New Video! Dietitian explains Nutrition Facts Label

In this video, You will see Dietitian, Kristi Highley sharing the importance of the Nutrition Facts Label. The photo on top is an image of the exact Label she is referring to, but enlarged. One more thing before we get started, Dr. Myers wants to know something about the beginning of the video, "What's up with the tongue Kristi?"

Vitamin D Deficiency and Bariatric Surgery

Vitamin D is very important since it helps to maintain appropriate calcium levels in the blood and keeps helps to make calcium available to strengthen bones.

The vast majority of bariatric operations including a Roux en-Y Gastric Bypass, Gastric Sleeve or Adjustable Gastric Band have little or no effect on Vitamin D absorption. Only the relatively rare bariatric operations that greatly shorten the last half of the small intestine such as a Duodenal Switch, Biliopancreatic Bypass or a Modified Gastric Bypass that leaves a very short portion of the small intestine to absorb nutrients result in inadequate absorption of vitamin D.

Nevertheless vitamin D deficiency is a frequent problem for all patients of size. Although some of the vitamin D we need in taken in as part of the food we eat, some of the vitamin D is formed by sunlight converting colesterol to vitamin D in our skin. Since I am a bariatric surgeon in Columbus, Ohio, 89% of all of my patients are found to be vitamin D deficient even before surgery!

That is the reason each patient that enters our program is tested to determine their vitamin D level. We routinely start our patients on vitamin D when they begin in our program.

Why do our patients often have low vitamin D levels? It is not because of surgery.

Vitamin D deficiency occurs partially because we live in Ohio instead of Phoenix! Ohio is not known for sunny weather. Also people of size often are not out in the sun very much. In addition there is some evidence that Vitamin D is stored in our fat deposits and it may take higher amounts of vitamin D to saturate all of the storage sites.

Vitamin D is converted to an active form as blood is circualated though our kidneys. A normal Vitamin D level is necessary to absorb calcium from the intestine and preserves calcium from being released in the urine.

After absorption, calcium circulates in the serum and is stored in bone. The balance between the amount of calcium circulating in the blood and stored in bone is controlled by a hormone released by four small quarter inch size glands located just behind the thyroid gland in your neck called the parathyroid glands. It is essential to your nerves, heart and other body tissues to have a normal level of calcium in the blood. Therefore if your calcium starts to decrease the parathyroid glands produce more parathyroid hormone which in turn tells some of the cells in the bone to take calcium out of bone and release the calcium into the circulating blood. If this goes on for a long time you can lose so much bone strength that you put you at risk of causing breaks in the bone called fractures. This circumstance is called osteoporosis because the bones, (osteo-), becomes more porous, (porosis).

Therefore, if your vitamin D level is low you will not absorb enough calcium and your calcium level will be low. This will result in higher levels of parathyroid hormone stimulating the bone cells to mobilize more calcium from the bone and make your bones weaker and more prone to break. The bones at most risk are your hips and the bones of your back.

You should take at least 800 mgs of calcium every day, (as calcium citrate for gastric bypass patients) and make sure your vitamin D level is checked yearly. Take Ergocalciferol 50,000 units each week to treat a low vitamin D level. In addition periodic bone density tests will check how much calcium is stored in your bones reflecting how strong the bones are. If you have a mild decrease in bone density called osteopenia, correcting the vitamin D deficiency and taking more calcium may be enough. However, if your bone density is low enough to be called osteoporosis you should speak with your primary care physician about taking a medicine that will reverse the bone loss such as Boniva or Reclast.

From Stephan R. Myers, MD, FACS, bariatric Surgeon, Columbus, Ohio

Dr. Myers, Why do I sometimes feel squeezing pressure in my chest when eating or drinking?

Squeezing pressure in the chest can be a symptom of several problems such as heart disease, gallbladder disease or pressure in the esophagus. If you think the symptoms may be related to your heart call your primary care doctor or go to the emergency room.

However, if this is happening to you several weeks or months after having a bariatric operation it is likely to be esophageal pressure from eating or drinking faster than the pouch or sleeve is emptying thus food, drink and or air is accumulating in the esophagus. The esophagus squeezes the food trying to get it out of the esophagus and into the stomach. However, if the pouch is full the food in the esophagus has nowhere to go. Although there are minimal pain fibers in the stomach, the esophagus is exquisitely sensitive to pressure and will definitely let you know when it cannot move food or drink into the stomach.

This can happen regardless of whether you have had a gastric bypass, gastric sleeve procedure or an adjustable gastric band operation.

In this situation the worst thing you can do is to try to get the food moving by drinking more. This just adds to the problem by adding more fluid into the esophagus and makes the pain more severe. The pain lasts even longer since the additional food or drink also has nowhere to go.

Throwing up what is in the esophagus can give you relief but if you are patient usually the food and drink is likely to pass through the exit of the pouch or sleeve and the pain will be relieved.

After bariatric surgery, eating and drinking too fast should be avoided and may cause squeezing chest pain. When it occurs after eating it may be a possible sign that you may have just eaten too much too fast for the length of time it takes for the food in the pouch or sleeve to pass. In band patients continuing to experience this problem may lead to band slippage. (See band slippage elsewhere in this blog.)Reviewing the “Rule of 30’s” in this blog can help you to avoid this symptom.

Of course, if you have any consern that this is not related to eating too fast call your doctor or go to an emergency room to make sure the pain you are experiencing is not related to your heart.

I asked the Fresh Start Bariatrics dieticians, Joann Schaumb and Alyssa Bixler, what they recommend for patients preparing for bariatric surgery.

"This is a very key topic! These comments are an initial response. We will share more later.

I think it is helpful to have people practice before surgery, eating the types of foods they will need to eat after surgery. I like to work together with clients to find foods that they like well enough to eat regularly instead of the high fat, high sugar choices they may have enjoyed in the past. This takes some trial and error, particularly in restaurants. It is important though, because people eat what they like. To achieve long term weight loss, they need to like lower calorie foods. It may seem hard, but we are usually able to help people find these foods.

When you focus on what to eat instead of what not to eat, it puts you in a more positive frame of mind and healthy eating becomes easier. We like to help people build confidence in their ability to enjoy healthy foods.

One of the most challenging goal on our pre-op list of goals is eating small, frequent meals. People are very busy and don't always think about eating much during the day. The typical American pattern is to eat very little or nothing through the early part of the day and consume most of the calories late in the day. This pattern leads to weight gain. Stomach capacity is limited after surgery, so we strive for high quality, nutritious foods. Every bite contributes to good health.

It is helpful to plan specific times for snacks and meals and design reminders, like setting a cell phone to beep when it is time for a snack.

It is very important to drink calorie free beverages. We recommend some weight loss prior to surgery and this is a very effective way to achieve that. Liquid calories are generally not satisfying. When you drink calories, you still eat the same amount of food, so total calorie intake is higher and leads to weight gain.

Replace liquid calories with calorie free drinks such as Crystal Light, Powereade Zero, Decaf coffee or tea, diet juices, diet flavored water or water with lemon."

I think their recommedations are terific and this is a great start to help people what changes would be helpful to make before surgery!

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