DS: Malabsorption Time Limit?

[Parousia]

I'm in an Australian Gastric Bypass FB group, from the days when I was considering one. I decided to stick around so that I could let people know about the DS as an alternative, in case they were interested. I've just been asked the following question:

"Does the malabsorption have a time limit like with a bypass".

I'm under the impression that the malabsorption lessens after the first couple of years as a result of some adaptation of our intestines, but we never actually lose it. Am I right? Is there more to it than this?

 

[Spiky Bugger]

Houston, we may have a problem here. Malabsorption from both surgeries lasts, as far as I know, forever. That's why, forever, we ALL need routine labs and supplements.

I'm not sure, but I think the questioner wants to know if the WEIGHT LOSS from malabsorption continues with the DS in a way it does not with the RnY. In my experience, weight loss from malabsorption lasts 8.5 years, anyway. Any time I want to get rid of carbs (which are not malabsorbed) and live off of ribeye steaks, prime rib and cheese omelets and have heavy whipping cream in my coffee, the weight comes off in a hurry.

With the RnY, they do continue to malabsorb...which is why they can end up with " bariatric beriberi," wernicke-korsakoff syndrome or other mind- and life-threatening problems...but the primary cause of their weight loss is having a pouch the size of an egg instead of a stomach, not malabsorption. With us, yeah...the stomach is MUCH smaller but can stretch over time...but the malabsorption is still working years later.

HTH,

Sue

 

[Munchkin]

Well, your body will do the best it can to adapt. And our bodies WANT to be fat. With the normal proximal RNY a couple years post op and the body has adapted the best it can. Grown a few new villi, etc. So for all practical purposes the malabsorbtion is mostly gone. That's why the RNY folks start gaining around the 2 year mark. Plus by that time, they know how to eat around the pouch and it's gotten a bit larger too. Most of the RNY folks I have known over the years eat total crap. The ones I knew who now weigh more than they did preop did it to themselves with dried fruit. I could never convince them dried pineapple, crusty with sugar, was making them gain weight. But the didn't puke up dried fruit so they ate it! Now feed them the lean protein they are supposed to eat and they still puke like crazy! The pouch teaches them to eat crap.

Too much gut is bypassed in the DS for our bodies to ever completely adapt. Someone(sorry don't remember who) did a study a few years back and said many of us even start absorbing some protein in the colon. So our stomachs get bigger, we grow a few new villi, and sometimes our CC grows a bit too. This is why we stop losing. The changes you will notice is being able to eat more and the oil slicks that used to be common become a rarity. Poop also becomes generally a bit more solid too.

When my H had his DS for Diabetes(switch only), the only study out then was by a doc named Noyes. Since nothing was done to the stomach you can remove it from the equation completely. The CC's were all 50cm, quite short. The doc said that the patients all lost about 30 odd pounds post op and then gained it back over the first 2 years postop. And that's exactly what happened to H as his body adapted to the malabsorbtion. This is why quite a few of us believe there is a synergy in having the whole DS done in one OP. The DS seems to have much better weightloss when both parts are done at the same time.

Our bodies want to get back to fat. That's why the free ride does end and after a few years DSers can gain weight. Some, the unlucky few like me, never had any free ride at all. And there are others, also few, who can eat as they please forever. That's why I always tell people to just lose the weight. As much as you can, as fast as you can. You can start playing with carbs when you are 10% below goal. Don't listen to people saying you are too thin. Don't worry you are losing too fast. Just get the weight off! That way if you are among the unlucky few you did the best you could with what you had. If you are one of the lucky ones, you get to have a carb fest or take a few months worth of enzymes. But you reached your goal!!!!!

 

[Parousia]

Well, your body will do the best it can to adapt. And our bodies WANT to be fat. With the normal proximal RNY a couple years post op and the body has adapted the best it can. Grown a few new villi, etc. So for all practical purposes the malabsorbtion is mostly gone. That's why the RNY folks start gaining around the 2 year mark. Plus by that time, they know how to eat around the pouch and it's gotten a bit larger too. Most of the RNY folks I have known over the years eat total crap. The ones I knew who now weigh more than they did preop did it to themselves with dried fruit. I could never convince them dried pineapple, crusty with sugar, was making them gain weight. But the didn't puke up dried fruit so they ate it! Now feed them the lean protein they are supposed to eat and they still puke like crazy! The pouch teaches them to eat crap.

Too much gut is bypassed in the DS for our bodies to ever completely adapt. Someone(sorry don't remember who) did a study a few years back and said many of us even start absorbing some protein in the colon. So our stomachs get bigger, we grow a few new villi, and sometimes our CC grows a bit too. This is why we stop losing. The changes you will notice is being able to eat more and the oil slicks that used to be common become a rarity. Poop also becomes generally a bit more solid too.

When my H had his DS for Diabetes(switch only), the only study out then was by a doc named Noyes. Since nothing was done to the stomach you can remove it from the equation completely. The CC's were all 50cm, quite short. The doc said that the patients all lost about 30 odd pounds post op and then gained it back over the first 2 years postop. And that's exactly what happened to H as his body adapted to the malabsorbtion. This is why quite a few of us believe there is a synergy in having the whole DS done in one OP. The DS seems to have much better weightloss when both parts are done at the same time.

Our bodies want to get back to fat. That's why the free ride does end and after a few years DSers can gain weight. Some, the unlucky few like me, never had any free ride at all. And there are others, also few, who can eat as they please forever. That's why I always tell people to just lose the weight. As much as you can, as fast as you can. You can start playing with carbs when you are 10% below goal. Don't listen to people saying you are too thin. Don't worry you are losing too fast. Just get the weight off! That way if you are among the unlucky few you did the best you could with what you had. If you are one of the lucky ones, you get to have a carb fest of take a few months worth or enzymes. But you reached your goal!!!!!

That is really interesting, Munchkin! That study has thrown me a bit, because it contradicts some of the things I thought I knew! I thought it was basically the restrictive stomach that helped us lose the weight, but the malabsorption that helped keep it off (yes, with some synergy between the two). So, the malabsorption isn't enough to keep any of the weight off on its own! The restriction remains important forever, it seems.

 

[Munchkin]

That is really interesting, Munchkin! That study has thrown me a bit, because it contradicts some of the things I thought I knew! I thought it was basically the restrictive stomach that helped us lose the weight, but the malabsorption that helped keep it off (yes, with some synergy between the two). So, the malabsorption isn't enough to keep any of the weight off on its own! The restriction remains important forever, it seems.

Truly the DS is more than the sum of it's parts. Neither one will do it all but both together are powerful juju.

Another thing I believe is that we relearn how to eat. We develop new skills and coping mechanisms when we are brand new and can't eat like we used to. We also become more active and participate more in life as the weight drops. We start living and acting more like 'normies'. I'm sure these things help too.

 

[Parousia]

Truly the DS is more than the sum of it's parts. Neither one will do it all but both together are powerful juju.

Another thing I believe is that we relearn how to eat. We develop new skills and coping mechanisms when we are brand new and can't eat like we used to. We also become more active and participate more in life as the weight drops. We start living and acting more like 'normies'. I'm sure these things help too.

I can see how it works to change our eating habits. Protein is so important, and cheating really doesn't bring much/any pleasure early out, so there is no reward for eating badly, and there are very real risks.

May I ask about your weight loss? Did you lose and then put some weight back on, or did you just stop losing well short of your goal? Did you stop losing before you were out of the generally accepted optimum weight loss window? Is there anything that could account for it, to some degree at least, such as common channel length, size of your stomach/amount of restriction you had? I hope you don't mind me asking all these questions. This is one thing most newbies wonder about, I think. We all hope that we will be able to reach our goal weight/size/state-of-health (however we decide that), and many, if not most, fear (at some point) that we never will.

 

[DianaCox]

Here's a more simplistic version:

With RNY, there is a little malabsorption of fat, carbs and protein (with only 100-150 cm of jejunum excluded from the alimentary tract) - i.e., CALORIES - which is overcome with time. However, there is essentially permanent malabsorption of micronutrients such as calcium, B12, zinc, copper, B1, because the entire duodenum is excluded from the alimentary tract. The stomach stays small, so no maceration or mixing with hydrochloric acid takes place, but the food dumps through the stoma, which enlarges with time, PLUS the excluded part of the stomach continues to churn out ghrelin - so little satiety, and ultimately, many experience metabolic derangements such as reactive hypoglycemia.

With DS, there is very significant malabsorption of fat, and fairly significant malabsorption of carbs and protein (all of the jejunum excluded from the alimentary tract - 400 cm or in some cases much more) - i.e., CALORIES - comparatively little of which is overcome with time. There is essentially permanent malabsorption of SOME micronutrients such as calcium, (not so much B12, because the at least some intrinsic factor that is made in the stomach, which is necessary to absorb B12, is still available), zinc, copper, B1, because only part of the entire duodenum is excluded from the alimentary tract. The stomach is smaller but fully functional, so significant maceration and mixing with hydrochloric acid takes place, and the food is released normally into the intestine in small boluses by the pyloric valve, generally avoiding dumping and the resulting metabolic derangements. Although the stomach enlarges somewhat with time, it remains smaller than pre-op, PLUS the removed part of the stomach does not continue to churn out ghrelin - so there is better satiety.

RNY: short term caloric malabsorption, long term micronutrient malabsorption.
DS: long term caloric malabsorption, long term (somewhat different) micronutrient malabsorption.

 

[Munchkin]

I can see how it works to change our eating habits. Protein is so important, and cheating really doesn't bring much/any pleasure early out, so there is no reward for eating badly, and there are very real risks.

May I ask about your weight loss? Did you lose and then put some weight back on, or did you just stop losing well short of your goal? Did you stop losing before you were out of the generally accepted optimum weight loss window? Is there anything that could account for it, to some degree at least, such as common channel length, size of your stomach/amount of restriction you had? I hope you don't mind me asking all these questions. This is one thing most newbies wonder about, I think. We all hope that we will be able to reach our goal weight/size/state-of-health (however we decide that), and many, if not most, fear (at some point) that we never will.

Here's my boring story... Perhaps it was my surgeon because I am not the only one of his postops to have this problem. Somehow he seems to do a kinder, gentler DS and that wasn't what I needed. My surgery was open and my recovery was perfect. To this day I have never thrown up. I am very healthy and never get sick. My CC is supposed to be 75 and that's quite short. I wish I would have held out for 50! He wanted to do 100 and we compromised on 75. But who knows. I wasn't there when it was done!

It's pretty certain that I am a superabsorber. I got my first diet at my 6wk checkup. The doc said I was gaining too fast and told my mom to replace one of my breastfeedings with a bottle of water. I knew the meaning of the word obese when I was 2. My mom was an RN and very aware of nutrition. I was fat before I ever made a single food choice of my own. Growing up there was never junk food in the house. Dinner was salad, veg, and meat. My father got to eat potatoes and corn but I never got any because of my weight. Dessert was a real treat and usually served on tiny plates so I couldn't overeat. The other kids ate ice cream and candy after school while I got celery and carrot sticks. And I grew up very bitter and hated my body.

I knew that some day there would be a surgery of some kind that would help me. I even looked into stomach stapling. In the meanwhile I did diet after diet. For years at a time. I lived on 2 cans of tuna and green salad for years of my life. And I was still fat and getting fatter. Every failed diet made it harder to lose the next time. I finally heard about the RNY and I found it impossible to get excited about it because post op life was so grim. I felt I had already suffered more than enough. One day my sister called and told me about the DS. It sounded great and I researched the heck out of it. I learned that Dr. Buchwald at the U of M did the surgery and he was only about 70 miles away from me. I went to his seminar with about 30 other people and I was the only one who wanted the DS. He spoke with me privately to find out if I knew what I was getting into. He must have thought I knew enough because he agreed to do the surgery. Everything flew through insurance with no problems and I got a surgery date. TWO YEARS IN THE FUTURE! I had to wait for 2 more years! Looking back with 20/20 hindsight I should have flown to Spain, self paid and had the surgery 2 weeks later! Time passed and I waited.

I worked in an office full of fat women. A bunch of them had wls, mostly RNY. I watched them getting skinny and I got angry. I hated their comments that I should just get the RNY and stop waiting for the DS. But I knew it would be miserable to live with the RNY. I got angry enough to do yet another diet. Starvation. I got to take my vites and my food every day was one can of tuna and one measured cup of dry green salad. On Sundays I got a handful of baby carrots. I started reading about Anorexia and tried to get myself into that mindset. Every day I stood in front of the mirror and repeated, "Food is not your friend." And, "Just look at you! You deserve to starve!" And one last time, starvation worked. My high preop weight was just under 400lbs and when I weighed in for surgery my weight was 251lbs. I had gone from heavyweight to lightweight. Probably the 12th or 13th time in my life I had lost 100 or more pounds. And I thought it was going to be my last diet. Silly me!

So I had my surgery and my perfect recovery. I lost 53 lbs in the first 6 months and that was it. Then I had a 6 month plateau. Nothing. Believe me, I know what a carb is and I wasn't eating any. I was freaked out because I knew I only had X amount of time to get off the rest of the weight. Anger is a great weightloss tool for me and I was angry once again. So I went extremely low carb(10 or less per day) and started running. Back to tuna, chicken, and salad. Back to being hungry all the time. Dieting and running got me down into the 160's and a size 6 for 10 minutes or so. But I couldn't maintain it and the weight came back. Today I am going on 11 years postop and my weight bounces between 180 and 200lbs. So the DS bought me 50lbs loss and that's about it. If I want more, I have to starve for it. I keep on hoping I will get angry enough to put myself through the diet again. Only next time I am going to stay on it till I get down to about 120lbs!

Statistics say I am a success. But if I could afford it I would be in Spain having the most drastic revision possible. I know I weigh too much but honestly I just look like a normal woman my age. Frumpy. And guess what? I have never had a single deficiency. Not a one. That tells me I still absorb a lot! Probably more than the average DSer. And I think it's pretty logical to deduce that's also why I have a hard time getting or staying thin. Just once in my life, I would like to have a normal BMI. At 160 I was still fat!

My personal story is why you will always hear me saying just lose the weight. You do not need a carb till you are 10% below goal! And just a little post script on my RNY co-workers, they ALL weigh more now than they did preop. So I did pick the right surgery! And truth be told, I might weigh 500lbs by now if I hadn't done anything. Or it's quite possible I would have been dead by now as well.

 

[Parousia]

Thank you for telling your story, Munchkin. It isn't boring at all. I'm glad you shared it, but I'm sorry that you had to live it! You really have done well with your weight loss and maintenance. Don't forget although you lost so much weight pre-op, your DS is helping you maintain the whole weight loss, whether you achieved it before the surgery or as a result of the surgery.