Good Morning. A matter of trust

Well, Dana has been posting studies, textbook excerpts and articles about vitamin and minerals for bariatric patients on her FB group, Nutrition Matters. I'm glad they are studying us but I still don't trust their hypothesis, methods or conclusions. Why am I so hard to convince? Maybe because I haven't experienced the problems some of the folks who are exceptions to Vitalady's guidelines have faced. I've seen more people get deficient due to following their doc's and dietitian's advice than Vitalady's. And, I've seen people struggle post-op to bring levels up because they decided initially not to follow Vitalady's preventive measures and go with "fix it after it breaks". It seems like the same mentality we talk about here regarding bad carbs. Sure you can eat them during your honeymoon phase and still lose, but that's going to be your downfall in maintenance the further out you get from your surgery. {sigh} Not sure what to think. 

--gina
   

I'm with you on this one Gina.  I've been playing the carb game with bad results.  I've taken your advice though and I'm working incredibly hard to raise my B12 and D levels.  I get my results on Wednesday. I have a friend *****ally didn't follow any nutritional guidelines at all.  Lost all her weight but now is suffering incredible nutritional deficiencies.  She even has welts on her arms from lack of nutrition.  So sad.
janet

It does irritate me that some folks don't get the information at all, and other chose to ignor it.  I don't think Drs basically learn diddley about nutritian in school and our surgeons who may be wisards with the knife, then count you as a success and don't keep track of you.  I do love my group and think we have good information.  They have tried very hard to educate folks and track folks and my Nut is pretty open and informed.  My PCP is trying and I am interested in what she has to say on Wed.  But in the long run, it is up to me what I take and get in my body to be healthy. 

I feel so lucky to have you guys.  I really don't want to have to do all the research myself.  I don't understand all those letters on the labs and don't want to have to.  But I have gina and others who can help interpret and keep me straight.

And for carbs, yeah, I still stay pretty darn low carb but it isn't painful and I am eating pretty much whatever I want.  I could get into a sweet kick but as long as I keep it at bay, I'm ok.

 Gina,

Thanks for sharing your concerns.
Mistrust of the medical community isn't really anything new, actually. :) 
Let's see, where do I begin - you touched on a lot.

Regarding Vitalady's guidelines:
I think her recommendations are much closer to what you all require than the ASMBS. Period.
However, I think some people take her recommendations and add and add and add, and that is when it can become dangerous. I do not KNOW your exact requirements, no one does. I think her recommendations are a bit high for some, and a bit low for others, but she certainly has more understanding of your needs than the ASMBS. The folks who have had liver issues recently were taking a LOT of vitamin A and they appear to have had underlying inflammatory issues. That is when it is going to become very tricky. In my own defense, I do worry when I see people responding to vitamin questions with comments suggesting "add more" when the amount is already exceedingly high. So, do not take offense when I respond with concern when it seems as though the patient or DS community is overzealous in their recommendations. I think bringing the two groups together in understanding, will ultimately, improve care drammatically in your population. I have nothing but respect for Vitalady and you all for caring for yourselves for so long without any guidance from the medical community. I often say if it weren't for this board, you all would be extinct (sorry). :( I think it's true.

However, it is very concerning to me to see the ferritin levels drop while taking iron supplements. I think most women will require an iron infusion and I would like to see that happening sooner than later (only because there is a direct correlation between anemia and death). If the Proferrin alone were working, I would say "great!" However, it isn't and I am not sure why - nor do I care. I want you all to be healthy. If we need to create an iron patch, we need an iron patch. Something has got to give. :) 

Regarding the articles, I or anyone else post: 
A good scientist can find a flaw within any study. :) You need to learn to become more critical of articles, that's all. Most of the data I report isn't large, randomized, controlled trials and it is largely of the bypass community and/or reviews. There isn't a whole lot out there for the DS community yet. I'm not sure it is any particular post that has been concerning to you, it is my suspicion that it just worries you in general and that is normal. :) I can appreciate that it is worrisome when someone new starts to post the "old and untrustworthy" papers, apprehension sets in. I can assure you, you are not the only one. :) You should be critical. A food would take everything I say and accept it is truth. Same is to be said for Vitalady. 
However, to bring up one example, because I know it was of concern to you-

The iron issue:
There are currently NO randomized, controlled studies of DS patients (that I know) of that were randomized to receive an equivalent amount of either a) ferrous sulfate, b) ferrous fumarate and c) proferrin or d) carbonyl.
With that said, the data is lacking. That's all. :)
I am playing devils advocate against myself now for a minute. lol
Just because the ASMBS doesn't recommend Proferrin, doesn't mean it has ever been studied in your population. If it hasn't been studied, it hasn't been proven to be ineffective or effective. 
The ferrous fumarate "guideline" (because there is a difference between a general guideline and large study with significant results that make it obvious a certain therapy is effective or ineffective) is simply that - a GUIDELINE. When there is no data, guidelines are made because it is better to provide some input, than none at all. 

Ferrous fumarate is the iron they have selected because it has been extensively studied - not so much in DS patients, but in others (that doesn't make it right). SO, it is an iron they feel comfortable with, and I feel that it is reasonable. However, it isn't fact because it hasn't been tested against Proferrin.  Proferrin might be more effective without an enteric coating and in larger amounts - Who knows! 

In my defense, Proferrin is only 12 mg of elemental iron and the claim that it is "23 times more potent than ferrous fumarate" is based upon little to no evidence. There is a lot of data to support the fact that bariatric patients require total daily iron amounts > 150 - 200 mg per day, so it is disheartening to see people taking < 60 mg per day while struggling with anemia. There is no evidence to support the "23 times more potent" claim and if people are becoming ill, then it is a problem. Observing people on the board develope anemia because they believe Proferrin taken in lower amounts is just as effective as other therapies in higher amounts is a dagger to my heart. Simply because, if something isn't working- it isn't working.
Pride needs to be set aside and the patient's health put at the center of the table. 
We all have something to learn in this (and life). No one knows everything and just because historically, it has worked, doesn't mean it will work for everyone and THEN what? 

Same is to be said for vitamin A. If I take a poll right now on the main DS board and ask how many people greaer than 1 year out have elevated liver enzymes and their respective vitamin A dose, I think it would be concerning. It is my opinion, not fact, that taking more than 100,000 IU per day is toxic to the liver. Yes, causing liver damage is very concerning to me. That is a one-way ticket to serious hospital time. There are so many other things that affect vitamin A status, it is not wise to keep increasing your daily dose of vitamin A without understanding the nature of vitamin A metabolism.

How many NUTS do you know who would even speak about 100,000 IU of vitamin A without screaming "Are you crazy?!?!? You are going to kill yourself!?!?!?" LOL. I've learned a lot from your group and I thank God for that. Honestly. It has been tremendous to my education. People ask me, "why do you hang around here and talk with us so much? Do you have a hidden motive? What's the deal?"

and my answer is this - "Yes, I have a motive. --> It's a damn good free education." 
I've learned WAY MORE working with you all then I have reading articles. I am like a sponge and I am going to learn every single thing I can when given the opportunity. 
And I want to help. :) I care and it makes me feel good to use my abilities and knowledge to improve a human life. We all should stive every day to leave a legacy of love for humanity. :) 

:) I know you all require much, much more than what the literature states, but there is a cut-off point and it is evidenced by people becoming very, very ill (on the DS main board). More is not always better - that is my main point. 

Perhaps you are right, you are a light-weight and patients with a lower BMI have less pre-op complications related to obesity than do the patients with higher BMIs. For instance, vitamin D deficiency.  There is a direct relationship with BMI and vitamin D deficiency. As BMI goes up, so does the incidence of vitamin D deficiency. It is incredible. 

I tell you what, in all my years, I've NEVER seen the types of lab results I started to see when I started practicing bariatrics. I am a dietitian with board certification in nutrition support and historically, we work in the ICU with all of the "comlex cases."
LOL, HOWEVER, there isn't an ICU patient out there that is more challenging to manage nutritionally than the morbidly obese population. I was BLOWN AWAY to see all of the pre-op vitamin and mineral deficiencies and electrolyte disturbances in the bariatric population (to say the least). I honestly went through a period of depression - it was hard to get used to seeing every single patient with complex issues walking around normally (not stuck in an ICU bed on a mechanical vent). 

Patients who have BMIs greater than 50 and 60 are simply not comparable to you. Obesity wrecks havoc on the metabolic and endocrine system.  It is incredible to compare the pre-op labs of someone who has a BMI of 40 to someone who has a pre-op BMI of 60. Two totally different animals. 

There is a huge need for more quality research in your population and I want to see it happen. I want you all to be healthy, but at the same time, I value and respect medical science and opinion and appreciate it's contribution to humanity. Medical professionals are not perfect - no one is. :)

So, no need to worry Gina. :) I respect and value your opinon and concern and appreciate you including me in the conversation.
OK, my daughter wants breakfast.. gotta run!

Thank for responding and taking my rambling as it was intended. Most definitely not against you, I am thankful for you.
 
Regarding those that double and triple up on vitamins, I agree with you there too. If I recommend people double up on vitamin D, for example, it's only for a few weeks or 3 months and retest. I do tell folks that I had to take 100,000IUs of dry A for 4 months and then have been able to cut back since then and hold at the top of the range with only 25,000IUs a day. I think it's a good idea to try different deliver methods of things like vitamin A and D if the large IUs aren't working. What worked for me on the vitamin D when it dropped, after starting Fosamax, was 50,000IUs in capsule and 20,000IUs in sublingual. So, I'm not in favor of going long term with double and triple the doses Vitalady recommends either. 

Anyway, I have to go back to work but wanted to say thanks.

--gina
 

This is very interesting and I feel like I still have a great deal to learn about vitamins.....

Dakota, is your facebook group open to accepting new members?  I would like to read what you have researched when I have a chance.......if so, how do you join?

I appreciate the time you have devoted to your career and being open to learning from your patients.  I am a big believer to research EVERYWHERE you can obtain info......I am a social worker and felt that my program did not devote enough on the psychological issues of food dependence, addiction, etc.  The NUT said that they needed someone like me....I am quite happy in my current job but was surprised how many patients enter surgery with very little education, reading on what was going to be taking place in their lives, be it with vitamin deficiencies, mood issues, food intake, etc.  It is confusing though with all the different info everyone receives.

~~~Jennifer

Yes, we are open to anyone (there are all types of surgeries represented there)! I'd love to have you and anyone else there! :)

Interesting you mentioned the psychological aspect of eating.
I brought it up at the Houston Area DSers group this past Saturday.
Obviously, obesity is not just what you eat, nor is it what causes you to eat, it is SO MANY things, but I think there is definitely a NEED for bariatric counselors.

Binge eating disorder is actually more prevalent than is anorexia or bulemia, but for some reason it doesn't get the attention that it deserves. 

any who! come on over!
https://www.facebook.com/danamarlane
Add me as a friend and I will add you into the group (it's closed BTW) and it is called "Nutrition Matters."
 

Dana,
I sent you a request on Facebook, but forgot to put that I was from the LW Board.
Linda

Dana,

I have sent you a friend request. I don't use FB much, so I didn't know how to say I was from the LW board.

Thanks,
Dot

It upsets me when there is a one plan fits all.  That everyone who had RNY should be on the same eating plan.  We are all so different and need to find a lifestyle that will fit with our everyday life.  I like my protein Drinks, if they are not hurting me and I can do better on my plan with them - what's the problem????

I find out tomorrow the results of the labs I had last week to see if the WBC has come up any and she tested me for some other things. 

Carbs are my downfall.  I don't eat them like I used to, but I just can't have them around.

Linda