Core Bariatrics

Episode 9: Q&A with Maria

• Dr. Maria Iliakova & Tammie Lakose

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In this episode, Tammie turns the tables on Maria, posing a series of insightful questions that illuminate key health topics for anyone navigating life post-op. Together, they delve deep into the critical vitamins necessary for optimal ongoing health, unpack the challenges of hypoglycemia—a hurdle for some individuals and explore the benefits and considerations of intermittent fasting. They also discuss age restrictions for bariatric surgery, among other pertinent issues. Whether you're seeking guidance for post-op well-being or curious about the impacts of bariatric procedures, this episode is packed with invaluable advice and expert insights.


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Speaker 1:

Welcome to Core Bariatric's podcast, hosted by bariatric surgeon Dr Maria Iliakova and TMA LaCoste, bariatric coordinator and a patient herself. Our goal is building and elevating our community. The Core Bariatric podcast does not offer medical advice, diagnosis or treatment. On this podcast, we aim to share stories, support and insight into the world beyond the clinic. Let's get into it. Maria, science is right. You were right. Vitamins are important. At my one year follow up, we took some labs and you're like Tami, your iron is really low. What are your vitamins and how do we need to tweak them? And I just gave you the. I am guilty, look, and you mean mug me.

Speaker 2:

I did, I did. I hunt people down for not taking their vitamins. This is my one hill to die on.

Speaker 1:

Yes, so I started taking my vitamins and I have more energy. Not perfect.

Speaker 2:

Yeah.

Speaker 1:

But yeah.

Speaker 2:

Yeah, that sounds about right.

Speaker 1:

I feel like I just have to learn the hard way in every situation, but at least you're learning.

Speaker 2:

So that's good, I am learning. There's no such thing as learning the wrong way, but you're right. So vitamins super important. After surgery, your body just does not absorb things the same way as it did before. So when we cut out part of your stomach, or if we were, you route things that plumbing just don't work the same way it did before, and so you have to take your vitamins. And you have to take them every day, and I know it's a pain in the butt, but it's very important. And eating a good, healthy diet definitely helps. Staying active, all those things, those are a given, yes, but honestly, the vitamins and nutrients that you got to take, so it's vitamin A, d, e and K, and then some calcium, some iron and then, if you are so inclined, things like copper and zinc also are a good idea. But at a minimum, those, those few, you got to do it, yes, ma'am. And B vitamins Right, I don't think I didn't mention B vitamins, but super important. Every day. Got to do it and you'll feel better. There's a lot of like. Everything will work better, your body will work better, your skin will work better, you won't lose as much hair Like it's, it's great. So please take your vitamins every day. Yes, ma'am, yes ma'am, yes, all right.

Speaker 1:

So this episode is questions coming from our friends and patients. I have a little Facebook group with them and these are just their questions.

Speaker 2:

You bet.

Speaker 1:

Okay, this first one is mine. Do you watch Grey's Anatomy?

Speaker 2:

I don't why. Why? Because it's too close to home, because I need a break. And this is my problem is I judge too hard, and if it's not perfect, then it bothers me, and if it's like too perfect, then it also bothers me. And no, I just. I can't do it. I got to relax, can't watch it.

Speaker 1:

And I feel like a lot more people die in Grey's Anatomy than in real life. That's true. None of her, like her bariatric surgery, that's true Less than 1% of people die, you know?

Speaker 2:

Oh, it's way less than 1%. It's like 0.01% Granted, like in the 80s and 90s. Yeah, in the 80s and 90s it was way higher because we were doing big open wax on people and we just didn't know how to follow people very well and how to support people. But now we do so. Now complication rates are really low and people survive, yay, yeah.

Speaker 1:

All right, I just have to know that Next one is hypoglycemia.

Speaker 2:

Yeah, that's a big one. Why does this?

Speaker 1:

happen, and how do people battle it?

Speaker 2:

That's a big one. So hypoglycemia let's break that down that means low blood sugar. A lot of people probably have had an episode at least of low blood sugar in their life, so they kind of know what that feels like. It's you get shaky, you get dizzy, you can get sweaty, you can get lightheaded, you can feel sick to your stomach, you can actually throw up, you can have diarrhea, you can have stomach cramps, all kinds of things, and overall it just does not feel good, right? So how do you fix it? So typically, if you drink something like if you're on an airplane and somebody has low blood sugar, you're giving orange juice. So some kind of juice, something that has a little bit of sugar in it, or a gel pack or something, is a really good idea. People can have low blood sugar for all kinds of reasons. Sometimes they're taking medications that can contribute to that. Sometimes they didn't eat all day. They've kind of fasted all day, even if they didn't mean to. Oh, lord knows that I did that quite a bit during residency and fellowship.

Speaker 1:

I feel like you still do it when you're just crazy busy. I'm like one day we were recording or whatever we were doing, and I'm like Maria, have you even drank anything today? You like coffee?

Speaker 2:

I do like coffee. I'm drinking some coffee right now. But yes so low blood sugar can happen all the time really to anyone. Our bariatric folks, after surgery, are way more likely to experience low blood sugar for a couple of reasons. One, because you're eating in a totally different way than before and you're absorbing foods differently, and we also encourage people not to eat things that are really high in sugar. You may be low, on the low side anyway as a result of how you're eating and then you also have very different signaling of the things that help to regulate your blood sugar than you did before surgery. And that's with a sleeve, that's with a bypass, that's with a saty, that's with any kind of bariatric surgery, some more powerful than others, yes, but even with a sleeve that can change. So basically, you've got sugar in your blood and that's normal, and that sugar gets moved into the cells from your bloodstream In part by how much insulin is being produced and when it's being produced. So insulin after you eat starts to increase and it helps your body actually move that blood sugar from the bloodstream to inside the cells, where cells can use it for all kinds of different things like building or other aspects of metabolism. Basically, and what happens is, after bariatric surgery, some people's response, their insulin response overdoes it. So what happens is it's too good at pushing that blood sugar from the bloodstream into the cells, so it can lead to there being too little blood sugar at that point and then you crash and have all those symptoms. It's really important in a lot of ways to listen to your body after surgery and figure out when those things are happening, because sometimes it can be related to the foods that you're eating or when you're eating them or going long periods without eating. It can be actually due to not drinking enough water too, because your body will respond differently in how it regulates its insulin, even based on how hydrated you are or not. And then if you're getting really low, like you're having these episodes happening on a regular basis or they're happening every day, or you're actually testing your blood sugar and it's like in the 60s or lower, that's a really good time to talk to your doctor, because what could be happening is there could be other medications that are having an impact, or we may need to talk about overall how you're eating and drinking in your daily life and when you're doing that, or we may need to actually look for other reasons, because it could actually be a thyroid issue, it could be a pancreas issue, it could be a pituitary issue, part of your brain. So there could be a lot of other things contributing to this too, especially if it's happening over and over again.

Speaker 1:

Right, and you talked about going long period of times without eating. So that brings up actually kind of my question of us as bariatric patients doing intermittent fasting, Yay, nay.

Speaker 2:

Nay Way. Nay, let me tell you why. So? Not that I don't think intermittent fasting can work for some people and it can be an appropriate way for some people to eat. And, honestly, you and I both have intermittent fasted in our lives at different times by accident, because, like you said, when you're really busy at work or with kids or traveling or something like that, sometimes you'll go really long periods without eating or drinking. But if you're doing that as a regular, on a regular basis, and doing it for the purpose of losing or maintaining weight, that can be really difficult to do. An overall that does more damage to metabolism than good if it's not sustained over a long time, which most people can't sustain that over a long time. So for our bariatric folks, I definitely do not recommend it. And here's why your tank after surgery is always going to be smaller than your tank was before, right? So before, yeah, you had a normal car tank and I mean like tank of gas kind of thing. If you got empty you could fill it up and you could go 300 miles. Again After bariatric surgery, we've either cut your stomach or we've rerouted things, but no matter what your tank is smaller. Your tank can only go 50 to 100 miles at a time. So if you're running on empty for miles and miles and miles and miles guess what? You're going to do a lot of damage and it's way easier to get dehydrated and have problems. If you're not drinking regularly throughout the day, it's way easier to have nutrition problems. And then the important part about that isn't that, like oh no, you missed an hour of eating or you didn't drink for a couple of hours or something. The big deal is it's going to affect how your body functions. It's going to have an impact on how your skin looks, how your eyes work out, whether or not you have hair loss, how successful you are in bed, how much energy you feel, like you mentioned in the beginning of the episode. So it really does impact how your body feels and moves, and so that's why it's super important.

Speaker 1:

Yeah, especially for us. Yes, yes, now we just got past holidays. One of our friends says how do we change habits and traditions that are usually based around food, such as like baking cookies?

Speaker 2:

Well, Tammy, how did you do it? I'm curious about your thoughts on this one.

Speaker 1:

Avoided. No, seriously, but we didn't do the typical Christmas this year. Usually we go to our sister-in-laws and she is a bakeaholic. She oh so yummy. So that helped there. But I honestly did not do great this year, and so one of the suggestions I did give her was trying to make those cookies healthier or making less of them. Yeah, but otherwise I'm still kind of trying to figure that out too.

Speaker 2:

It's tough because I feel like a lot of this stuff. It's like it's easy to say but it's really hard to do and I relate to this a lot too. So my family's Russian. We go crazy over the holidays and, honestly, any time that we get together it's food-based Food is big. And not only that, but, like you had mentioned earlier, there's some foods that are traditional or some foods that are only around during the holidays, like certain kinds of cookies and breads and cakes and all kinds of things, and they're usually goodies, right. They're usually not like oh we do this amazing thing with celery, no, we do this amazing baked good thing, right. So I hear you, and it is easy for me to give Pithy advice and say eat less or make it healthier or something on those lines, but instead maybe let me put it this way I think it is important to indulge sometimes.

Speaker 1:

Yes, it is. I personally agree with that. Yes, because if you do not indulge a little bit, you're going to indulge a lot of it.

Speaker 2:

Yeah, Because that constant restriction I think creates food noise actually and contributes to overall just feeling deprived or unhappy. And food, especially when it's partnered with tradition or when it's partnered with family and friends and having a good time, I think it's really, really important to actually indulge sometimes, and let yourself do that. I will say there is an important difference between indulging sometimes and sort of being like, oh, I indulged this time and therefore to heck with it and I'm just going to overdo it every time from now on.

Speaker 1:

Yeah, that's hard to not go down that way, yeah.

Speaker 2:

So that, honestly, is more of a mental tricks and figuring out what things trigger you or what things make you continue eating or overeating, if that's an issue. So I think that's a really personal kind of take a survey, honestly, of yourself and be pretty realistic about what am I eating? How much am I eating? Am I eating because I'm hungry? Am I eating because I'm bored? Am I eating because I'm thirsty?

Speaker 1:

And I did see a patient on one of the Facebook groups say I go into Thanksgiving or Christmas and I pre-planned what I'm going to eat with what I know is going to be there. But then I also give myself a little leeway and they said I do not go into Christmas or Thanksgiving, saying this is going to be my best day.

Speaker 2:

Right.

Speaker 1:

So I like that mentality of even if you go in and be like I'm going to have five cookies, yes, yes, five cookies is a lot, but if it's five cookies you don't get all year, instead of going in saying I'm going to have no sweets.

Speaker 2:

Right, right.

Speaker 1:

So I think that's trying to figure out how to do it with your family. Telling a kid, you can't decorate Christmas cookies. That's probably not going to go over well, Right. But if you have teenagers or something instead of baking, I actually saw where people are making these new year boards. And they have all these magazines and you clip out of there what you see this year going.

Speaker 2:

I love it.

Speaker 1:

So let's say, you grab.

Speaker 2:

Speaking of kiddos by the way, there's one in the background and I hear you, involving your kids and your family is super, super important in this stuff, because it's not just you.

Speaker 1:

Absolutely yeah, yeah, yeah, if anybody ever hears my kids in the background, yeah, sorry, not sorry, Sorry not sorry, it's part of life. We do the best we can. We just had a. We have a blizzard right here.

Speaker 2:

The whole Midwest actually is blizzarding, right, yeah. Yes it's blizzarding today.

Speaker 1:

And so my husband's outside snow blowing. Yes, so he can't wrangle kids.

Speaker 2:

Yes, totally reasonable. No, but you're right, it is about creating, maybe, new traditions. Sometimes I have some friends who do a photo, sort of photo collage, but they do it digitally online and that's their tradition. They go through photos from the whole year and they, as a family, create a book of photos together and album of photos together. And our family we do a lot of. We played like board games together or we'll do like we'll read together. I don't know, we're kind of a weirdo family though, but I think board games is awesome. Yeah, and there's just stuff that we do that, or like we'll go out together to go to the museum or something like that, or we'll go.

Speaker 1:

So planning ahead.

Speaker 2:

Planning ahead absolutely.

Speaker 1:

Honestly, everything after bariatric surgery is planning ahead Exactly.

Speaker 2:

And I will say, you know one of the ways that we sort of forget we can do this. I don't know why, but when we get together with people we don't like go outside and go on walks and things like that. Luckily, I have a dog, so I have to go outside and walk her on a regular basis, no matter what, but with your family, maybe start a tradition where you actually go outside for a walk before you sit down and eat or after you sit down and eat. That's something that we do in my family for Thanksgiving. We always go on a walk after eating and the walk is usually like 30 minutes. It's a pretty or longer. It's a pretty decent walk and that just helps everyone rest and digest a little and then have a break from the table and I don't know, having a way to maybe fit in a little bit of activity not a bad idea.

Speaker 1:

My three year old thinks that he wants to go outside.

Speaker 2:

Ah sorry.

Speaker 1:

And I think there's more snow there than he is tall.

Speaker 2:

Yeah, definitely that's the best snow day, All right snow.

Speaker 1:

Yeah, it's so beautiful.

Speaker 2:

Yep, that sounds really beautiful.

Speaker 1:

It's a good thing I don't have to work today. Another question how come some programs allow straws, allow carbonation, but some are like, absolutely not?

Speaker 2:

Yeah, that's a great question and that's not just limited to straws and carbonation. You'll notice programs differ Like. Some programs are like, oh, you definitely can do this thing, and then another program is like, oh, you definitely cannot do that thing. There's a lot of variation and those are areas in which we don't have a definitive answer. So if you actually look at research and people who have studied this and what they find about it, there isn't a definitive answer there, which means that since we don't have a definitive answer, all answers are potentially correct and also all answers are potentially not correct.

Speaker 1:

The flip side of it Right, right, and I know the biggest thing with a straw for our program, we told our patients obviously definitely not six months. Yes, yes, because the air is the thing. Yes, but afterwards, if you can handle a straw and you're not obviously chugging, it's just however you feel.

Speaker 2:

Yeah, I mean, I think with straws and carbonation and all of these other things. It's think about the fact, like we said earlier, that your tank is smaller than it used to be. So if you're filling your tank really fast, or if you're filling your tank with air instead of with fluids and food and things like that, you may have problems with bloating or nausea or just feeling too full or not getting in what you need instead of getting in what you're like air and what you're getting instead Right. So it's more about how you use it, and that's kind of the tricky. Yeah, this is one of those areas where there's no right or wrong answer, because it depends on how you do it more than on the thing, itself.

Speaker 1:

And I just know that I do better with a straw. Yeah, yeah, and my big old staple.

Speaker 2:

Stanley cup. Right, that's right. But no, you're absolutely right, it's if a straw helps you get more fluids in. The fluids are more important than whether you have a straw or not. And if you're not overdoing it, if you're not causing yourself to become feeling bloated or feeling nauseated or those kinds of things, then by all means. And if you're doing a little bit of carbonation because you can handle it great, then do that too. So I don't know that these fast and hard rules aren't necessarily there Because we have a great reason for it. I will say, a lot of times programs make these kinds of rules or make these kinds of guidelines based on the worst case scenario. So they're trying to prevent problems rather than then give a really big leeway to people, because sometimes we see more problems with people overdoing it with straws and with carbonation and things like that. Okay, yeah, does that make sense? So it's more Because we we don't have necessarily all the time in the world to like explain it to this level of detail that we do between us. That's true, that's true. So it's more to prevent problems rather than necessarily because it's like truly banned and can't be done.

Speaker 1:

Right that? Yeah, that does make sense. That's what's nice about us doing this, is we have time to explain these things.

Speaker 2:

All the time in the world, because it's up to us.

Speaker 1:

Yes, so how old is too old?

Speaker 2:

Mm-mm Doesn't exist, bariatric surgery does not exist, and let me explain why. So there's people, that there's all kinds of people. So there you have seen 80 year olds that are really 50 year olds in their bodies, and there's 50 year olds who are 80 year olds. It's very true, and you do not have to be a doctor or a coordinator or anything like that to see that. There's people you see on the street or people in your family maybe, but that applies too. Age is truly just a number. Here and again, when we're talking about guidelines for bariatric surgery, there actually are no age cutoffs on the upper side. On the lower side there are, but on the upper side there aren't. And there's a reason for that because every person is different and even people in their 70s and 80s and even older, really can benefit from bariatric surgery. It just depends on how healthy are they overall and will they, for instance, get a really big benefit in their joint pain and their their relief of overall not being able to move as much? Or maybe they have diabetes or high blood pressure and they want to get off of medications that can actually make them dizzy and make them fall. So you know there's there's always a risk benefit here, right, and we have to weigh the benefits versus the risk. And you know, in our program we've operated on people who are in their 70s and those folks have done really, really well. So really well, yeah.

Speaker 1:

And then and they go through the same process that everybody else does. If you need to see cardiology cardiology pulmonary, all that stuff.

Speaker 2:

And just like every 30 year old is not a good candidate for surgery, every 70 year old is not a good candidate for surgery, there are some special factors you have to take into account when you're at the older ages, like 65 and older, because people can have a higher risk for being dehydrated and higher risk for having other medical conditions and medications and things like that on board. But, like you said, it's you know, we've all seen it ourselves. There's people who look like they're 80 and they're only like 30, and vice versa, right, right, and that applies to to this, this process too. So it's really not a number limitation, it's more a discretion, a choice made by the person and the team.

Speaker 1:

That makes sense. Okay, let's see a person has had bariatric surgery, has been maintaining it well, and then go through, let's say, menopause. All of a sudden they start gaining weight, but they're not doing anything different.

Speaker 2:

Yes, that can happen.

Speaker 1:

How do they mentally? I don't know. I just want to bring more awareness to the women that are at that stage of their lives and their body is really working against them.

Speaker 2:

Yes. So our bodies gain weight over time. That is just how human bodies work. There are some human bodies that are the exception to this, but that is not common. So we gain weight over time, and especially as we age, especially as we go through menopause, and for men there's not technically menopause, but there's also hormonal changes that are similar to what women go through. So, in fact, you know, that's kind of funny because we now have some research that's coming out that says or quite a bit actually at this point that says a BMI of 25 to 30 is actually probably the best range in terms of healthy bones and healthy joints and things like that for people who are postmenopausal, for women who are postmenopausal. So why is our goal necessarily still under 25 then, for everyone? That may not be the safest range for everyone, and trying to get under 25 can actually cause people to harm their metabolism and then regain weight and gain more.

Speaker 1:

And mentally trying to get to that 25, yes, holy moly, but even, yeah, older, not even older, but everybody. If you have a little extra and you get super, super sick, right, that's helpful that extra weight is helpful.

Speaker 2:

That extra weight is helpful. That extra weight is helpful if you have a trauma, if you have a fall, if you have really exactly any kind of illness. Actually being in that BMI range of 25 to 30 can be protective and there's some studies that show it's protective for your heart, your bones, your muscles, your brain, all kinds of things. So I'm not sure, and there's actually very little evidence, that a BMI of up to 30 for most people not for everyone, for most people actually causes disease or contributes to disease. It's more the trajectory like, it's more the are we continuing to go up or are we staying in the under 30 BMI range? So yeah, so it's kind of interesting because I don't know that that's necessarily the general. That's not the general view, I think, in the public and that's not necessarily the general view even in our own industry and healthcare. But there's a lot of evidence that says what the efforts that we take to try to get under a BMI of 25 for everybody at all ages is actually probably more harmful than staying under 30 for well, even for bariatric patients, right, it'd probably be almost impossible.

Speaker 1:

Right here he's saying Cohen, saying hi back here, hi Cohen, but we have saggy skin.

Speaker 2:

Exactly.

Speaker 1:

That weighs exactly.

Speaker 2:

You know, so and, realistically speaking, once people are have a BMI over 30, it's really difficult to get under 25 in any healthy way, even with surgery. So even with surgery for those in the back just saying it twice and there are times in people's lives like menopause and pregnancy and illness sometimes or others, that will cause people to gain weight I think if someone's gaining weight and really nothing has changed, that's a really good time to get involved back with your program and to actually talk to a dietitian, be open minded to talking to somebody who will discuss your mental health and talk with a physician or whoever else is in the practice. That that manages helps manage weight. To be open minded to what kinds of things are out there. If you're getting really fast and a lot of weight, then that's probably that's a very different scenario than if you're gaining a little bit of weight over a long period of time. Sometimes medications can help with that, sometimes lifestyle changes can help with that and sometimes there's more going on and it actually is a true problem with either metabolism, endocrine function, hormone function, and that needs to be investigated further.

Speaker 1:

Right, Okay, last question. I may or may not struggle with this. Yes, how do we battle dry skin? Like what? What causes it Like yeah?

Speaker 2:

So dry skin can be caused by a lot of different things. One we're in the middle of winter, so you know good luck, dry skin is Ain't that the truth?

Speaker 1:

Yes, ain't that the truth? Dry skin is and I work in a hospital, so even drier.

Speaker 2:

Yes. So anytime you're getting alcohol on your hands, for instance, doing all that sanitizing, that's not going to help Keeping hydrated. I think a lot of times, in the wintertime especially, we forget to drink because we don't feel hot and we don't feel as thirsty, but your water required or your food requirements don't change. So make sure that that's not something that's lagging. And then vitamins and minerals. Sorry to say it again, but it's true. In the wintertime we are not eating as many fruits and vegetables. Typically, we're not eating as varied of a diet, we're eating a lot more kind of meat and starches and it's a little bit less diversity in our diet in general. So it's that much more important to make sure we've got all of those vitamins and micronutrients that are really essential for good skin health, and those things include things like zinc, copper, selenium, which are micronutrients and not typically something you would ever be like oh, does this potato have selenium in it? That's not necessarily thinking of it that way. So it's important to take your daily multivitamin because that will have those things in it and that will help you protect your skin too.

Speaker 1:

Yeah, and I think we need to come up with not oily lotion.

Speaker 2:

How does?

Speaker 1:

that happen. I hate lotion, I agree, I have found that's just a me thing.

Speaker 2:

Yes, it takes a long time and, honestly, I feel like I have different lotions for different times of the year because my skin does different things during different times of the year. That's very true.

Speaker 1:

Yes, that's very true.

Speaker 2:

Yes, but that's all.

Speaker 1:

I got Perfect, love it, so we'll end this episode. Thank you all for listening. This is definitely a learning journey, but we're going to keep going at it because there's much information and questions and all the things that we want to provide, so don't forget to follow our show. Don't hesitate to comment if you have anything you want us to talk about, but otherwise we'll see you next time.

Speaker 2:

See you next time, thank you.