elizabeth Haglind told the endocrinology meeting that a quarter of the 142 surgery recipients studied so far experienced at least one fracture in the following years. That group had twice the average risk six years after the surgery.

Interestingly, the surgery recipients had three times the risk of hand and foot fractures than their Minnesota neighbors.

Dr. Scott Shikora, president of the bariatric surgeons group, said he was shocked at the numbers because he hasn't seen a significant fracture problem in his own practice.

Shikora estimates about half of surgery patients follow their doctor’s advice to take extra calcium and vitamin D, and other research suggests higher doses may be needed anyway as the obese tend to start out with vitamin D deficiency.

“Don't skip checkups, where doctors monitor bone health, and aggressively treat nutrient deficiencies,” Clowes advised.

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Gastric Bypass surgery: Pros and Cons

Tulsa, OK

Gastric bypass surgery is growing more popular every year as America's obesity epidemic tips the scales. Even the elderly, and people with health problems are turning to this surgical solution to obesity.

It is a surgery that saves lives. But some also warn there can be life-changing drawbacks.

"These were 26 - and I wear a size 8 now," said Leslie Blunt as she proudly showed off the pants she will never wear again thanks to gastric bypass surgery. She has lost 140 pounds. "It works. It does. You live a healthier life," she added.

Micah Anderson chose gastric bypass surgery when his weight ballooned to 500 pounds. "Lost little over 200 pounds - easy," he told 2News anchor Karen Larsen. "I'm happy with myself. More confidence."

While gastric bypass is known for bringing on drastic weight loss, what many do not realize are specific changes it may cause for an individual, along with health benefits.

"A lot of this junk food they were eating before - their taste has disappeared they don't want it anymore," according to Dr. Luis Gorospe, gastric bypass surgeon at Bailey Medical Center in Owasso. Both Anderson and Blunt went to Dr. Gorospe for surgery. His patients come from surrounding states, drawn by his surgery success rate, the promise of dramatic weight loss and the immediate health benefits of gastric bypass.

"If they have diabetes - 70 percent of these patients wake up with normal blood sugar and will not require medications - forever," Dr. Gorospe said.

Studies show gastric bypass may improve or even eliminate such health problems as:

Leslie Blunt says she is living proof, "I don't have high blood pressure. I don't have diabetes. I am pill free."

However, Micah Anderson tells a different story. "I'll vomit maybe not every week - but if something doesn't agree it does come right back up."

When surgeons create a tiny new stomach for patients, vomiting is a common problem when patients eat too much, too fast - until they get used to their new, smaller stomach. Micah says he expected that - but then he started fainting - once behind the wheel of his car.

Anderson's wife Katie said, "The passing out has happened four times. Spells where he could potentially pass out... weekly!"

Frightened by the potential danger such episodes represented, the Andersons began researching online and discovered other gastric bypass patients having such problems.

"Describing the same kind of drunk-like symptoms, incoherent, can't talk, slurring the speech. and people were experiencing the same things," Katie added.

The Andersons say they went to numerous doctors and nutritionists, trying to find a physician who was experienced with gastric surgery side effects. After trial and error, they say they have finally found the right doctor to care for Micah. As a result, Micah now follows a diet carefully crafted to meet his personal needs. He eats every two hours, consumes plenty of protein and takes vitamins.

"For me its lack of eating. I forget to eat and that's what causes my issues. It's partially my fault as much as it is the surgery," Micah said. "If I don't follow the rules like they tell you - you do have issues."

Doctor Gorospe agreed. He said healthy eating - the same issue obese patients struggle with before gastric bypass - is more important than ever after surgery. "If you follow the rules, this surgery will be successful," Dr. Gorospe said.

Because some patients do encounter issues following surgery, and with their new lifestyle, Doctor Gorospe offers monthly support groups. "I make it a point of being there," he said. "I want to be available to my patients." The meetings offer patients an opportunity to share their stories and talk with Dr. Gorospe.

Micah did attend the monthly meetings. However, some of his problems did not occur until several years following the procedure. As a result of his struggle, the Anderson's suggest to those considering gastric bypass surgery: do plenty of research, know the rules they will have to live by, and read up on potential side effects.

"There is a list and, by golly, one of those things on the list will affect you," Katie Anderson said. "They just need to tell you flat out - you are trading one set of issues for another set of issues."

However, when asked if he would have the surgery again, Micah's answer is, "Unfortunately, yes." He went on to say he is pleased with his more than 200 pound weight loss. His joints ache less when he gets out of bed in the morning, and it is easier to be active.

Leslie Blunt agrees. Now, this svelte hair stylist says work is easy. No more suffering from carrying too much weight while being on her feet each day. Plus, she loves buying clothes with her new look and the fact that she is setting a good example for her young children by living a healthier lifestyle.

In fact, Leslie says gastric bypass surgery is the best thing she ever did for herself. "Yes! I would do it over and over and over again! I never want to be that way again."

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Gastric bypass surgery’s complications can be devastating for some patients

Modesto, CA

Sandi Krueger of Turlock, Calif., dropped 120 pounds with weight-loss surgery, but she is hardly a success story.

The 2002 surgery led to chronic malnutrition and anemia. As the pounds melted away, so did her life.

With a sunken face and protruding collar bones, she is too weak to work and spends most afternoons on the couch wrapped in a blanket.

She has thoughts of giving up, but wants to be there for 12-year-old daughter Megan and 19-year-old son Dustin.

“It’s not acceptable leaving me like this,” said the 103-pound Krueger, who at 38 looks closer to 50. “I’ve gone to doctor after doctor and basically they don’t help me.”

According to studies on bariatric surgery, patients with long-term complications are in the minority and disastrous outcomes such as Krueger’s are rare. But with 200,000 weight-loss surgeries being performed each year, she and other patients believe the long-term complications deserve more attention.

Looking for hope

Krueger’s options appear to be running out. Her anemic blood hasn’t been responding to iron shots and she was told last month that she can’t have the gastric bypass reversed.

“This isn’t a life,” said Robert De Kasha, her brother. “If she doesn’t find an answer, she is just going to fade away.”

Spurred by a national epidemic of obesity, bariatric surgery has become a standard of care for people with weight-related health issues. It has improved the lives of people who suffered from diabetes, high blood pressure, sleep apnea and other issues, experts say. No one is sure why some bariatric patients fare better than others.

The stomach-shrinking surgery has risks, such as leaks that can cause life-threatening infections, hernias and bowel obstructions. After the surgery, patients are expected to follow nutritional and lifestyle guidelines to achieve weight loss and avoid trouble with their altered digestive tracts.

Most patients will have “dumping syndrome” at some point, when food passes too quickly from the tiny stomach pouch into the small intestine. Because the stomach hasn’t broken down the food, the person gets a rush of blood sugar, rapid heartbeat, sweating and nausea.

Other patients may have iron and vitamin B-12 deficiencies years after surgery. All bariatric patients need to take vitamin supplements for life.

A nationwide study released in 2006 concluded that bariatric surgery complications are common. By examining insurance claims for 2,522 surgeries, researchers with the federal Agency for Healthcare Research and Quality found that 40 percent of patients had complications in the six months after surgery, about double the rate in previous studies.

The complications ranged from the minor to the severe, including dumping syndrome, problems with the bariatric connections, hernias, infections and pneumonia. Post-surgery problems sent 18 percent of patients back to the hospital, some for costly readmissions or corrective surgery.

The agency contends that surgical advances recently have lowered the complication rate to 30 percent, still high for an elective procedure, said William Encinosa, lead author of the study.

“Anytime you can cut into the intestine, you have a risk of complications,” he said. “Clearly there are benefits for people who are morbidly obese, but these patients need to know what they are getting into.”

Live longer

Less is known about complications years after the surgery, although a 10-year Swedish study found many patients kept the weight off and had increased longevity.

Krueger, who once worked two jobs as a nursing assistant, sought treatment for an injured back in 2002. A specialist suggested that the 5-foot, 250-pound woman lose weight through bariatric surgery to deal with the back problem, she said.

She had what’s called a Roux-en-Y gastric bypass at Doctors Hospital of Manteca, Calif. To perform the common procedure, surgeons create a small pouch from the stomach and make a connection between the bottom of the pouch and a section of small intestine.

Most of the stomach and part of the intestine are bypassed, so the person feels full after a few bites of food and the intestine absorbs fewer nutrients.

Krueger, weighing 219 by the time of surgery, lost weight quickly as dumping syndrome made her sick for months. When she went to the doctor with complaints, he urged her to stick with the dietary instructions and take supplements, she said.

Bariatric surgeries were discontinued at Doctors Hospital of Manteca, so Krueger sought help from specialists at University of California at San Francisco Medical Center. In 2004, surgeons there corrected a problem from the initial surgery and, as her strength returned, she got up on water skis for the first time.

She gained 22 pounds, then her troubles returned and she bottomed out at 98 pounds.

With her body starved of nutrients, her blood sugar dropped so low she was admitted to Emanuel Medical Center for a week of monitoring, she said.

Tests have shown that her pouch no longer holds food but dumps it directly into the small intestine. Even if she eats five times a day, she doesn’t get the protein and other nutrients she needs.

She’s tried protein bars and countless other foods and even finds that fish is hard on her digestive tract. Daughter Megan brings her toast and crackers because she knows those are easy on her stomach.

Krueger said it’s heartbreaking for her daughter to see her tired and faint all the time. She has lost hair, her teeth are decaying, and she’s often out of breath.

To treat her anemia, she’s had a blood transfusion and three rounds of iron infusions. A reaction to the last infusion caused her blood pressure to plummet and nurses to come to her aid.

Second thoughts

Last year, she was considered for having the gastric bypass reversed at UCSF, but doctors told her in December that it was too dangerous. They were concerned that her remaining stomach would have inadequate blood flow and would rot, she said.

“That day was hard for me,” she said. “I don’t know what is ahead. I feel my life has been taken from me.”

Dr. Guilherme Campos, director of bariatric surgery at UCSF, said about 1 percent to 4 percent of the center’s patients suffer from nutritional deficiencies over the long term. The UCSF center has dieticians and other staff to work with patients with malnutrition. Reversal operations are major procedures and are done as a last resort, he said.

The surgeon contended that bariatric surgery is an effective way to treat morbid and superobesity, the main reason university hospitals have adopted the treatment in recent years.

“The benefits by far outweigh the risks that are associated with the procedure,” he said.

While many patients sing the praises of weight-loss surgery, including television personalities Al Roker and Star Jones, some patients say they’ve had a tough time.

Donna Sellers, 61, of Modesto, said four members of her family had weight-loss surgery with mixed results. Her husband and younger daughter lost weight with no complications. But Donna shed weight too fast and suffered from dumping, malnutrition and dehydration the first year after her 2004 surgery at Memorial Medical Center.

Attempts to eat made her feel sick and sweat profusely, even though she followed the guidelines to eat pureed food and take small bites, she said. She went from 246 pounds to 123 in six months and landed in the emergency room, where she was treated for dehydration for several hours, she said.

She finally discovered she could eat chicken and Swiss cheese, and force-fed herself. To deal with the hot flashes of dumping syndrome, she laid on the cold floor tiles of her kitchen to eat meals, she said.

Five years after the surgery, she still is forcing herself to eat and is relying on her nursing training to maintain her weight in the 130s.

“I eat three or four bites and then wait 10 minutes and eat some more,” she said. “I eat a scrambled egg for breakfast, and tomorrow a scrambled egg makes me sick.”

She said one of her daughters had the same post-surgery troubles, as well as a calcium deficiency resulting in dental problems.

A 2001 surgery in Southern California saved Alycsha Bostic of Merced, Calif., from sleep apnea and asthma attacks. But she developed hernias requiring two operations and iron deficiencies that cause headaches and dizziness.

Losing 160 pounds boosted her fertility and she got pregnant twice despite being on birth control, she said. Doctors put a port in her chest to feed iron into her blood during pregnancy. Her ferrous levels are a third of normal since her second child was born in 2007.

Bostic, 34, hopes doctors can figure how to get more iron into her system — and she needs another hernia operation.

“I am so tired of having surgery,” said Bostic, who talks with other bariatric patients with complications. “We’ve all had hair loss. I still get dumping syndrome. If I don’t chew my food 50 times, it collects at the bottom on my esophagus and I throw up.”

More than 3,000 weight-loss surgeries have been performed at Memorial Medical Center in Modesto since 2003.

Deana Chiarchianis, health center manager, said the post-surgery complications at the hospital are far lower than the numbers in the AHRQ report. The study considered data before widespread use of laparoscopic techniques, which have reduced problems such as surgical wound infections and hernias, she said.

The hospital tries to ensure good outcomes by evaluating and educating surgical candidates, including a psychological assessment of their ability to cope with the surgery. It also stresses post-surgery guidelines such as teaching patients to prevent dumping through the proper choice of foods.

“They need to understand that the surgery is a tool and the patient is responsible for complying with the recommendations for follow-up, nutrition, exercise and behavior change,” she said.

Dr. Kelvin Higa, a Fresno, Calif., surgeon and past president of the American Society for Metabolic and Bariatric Surgery, said it’s important for patients to have lifelong follow-up with their surgeons. Usually, there are surgical options for patients with severe complications such as Krueger’s.

“Any patient that has those problems should not be sitting there. They should seek help,” he said. “Almost invariably we can take these patients and adjust their anatomy to take care of their nutritional issues.”

Krueger said her poor health has taken a toll on family life. No longer does she take Megan to cheerleading and dance classes. She and her husband have postponed their dream of building a home.

Krueger worked as long as she could at Emanuel Medical Center last year to keep her health benefits, but ran out of strength. Her primary care doctor is trying to line her up with a nutritionist or hematologist who accepts Medi-Cal.

A feeding tube could be next if she loses more weight, which reminds her of a 32-year-old bariatric patient at a care facility where she worked.

“She had a feeding tube and it really bothered me,” Krueger said. “If I don’t get better, I know my organs will take a toll. If they would put me on the operating table to take me back to 250 pounds, I would do it.”

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The trouble with gastric bypass surgery

Phoenix, AZ

Many extremely obese people these days, under the mistaken belief that it will be the answer to their health problems, are flocking to get gastric bypass surgery. Now this treatment option may be pushed on even more people. A study published in The American Journal of Managed Care reports that bariatric surgery can "pay for itself" by diminishing the number of insurance claims filed by people who are grossly overweight.

Gastric Bypass Surgery Is No Picnic

However, gastric bypass surgery has many associated risks. The risks, according to a Mayo Clinic article, include death, blood clots in the legs, leaking at the staple lines in the stomach, incision hernia, narrowing of the opening between the stomach and small intestine, dumping syndrome, iron deficiency anemia, vitamin B-12 deficiency, vitamin D deficiency, dehydration, gallstones, bleeding stomach ulcers, intolerance to certain foods, kidney stones, low blood sugar, body aches, fatigue (like when one has the flu), feeling cold, dry skin, hair thinning and hair loss, and mood changes. Of course, there are also the same risks that go along with any surgery, like bleeding, infections, and adverse reactions to the anesthesia. That doesn't exactly sound like a picnic, no pun intended.

Will Surgery Save Insurance Companies Money?

Unfortunately, there is even more reason to be concerned about gastric bypass surgery. Dr. Douglass warns in an article that the funding for the study that purports that this surgery will save insurance companies money came from a company known as Johnson & Johnson's Ethicon Endo-Surgery, Inc., which is a major manufacturer of bariatric surgical instruments. Additionally, Dr. Douglass points out that Dr. Scott Shikora, a co-author of the study, is the president of the American Society for Metabolic and Bariatric Surgery. It's easy to see that the members of this group would clearly benefit if insurance providers would decide that they could save money if more patients were approved for this course of treatment.

Up to Five Percent Die Within a Year of Surgery

The sad truth of the matter is that, according to Dr. Douglass, up to five percent of the patients who undergo this course of treatment are dead within a year. (That's certainly one way to trim down future medical costs.) While Dr. Douglass believes that surgery should always be a last resort, many other doctors believe that the current requirement by insurance companies that people first try to lose weight by a six-month doctor-supervised weight loss program is unreasonable. Says Douglass: "People like Shikora would prefer that patients go right from the dining room table to his operating table." While natural health advocates might not agree with Dr. Douglass on all of the issues, most certainly appreciate his acerbic wit. Hmmm... was the guy who said that "the way to a man's heart is through his stomach" a bariatric surgeon?

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Study: Gastric bypass not effective diabetics

San Francisco, CA

Gastric bypass has helped thousands of people effectively lose weight, but a new study finds diabetics who undergo the surgery are less likely to see good results.

Researchers at the University of California San Francisco studied over 300 gastric bypass patients a year after their procedure.

They found patients with diabetes were unable to lose more than 40-percent of their excess body weight.

Researchers believe the medications diabetics take like insulin actually stimulate the body's production of fat and cholesterol.

They say changes in the use of these medications could give diabetics a better chance to achieve better weight loss results after gastric bypass.

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Risks of gastric-bypass surgery are often underplayed, some experts say

Greenwood Lake, NY

Despite the growing popularity of obesity surgery, it’s no easy path. Four in 10 patients developed complications within the first six months, according to one study.

Eileen Wells was smiling as she was wheeled into surgery. She was too excited to feel nervous. At 38, she was about to get “a new lease on life,” she says, echoing jargon in weight loss surgery ads. She had seen the before and after pictures in celebrity tabloids, watched the TV infomercials, listened to the patient testimonials and researched online. She was ready to begin her own transformation. At 5 foot 3 and 290 pounds, she was sick of being fat. Her joints ached. Her feet hurt. A stroll through the mall near her home in Greenwood Lake, New York, was enough to leave her sweat-slick and gasping for air. She was anxious to say good-bye to sleep apnea and dieting, ready to take control. And so in March 2005, Wells underwent a laparoscopic gastric bypass. She was grinning right up until the anesthesia knocked her out.

From the menu of weight loss (bariatric) operations, Wells had chosen the Roux-en-Y bypass, the most popular option in the United States. The surgery sectioned off her stomach to a thumb-sized sac — sharply limiting the amount of food Wells could eat — then connected it to a deeper portion of her small intestine, to limit absorption of the calories she did consume. (An increasingly popular alternative, gastric banding, cinches in the stomach to restrict its capacity.) The rearrangement required Wells to radically overhaul her eating habits. She learned to eat tiny, frequent meals, cutting her food into pencil eraser–sized bites. On her doctor’s orders, to replace nutrients no longer absorbed by her digestive tract, she faithfully swallowed a multivitamin, calcium and B12 supplements and two protein shakes daily. Soon she resembled the women in those weight loss infomercials: Fifteen months post-op, Wells had lost an amazing 160 pounds — more than half her body weight — bringing her down to a trim 130.

But although Wells looked like a satisfied customer, she didn’t feel like one. Seven months after surgery she had developed an agonizing ulcer on the new inner seam between her stomach and intestine, which required a second operation. Not long afterward, Wells recalls eating a bite of tuna steak her husband, Ron, had prepared and doubling over in pain; an ambulance rushed her into surgery yet again, this time for an intestinal hernia — her bowel had snagged on a slit in her abdominal wall. A fourth procedure followed to ease the pain of the abdominal scarring from her previous surgeries. Meanwhile, Wells’s gastrointestinal pain had become so severe that she could barely eat. One day while shoe shopping, she realized she couldn’t flex her right foot. Within weeks her limbs began to tingle, her energy evaporated and her weight plummeted. She stopped menstruating. By late 2006, Wells had shrunk to 105 pounds.

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Laparoscopic gastric bypass provides better results

New York, NY

Performing gastric bypass surgery to reduce the weight of morbidly obese patients using a laparoscopic method, rather than the conventional more invasive "open" abdominal method, reduces postoperative complications, the need for a second operation, and shortens hospital stays, new research shows. Nevertheless, laparoscopic gastric bypass is more expensive.

Obesity surgery, also called bariatric surgery, is growing in popularity and more and more of these operations are being done using a laparoscope, note co-authors Dr. Wendy E. Weller, from the University at Albany in New York, and Dr. Carl Rosati, from Albany Medical Center.

This is done by placing one or more small incisions in the abdomen, through which a hollow tube is inserted. This allows very small instruments to be inserted to perform the gastric bypass. The entire procedure is visualized on a screen. In contrast, the more invasive "open" procedure involves making an incision to open the abdomen so the procedure can be performed.

The current study, reported in the Annals of Surgery, involved an analysis of data from 19,156 subjects who underwent gastric bypass surgery in 2005 and were logged in the Nationwide Inpatient Sample, the largest all-payer inpatient database in the U.S.

Slightly less than 75 percent of the patients underwent laparoscopic gastric bypass, the report indicates.

Laparoscopic gastric bypass was linked to a reduced risk of several complications. With open surgery, the risk of pulmonary complications was increased by 92 percent, for cardiovascular complications it was 54 percent, for sepsis, a serious system-wide infection, the risk was more than doubled and the risk of anastomotic leak, leakage from the operative site, 32 percent higher.

On average, performing laparoscopic rather than open gastric bypass reduced the hospital stay by about 1 day.

The average total charges were similar for the two procedures, but median total charges were significantly higher with laparoscopic gastric bypass: $30,033 vs. $28,107 respectively.

After accounting for various patient and hospital factors, laparoscopic surgical patients were less likely than their open-surgery counterparts to require reoperation, the investigators found.

While these findings suggest some advantages with the laparoscopic operation, "most reassuring for the bariatric surgery community is that the hospital outcomes were excellent overall in both the laparoscopic and open procedures," Dr. Michael G. Sarr, from the Mayo Clinic in Rochester, Minnesota, comments in a related editorial.

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Post-gastric byass body lift surgery, only way to lose excess skin

New York, NY

Tipping the scale at 330 pounds, 47-year-old Cindy Schreiner decided to get gastric bypass surgery in 2002.

“I was downtown on 9-11,” Schreiner recounted. “And I couldn’t run … I had a colleague pulling me down the street saying come on, you can run, you can run and I just thought, I can’t move anymore and I was so huge.”

It was turning point for Schreiner, who has lost 185 pounds to date.

But working out daily and changing her eating habits has not helped Schreiner obtain the body she has always wanted.

“I would grab the skin and go I want this gone,” she told FOXNews.com. “Because I had worked so hard to lose the weight and I didn’t see all the benefits because the skin was hanging.”

Click here to watch Schreiner tell her story.

Dr. Lyle Leipziger, chief of plastic surgery at Long Island Jewish Medical Center and North Shore University Hospital, said weight loss surgery is only half the battle for patients like Schreiner.

The majority of patients have excess skin, which could weigh five to 10 additional pounds. As a result, psychological and physical issues often plague patients after weight loss surgery.

“We've had patients that have excess abdominal skin almost hanging down to their knees,” said Leipziger, adding that the skin sometimes makes it difficult for patients to walk or move. “Patients can come in and sometimes they can get infections in the area underneath that abdominal extra skin.”

Body lift surgery was the answer to Schreiner’s problems. Sort of like a tummy tuck for your whole body, Leipziger said, a body life is the only way for these patients to get rid of the extra, baggy skin.

“You feel self-conscious about it,” she said. “You feel like you have, you’re flattening it, pushing it down … to hide it.”

But even with surgery, results do not happen overnight.

“The patient should have most importantly realistic expectations, understand that we can do a lot, we can’t turn people into supermodels, but we can certainly improve their appearance and quality of life.”

Schreiner has undergone five body lift procedures to contour her tummy, breasts, outer thighs, buttock and back. With one more surgery left to go, Schreiner is excited to finally have her "dream body". “I feel like I’ve been given a new life,” admitted Schreiner. “I’ve always dreamt of looking like this. I really did. And it’s like, I’m here.”

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Nutritional deficiencies after Roux-en-Y gastric bypass often cannot be prevented by standard multivitamin supplements, study says

Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation

From the American Journal of Clinical Nutrition, Vol. 87, No. 5, 1128-1133, May 2008

Background: Despite the increasing use of Roux-en-Y gastric bypass (RYGBP) in the treatment of morbid obesity, data about postoperative nutritional deficiencies and their treatment remain scarce.

Objective: The aim of this study was to evaluate the efficacy of a standard multivitamin preparation in the prevention and treatment of nutritional deficiencies in obese patients after RYGBP.

Design: This was a retrospective study of 2 y of follow-up of obese patients after RYGBP surgery. Between the first and the sixth postoperative months, a standardized multivitamin preparation was prescribed for all patients. Specific requirements for additional substitutive treatments were systematically assessed by a biologic workup at 3, 6, 9, 12, 18, and 24 mo.

Results: A total of 137 morbidly obese patients (110 women and 27 men) were included. The mean (±SD) age at the time of surgery was 39.9 ± 10.0 y, and the body mass index (in kg/m2) was 46.7 ± 6.5. Three months after RYGBP, 34% of these patients required at least one specific supplement in addition to the multivitamin preparation. At 6 and 24 mo, this proportion increased to 59% and 98%, respectively. Two years after RYGBP, a mean amount of 2.9 ± 1.4 specific supplements had been prescribed for each patient, including vitamin B-12, iron, calcium + vitamin D, and folic acid. At that time, the mean monthly cost of the substitutive treatment was $34.83.

Conclusion: Nutritional deficiencies are very common after RYGBP and occur despite supplementation with the standard multivitamin preparation. Therefore, careful postoperative follow-up is indicated to detect and treat those deficiencies.

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Despite risks, gastric-bypass surgeries soar

Herald, FL

Monica Ramos lost about 200 pounds the hard way.

In 2004, a doctor stapled her stomach and rerouted her intestines.

A year later, Ramos collapsed in her home and was rushed to the hospital, where she needed another operation to stop internal bleeding.

Her weight-loss surgery represents the gamble that legions of morbidly obese Americans are taking every year. For many, it is worth the risk.

When Ramos had her initial operation, she was on 17 medications for diabetes and other ailments. Today, she needs no prescriptions. Her diabetes is gone; she feels great.

But the soft-spoken nursing student warns that surgery is not a cure for obesity.

"This is a lifelong commitment, and there are going to be days when you're sorry you've made this commitment," said Ramos, 26, who runs a support group in Orlando for weight-loss-surgery patients.

If current trends continue, she will be busy.

Weight-loss surgery -- commonly referred to as bariatric surgery -- has exploded in the United States from an estimated 16,200 procedures in 1992 to about 205,000 in 2007. More >>

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Gastric Bypass: Star Jones Opens Up About Her Weight Loss

November 22, 2007

For years, Star Jones Reynolds refused to reveal how she lost half of her body size, but now a confident and secure Star is talking in detail about her gastric bypass surgery --- to Access Hollywood’s Tim Vincent.

“The only reason I am talking to you today is to help other women understand they are not by themselves. They are not alone,” Star told Tim.

“Do you regret not having said something earlier?” Tim asked.

“I really wished, god, I could have. I really do. If there’s a regret that’s it,” Star said. “The regret is I wish I was stronger.”

Undergoing gastric bypass surgery in 2003, it wasn’t until August of this year that Star Jones Reynolds finally went public on how she dramatically lost 160 pounds. More >>

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LAP-BAND(R) System Weight-Loss Surgery Associated With More Than 70 Percent Reduced Risk of Death in People With Severe Obesity

November 21, 2007

About Obesity

In the United States, obesity is considered the second leading cause of preventable death (7). Further, research has shown that individuals with a BMI of 35 or more have a reduced life expectancy of nine to 13 years (8). A BMI of 35 or more translates to a weight of 200 pounds or more for a woman of average height (5' 4") when ideal weight at this height is considered to be 140 pounds, and to a weight of 250 pounds or more for man who is six feet tall when ideal weight for this height is considered to be 177 pounds.

About the LAP-BAND(R) System

The LAP-BAND(R) System was approved by the FDA in June 2001 for severely obese adults with a Body Mass Index (BMI) of 40 or more or for adults with a BMI of at least 35 plus at least one severe obesity-related health condition, such as Type 2 diabetes, hypertension and asthma. Used in more than 300,000 procedures worldwide, this simple reversible surgically implanted device has safely helped severely obese adults successfully achieve and maintain long- term weight loss.

The LAP-BAND(R) System was developed to facilitate long-term weight loss and reduce the health risks associated with severe and morbid obesity. Unlike gastric bypass, it does not involve stomach cutting, stapling or intestinal re-routing (9,10). Using laparoscopic surgical techniques, the device is placed around the top portion of the patient's stomach, creating a small pouch. By reducing stomach capacity, the LAP-BAND(R) System can help achieve long-term weight loss by creating an earlier feeling of satiety. The LAP-BAND(R) System is adjustable, which means that the inflatable band can be tightened or loosened to help the patient achieve a level of satiety while maintaining a healthy diet. It is also reversible and can be removed at any time.

Severely obese people who received the LAP-BAND(R) Adjustable Gastric Banding System to lose weight had a 72 percent reduction in their risk of dying compared to obese people who were not offered any specific weight-loss treatment, according to findings published in the December issue of the Annals of Surgery (1). The LAP-BAND(R) System was approved in June 2001 by the U.S. Food & Drug Administration for weight reduction in severely obese adults.

"This research is critical because it shows that people with severe obesity, who are known to be at a much higher risk than the general population for dying prematurely, may be able to significantly decrease their risk with laparoscopic adjustable gastric banding," explains Dr. Paul O'Brien, FRACS a study author from the Monash University Centre for Obesity Research and Education (CORE) in Melbourne, Australia, head of the Centre for Bariatric Surgery in Melbourne and the National Medical Director for the American Institute of Gastric Banding in Dallas, Texas. "What is also particularly compelling is that this study shows it is possible to gain a significant survival benefit without the risks associated with more invasive bariatric surgical procedures, such as gastric bypass." http://www.earthtimes.org/articles/show/news_press_release,228703.shtml

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Singer Tammy Fletcher's Gastric Bypass Story

A different tune: Singer Tammy Fletcher: On her career, weight loss, her life

Tammy Fletcher is known for her big voice and commanding stage presence. But in the past two years, the Eden singer’s presence has physically shrunk. The 47-year-old diva lost 170 pounds off her 5-foot, 4 inch-tall frame.

The weight loss was spurred by the discovery that Fletcher had Type 2 diabetes and further fueled by her mother’s death last year. A stressful job and unhealthy lifestyle factored into her weight gain, which topped at 344 pounds.

“I was an apple — a very big apple. But I carried it well. I’m an entertainer, and I have a good self-esteem,” said Fletcher, speaking by phone from her home this week. “But it’s a very unhealthy lifestyle for me.”

Fletcher lost 70 pounds through diet and exercise before she decided to have gastric bypass surgery in November last year. She’s lost 100 pounds since.

Here the well-known jazz, blues and gospel singer talks about her life-altering weight loss, her career and the “second half” of her life:


On why she undertook such a huge lifestyle change:

“I’m going to be 50 years old soon, and I want the other half of my life to be one of physical fitness. To do anything I want to do — to ride on a roller coaster because I’ll fit, to wear a size 12, which I do now. I don’t want my frame to get in the way of that.”

“Everyday of my life I’ve dedicated to service. ... For once I want to take care of myself. Me first. Then I can do a better job at all the other stuff.”


On gastric bypass:

“I had gastric bypass. I need to tell people because they say I did it the easy way. In no way do I recommend this surgery to anyone. It was the most difficult thing I’ve ever been though. It was grueling, painful. It was a lifestyle change. It is a tool, not a miracle.”


On discrimination she faced for being overweight:

“I didn’t mind being a big girl. I loved being a big woman. ... It was just an outer shell. I didn’t like the way the world treated me. I didn’t like having to not to sit in an airplane without getting an extension, things like that bothered me. I liked myself. I tried to be a good role model for other large women. I try to carry the torch, to fight that fight. To not allow discrimination that is blatant.”

“I was booed at the Apollo not because I was white — because I was fat. Fat and white are a double death. Until I opened my mouth, and I won — until I sang, and I proved myself. I got tired of holding that torch.”


On her slimmer persona:

“I am who I am. I’m just a smaller version of that person. I command attention, no matter if I’m as big as I was or as medium as I am now. ... I’m half the girl I used to be, and I’m still a ton of fun, as I like to say. And I mean it. Now I can juggle more than one or two things.”

“I think it’s funny, people just stare at me. They don’t believe how I could possibly do this. Some people were angry; they missed this big girl who I was. That’s their problem.”


On her voice:

“People ask silly questions like ‘Is your voice the same?’ I can still sing, and I have more energy now to sing longer. Because I was so heavy it was an incredible workout to sing, it was very tiring. I was warm all the time, sometimes I’d get lightheaded and I never knew why. (Diabetes) was coming on. My body was starting to show signs.”


How her renewed health affected her career and propelled her back into the recording studio in December:

“I have a purpose. There’s meaning to my life, and I have a direction and I couldn’t do it being unhealthy. One of which is writing my own music and recording an album of my stuff with musicians who are the best. I couldn’t do it because I was physically unhealthy, depressed and just sick, physically sick.”


On continuing to lose weight and maintain her health:

“I have a sweet tooth, and it’s tough for me. My blood sugars are all normal because I’ve lost so much weight. I’ve been able to maintain it and keep a healthy attitude about it and realize it’s about portion control. A calorie is a calorie is a calorie.”

“I completely changed the amount of food I ate. I changed the quality of the food I ate. I don’t eat fast food. I try to pre-prepare ... I’m not perfect at this, I’m just learning. I work out on a daily basis in a small way. Anything I can do, whether its dancing in my house, running up and down the stairs. Every step counts. Don’t think it doesn’t because it all adds up.”

Her advice to people who are considering gastric bypass surgery:

“If you can do it conventionally, do it. (The surgery) saved my life, but by no means is it simple. I cannot stress support enough. You must surround yourself with people who support you on this. You cannot support yourself with naysayers. You will suffer.”

“I didn’t go into this lightly. This is a serious change of life and your family will change with you or they won’t. You’ll have to bear that. It’s not about your family it’s about you.”

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