Iron Deficiency After Bariatric Surgery

We need iron to stay healthy. 

Usually the amount of iron we ingest in our diet is enough to keep up with our needs.

The iron we ingest as food is absorbed very efficiently by the first part of our small intestine.

However, gastric bypass patients have reduced ability to absorb iron since the first part of the small intestine is bypassed along with much of the stomach.

Anemia, or decreased red blood cells, may be the result of not absorbing enough iron. Persons who are anemic often look pale and feel tired. If the anemia is severe the heart rate may increase to compensate for too few red blood cells to transport oxygen to the body. In some situations this increased heart rate can be dangerous.

Persons who are anemic often crave ice and eat ice frequently.

To prevent iron deficiency anemia we suggest a gastric bypass patient consider iron supplementation taken by mouth.

To check if someone has an iron deficiency anemia doctors check a ferritin level as a blood test. If this is low we know the person has low iron storage and iron deficiency is likely to be the cause of their anemia and we will place them on daily iron supplementation.

This supplement should be Ferrous Fumarate or Ferrous Glucanate since the usual form of iron supplementation, Ferrous Sulfate, will not be absorbed well since it needs acid to make the iron available for absorption and the new small gastric pouch formed at the time of the gastric bypass makes very little acid, Ferrous Sulfate is likely to pass out in the stool without being absorbed.

You any need to remind your family doctor about this since he or she are so used to writing for Ferrous Sulfate and may forget you need a different form of Iron.

Menstruating women are a particular risk for anemia since they may have difficulty keeping up with their monthly blood loss. In this situation a woman with iron deficiency anemia will be referred to her gynecologist for intervention like hormonal therapy, endometrial ablation or even hysterectomy. 

If these interventions are not acceptable she may need to be seen by a hematologist for periotic intravenous iron infusions.

Of course a thorough evaluation is often in order. This may require a colonoscopy since patients with a history of obesity have a higher risk of colon polyps and colon cancer.

Avoiding Constipation after Bariatric Surgery

Patients often complain of constipation after bariatric surgery. Constipation can happen a few weeks after surgery or complaints may continue for months or even years. 

Why do people often have constipation following bariatric surgery? This symptom is usually the result of too little fiber in the diet following bariatric surgery.

After a gastric bypass, gastric sleeve or even a gastric band, patients are asked to take liquids for several weeks and slowly transition through puree to soft and eventually to regular foods. However, often these foods are low in fiber. Also since portion sizes are smaller less total fiber is consumed.

The solution?

1)     Fiber – 25 grams every day. If you are consistent your stools should be softer and more regular in 2 weeks.

2)     Choose soluble fiber that dissolves in water and is tasteless such as Benefiber or another soluble fiber product suggested by your pharmacist.

3)     Avoid gooey fiber products (such as Metamucil) or tablets (such as Fibercon) since they may be difficult to pass through the modified stomach.

4)     Make sure sugar or other calories are not added to your fiber product. You do not want the extra calories.

5)     Take the supplemental fiber every day whether you feel you need it that day or not. This is a long term solution not a quick fix.

6)     Taper to smaller amounts of supplemental fiber slowly as your regular diet includes more fiber.

7)     Stool softeners may help but you need enough fiber to make sure you have stool to soften.

Other suggestions:

1)     Avoid narcotic pain meds where possible as all narcotics slow bowel function and cause constipation.

2)     Discuss adding fish oil to your medicines with your doctor. Fish oil may improve your cholesterol and help constipation as well.

3)     For temporary and rapid relief I would suggest as much Miralax as needed. Other products such as Milk of Magnesia can provide relief as well.

Being proactive by taking enough supplemental fiber soon after surgery can help you avoid this problem altogether!

Doing Great Six Years After Bariatric Surgery

I recently received this note from Joanna Baker who had her gastric bypass 6 years ago. She she has some great words of wisdom and encouragement. Here is what she wrote:


Dr. Myers,

Now

Before

I just was having one of those times of reflection, counting my blessings, and you and your program are near the top of my list. I am so grateful at your dedication to good medicine, safe practices, and stellar patient outcomes.

I can't believe that it's been 6 years since I started this journey with you! My six-year surgery anniversary is in September, and my BMI is still 25 (down from 45).

My best advice for those considering or just having had weight-loss surgery--allow the surgery and recovery to give you the precious gift of the time and physiologically forced discipline you need to recover from dependence on sugar.

Patients who are considering or who have just had weight-loss surgery, especially bypass, no doubt understand the need to avoid sugar, particularly processed sugar, and particularly in the absence of fiber (which is why I'm so grateful for fiber-rich fruits)!

Don't ever go back! Don't dabble. Don't toe dangle. Read labels. Try not to consume anything with more than 5 grams of sugar per serving. There it is. The rules I live by.

Do I miss sugar? No! (Though I'm sure results will vary patient to patient.) I am sure that this is why I have not struggled with keeping the weight off. I'm also sure that if I started playing games with myself trying to find the "safe" amount of sugar I could consume, my body would remember "the good old days" of sugar-coma bliss, start building a "tolerance level" for sugar, and I would end up back where I started more than 6 years ago--a slave to my sugar addiction.

I follow the other rules too. I don't use straws, I don't drink carbonated beverages (OK--this one is really hard for me. I genuinely miss Diet Coke, especially on a hot summer day! Still, it's not worth it.), I eat slowly, and genuinely enjoy the colors, flavors, aromas, and textures of my meals, as well as some really good company as often as possible (aka, family dinner)! I eat several small meals a day. (You will rarely find me without a baggie containing a variety of nuts and Kashi Heart-to-Heart cereal in my purse!)

I am so grateful for the time and discipline that by-pass surgery gave me. It's the best decision I ever made for my health and quality of life. I would never go back!

With warm, fond regards and much gratitude,

Joanna Baker

Avoiding Skin Fold Irritation

Avoiding Skin Fold Irritation in Warm Weather

We have had several very warm days already this Spring. Summer will soon be upon us.

During warm weather my patients often complain of a rash or skin ulceration especially in the abdominal skin fold or under the breasts. These are areas where skin lies on skin and there is little opportunity for evaporation. As the weather becomes warmer we sweat more. These dark moist, regions are a "set up" for the yeast (or fungus) we all have on our skin to grow much more rapidly. The yeast can be irritating to the skin, deposit a white paste like material and result in a foul smell.  The skin becomes red and irritated like a diaper rash and can lead to skin break down bleeding and ulceration.

If you have this problem and may have interest in having the skin removed by a plastic surgeon I would suggest you take pictures of the irritation and keep the pictures on file to show your plastic surgeon. This may you get insurance coverage for removal of the skin since it would be considered medically necessary and not cosmetic.

I discussed this with a friend of mine who is a dermatologist and he suggested a great product that I have found works really well. This is a powder that you can purchase at your local drug store over the counter called Zeasorb-AF. This seaweed based powder is excellent for absorbing liquid that can accumulate on the skin and the AF is for the anti-fungal ingredient Miconazol Nitrate that will kill the yeast.

Here is how I would suggest you use it.

Clean the areas well during your morning bath or shower and gently pat dry with the towel. If necessary dry with a hair drier but make sure not to burn the skin. Apply Zeasorb-AF powder to the affected area. Repeat later in the day if necessary.

This product is great to prevent groin irritation and athlete's foot as well.

So stay dry and enjoy your Summer without the skin fold irritation!

Gastric Sleeve: Eating for Success

Successful Weight loss after a Gastric Sleeve Operation

Remember, for those of you who have had a Gastric Sleeve Operation, you have asked your bariatric surgeon to reduce the size of your stomach to only about ¾ to one cup is size.  The outlet of the stomach is restricted by the Pylorus, (the circular muscle located at junction of the stomach and small intestine). The Pylorus opening is only about the size of the end of your ring finger. This is what gives you the resistance to eating too fast and too much at any one time.

Consistently applying the following principles will help.

1). Liquid calories are not your friend

            Your sleeve and narrowed outlet from the pylorus is like a funnel. The purpose is to hold solid food in your pouch for a time, allowing the solid food to slowly leave the pouch and therefore suppress your appetite by releasing a small amount of the food over the next couple of hours.

            I often hear, “but liquids go down so easily!” but that is exactly the point; too easily! The restriction caused by your pylorus is not made to hold back liquid food. All liquids will run straight through the narrow outlet. So take your calories as solid food not liquids.

Avoid milk, (even skim since it has too many sugar calories), ice cream, cream soup, soda and fruit juices. Fruit is just sugar water with some fiber. One serving of fruit a day is reasonable. More fruit may sabotage your goal of weight loss.

Get your protein in solid food and only use protein shakes if you cannot get enough protein in your solid foods.

Instead drink water, tea with sweetener, and Crystal lite or other non caloric beverages. This is an easy way to reduce your overall calorie intake and help you lose weight.

2). Minimize crunchy foods

            Crunchy foods like chips, crackers, pretzels and cookies, after saliva is added, go to mush and will go into the sleeve and pass through the narrowed outlet too quickly. One small Ziplock bag a day may be OK but more may sabotage your goal of weight loss. These types of foods can be your downfall. I am not saying you should never eat them but when you see them train your brain to flash “DANGER”. It is a question of portion size.

One of my patients did a video on my blog sharing how she deals with this problem. She swore off ever eating out of a bag or box again. Now when she brings home the groceries she breaks down the crunchy foods into small zip lock bags for portion sizes. She no longer takes the large bag to the TV for her snack but goes to the pantry to get a zip lock portion size for her snack.

3). Apply the “rule of 30s” consistently

            Chew 30 times before swallowing

            Wait 30 seconds before your next bite

            Wait 30 minutes before drinking

4). Avoid feeling chest pressure after eating

            Chest pressure after eating is a sign that you have eaten too much too fast for the time it take for your sleeve to empty through the pylorus into the small intestine and the food, drink or air is backing up into your esophagus. The esophagus is pressing the food downward but it has nowhere to go so the pressure just builds up in the esophagus causing the pressure sensation in your chest or even into your mid back.

            Instead use your eyes and brain to determine how much you can eat over what period of time so you do not cause the chest pressure. This frequently occurs in social situations when you are distracted and not paying attention.

5). Establish a “No Fly Zone”

            I want my patients to establish good boundaries for what comes on their property and tell their friends and family, “Certain foods just don’t fly here.” We all have what I would call trigger foods; that is foods that comfort us and when these are around we have difficulty staying away from them. For me it is cookies, so guess what? My wife only buys one type of cookies to bring home from the grocery; Fig Newtons. That is because I really don’t like Fig Newtons much and they will stay around along time. If she brought chocolate chip cookies they would be gone in a flash because I have difficulty staying away from most other cookies. Without fully realizing it my wife has established a “No Fly Zone” at our home. Cookies just don’t fly at our house.

            Maybe your food trigger is pizza or soda or ice cream. Whatever it is you should establish a no fly zone at your house. You don’t bring these things into your house and family or friends and not welcome to bring these things as well. Let them know they are welcome to go out for these things but these foods just don’t fly at your house.

Applying these principles consistently is the key to understanding what is going on with your body after having a gastric sleeve operation. If you are doing these things consistently you are more likely to understand what is going on if you are having difficulty.

I wish you the very best as you continue on your journey to better health!