Fw: Protein deficiency studies?? RESPONSE-LONG

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Re: Protein deficiency studies?? RESPONSE-LONG

Moderators: I realize you have asked for this discussion to be closed, however I

ask to please allow this to be posted as I have worked for many hours to pull

the medical documentation Ray has requested. Thank you, doc carolyn

Ray, I will address your points as mentioned below. The multiple journal

articles your requested are listed at the end of the response. I have included

large and small studies from American, Canadian and European journals (all peer

reviewed), as well as case reviews, all documenting protein deficiency protein

malnutrition requiring supplementation and/or total parenteral nutrition (TPN)

following gastric bypass surgeries (including RNY, proximal and distal, as well

as BPD, and BPD/DS). doc carolyn

>>>> I personally do not take any protein supplements,.......The surgical

practice that did my surgery,

http://www.sabariatric.com recommends iron, calcium, B-12 and folic acid

supplements, but does not recommend protein supplements. .........with the

possible exception of for BPD/DS patients, I do not remember reading any

medical journal articles that document protein deficiency as an unavoidable

result of WLS without supplementation. ...........I never see any studies cited

to the effect. Can some one please refer me to some peer reviewed medical

journal studies that document the need for protein supplementation?

*******While I have read your operative report, I assume you had a proximal RNY

surgery, in which a short portion of duodenum was bypassed and a minimal amount

of small intestine malabsorption occurs. I gathered this from the website you

referred to in your post. This would allow a greater amount of time in which the

digestive enzymes are exposed to the food products from the pouch allowing

dietary protein to be absorbed. This is not the case for all proximal RNY

procedures, depending on how they are done, though, for you, it seems to be the

case. If you want to be sure, you can have a pre-albumin test done which would

tell your recent nutrition status. Most other RNY procedures, and all BPD

procedures, do require protein supplementation. This is because the dietary

protein from the pouch does not have enough physical time in contact with the

digestive enzymes for the protein to be broken down into amino acids and then to

be absorbed into the small intestine. The only way protein can be absorbed into

the body is through the small intestine in the form of amino acids. Accordingly,

for people with these procedures to get any protein into their systems, it has

to be in a predigested form, a protein drink.

I personally do not care who uses protein drinks. Where I become concerned is

when lurkers, and those looking for advice read comments like (I am

paraphrasing) " I am two years out, don't use protein, and haven't seen any

medical literature saying there is a need for it. " This can be, and IS

deceiving to those to who are just looking into the surgery, or don't fully

understand the medical side of things, or may just be looking for the easy way

out. Individuals who hold positions of responsibility in others eyes have a

responsibility to conduct themselves in a way that their actions will " above

all, do no harm " . All of us on this list know that we are to use the

information we gather here as opinion, and discuss it with our medical provider,

however, we also have to remember that whether right or wrong, there are still

some " old school " folks out there that hold people with medical knowledge up on

a pedestal (even though we put on our pants one leg at a time, just like

everyone else). I guess what I am trying to say is. If you are lucky enough to

not have to use protein drinks and have great labs, that's great, but many

people won't be that lucky, even with the same procedure you had. Please don't

do them harm by proclaiming it gospel that they don't need protein, when they

may. There is no black and white in medicine, just many, many shades of grey.

Every single body works just a little bit different.

***** Your surgeon's website makes a recommendation on calcium opposite of what

you, I and most of this list propose and recommend. It recommends 1500mg of

TUMS, or at least calcium OF ANY TYPE daily. Given this, how can you sure this

group is necessarily up to the most current standards on protein if they are not

up to the most current standards on calcium? I am in NO WAY questioning their

surgical ability. The website also listed that the patient is to take two

multivitamins with iron a day for life. There is no mention of B12 or folic

acid that I could find, but am not doubting you have been instructed to take

these.

I did find in the " Keys for Success " regarding water and hydration it states:

" Pre-load with water. Just as you can avoid severe hunger with proper use of the

pouch/tool, it is also manageable to avoid thirst and remain adequately

hydrated. Beginning about 2 hours after a given meal, you should begin to drink

(zero calorie) liquids aggressively. This brisk liquid consumption should finish

with a " water load " about 15 minutes before you are to eat again. " Water load "

means that you quickly drink as much liquid as you can hold, intentionally

stretching your pouch. This maneuver serves to top off your hydration and to

send satiety signals to your brain before you eat - this should moderate the

pace and amount of your eating. Some allowance in this system must be made for

the time of day. It is a good idea to get fluid in before breakfast, including

the water load. It is also OK to wait longer after dinner (three or four hours)

before drinking fluids. "

While it doesn't state the fluid must be water, the point is made to push zero

calorie fluids and avoid dehydration. I will address the caffeine issue and its

physiologic effects on hydration and other things at another time, as it was I

who said that drinking a caffeinated beverage had to be replaced by equal amount

of non-caffeinated beverage to return to " neutral " , so to speak, for the kidneys

and the body physiology. More on that later.... >>>>>>if someone drank 12 oz

of soda, they had to drink 12 oz of water just to overcome the dehydration

effect of the 12 oz of soda, and then another 64 oz of water to meet daily water

needs.

>>>>>Journal References to Protein Malnutrition following Gastric Bypass:

1. Hsia AW, Hattab EM, Katz JS: Malnutrition-induced myopathy following

Roux-en-Y gastric bypass. Muscle Nerve (United States), Dec 2001, 24(12) p1692-4

2. Fobi MA, Lee H, Igwe D, et al.: Revision of failed gastric bypass to distal

Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg (Canada), Apr 2001,

11(2) p190-5

3. Kushner R: Managing the obese patient after bariatric surgery: a case report

of severe malnutrition and review of the literature. JPEN J Parenter Enteral

Nutr (United States), Mar-Apr 2000, 24(2) p126-32

4. Brolin RE, La Marca LB, Kenler HA, et al.: Malabsorptive gastric bypass in

patients with Superobesity. J Gastrointest Surg (United States), Mar-Apr 2002,

6(2) p195-203; discussion 204-5

5. Fobi M, Lee H, Igwe D, et al.: Band erosion: incidence, etiology, management

and outcome after banded vertical gastric bypass. Obes Surg (Canada), Dec 2001,

11(6) p699-707

6. Gagner M, Gentileschi P, de Csepel J, et al.:Laparoscopic reoperative

bariatric surgery: experience from 27 consecutive patients. Obes Surg (Canada),

Apr 2002, 12(2) p254-60

7. Sugerman HJ: Bariatric surgery for severe obesity. J Assoc Acad Minor Phys

(United States), Jul 2001, 12(3) p129-36

8. Sugerman HJ, Kellum JM, De EJ: Conversion of Proximal to Distal Gastric

Bypass for Failed Gastric Bypass for Superobesity J Gastrointest Surg (United

States), Nov 1997, 1(6) p517-525

9. Sugerman HJ, Starkey JV, Birkenhauer R: A randomized prospective trail of

gastric bypass versus vertical banded gastroplasty for morbid obesity and their

effects on sweets versus non-sweets eaters. Ann Surg 1987; 205:613-624

10. Sugarman, Harvey J.: Highlights From the Annual Scientific Assembly:

Mechanisms to Stop the Epidemic of Obesity: Surgical Therapy for Obesity South

Med J 95(6):657-659, 2002.

11. Mason EE: Starvation injury after gastric reduction for obesity. World J

Surg (United States), Sep 1998, 22(9) p1002-7

12. Fox SR, Fox KS, Oh KH:The Gastric Bypass for Failed Bariatric Surgical

Procedures Obes Surg (England), Apr 1996, 6(2) p145-150

13. Adami GF, Summa M, Castagnola M, et al.: Malnutrition, nutritional support

and total body composition. Ital J Surg Sci (Italy), 1988, 18(1) p63-7

14. Scopinaro N, Adami GF, Marinari GM, et al.: Biliopancreatic diversion. World

J Surg (United States), Sep 1998, 22(9) p936-46

15. Scopinaro N; Gianetta E; Adami GF, et al.: Biliopancreatic diversion for

obesity at eighteen years. Surgery 1996 Mar;119(3):261-8

16. Forestieri P; De Luca M; Formato A,et al.:Restrictive versus malabsorptive

procedures: criteria for patient selection. Obes Surg 1999 Feb;9(1):48-50

17. Byrne TK: Complications of surgery for obesity. Surg Clin North Am 2001

Oct;81(5):1181-93, vii-viii

18. Breaux CW: Obesity Surgery in Children Obes Surg 1995 Aug;5(3):279-284