How we eat, can make a difference

According to a new study from Japan, published in the British Medical Journal (BMJ), the combination of eating quickly and eating until full was associated with being overweight. That effect was observed, regardless of how many calories were consumed. The study enrolled 3287 adults, and was designed to examine whether eating until full and/or eating quickly, are associated with being overweight.

Eating to fullness doubled the odds of being overweight. Eating quickly also doubled the chance of becoming overweight. This reminds me of a previous posting a little less than a year ago.

The source article:

Maruyama K, Sato S, Ohira T, Maeda K, Noda H, Kubota Y, Nishimura S, Kitamura A, Kiyama M, Okada T, Imano H, Nakamura M, Ishikawa Y, Kurokawa M, Sasaki S, Iso H. The joint impact on being overweight of self reported behaviours of eating quickly and eating until full : cross sectional survey. BMJ. 2008 Oct 21;337:a2002. [PMID: 18940848] (Full Article)

First Heart Attack - How Young?

A study from Michigan gave an answer to a question: Can obesity make someone suffer a heart attack at a younger age? The authors examined the data of 111,847 patients who suffered from a type of heart attacks called "non-ST-segment elevation myocardial infarction (NSTEMI)." They found that the leanest individuals whose BMI was 18.5 kg/m(2) or less, developed that type of heart attacks at an average age of 74.6 years, compared to those with BMI of 40 or above, whose average age for the first heart attack was only 58.7 years.

Notice that a BMI of less than 18.5 is considered, by definition, underweight (see the Bariatric Surgery Glossary), which is abnormal and not healthy. Remember, the benefits of a healthy heart can only be realized in an overall healthy body. Having said so, the contribution of obesity to the premature occurrence of a heart attack cannot be ignored. We should do everything possible to treat and prevent obesity when as young as possible, to help preventing life-threatening complications.

Reference:

Madala MC, Franklin BA, Chen AY, Berman AD, Roe MT, Peterson ED, Ohman EM, Smith SC Jr, Gibler WB, McCullough PA; CRUSADE Investigators. Obesity and age of first non-ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2008 Sep 16;52(12):979-85. [PMID: 18786477] (Abstract)

Overweight, Excessive Insulin Secretion and Higher Prostate Cancer Mortality

This time, a men's health topic. A new study from Boston, published in a Lancet Oncology Early Online Publication on October 6, 2008, presented evidence that being overweight, and/or having excessive insulin secretion (as indicated by a high plasma C-peptide concentration), increases the risk for death in prostate cancer.

The study reported on 2546 men who are participants in a Physicians' Health Study of 24 years, and who developed prostate cancer. Patients who started off being overweight or obese a higher risk for death from prostate cancer, compared to normal-weight men Patients who were both obese and who also had high insulin levels had four times the risk compared to controls. The authored cautioned "Further studies are now needed to confirm these findings."

The study confirms previous evidence regarding the relationship between prostate cancer mortality and obesity. Although diabetes is associated with lower risk of prostate cancer, the new study suggests a correlation to high secretion of insulin, which is a characteristic of insulin resistance. Insulin resistance is common in overweight and obese people. Despite the complex relationship, being overweight or obese appears to have an all in all bad effect on those who develop prostate cancer.

References:

Ma J, Li H, Giovannucci E, Mucci L, Qiu W, Nguyen PL, Gaziano JM, Pollak M, Stampfer MJ. Prediagnostic body-mass index, plasma C-peptide concentration, and prostate cancer-specific mortality in men with prostate cancer: a long-term survival analysis. Lancet Oncology Early Online Publication. October 6, 2008. (Abstract)


Smith MR, Bae K, Efstathiou JA, Hanks GE, Pilepich MV, Sandler HM, Shipley WU. Diabetes and mortality in men with locally advanced prostate cancer: RTOG 92-02. J Clin Oncol. 2008 Sep 10;26(26):4333-9. [PMID: 18779620] (Abstract)

Low Serum Vitamin D and Hip Fracture Risk

A new study published in the Annals of Internal Medicine showed that low vitamin D levels in the blood are associated with an increased risk of hip fracture in postmenopausal women. The study included 800 individuals (400 who had hip fractures, matched with 400 women who did not have hip fractures). Hip fracture risk was highest among women who had the lowest levels of vitamin D in their serum.

As we know, there is an association between low vitamin D levels and obesity. Also, after bariatric surgery, there is a possibility of developing low serum levels if supplementation is not taken regularly. Those were discussed before here and here.

Reference:

Cauley JA, LaCroix AZ, Wu L, Horwitz M, Danielson ME, Bauer DC, Lee JS, Jackson RD, Robbins JA, Wu C, Stanczyk FZ, LeBoff MS, Wactawski-Wende J, Sarto G, Ockene J, Cummings SR. Serum 25-Hydroxyvitamin D Concentrations and Risk for Hip Fractures. Ann Intern Med. 2008 August;149:242-250. (Summary for Patients, Abstract)

Oxalate Kidney Damage

Make sure you stay hydrated, and take precautions to help preventing oxalate kidney stones. Those precautions can also help preventing a condition called "Oxalate Nephropathy"

Some definitions:

Nephropathy: A disease or an abnormality affecting the kidneys

Oxalate: A chemical that, when combined with calcium, can form calcium oxalate stones (usually called oxalate stones)

Oxalate Nephropathy: An abnormal condition of the kidneys that results from precipitation of calcium oxalate crystals in the kidneys.

Oxalate nephropathy can lead to kidney failure. Oxalate nephropathy leading to kidney failure has been previously reported in a patient who took a high dose of Orlistat (the active ingredient in Xenical and Alli). That one reported patient had, before taking Orlistat, an abnormal kidney (chronic kidney disease from hypertension and possibly diabetes).

This time, I am commenting on a new article that appeared in the Clinical Journal of the American Society of Nephrology which reported cases of oxalate nephropathy complicating Roux-en-Y gastric bypass in patients who had, prior, an underlying mild chronic kidney disease from obesity, hypertension and /or diabetes.

The authors identified eleven patients with oxalate nephropathy after gastric bypass. Those patients developed end-stage kidney disease. The mean age was about 61 years. All patients had a history of high blood pressure disease, and 9 had diabetes. Patients were likely to have an underlying mild chronic kidney disease from obesity, hypertension and /or diabetes. There is actually a nice summary of the effects of obesity on the kidneys in Dr. Sharma's blog. The conslusion of the study we are discussing today is that, patients with kidney disease may be at a higher risk for oxalate nephropathy after gastric bypass.

Ways to help preventing oxalate kidney stones can also help preventing oxalate nephropathy, and they were described here. Remaining hydrated in this hot weather is particularly important. Low fat intake, restricting foods rich in oxalates, taking calcium supplements, low sodium diet, and possibly considering a medication (hydrochlorothioazide) in selected patients, my all help.

References:

Nasr SH, D'Agati VD, Said SM, Stokes MB, Largoza MV, Radhakrishnan J, Markowitz GS. Oxalate Nephropathy Complicating Roux-en-Y Gastric Bypass: An Underrecognized Cause of Irreversible Renal Failure. Clin J Am Soc Nephrol. 2008 Aug 13. [PMID: 18701613] (Abstract)

Singh A, Sarkar SR, Gaber LW, Perazella MA. Acute oxalate nephropathy associated with orlistat, a gastrointestinal lipase inhibitor. Am J Kidney Dis. 2007 Jan;49(1):153-7. [PMID: 17185156] (Abstract)

Two Hundred Seventy Five Minutes per Week

A new study that is published in the Archives of Internal Medicine, reported that the commonly recommended physical activity levels (150 minutes per week) are not good enough to maintain weight loss. They concluded that 275 minutes of physical activity per week , in combination with a reduction in calorie intake, is important to maintain a weight loss of more than 10%. The study was conducted on 201 overweight and obese women with body mass index ( BMI) of 27 to 40.

The basics of achieving weight loss and maintaining a healthy weight have always been the same:

(1) Dietary management: portion control and high quality food.
(2) Increasing the activity level: by exercising, and by leading a physically active attitude during everyday normal activities.

This study validated the combined approach and, furthermore, has set a new recommendation for physical activity. Although the study is not a post-surgery study, the recommendations are valid for postoperative bariatric surgery individuals. The surgery is just a tool to achieve weight loss that cannot be achieved otherwise in a majority of people.

Reference:

Jakicic JM, Marcus BH, Lang W, Janney C. Effect of exercise on 24-month weight loss maintenance in overweight women. Arch Intern Med. 2008 Jul 28;168(14):1550-9. [PMID: 18663167] (Abstract)

Affiliations: University of Pittsburgh, Pennsylvania, Brown Medical School and The Miriam Hospital, Providence, Rhode Island.

A Food Diary Works!

Probably it is not new knowledge that recording a diary of the food intake and exercise activities does help. Now, a new study from Portland, Oregon has verified the positive outcomes of keeping a food diary. The weight loss actually doubled to 18 pounds in 20 weeks, compared to 9 pounds, by using that method. So, here is a nice simple tool that can go a long way, and that needs only a pencil and a sheet of paper. Remember, the best time to enter your food intake into your diary is right on the spot. Once you're done with the meal. For more coverage of this subject, you can go to an article in Informify News and an article in the Washington Post.

Somewhat related, is an old report published in 1992 in the New England Journal of Medicine (Abstract). It showed that, among obese individuals who repeatedly failed to lose weight despite reporting adherance to a 1200 Kcal-per-day diet, the study group underreported their actual food intake by an average of 47%, and overreported their physical activity by an average of 51%.

Stay Healthy!

Reference:

Hollis JF, Gullion CM, Stevens VJ, Brantley PJ, Appel LJ, Ard JD, Champagne CM, Dalcin A, Erlinger TP, Funk K, Laferriere D, Lin PH, Loria CM, Samuel-Hodge C, Vollmer WM, Svetkey LP; Weight Loss Maintenance Trial Research Group. Weight loss during the intensive intervention phase of the weight-loss maintenance trial. Am J Prev Med. 2008 Aug;35(2):118-26. [PMID: 18617080] (Abstract)

At what age do we stop being so active?

I wondered, at what point in our lives have we shifted from running to walking? From moving a lot to moving only if we need to? Basically, when does our moderate-to-vigorous activity level shift from the tireless running allover the place to the more adult-like style of moving when we need to? A very interesting study, published in the July 16, 2008 issue of JAMA gave some insight. The authors analyzed the data of more than 1000 children, almost half of them were boys and the other half were girls. The researchers followed their patterns of moderate-to-vigorous physical activity from age 9 to age 15. They found that at 9, the average child engaged in good 3 hours of moderate-to-vigorous physical activity, which is well more than the recommended minimum of 60 minutes per day. By age 15 years, adolescents were active at that level for only 49 minutes per weekday and 35 minutes per weekend day. Boys were more active than girls. It is well-known that decreased physical activity is an important factor in childhood obesity.

I am not sure what exactly happens. Why at some point in our lives we start walking if we don't have to run, and sit if we don't have to walk? At any rate, knowing that the transition takes place between the ages of 9 and 15, we can target that time interval and aim at keeping children engaged in organized moderate-to-vigorous activities during that period, hoping that the habit continues with them for so many more years of their lives.

Reference:

Nader PR, Bradley RH, Houts RM, McRitchie SL, O’Brien M.
Moderate-to-Vigorous Physical Activity From Ages 9 to 15 Years.
JAMA. 2008;300(3):295-305. (Abstract)

Affiliations of the authors of the reference article: Department of Pediatrics, University of California San Diego, La Jolla; Center for Applied Studies in Education, University of Arkansas, Little Rock; Statistics and Epidemiology, RTI International, Research Triangle Park, North Carolina; and Department of Human Development and Family Studies, University of North Carolina, Greensboro.

Obesity and Weight Loss Surgery in Older Age

Older age has been defined differently in different studies, as either 60 or 65 years of age.

The average body weight and BMI gradually increase during most of adult life and reach peak values at age 50–59. After the age of 60 years, the average population body weight and BMI tend to decrease. Notice that those who die prematurely because of obesity will be removed from the count of older population, and hence the lower average BMI. There is evidence that, in reality, body weight and BMI do not change, or decrease only slightly, in older people. In persons who are more than 80 years of age, obesity is about one-half that observed in the age group of 50–59. As you may see, this is another evidence that the chances that a morbidly obese patient survive through the age 80 are markedly diminished.

How about weight loss in older age? Well, we have to be very careful reading the data, because it is very easy to jump into the wrong conclusions. Several studies evaluated the relationship between weight loss and mortality in older age. Population data from all studies found that losing weight or experiencing weight variability in older age was correlated with higher mortality compared with those whose weight did not change on the average. But read carefully, because the studies did not show if the weight changes were intentional or unintentional. Older patients may lose weight, without intending to, because of serious health problems, terminal disease, or dementia. So, it is no wonder if weight loss on the average is associated with higher mortality, if the population includes those who did not intend to lose weight. Indeed, a study from the Royal Free and University College Medical School, London, England, concluded that intentional weight loss was associated with a significant reduction in mortality in markedly overweight men. The data also suggested that the earlier the intervention, the greater the chance of benefit. So, older patients can benefit from the health advantages of losing some extra weight. Another statistical twist for the mathematically inclined, is that obese patients who survive through older years represent already a pre-selected subgroup that has already defeated the fatal effects of obesity, and their survival represents selection bias, skewing the statistics in favor of better health for higher BMIs. However, it is hard to predict if an individual obese person will be one of those who will defeat the obesity, or will suffer the consequences.

There are changes that are likely to develop with age, like loss of muscle mass and loss of bone (osteopenia and osteoporosis). Whether weight loss is intentional or unintentional, there is a higher risk of bone loss (osteopenia and osteoporosis) and bone fractures, including hip fractures. Therefore, it cannot be emphasized enough that older patients (and, of course younger patients, too) who seek bariatric surgery should adhere to the dietary instructions, supplements and maintain a high level of activity, including exercise. They also should check their bone density, vitamin D and parathyroid hormone levels periodically.

Stay Healthy!

References:

Villareal DT, Apovian CM, Kushner RF, Klein S; American Society for Nutrition; NAASO, The Obesity Society. Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society. Am J Clin Nutr. 2005 Nov;82(5):923-34. Review. [PMID: 16280421] (Full Text)

Wannamethee SG, Shaper AG, Lennon L.Reasons for intentional weight loss, unintentional weight loss, and mortality in older men. Arch Intern Med. 2005 May 9;165(9):1035-40.[ PMID: 15883243] (Abstract)

French SA, Folsom AR, Jeffery RW, Williamson DF.P rospective study of intentionality of weight loss and mortality in older women: the Iowa Women's Health Study. Am J Epidemiol. 1999 Mar 15;149(6):504-14. [PMID: 10084239] (Abstract)

A Plateau

Weight loss after gastric bypass or Lap Band surgery is reaching a plateau. How to deal with that?

First things first. Do not get frustrated. Frustration is a negative emotion that will take you to nowhere. It's never too late to get back to basics.

Here are some tips that may help you every time (yes, plateaus are not a once in a life-time event):

1. Sit back and reassess the situation. Have you reached a healthy weight goal. You do not expect to keep losing weight endlessly. The aim is not to reach the weight that you simply desire. The goal is to achieve the weight that brings to you the best health benefits. If you underwent weight loss surgery (bariatric surgery), your clinic had probably made a calculation as to the average target weight for you. Have you reached that goal? if so, any additional weight loss is just a bonus, as long as you stay healthy.

2. Remember that on average, individuals do regain some weight after reaching the lowest weight. This is OK and healthy, and may represent a normal variation or re-setting of your stable weight, rather than a new trend with increasing weight. Also it may indicate adding up muscle mass if you are exercising. So, if you are doing everything right, and you regain a little bit then plateau again, you have probably reached where you need to be.

3. Regardless whether you reached the weight you ought to be or not, re-evaluate your performance. Eating habits (portion control, watching the quality of the food) and physical activity, get back to basics. Refresh your memory about what you have learned before as part of your weight loss program.

4. If you are lagging behind in some of the basics, maybe you need to sit down and write a diary of your eating and physical activity habits. Writing a log is a very powerful tool, since it makes you accountable to yourself. You may be amazed when you see the reality in your own handwriting somewhat different from what you thought you were doing.

5. Increasing physical activity is particularly useful for getting you out of a plateau. Take every opportunity in your everyday life to spend some extra calories. They add up by the end of the day. Increasing physical activity has tremendous benefits to your state of mind, emotional well-being, physical efficiency, muscle mass preservation, and loss of fat tissue.

6. If you suspect that your motivation is cooling off, remind yourself of the the reasons why a healthy weight is important for you, and make that list handy.

7. Get involved with support group meetings. They are proven to help with long-term outcomes.

8. If after all, you find certain things are presenting an obstacle to achieving the realistic goals that you set, have an honest critique yourself. Write down the reasons that you think are contributing to your situation. Keep the list handy and sleep on it. Review it another day, and see if you can do something about it, or if you need professional help.

Stay Healthy!

More on Fibromyalgia and Bariatric Surgery

A new article adds to the growing evidence that fibromyalgia symptoms improve significantly after bariatric surgery. In a previous posting, we reported on the study that came out of Cleveland, OH. This time a new study from Kalamazoo, MI, reaffirmed the positive outcomes of gastric bypass in patients with fibromyalgia symptoms. The authors concluded that significant weight loss following gastric bypass was associated with resolution or improvement of fibromyalgia. They went further to suggest that the bariatric surgeon should be a member of the multidisciplinary team approach for treating fibromyalgia.

References:

Saber AA, Boros MJ, Mancl T, Elgamal MH, Song S, Wisadrattanapong T.The Effect of Laparoscopic Roux-en-Y Gastric Bypass on Fibromyalgia. Obes Surg. 2008 Apr 8; [Epub ahead of print] PMID: 18401670 (Abstract)

Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW. Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond). 2007 Jan;31(1):114-20. (Abstract)

Kidney Stones, Obesity and Bariatric Surgery

The most common type of kidney stones in the general population, and bariatric surgery is no exception, is "calcium oxalate" stones. Historically, calcium oxalate kidney stones formation was a complication of the obsolete jejuno-ileal bypass (JI Bypass) of the 1970s. The risk for kidney stones, kidney failure, and liver disease led to the abandonment of that surgery more than 20 years ago.

A Mayo Clinic retrospective study showed that by 12 months after gastric bypass, the mean urinary oxalate and calcium oxalate supersaturation were both increased in a group of patients who did not have a history of forming stones.

Notice that, even without surgery, recent data have suggested an increased prevalence of stones with diabetes and obesity. Insulin resistance may lower urinary citrate and increase urinary calcium. Obesity may increase oxalates in urine.

It is safe to say that bariatric surgery can increase the risk of forming kidney stones, and certain recommendations need to be followed. Water and fluid intake, calcium citrate supplements and a low fat diet, go a long way. Remember: Oxalate is not good. Citrate is good. Calcium is good in the intestine but not good in the urine. Sodium is not good. Too much fat in the stool is not good. Here are more details.

Water and fluid intake: Drinking plenty of water is one of the most important measures to help preventing kidney stones. At least 10 glasses (cups) of water (80 ounces = two and a half liters) is recommended. In the presence of a history of kidney stones, even more is required. Lemonade (made from real lemons or a frozen concentrate), is good because it increases the citrates in the urine, which helps preventing kidney stones. Citrate is good; it inhibits the formation and growth of calcium crystals. But grapefruit Juice is not so good in this situation. A number of studies reported an increased risk for kidney stones from drinking grapefruit juice.

Low fat diet: The amount of oxalate in the urine increases with the amount of fat in the stool (fecal fat). After JI bypass the overall fat absorption was reported to be only 15%. So, the amount of fat passing into the stool, because of not being absorbed, is huge, and hence the higher likelihood of developing kidney stones. After purely restrictive surgeries (adjustable gastric band or vertical banded gastroplasty), fat absorption is normal, that is 97%. Biliopancreatic diversion +/- duodenal switch caused only 19% fat absorption. After gastric bypass, it was intermediate (67%) although the study group was very small. Probably the effect is less with proximal than distal bypass.

Restricting foods rich in oxalates: These include chocolate, cocoa, spinach and other dark green leafy items, most nuts, soy products, most berries, beets, beans, and tea. Because oxalates are so common in otherwise healthy food items, it is very difficult to completely eliminate them from a daily healthy diet. You can diminish the effect of oxalate rich foods by accompanying them with dietary sources of calcium to lower oxalate absorption, and by drinking additional fluids along the day.

Dietary calcium and calcium supplements: Calcium in the diet binds with oxalates in the gastrointestinal tract. So, less oxalates will be absorbed in the intestine, and less will be available by the kidney to form stones. Calcium supplements seem to have the same protective effect, but they have to be taken with meals. Calcium citrate is preferred because it helps to increase urinary citrate excretion.

Notice that vitamin C can convert to oxalate. Therefore, vitamin C supplements should be limited to less than 1000 mg/d.

Sodium: Sodium is not your friend. Lowering sodium intake lowers calcium in urine, since calcium excretion is linked to sodium excretion. So, less sodium makes less calcium available in the urine to form stones.

Protein: Animal protein was shown to lower citrate excretion in urine and to increase calcium and uric acid excretion. It is unknown if the malabsorption accompanying gastric bypass (which is why patients are asked to take more proteins), would weaken that bad effect. Also, a study showed that urinary calcium, oxalate, magnesium, citrate, and phosphorus did not differ between a diet of plant protein and beef protein.

Medications: Thiazide diuretics (example, hydrochlorothiazide "HCTZ" ): have been proven to be effective in reducing calcium in urine and stone recurrence. These "water pills" help decreasing the calcium in urine, and lowering the chance of developing kidney stones. Usually patients also receive potassium supplementation, which, in this case, could be potassium citrate to provided more citrate.

Oxalobacter formigenes: This organism relies completely on oxalate as its source of energy . This colonic bacterium could be a promising treatment for oxaluria.


References:

Asplin JR, Coe FL. Hyperoxaluria in kidney stone formers treated with modern bariatric surgery. J Urol. 2007 Feb;177(2):565-9. PMID: 17222634 (Abstract)

Lieske JC, Kumar R, Collazo-Clavell ML. Nephrolithiasis After Bariatric Surgery for Obesity. Semin Nephrol. 2008 Mar;28(2):163-173. PMID: 18359397 (Abstract)

Finkielstein VA, Goldfarb DS.Strategies for preventing calcium oxalate stones.CMAJ. 2006 May 9;174(10):1407-9. PMID: 16682705 (Full Text)

Nelson WK, Houghton SG, Milliner DS, Lieske JC, Sarr MG. Enteric hyperoxaluria, nephrolithiasis, and oxalate nephropathy: potentially serious and unappreciated complications of Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2005 Sep-Oct;1(5):481-5. PMID: 16925274 (Abstract)

Duncan SH, Richardson AJ, Kaul P, Holmes RP, Allison MJ, Stewart CS. Oxalobacter formigenes and its potential role in human health. Appl Environ Microbiol. 2002 Aug;68(8):3841-7. PMID: 12147479 (Full Text)

Lieske JC, Goldfarb DS, De Simone C, Regnier C. Use of a probiotic to decrease enteric hyperoxaluria.Kidney Int. 2005 Sep;68(3):1244-9. PMID: 16105057 (Abstract)

Bone Health, Vitamin D, and Obesity - Again!

Vitamin D deficiency is common with obesity. When vitamin D is deficient, calcium tends to be deficient, too. But the body has a way of keeping the calcium level in the blood looking normal. That is, by raising the level of a hormone called "parathyroid hormone" (has nothing whatsoever to do with thyroid hormone), calcium is actually taken away (say, stolen away) from the bones, to keep its level looking normal in the blood. The bones lose calcium, and become weaker, more fragile and more likely to break. We are talking osteopenia and osteoporosis.

A new study from the University of Nebraska Medical Center, Omaha, was published recently in the Journal "Obesity Surgery". The study found out that vitamin D deficiency is common in obese patients at the time of bariatric (weight loss) surgery and is also accompanied by an increased level of parathyroid hormone, approximately half the time. So, vitamin D deficiency after bariatric surgery is not purely a complication of bariatric surgery. It is, at least in part, caused by vitamin D deficiency before the surgery itself. To reach those conclusions, the authors did blood tests to measure the levels of 25-hydroxyvitamin D, iPTH (intact parathyroid hormone), and calcium in 41 patients before undergoing Roux-en-Y gastric bypass. Then, they compared them to healthy non-obese matched controls. About half of the pre-bariatric surgery patients had elevated hyperparathyroid hormone level, compared to only 2% of controls. Levels of vitamin D (25-hydroxyvitamin D) were significantly low in more than half of the obese patients.

This actually reminds us of a previous study that we reported here. In that study, from Maine, before bariatric surgery, 34% of patients had suboptimal levels, and 54% had deficient levels, of 25-hydroxyvitamin D in their blood. By one year after Roux-en-Y gastric bypass surgery, the vitamin D deficiency improved remarkably with the intake of vitamin D supplements. The researchers actually recommended higher-than-average doses of vitamin D supplementation.

Reference Article:

Goldner WS, Stoner JA, Thompson J, Taylor K, Larson L, Erickson J, McBride C. Prevalence of vitamin d insufficiency and deficiency in morbidly obese patients: a comparison with non-obese controls. Obes Surg. 2008 Feb;18(2):145-50. [PMID: 18175194] (Abstract)

More References:

Nelson ML, Bolduc LM, Toder ME, Clough DM, Sullivan SS. Correction of preoperative vitamin D deficiency after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis. 2007 Jul-Aug;3(4):434-7. [PMID: 17400028] (Abstract)

Support Groups - Do They Make A Difference?

A new research from Memphis, TN, published in the journal "Obesity Surgery" provides another evidence that attending support group meetings after bariatric surgery does make a difference. The article's title is "Support Group Meeting Attendance is Associated with Better Weight Loss". Postoperative bariatric patients completed a questionnaire regarding their opinions of support group meetings. Patients who did not attend support group meetings tended to feel that such meetings were not needed after bariatric surgery. Furthermore, patients who did not attend support group meetings tended to feel that they would lose the same amount of weight with or without attending. Despite those feelings, the study found that gastric bypass patients who attended support group meetings had significantly better weight loss than patients who did not attend. Those findings are consistent with those of Song and associates (Harvard Medical School and Johns Hopkins University). The latter study concluded: "Support groups are important for maintaining weight loss throughout the first year after surgery, especially after 6 months when the rate of weight loss from surgery begins to naturally decline."

This reminds us of the study of Gould and associates, that was reported here, not too long ago, that showed the importance of the follow-up postoperative appointments for long term weight loss.

References:

Orth WS, Madan AK, Taddeucci RJ, Coday M, Tichansky DS. Support Group Meeting Attendance is Associated with Better Weight Loss.Obes Surg. 2008 Feb 20; PMID: 18286346 (Abstract)

Song Z, Reinhardt K, Buzdon M, Liao P. Association between support group attendance and weight loss after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007 Mar 30; PMID: 17400030 (Abstract)

Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surg Obes Relat Dis. 2007 Nov-Dec;3(6):627-30. PMID: 17950045 (Abstract)

Super Size Me - the Swedish Experiment

A research from Linkoping University, Sweden, published in the medical journal "Gut", showed that regular indulging in fast food caused, in less than 4 weeks, a pathologic rise in the level of a liver enzyme, alanine aminotransferase (ALT) in the blood. The fast food experiment subjects aimed for a body weight increase of 5-15% by eating at least two fast food-based meals a day with the goal to double the regular caloric intake in combination with adoption of a sedentary lifestyle for four weeks. They limited their daily exercise to less than 5000 steps for 4 weeks. The authors suggested that an increased flow of monosaccharides to the liver could induce the production of the enzyme in the liver cells. The authors, therefore, recommended that physicians should include not only questions about alcohol intake, but also recent excessive food intake, when evaluating reasons for a new elevation of ALT.

An article in the Guardian gave a little history how the Dr. Fredrik H Nystrom's Swedish experiment design was influenced by Morgan Spurlock's 2004 documentary "Super Size Me", in which Spurlock ate nothing but McDonald's food for a month. You may remember that doctors urged him to abandon his experiment after getting the results of blood tests which show that his liver is so badly damaged it looks as though it is the result of heavy drinking. The results of the Swedish study did document liver enzyme test abnormalities, but those were not as dramatic as Spurlock's.

It is actually not necessarily a matter of whether the food is consumed from McDonald's, a family restaurant, or cooked at home. It is not entirely a matter of whether the food is "fast food" or a fully served multi-course meal in a fancy restaurant. The central issue is all about choices. How many calories, how many of those are proteins, how many are from carbs, and how many are from fat. Wherever you eat, you have to make the best choices regarding the portions and the quality of food. Stay healthy!

Reference:

Fast food based hyper-alimentation can induce rapid and profound elevation of serum alanine aminotransferase in healthy subjects. Stergios Kechagias, Åsa Ernersson, Olof Dahlqvist, Peter Lundberg, Torbjörn Lindström, and Fredrik H Nystrom. Gut 2008 Feb 14; [Epub ahead of print] PMID: 18276725

Economy of Health and Obesity

You probably heard about this study that was recently reported in the media. The title is: "Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure". The study indicates that it costs more if people live longer, than if they die at an earlier age from obesity. Using a mathematical simulation model, the study concluded that total lifetime health spending was greatest for the healthy-living people, lowest for the smokers, and intermediate for the obese people.

Notice that previous studies have consistently calculated the health expenditure savings resulting from reducing the financial burden caused by treating comorbidities related to obesity. Those studies did not enter in the calculations, the life prolonging effects of treating obesity, and the costs of living longer. Pieter van Baal and colleagues conclude, based on their simulation model, that obesity prevention leads to a decrease in costs of obesity-related diseases, but this is offset by cost increases from diseases unrelated to obesity in life-years gained.

I do not know how to use this information. The study that came from the Netherlands is very objective, and proposes no policy recommendations based on the findings. As a matter of fact, the authors stated that it does not imply that preventing obesity is not worthwhile, since the associated health gain is valuable in itself, for society and the individuals concerned. Furthermore, the article commented that Bonneux et al. (from the Netherlands, as well) made it very clear: “The aim of health care is not to save money but to save people from preventable suffering and death. Any potential savings on health care costs would be icing on the cake.”

I cannot imagine anyone finding it morally attractive or ethical to not prevent or treat obesity and smoking, because of the above findings. Those two particular health problems are not the only ones that can potentially affect the life span. How about stopping being aggressive in preventing or treating heart disease, diabetes, etc. Wouldn't that save dollars, too? Living better, healthier, and hopefully longer, is priceless. Stay Healthy!

The study in focus:

van Baal PHM, Polder JJ, de Wit GA, Hoogenveen RT, Feenstra TL, et al. (2008) Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure. PLoS Med 5(2): e29 doi:10.1371/journal.pmed.0050029 (Full Text)

PLoS Med is the Public Library of Science Medicine

Reference:

Bonneux L, Barendregt JJ, Nusselder WJ, der Maas PJ. 1998. Preventing fatal diseases increases healthcare costs: cause elimination life table approach. BMJ. 316:26–29. (Full Text)

Surgery for Type 2 Diabetes with Obesity?

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Who would have thought that the most effective available treatment of a metabolic medical disease (that is, type 2 diabetes) could be a surgical solution? A new study in JAMA showed that patients who have type 2 diabetes and who are obese, were far more able to come off their diabetic medications than those who were treated by non-surgical means.

From Melbourne, Australia, an article titled "Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes - A Randomized Controlled Trial" is published in the January 23, 2008 of the Journal of the American Medical Association (JAMA). The aim of the study is to determine if weight loss surgery resulted in better control of type 2 diabetes than medical (non-surgical) approaches to weight loss and diabetes control. Among 55 patients who completed the follow-up (out of 60 patients), remission of type 2 diabetes was achieved by 73% in the surgical group and 13% in the non-surgical group. In this study, the surgical procedure was laparoscopic adjustable gastric banding (Lap Band). Remission meant being able to keep normal diabetic blood tests while not taking diabetes medications anymore. Please notice that the participants' BMI was more than 30 and less than 40. So, the surgeons accepted lower BMI than the usual cut-off of BMI of 35 that is mostly recommended. Furthermore, the study excluded BMI above 40.

This study adds to other pointers from previous research. Dr. Henry Buchwald in his frequently quoted study: "Bariatric Surgery: A Systematic Review and Meta-analysis" reported that weight loss surgery resulted in complete resolution of type 2 diabetes in 76.8% of patients. To my knowledge, not a single conventional non-surgical treatment of diabetes reported anything even close.

Diabetes treated by surgery? Well, this is not a new concept. Actually, in 1992, an article was published under the provocatrive title: "Is type II diabetes mellitus (NIDDM) a surgical disease?". This is one reason why the professional organization for bariatric surgeons in North America changed its name from the "American Society for Bariatric Surgery" (ASBS) to the "American Society for Metabolic and Bariatric Surgery" (ASMBS)

The authors of the reference article, John B. Dixon, MBBS, PhD; Paul E. O’Brien, MD; Julie Playfair, RN; Leon Chapman, MBBS; Linda M. Schachter, MBBS, PhD; Stewart Skinner, MBBS, PhD are from the Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia

References:

Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, Proietto J, Bailey M, Anderson M. Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes: A Randomized Controlled Trial. JAMA. 2008 Jan 23;299(3):316-323 (Abstract)

Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004 Oct 13;292(14):1724-37. PMID: 15479938 (Full Text)

Dixon JB, Pories WJ, O'Brien PE, Schauer PR, Zimmet P.Surgery as an effective early intervention for diabesity: why the reluctance? Diabetes Care. 2005 Feb;28(2):472-4. PMID: 15677819 (Full Text)

Pories WJ, MacDonald KG Jr, Flickinger EG, Dohm GL, Sinha MK, Barakat HA, May HJ, Khazanie P, Swanson MS, Morgan E, et al. Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg. 1992 Jun;215(6):633-42; PMID: 1632685 (Full Text)

Abdominal Pain after Gastric Bypass

Let's start with a bottom-line statement: Abdominal pain after gastric bypass (other than the early postoperative recovery) is not normal. You are not expected to have on and off severe pains, nausea or vomiting. Chronic abdominal pain is debilitating and may lead to avoiding eating, and, therefore, unnecessary malnutrition.

Here are some causes of pain after gastric bypass:

1. Bowel obstruction from internal herniation. This condition can be very serious, and may lead to loss of bowel or life. A loop of small bowel glides (herniates) into a defect inside the peritoneal cavity, then becomes trapped. The herniated loop may become strangulated, cutting off the blood supply, which could lead to death of that part of the bowel. I placed this as #1 not because it is common, but because it is probably the most serious and dreaded of all causes of later pain after abdominal surgery.

2. An ulcer, either in the pouch, on the anastomosis, or in the bypassed stomach or duodenum. Ulcers can cause not only severe pain, debilitation and malnutrition, but also may lead to bleeding. An ulcer may even perforate, causing peritonitis. Smoking and chronic intake of non-steroidal anti-inflammatory medications (NSAIDs) are risk factors for the development of ulcers.

3. Gallstones and gallbladder disease.

4. Abdominal wall hernia (incisional hernia, also called ventral hernia) my entrap a loop of bowel causing severe pain. When a hernia does not reduce itself, it is called "incarcerated". An incarcerated hernia may become strangulated, cutting off the blood supply to that loop of intestine. Incisional hernias can occur after any abdominal surgery, and bariatric surgery is no exception.

It is important to not accept pain after gastric bypass surgery as a normal sequence. Make sure that you seek expert help.

Hair Loss after Weight Loss Surgery

Here is a common question: Will I lose all my hair after gastric bypass? How do I keep my hair from falling out? The reality is that hair loss after bariatric surgery is common. But patients do not lose all their hair. In the most severe cases, patients may find clumps of hair in their hair brushes, or in the shower drain. However the hair loss normally corrects itself. The most accepted explanation is inadequate protein intake. Hair loss tends to start about three to five months after surgery. The best way to prevent hair loss is to make sure that you take your proteins first, with each meal.

Hair loss after bariatric surgery is considered a type of Telogen Effluvium. To explain, we need to talk a little bit about the normal phases of the cycle of hair development. Each strand of hair goes through three stages of development. These stages are Anagen – the growing phase, Catagen – the intermediate or transitional phase, and Telogen – the resting phase.

Anagen (The Growth Phase): Lasts 2-6 years. About 85% of all the hairs are in the growth phase at any given period of time.

Catagen (The Transitional Phase): The outer root sheath of the hair follicle shrinks and stops producing hair. The catagen phase usually lasts 2-3 weeks.

Telogen (The Resting Phase) The hair does not grow at all. This phase lasts about 3 months (100 days). An average of 5-15% of all hair is in the resting phase at any given period of time. At the end of this phase, the hair follicle starts a new Anagen phase. The resting (telogen) hair remains in the follicle until it is pushed out by growth of a new anagen hair, unless it was shed earlier. There is some recent evidence suggesting that shedding of a telogen hair might be an active process, independent of an emerging anagen hair.

Telogen effluvium occurs when an event prematurely terminates anagen and causes an abnormally high number of normal hairs to enter the resting, or telogen phase. Not all hair enters the telogen phase, but the percentage is much higher than normal. The hairs that are shed due to telogen effluvium are in the telogen phase. Examples of such events include childbirth, gastric bypass surgery, crash diets with inadequate protein intake, acute blood loss, and high fever. Notice that the follicle is not diseased. Simply, the hair follicle’s biologic clock has been reset. On the average, telogen hair loss occurs 3 months after the event.

For the record, this is very different from another type of hair loss called "Anagen Effluvium". The latter is abrupt loss of hair in the anagen phase, which may be caused by cancer chemotherapy and irradiation therapy. This is very different from telogen effluvium.

In conclusion, hair loss after bariatric surgery (a form of acute telogen effluvium) is fully reversible. Patients never completely lose all their scalp hair, although the hair can be very thin. The hair follicles are not irreversibly affected. With restoration of the nutritional balance, helped by increasing the intake of proteins, hair regrowth is expected within 3 - 6 months.