Even 2000mg of calcium citrate isn't enough, apparently

This post is especially for those of you who are pre-op and may still be deciding between RNY and VSG. Please don't think the permanent lack of vitamin absorption with RNY is no big deal.  It can be a very big deal even if you take what the ASMBS says you need to take and you have routine lab work done and adjust your vitamins accordingly.  I have been very successful with my RNY, but if I wreete making the decision now (VSG wasn't an option 8 years ago), I would opt for the sleeve and leave my intestinal tract intact.

I am 7.5 years out from RNY, am 52 years old, and for the second year in a row my DEXA scan has shown new bone loss in one hip.  I didn't have a DEXA scan until I was about 3 years out because my surgeon never told me that I needed one (nor did she tell me that the serum calcium blood test DOESN'T tell you that you are getting enough calcium from diet and supplements, that it only tells you whether or not your body is pulling enough calcium from your bones if you AREN'T getting enpugh from food/supplements).  It was normal. The next one was also normal.  I continued to take 1500-1800mg of calcium citrate every day. (My calcium blood tests have always been fine, including the one two months ago.)

Then last year the DEXA scan showed some bone loss, so I increased my calcium citrate to FOUR 500mg doses per day (you can only absorb 500mg at a time).  It obviously wasn't enough, because I had it done again this year (instead of waiting the normal two years between bone scans) and there is more bone loss in that hip.  I have no idea when I am going to be able to get in a SIXTH vitamin dose every day (five calcium and one with iron, since you cannot take iron and calcium together).   Calcium dose as soon as I wake up, I guess...

Anyway, I have been pretty damn compliant with my vitamins and have been very compliant with lab work and adjusting dosages.  Yet I now have "moderate" bone loss in one hip and "minimal" bone loss in the other hip (which showed no bone loss a year ago).

So... Even if you do everything right, as you age, you can have significant problems with vitamin deficiencies.  Some RNYers have to get iron infusions because even large doses of iron supplements aren't sufficient; many of us take 100,000-150,000 units of D3 every week; some, like me, end up with bone loss (which is, of course, irreversible) despite taking more than the "minimum" amount of calcium.

So please consider this, as well as potential complications like kidney stones and reactive hypoglycemia, before you let someone talk you into RNY just because it is the "gold standard".  MANY surgeons no longer consider it such because the sleeve can often accomplish the weight loss without altering your digestive processes and nutrient absorption. You have to live with the surgery (and its effects) for the rest of your life, so please consider more than just the initial goal of losing weight.

Ther are many who will disagree with me, no doubt -- I also know there are many RNYers who will agree -- but, IMO, a lifetime of vitamin malabsorption (and possible RH, kidney stones, etc.) is a high price to pay for 18 months of caloric malabsorption... and in my case) irreversible bone loss.

Lora

Thanks, that was a really interesting post! I just was sleeved two weeks ago. This makes me feel good about my decision. I'm such a newbie that I haven't come to grips with the idea yet that this is for life!

Sorry to hear about this Lora.  

I will pay devil's advocate though and say that I have always had excellent results from my Dexa scans.  Having said that, I have never had any joint problems either - hip/knee replacements etc so I assume my bone health is a genetic thing (my parents are both in their 80s and neither have had any joints replaced or bone problems either) 

I hope you are able to find a solution to at the least, slow down this loss of bone.

Yes, I think genetics does play a big role when it comes to cardiovascular stuff and bones, particularly.  My mom --who is small boned, taller, thin, and whose knee caps are literally half the size of mine -- has osteoporosis, and both of my grandmothers had horrible arthritis in their hands, backs, and knees.  (I already have it in several fingers and in one spot in my back... And my knees have already been replaced, but I attribute that to the years of being SMO.)  Other than my weight and my issues with blood clots, I was always pretty healthy for someone SMO. But then between menopause and RNY....

I fully realize that many people may have absolutely no issues ever after RNY -- although I would bet my next paycheck that almost everyone runs into trouble once they get elderly and the body naturally absorbs nutrients less -- but you never knew which "camp" you are going to be in.

Glad that you are in the other camp!  

I was going to ask if osteoporosis ran in your family. It does in mine, too. My grandmother had both hips replaced in her 50's.

20% of Caucasian women over 50 have osteoporosis.

Hi Lora....maybe you can point me to a resource that will shed some light on this for me but why do we lose caloric malabsorption over time but not vitamin malabsorption? I would like to understand the biology of that. Also, loss of caloric absorption over time is not something ever brought up by my surgeon, nutritionist or nurse presurgery. I didn't learn this till I found this site post op. I wonder if this is something most surgeons do mention...but not mine. Hmmm. Thoughts to ponder.

Excellent questions! Caloric malabsorption was never mentioned by my surgeon or dietitian. Frankly, I doubt that it really exists. If it does exist, like you said, why would it stop and vitamin malabsorption not stop. 

See response below.  Macronutrients (calories) are absorbed via a slightly different process and more widely throughout the intestine and the body can adjust itself to absorb MORE in the existing portion of the intestine  

Micronutrients (vitamins), however, are only absorbed in certain portions of the intestine, and the body cannot change where those things are absorbed.

The temporary aspect of the caloric malabsorption is quite real.  Google "short bowel syndrome".

Lora 

The short answer is that the caloric malabsorption is temporary because the body has the ability to grow more (and longer) villi (the little tentacle-like things that do the macronutrient absorption) and overcome the absorption that is not happening in the bypassed portion of the intestine, but different micronutrients (vitamins) are absorbed in different parts of the intestine and the body cannot change which portions absorb which nutrients... so because we have bypassed the portion of the intestine that does the primary absorption of calcium, iron, and several other vitamins, we are left with only the secondary areas (which don't absorb as well).

[Edited to add: see the diagram at the bottom of this page for a visual representation of why we lose much of our vitamin absorption with a RNY bypass.]

The process of adaptation to the caloric malabsorption is similar to "short bowel syndrome" in people who have portions of their intestine entirely removed because of disease or injury.  If you Google that, you can find a number of articles on the adaptation process.

Based on my 8 years here on OH, it appears that a lot of surgeons never bother to tell their potential RNY patients that the caloric malabsorption is NOT permanent. I personally find that deplorable and borderline unethical. You need to know exactly what you are signing up for when you sign that surgical consent! You will never absorb 100% of your calories and fat again, but a number of studies indicate that the body adapts to still absorb 80-90% of calories from fat and almost 100% of the calories from carbs (so if you eat 1400 calories a day, you are actually only NOT absorbing roughly 140, depending on how many of those calories come from fat vs carbs or protein.)

Lora

When do you start having bloodwork?  Is it done by the surgeon in follow up?  Is the DEXA scan ordered by the surgeon? or do I need to ask my primary doctor?  I am 50 and have had menopause so I want to watch this carefully.  No one has mentioned bloodwork yet.  I am only 2 months out though.