The Bariatrics Lounge

My Favorite WLS in 2011? Sleeve Gastrectomy!

2011-03-06T22:29:00.000-08:00

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It is official now. My favorite weight loss surgery (WLS) now is the sleeve gastrectomy. Does it cause the most weight loss among all weight loss surgeries? No. Duodenal switch and gastric bypass would cause more weight loss. Is it the easiest operation? No. Probably the adjustable gastric band (Lap Band for instance) is easier to perform. However, the sleeve gastrectomy operation combines a unique set of advantages that, together, make it extremely appealing.

1. It is a true restrictive operation. It does not place an obstructive foreign body like the adjustable gastric band. All it does is, to make the stomach smaller, much smaller. We remove 60-80% of the stomach. And the part that we remove is the most expansible part.

2. Patients feel much less hungry in between meals. Doing so is of great help to the vast majority of morbidly obese patients. The mechanism could very well be due to removing the fundus of the stomach. That part of the stomach is the major source of Ghrelin, aka the "hunger hormone". In that particular aspect, it is more effective than the adjustable gastric band.

3. The weight loss after sleeve gastrectomy is reported to be 68% of the excess weight, which is comparable to gastric bypass. This is more than the average for the adjustable gastric band. Success is also more consistent after sleeve gastrectomy. But notice that we do not have long-term follow-up data for sleeve gastrectomy beyond 5-6 years. Having said so, the data thus far beat the weight loss data with the adjustable gastric banding.

4. The surgery is laparoscopic (so-called "minimally invasive") and does not involve implanting any prosthesis around the stomach. Furthermore, the small intestine (small bowel) is not touched. No division. No bypassing. Therefore, a whole set of potential complications (even though rare or uncommon) that are connected with gastric bypass become no issue.

5. For cash paying patients, sleeve gastrectomy is far less expensive than gastric bypass and even, in many institutions, Lap Band. As such, it is becoming the most appealing operation for weight loss among cash-paying patients.

6. Since there is no need for adjustments (as compared to the adjustable gastric band), sleeve gastrectomy is a relatively a low-maintenance type of weight loss surgery. 7. The recovery time is faster than gastric bypass.

So, all in all, sleeve gastrectomy is a nice balance between the gastric bypass and the adjustable gastric band. In our practice, it is now the most commonly requested (and performed) weight loss surgery. You may wonder, do we insert anything that looks like a sleeve in the stomach? No. Then why is it called "sleeve" gastrectomy? Well, someone looked at the final look of the stomach by the end of the operation, which is almost like a tube, and with some imagination called it a "sleeve".

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Weight Loss Surgery for BMI 30?

2011-02-16T20:54:00.000-08:00

As you may know, the standard recommendation has been that bariatric surgery is indicated for BMI 35 or above, in the presence of at least 1-2 comorbidities. In the US, patients whose BMI is between 30 and less-than-35 have hard time being accepted for weight loss surgery and, by and large, have had no surgical option.

One bariatric surgery, adjustable gastric band placement, involves the placement of a device that is produced by Allergan (Lap Band). In an Allergan News Release, the U.S. Food and Drug Administration (FDA) approved the expanded use of the LAP-BAND® System, Allergan’s gastric band, for adults with obesity who have failed more conservative weight reduction alternatives, such as diet and exercise and pharmacotherapy, and have a Body Mass Index (BMI) of 30-40 and at least one obesity related comorbid condition. The LAP-BAND® System study, initiated by Allergan, Inc., is a prospective, single-arm, non-randomized, multi-center five year-study. The study was initiated in 2007, and included 149 patients. The criterion for success was at least 40% of patients achieving clinically meaningful weight loss at the 12-month time point, where clinically meaningful weight loss was defined as at least 30% Excess Weight Loss (EWL).

The 12-month results showed that almost 84% of the patients lost at least 30% of their excess weight at one-year. In terms of improvement in comorbid conditions of dyslipidemia, Type 2 diabetes, and hypertension, 22-33% of patients with those conditions, saw their conditions resolved after one year.

Comparing the Lap Band with non-surgical weight loss (which has very low success rates), and setting the threshold of "success" to the level of losing 30% excess weight, allowed those results to shine. However, if those were compared to sleeve gastrectomy (1-2 year average excess weight loss of 60-68%, and 5 year average loss of 50% excess weight) such a standard for success would not be met by the Lap Band. But the sleeve gastrectomy is a surgical procedure, not involving the implantation of a device. Therefore, there is no basis for FDA to have any saying about the sleeve gastrectomy or gastric bypass. It is safe to say that the improvement in comorbidities is, on the average, much better with the sleeve gastrectomy than the adjustable gastric band.

Will bariatric surgeons become more encouraged to apply the same BMI guideline of 30 for other bariatric surgeries (instead of 35) based on the FDA approval of the Lap Band? Would they be supported by the American Society of Bariatric Surgery if they do so? Will insurance companies change their coverage criteria based on that? So many questions. But it is a good start.

The Sleeve

2009-05-10T15:55:00.000-07:00

I have attended a Master Course of Laparoscopic Sleeve Gastrectomy held in Boston on May 8, 2009. Dr. Raul Rosenthal (Cleveland Clinic, Weston, Florida) directed the course. My goal was to interact with colleagues who perform the same, and to get a sense of what’s new.

Sleeve gastrectomy is a weight loss (bariatric) procedure that removes 60-80% of the stomach (that bag-like part), leaving behind a tube-like stomach.

A Short History: Sleeve gastrectomy has been the first part of the more extensive bariatric surgical operation named “Biliopancreatic bypass with Duodenal Switch”, or, in short, the Duodenal Switch. Sometimes, in super super obese patients, the sleeve was performed as a first step, allowing patients to lose weight and be under less risk to perform the second step, that is, the switch. As a matter of principle, a second surgery is not as easy as a first operation. An exception is when the first operation is not easy, either, because of severe obesity, in which case, weight reduction may actually make a second stage relatively easier, but not exactly a piece of cake. Well, some patients did not follow through, and stayed content with the first step. Noticing that a good number of those patients achieved health benefits from the sleeve alone , the concept of accepting the “sleeve gastrectomy” as a stand-alone, or a “final” operation arose. Even though it is now an accepted “final” procedure, it can be later followed by a gastric bypass, for example, to achieve more weight loss, or stop weight regain.

Technical points: These were presented by Dr. Rosenthal and Dr. Nathan Zundel of Florida International University School of Medicine. The technique of “sleeve gastrectomy” as a “final” procedure evolved from its predecessor, the “step” procedure aiming at achieving more weight loss, and, hopefully, more durable, weight loss. The following technical points remain today, as they have been in the past, controversial.

Distance of starting dividing the stomach, as measured from the pylorus: There is a tendency to accept 5-6 cm among surgeons in the meeting. There is, however, a school that goes as little as 2 cm.

Size of the bougie: The tube (sleeve) is fashioned by dividing the stomach while a bougie is in place. Smaller-diameter bougies replaced the large ones used for the step procedure. The course surgeons used sizes 34-38. There is a school of surgeons that goes as tight as size 32. Notice that one point in that system equals only 0.3 mm. It is quite possible that, due to other fine differences in the technique of dividing the stomach, the actual final product of the surgeons who use 32 is not too different from those who use size 34. In other words, the size of the bougie is not the only determining factor of the final size, when we are talking in terms of less than a millimeter difference.

To buttress or not to buttress: Reinforcing the staple line has been performed by the presenters. The presenters used over-sewing (suturing), rather than buttressing strips. This is a matter of a surgeon’s preference, though.

Outcomes of Sleeve Gastrectomy as a final step: The quoted weight loss was 67-68% of the excess weight in 2 years. This is more than the average for an adjustable laparoscopic gastric band (example: Lap Band), but a little bit less than a gastric bypass. Resolution or improvement of comorbidities was comparable to gastric bypass in the short term. Again, we do not have long-term results.

Complications: No surgery is free from complications. The quoted incidences were leak, abscess, hemorrhage, and stricture in 0.3% each. This compares favorably to other weight loss surgical procedures.

Notice that the risks include a leak, which is rare, but can cause a long stay in the hospital. A leak is also a risk with gastric bypass. How about Lap Bands? The risk is less, but not zero. A leak can arise when a Band causes erosion (that is, cuts through or erodes through the stomach wall), and therefore needs to be removed, which potentially leaves a hole in the stomach that needs to be repaired.

For Prospective Patients: Dr. Matthew Hutter of Massachusetts General Hospital highlighted the importance of informing prospective patients that the Sleeve Gastrectomy as a final procedure is a newer approach and that we are still learning about it. We have limited experience, and there is very limited information as to the long term results. He also stressed that right now, experience is greater than what is published in the literature.

Insurance coverage: Unfortunately, access to this operation is very limited because most insurance companies still consider this as an investigational procedure. It is becoming more and more a favorite among cash paying patients, though. Insurance may pay, after a time-consuming process, if a convincing case can be made, that the other options are contraindicated or are bad choices for a particular patient who needs bariatric surgery.

Cash-paying patients are to be reminded, though, that, if an insurance company does not approve their procedure, it is very unlikely to cover for complications, and the costs of complications from any type of surgery can be staggering. Discuss that with your doctor and see what arrangements may exist, if any. This is sad, because most insurance companies would pay for treating diseases and injuries that may be caused by certain choices (for example, smoking, ovreating, etc.), but not when a patient does the responsible thing and takes charge of their health and chooses the best available treatment for obesity, and pay for it out of -pocket. Oh, I guess I deviated from the main topic.

Middle Aged? Not Too Late to Get Benefit from Activity

2009-03-30T21:50:00.000-07:00

Swedish researchers published in the British Medical Journal (BMJ) a study that aimed to examine how change in level of physical activity after middle age influences mortality and to compare it with the effect of smoking cessation. Researchers surveyed 2205 men aged 50 in 1970-3, then re-examined them at ages 60, 70, 77, and 82 years. They found that mortality was lowest among the most active men. Men who increased their activity level from low/moderate to high between the ages of 50 and 60 saw a drop in mortality after an initial period of 10 years. Before 10 years, no survival advantage was observed. An increase in physical activity has the same impact on lowering mortality rate in the long term as smoking cessation.

Reference Article:

Total mortality after changes in leisure time physical activity in 50 year old men: 35 year follow-up of population based cohort.
Byberg L, Melhus H, Gedeborg R, Sundström J, Ahlbom A, Zethelius B, Berglund LG, Wolk A, Michaëlsson K. BMJ. 2009 Mar 5;338:b688. (Free Full Article)
doi: 10.1136/bmj.b688.
PMID: 19264819

BMI and mortality

2009-03-28T01:55:00.000-07:00

The Body Mass Index (BMI) is one way of assessing weight categories. According to a study published online by the medical journal Lancet, high and Low BMIs were associated with increased mortality risk.

This large research examined data from 57 prospective studies with 894,576 participants, mostly in western Europe and North America. Mortality was lowest among those associated with BMIs in the range of 22.5 to 25 kg/m2. Above 25, every 5-unit increase in BMI translated to a serious 40% higher risk for death from ischemic heart disease or stroke and 10% increased risk for cancer-related deaths.

The authors commented "Although other anthropometric measures (eg, waist circumference, waist-to-hip ratio) could well add extra information to BMI, and BMI to them, BMI is in itself a strong predictor of overall mortality both above and below the apparent optimum of about 22.5—25 kg/m2."

Even though the "normal" BMI range is usually quoted to start from BMI of 18.5, the study showed that adults whose BMI was below 22.5 were also at higher risk for death. However, such a higher mortality was mainly, but not entirely, due to smoking-related lung diseases and cancer.

This important study was funded by UK Medical Research Council, British Heart Foundation, Cancer Research UK, EU BIOMED programme, US National Institute on Aging, and Clinical Trial Service Unit (Oxford, UK).

Reference article:
Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Prospective Studies Collaboration. Lancet. 2009 Mar 28;373:1083-1096.
(Abstract)
doi:10.1016/S0140-6736(09)60318-4
(How to use the doi system?)

Type 2 Diabetes Calculator

2009-03-28T00:35:00.000-07:00

There is a nice online type 2 diabetes risk calculator (the QDScore diabetes risk calculator). After you enter the data, see your risk of developing type 2 diabetes. It becomes quite interesting when you start playing with changing your BMI and see what happens to your diabetes risk. Notice that the calculator uses metric system. If you want to calculate your BMI using pounds and feet/inches, you may use the NIH BMI Calculator link. the QDScore diabetes risk calculator is the product of a British research that has recently been published in the British Medical Journal (BMJ).

Using easily collected data (no labs needed) researchers reported that it is possible to determine a patient's 10-year risk for developing type 2 diabetes. To develop the formula (algorithm), the investigators used data on some 2.5 million patients in the U.K. The algorithm was then tested in almost 1.2 million adults. The data needed to be entered for the calculation are simple: age, BMI, family history of diabetes, smoking status, treated hypertension, corticosteroid use, presence of cardiovascular disease, socioeconomic status, and self-reported ethnicity.

Reference article:
Predicting risk of type 2 diabetes in England and Wales: prospective derivation and validation of QDScore. Hippisley-Cox J, Coupland C, Robson J, Sheikh A, Brindle P.
BMJ. 2009 Mar 17;338:b880. (Free Full Article)
doi: 10.1136/bmj.b880.
PMID: 19297312

The QDScore diabetes risk calculator

High Intake of Red and Processed Meats Increases Mortality Risk

2009-03-27T23:08:00.000-07:00

A recent research supported by the National Institutes of Health, published in the Archives of Internal Medicine has shown that daily intake of red and processed meats (examples: beef and pork) is associated with increased risk for death in older adults, while white meat (examples: chicken, turkey and fish) may have a small protective effect. This is the largest study ever, including more than a half million adults aged 50 to 71, who were followed for 10 years. After adjustment for BMI and smoking, those who had the highest red meat intake had significantly higher risk of dying overall, and of dying from cancer and cardiovascular disease. Same applied to processed meat (examples: sausage, cold cuts or hot dogs). As the authors pointed out in the discussion of the article, meat is a source of several carcinogens (substances that can cause cancer) which are formed during high-temperature cooking of meat. Iron in red meat may increase oxidative damage increasing the formation of N-nitroso compounds. While red meat is a major source of saturated fat (not good), fish is rich in omega-3 fatty acids (good). In 2004, the FDA Announced a Qualified Health Claim supporting that consumption of omega-3 fatty acids reduces the risk of heart disease (coronary artery disease).

Reference article:

Meat intake and mortality: a prospective study of over half a million people. Sinha R, Cross AJ, Graubard BI, Leitzmann MF, Schatzkin A. Arch Intern Med. 2009 Mar 23;169(6):562-71. [PMID: 19307518] (Free Full Article)

Washington Post coverage

How we eat, can make a difference

2008-10-23T23:27:00.000-07:00

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?

2008-10-13T22:25:00.000-07:00

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

2008-10-06T20:42:00.000-07:00

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

2008-08-19T19:06:00.000-07:00

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

2008-08-18T05:28:00.000-07:00

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

2008-07-30T22:43:00.000-07:00

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!

2008-07-18T16:34:00.000-07:00

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?

2008-07-16T10:02:00.000-07:00

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

2008-06-01T15:23:00.000-07:00

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

2008-05-25T21:56:00.000-07:00

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

2008-04-14T16:05:00.000-07:00

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

2008-04-13T21:27:00.000-07:00

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!

2008-02-27T23:21:00.000-08:00

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?

2008-02-24T00:43:00.000-08:00

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

2008-02-16T21:19:00.000-08:00

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

2008-02-06T20:57:00.000-08:00

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?

2008-01-23T21:07:00.000-08:00

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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

2008-01-12T23:03:00.000-08:00

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

2008-01-12T16:18:00.000-08:00

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.

Roundup - What's the Problem?

2007-12-22T12:24:00.000-08:00

"... as an adult, we understand even if you ruin an appetite, there's another appetite coming right behind it. There's no danger in running out of appetites. I've got millions of them." --Jerry Seinfeld. The "Heart Attack" episode.

Fact: When food is in short supply, obesity as a public health problem does not exist. As a matter of fact, being obese under those circumstances signifies being wealthy or of higher economic status than the average population. Look at countries where some are living in poverty, and others are more affluent. Which segment of that society has a problem with obesity?

Fact: When food is made available and affordable, in the presence of abundance, the average person will eat more. Much more. Bigger portions. It is surprising to see people who immigrated as adults from less affluent countries continuing to eat the portions and at the times that they were used to, and stay slim. They have already developed the habits and controls and they stay satisfied with the portions and types of food that they used to consume. Their first generation kids, however, who were not raised in such a controlled environment, may become overweight or obese.

Fact: When food is not only made available in abundance 24 hours a day, but is also advertised all day long, people tend to consume even more. And branding does affect their choices.

Fact: Social networks can strongly enhance the spread of obesity.

One conclusion I can draw here is that: External influences tend to have a stronger effect on controlling how much we eat than spontaneous internal influences, in the average person. It takes a conscious effort and proper habit building and modifications to overcome those external influences. That we are victims of an environment and a culture that facilitates (or may even encourage) habits that will make us unhealthy, the only true refuge is our own ability to change habits and behaviors that developed under those circumstances. Although I stress on over-eating as a deadly habit, it is important to notice that serious under-eating as in anorexia nervosa is at least as deadly, if not more.

Remember, weight control is achieved through three elements:

1. Diet (portion acontrol and quality control)

2. Exercise or physical activity

3. Behavioral change towards healthy habits

Everything else (a diet program, a trainer, a pill, a surgical operation) is a tool that helps you control your energy storage (and, consequently, the weight of fat) through one or more of the above mechanisms.

Stay healthy! Happy Holidays!

Childhood and Adolescent Obesity - A Real Concern

2007-12-15T00:06:00.000-08:00

Well, this is another blog entry that is not a bariatric surgery issue, but a real public health and epidemiology concern. The New England Journal of Medicine issue of December 6, 2007, has three excellent articles:

1. Childhood Obesity — The Shape of Things to Come by Dr. D.S. Ludwig (Link) from Harvard Medicalo School
2. Childhood Body-Mass Index and the Risk of Coronary Heart Disease in Adulthood by Dr. J.L. Baker and others (Link) from Copenhagen, Denmark
3. Adolescent Overweight and Future Adult Coronary Heart Disease by Dr. K. Bibbins-Domingo and Others (Link) from the University of California, San Francisco

The Journal is making the full text of those articles (not just the abstracts) available for free.

In the perspective article "Childhood Obesity — The Shape of Things to Come", Dr. David Ludwig (Director of the Optimal Weight for Life Program, Children's Hospital Boston, Harvard Medical School) views the obesity epidemic as consisting of four phases. The first phase (began in the early 1970s) witnessed a progressive increase of the average weight among children from all socioeconomic levels and geographic areas in the United States.

The second phase, which we are now entering, is characterized by the emergence of serious weight-related problems in adolescents, including type 2 diabetes, fatty liver, orthopedic problems, sleep apnea, social isolation, anxiety, and depression.

Phase 3 will signal opening the doors for the medical complications of obesity to lead to life-threatening or limb-threatening disease. There will be an increased risk of coronary heart disease in adulthood, a high risk for limb amputation, kidney failure requiring dialysis, and premature death. The article quotes that the risk of dying by middle age is already two to three times as high among obese adolescent girls as it is among those of normal weight. Dr. Ludwig has predicted that pediatric obesity may shorten life expectancy in the United States by 2 to 5 years by midcentury, which would be equal to that of all cancers combined.

Phase 4 of the epidemic, if allowed to take place, will lead to even higher obesity rates because of transgenerational mechanisms.

Those articles are a highly recommended reading for anyone who feels that childhood obesity is hitting home.

CDC: Adult Obesity Prevalence - No Significant Increase

2007-12-04T23:22:00.000-08:00

The Centers for Disease Control and Prevention (CDC) has announced the new obesity prevalence statistics in a report titled, "Obesity Among Adults in the United States -- No Change Since 2003-2004". There was no "significant" change in obesity prevalence between 2003-2004 and 2005-2006 for either men or women. I would consider this "encouraging", but far from being exactly "good" news.

Some have declared that the media headlines should, at the very least, be shouting: “Obesity Epidemic Over!” (1). In literal terms, and based only on this piece of information, an obesity epidemic may, indeed, be over. After all, the definition of "epidemic", according to Webster's New World Medical Dictionary is "The occurrence of more cases of a disease than would be expected in a community or region during a given time period." Well, so what? Should we be proud of the current number of 34% being obese, knowing of the adverse health effects of obesity? According to the news release, more than one-third of U.S. adults -– over 72 million people -- were obese in 2005-2006. This includes 33.3 percent of men and 35.3 percent of women. The reality is that the lack of statistically significant increase in prevalence does not mean at all that we are OK. At the very best, we are just maintaining a peak high prevalence of obesity. Actually, the 2007 report of the Trust of America's Health (posted in the Bariatrics Lounge blog), using a different methodology, concluded that adult obesity rates showed an increase in 31 states last year. So, where is the truth. I would say, at the very best, and if we take only the CDC report, we are maintaining a dangerously high prevalence of obesity. And that all is about obesity in adults. Folks, we are not even talking about childhood obesity. Epidemic or not, it is already pretty bad.

(1) Please note: This blog does not endorse the Junkfood Science blog, which is mentioned here purely as a reference to an article that indicated one point of view.

Is it really important to do the follow-up visits after bariatric surgery?

2007-11-23T12:33:00.000-08:00

After weight loss surgery (let's say gastric bypass or Lap Band), the majority of patients will initially lose some of their excess weight very well. In fact, they may do so well that they take for granted their weight loss trend, and some become less and less compliant with their follow-ups. Does it make a difference? Should patients do their follow-ups with their bariatric surgery programs, in addition to the usual check-ups with their own family doctors? We always felt that patients benefit tremendously from being committed to their long-term follow-ups. Is there any evidecne that long-term follow-ups make any difference? A study is published in the Nov-Dec 2007 issue of the journal "Surgery for Obesity and Related Diseases" titled "Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass". It is another addition to a mounting evidence. The authors, (Gould JC, Beverstein G, Reinhardt S, Garren MJ) from the University of Wisconsin School of Medicine, Madison, Wisconsin, looked into the data of patients with 3-4 years of follow-up data after laparoscopic gastric bypass. The patients were divided into 3 groups:

Group 1 patients: had attended every scheduled postoperative appointment
Group 2 patients had attended every appointment for 1 year, then were lost to follow-up
Group 3 patients had been lost to follow-up before 1 year.

Although the excess weight loss (EWL) did not differ at 1 year of follow-up, a significant difference in the EWL was observed at 3-4 years (74% for Group 1; 61% for Group 2; 56% for Group 3). The authors found that the most common explanation for missed follow-up appointments was a lack of insurance coverage. They concluded that on-going, multidisciplinary care is likely a critical component in maintaining the benefit after surgery.

Source Article:
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)

Other References:

Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg. 2004 Apr;14(4):514-9. PMID: 15130229 (Abstract)

Harper J, Madan AK, Ternovits CA, Tichansky DS. What happens to patients who do not follow-up after bariatric surgery? Am Surg. 2007 Feb;73(2):181-4. PMID: 17305299 (Abstract)

"Surgery for Obesity and Related Diseases" (SOARD) is the official journal of the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Brazilian Society for Bariatric Surgery (SBCBM - Sociedade Brasileira de Cirurgia Bariátrica e Metabólica).

"Obesity surgery" is the official journal of several international societies including, among many others, the International Federation for the Surgery of Obesity (IFSO) , the Obesity Surgery Society of Australia and New Zealand and the French Society for Obesity Surgery (Société Française de Chirurgie de l'Obésité)

Obesity Among Friends, Spouses, Siblings and Neighbors

2007-11-17T22:38:00.000-08:00

Obesity has become an epidemic. Right? We hear this all the time. Well, isn't the term "epidemic" used often for diseases that are spread from a person to a person, like infectious diseases? Could the phenomenon of the prevalence of obesity be actually behaving as an infectious process? Could the benefits of obesity control, likewise, spread in an epidemic (good) way? Should the treatment of obesity be considered not only a form of individual therapy, but also, and probably more importantly, a treatment of public health proportions and general community benefits?

A very important article appeared in the July 26, 2007 issue of the New England Journal of Medicine "The Spread of Obesity in a Large Social Network over 32 Years" by Drs. Nicholas A. Christakis and James H. Fowler from Harvard Medical School, Boston and University of California, San Diego, San Diego. The researchers analyzed the nature and extent of the person-to-person spread of obesity as a possible factor contributing to the obesity epidemic. To do so, they evaluated a social network of 12,067 people assessed repeatedly from 1971 to 2003 as part of the Framingham Heart Study.(1) They examined whether weight gain in one person was associated with weight gain in his or her friends, siblings, spouse, and neighbors.

What they found? A person's chances of becoming obese increased by 57% if he or she had a friend who became obese. The type of friendship appeared to be important. Between mutual friends, a person's risk of obesity increased by 171% if the other became obese. In contrast, the influence did not appear to be statistically significant when one person, but not the other, defined the relationship as a friendship. The sex also appeared to be important. When analysis singled out same-sex friendships, the probability of obesity in a person increased by 71% if the friend became obese. For friends of the opposite sex, however, the probablity of obesity did not increase significantly. Among friends of the same sex, a man had a 100% increase in the chance of becoming obese if his male friend became obese, whereas the female-to-female spread of obesity was not as significant.

How about siblings? If one sibling became obese, the other's chance of becoming obese increased by 40%. As for married couples, if one spouse became obese, the likelihood that the other spouse would become obese increased by 37%. By the way, those effects were not seen among neighbors.

If social networks are so influential in the spread of obesity, then this may actually explain another well-known observation. Individuals in weight loss programs or after weight loss (bariatric) surgery, who attend regular support group activities, that modify the person's social network, are more successful than those that do not.

This is a great study that will certainly be quoted over and over in the future.

(1) The Framingham Heart Study is an ambitious project that was initiated in 1948, when 5209 people were enrolled in the original cohort. The Framingham Offspring Study began in 1971, when most of the children of members of the original cohort and their spouses were enrolled in the offspring cohort. In 2002, the third-generation cohort, consisting of 4095 children of the offspring cohort, was initiated. All participants undergo physical examinations (including measurements of height and weight) and complete written questionnaires at regular intervals.

Source:

Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007 Jul 26;357(4):370-9. [PMID: 17652652]

Excess Fat, Red Meat, Alcohol, and Cancer

2007-11-11T23:31:00.000-08:00

"Food, Nutrition and the Prevention of Cancer: a global perspective", a report produced by the World Cancer Research Fund together with the American Institute for Cancer Research , has been the most authoritative source on food, nutrition, and cancer prevention for 10 years. In October 2007, the updated Report was released in Washington, DC. The Report is the result of a five-year process that included examination of the world's literature by a panel of the world's leading scientists, supported by observers from United Nations and other international organisations

The Report found out that carrying excess body fat increases the risk for cancer of the colon, kidney, esophagus, pancreas, and endometrium, as well as breast cancer in post-menopausal women. Their first recommendation is: Be as lean as possible within the normal range of body weight.

The Report also indicated that there is convincing evidence linking consumption of red meats like beef, pork and lamb to colorectal cancer. The recommendation is: Limit intake of red meat and avoid processed meat. People who eat red meat to consume less than 500 g (18 oz) a week, very little if any to be processed. ‘Red meat’ refers to beef, pork, lamb, and goat from domesticated animals including that contained in processed foods. "Processed meat" refers to meat preserved by smoking, curing or salting, oraddition of chemical preservatives, including that contained in processed foods.

Another recommendation: Limit alcoholic drinks. The evidence on cancer justified a recommendation not to drink alcoholic drinks. The report specified that, based solely on the evidence on cancer, even small amounts of alcoholic drinks should be avoided. But, because other evidence shows that modest amounts of alcoholic drinks are likely to reduce the risk of coronary heart disease, the Report recommended limiting rather than avoiding, alcohol consumption.

The strongest evidence on methods of food preservation, processing, and preparation showed that salt and salt-preserved foods are probably a cause of stomach cancer.

The World Cancer Research Fund global network consists of the following charitable organisations: The American Institute for Cancer Research (AICR); World Cancer Research Fund (WCRF UK); Wereld Kanker Onderzoek Fonds (WCRF NL); World Cancer Research Fund Hong Kong (WCRF HK);Fonds Mondial de Recherche contre le Cancer (FMRC FR) and the umbrella association, World Cancer Research Fund International (WCRF International)
The World Cancer Research Fund global network funds research on the relationship of nutrition, physical activity and weight management to cancer risk, interprets the accumulated scientific literature in the field, and educates people about choices they can make to reduce their chances of developing cancer.

Source:
An abbreviated version of the full Report http://www.dietandcancerreport.org/downloads/summary/english.pdf

For a summary of the recommendations:
http://www.wcrf.org/home/recommendations.lasso

Hungry, Satisfied, or Full?

2007-11-10T16:51:00.000-08:00

For the sake of simplicity and to make points clearer, I will use definitions that may be different from the standard broad dictionary definitions:

Hunger: The unpleasant feeling that accompanies a real physical need for nourishment or food.
Fullness: The feeling that maximum capacity to eat has been reached.
Satiety: A state of satisfaction that can be reached when not hungry, but before feeling full.

When we are hungry, we know it. Of course we need to eat. The trick is either not let yourself get really very hungry, so that you can avoid over-eating, or simply develop the habit of recognizing a point of satiety, or satisfaction, before actually feeling full. Remind you, I am using the definitions outlined above. So, how to recognize that point of satisfaction? Well, that point can be appreciated by allowing your brain to recognize that you are not hungry anymore. The signal will come up, but you have to give it time to reach up there. What that means? Don't eat too fast. Do not enter in your mouth one large bite at a time. Once in your mouth, take your time chewing your food. Enjoy the taste of the food. Chew 20 times before actually swallowing. After swallowing the well-chewed bite, wait a little bit before you get the next bite into your mouth.

If you are using portion control (for example, after weight loss surgery, or as a part of dieting), put on your plate only the portion that you are supposed to eat. If there is more on your plate, do not clear your plate. Eat slowly as described above, till you have almost completed your portion, then STOP. Even if you are not satisfied, stop. Distract yourself. Do something. Then ask yourself in 10 minutes or so: "Am I still hungry? Or do I want to eat just because? If you are not truly hungry, and if you reached the portion size that you have decided, you have probably reached the point of satisfaction and hopefully the above techniques gave your brain enough time to appreciate that signal. Remember, feeling full (using the definition that I wrote above) is not a good signal to stop eating. It is too late. And if you had Lap Band, gastric bypass, or a sleeve gastrectomy, you are probably setting yourself up for a stretch of the pouch. In case of an adjustable gastric band in particular (like the Lap Band), stretching the pouch may be a factor in slippage (prolapse). So, be careful, and stay healthy!

Urinary Incontinence & Weight Loss Surgery

2007-10-25T21:33:00.000-07:00

We saw some great data about the improvement or resolution of diabetes type 2, hypertension, high cholesterol and sleep apnea after bariatric surgery.

We also read the report about the improvement in fibromyalgia symptoms. Stress urinary continence, however, is not widely talked about. It is the condition in which patients may lose control on their bladder when they sneeze, lift something heavy, laugh or cough. We know that this is common with obesity. Do we have research to back-up the common knowledge that stress urinary incontinence may improve or resolve after bariatric surgery? Well, a recent study from the Weight Management and Metabolic Health Center, University of South Florida, Health Sciences Center, Tampa, Florida by Kurubam et al, that was published in the October 2007 issue of the journal "Surgery for Obesity and Related Diseases"

They, prospectively, collected data from 201 candidates for bariatric surgery. They found that 32% of the patients reported urinary incontinence. Of those 65 patients, 45 underwent bariatric surgery. Of the 38 patients who had complete postoperative follow-up for at least 6 months, 50% enjoyed resolution of urinary incontinence while 37% had reported residual slight-to-moderate incontinence. Residual severe urinary incontinence was reported by 13%. In general, patients reported improvement within 4 months or after losing 50 lb. While the findings of this study are certainly very encouraging, the authors concluded that their findings warrant additional investigation with urodynamic studies.

Reference:

Kurubam D R, Almahmeed T, Martinez F, Torrella TA, Haines K, Nelson LG, Gallagher SF, Murr MM. Bariatric surgery improves urinary incontinence in morbidly obese individuals. Surg Obes Relat Dis. 2007 Oct 17; [PMID: 17950043]

Video clip of animated bariatric procedures

2007-10-24T09:25:00.000-07:00

A very good and easy-to-understand animation of the principles of the Roux-en-Y gastric bypass, the biliopancreatic diversion with duodenal switch procedure and the Lap Band, can be viewed in a video clip on the Mayo Clinic website.

http://www.mayoclinic.com/health/gastric-bypass/MM00703

LAP-BAND and REALIZE in USA

2007-10-12T04:38:00.000-07:00

While world-wide, there is at least half a dozen of brands of adjustable gastric bands, the USA market had one brand, the Lap Band (manufactured by Inamed, a subsidiary of Allergan, Santa Barbara, California). (see "Adjustable Gastric Band" in the Glossary)

On Sept. 28, 2007, Ethicon Endo-Surgery, Inc. , Cincinnati, Ohio (an operating company of Johnson & Johnson) announced that the U.S. Food and Drug Administration (FDA) has approved for marketing the REALIZE(TM) Adjustable Gastric Band.

In the multi-center U.S. clinical trial of 276 patients with the REALIZE Band, patients who completed the three-year U.S. clinical trial (n=228) lost an average of 42.8 percent of their excess body weight. Thirty-five percent of patients who completed the three-year trial lost 50
percent or more of excess body weight and 10.5 percent lost 75 percent or more of excess body weight. The most commonly reported adverse events after surgery during the U.S. clinical trial were nausea, vomiting, constipation and gastroesophageal reflux (GERD). According to the report, nine (3.3 percent) patients experienced a serious adverse event that was considered unanticipated and related to the REALIZE Band.

According to the press release, the REALIZE Band, which is marketed under the name "Swedish Adjustable Gastric Band" (SAGB) outside the U.S., has been commercially available outside the U.S. since 1996 and has been used by more than 100,000 patients worldwide.

Source:
http://www.ethiconendo.com/.
http://www.realizeband.com/.

Bariatric Surgery Glossary

2007-10-11T20:40:00.000-07:00

Last updated: October 15, 2008

A.M.I. Soft Gastric Band: A type of adjustable gastric bands that is produced by the Austrian Agency for Medical Innovations Ltd, Austria. It is not available in USA.

Abdominoplasty: Also called "Tummy Tuck", is a plastic (cosmetic, aesthetic) surgical procedure that involves dissection and preservation of the umbilicus itself, and a more extensive skin mobilization and more aggressive skin removal than panniculectomy. A complete abdominoplasty also includes tightening of the abdominal wall muscles. This is not considered a "Weight Loss (=Bariatric) Surgery"

Adjustable Gastric Band: A weight loss surgery tool that is essentially a band with an inner balloon. It is placed by a laparoscopic surgical procedure. The band is folded and locked around the top-most part of the stomach to produce a constriction, between a small pouch of the stomach above the band, and the rest of the stomach. The balloon is connected, via a narrow tube, to a small reservoir that sits under the skin . By adding or removing saline from the reservoir (aka, the port), the balloon of the band can be inflated or deflated. Hence, the band is adjustable. Types of adjustable bands in no particular order: the Lap Band, the Swedish Adjustable Band (and the REALIZE Band), the Heliogast Band, the Bioring Band, the Midband, the A.M.I Soft Gastric Band, the MiniMizer band, the GastroBelt II, the EasyBand Gastric Banding System.

Alimentary limb: In a Roux-en-Y gastric bypass and other operations that employ the Roux-en-Y configuration, the "alimentary limb" is the length of small intestine that extends from the gastric pouch to the Y-junction (which leads, then, to the common channel). It is the limb through which ingested food would travel from the pouch to the distal intestine.

Anastomosis: Surgical connection of two hollow organs or parts of an organ, allowing their lumina(cavities, plural of lumen) to be open to each other and to be continuous with each other. Example: A gastro-jejunal anastomosis means an anastomosis between the lumen (cavity) of a part of the stomach (gastro-) and the part of the small intestine called jejunum (jejuno-), providing an opening between their cavities to each other.

Arm lift: See "Brachioplasty".

BMI: See "Body Mass Index"

Balloon: See "Intragastric Balloon"

Bariatric Surgery: Same as "Weight Loss Surgery". See "Weight Loss Surgery"

Bariatrics: The branch of medicine that deals with the causes, prevention, and treatment of obesity. The American Heritage® Dictionary of the English Language: Fourth Edition. 2000.
(Baros = weight. -iatrics = healing. Origin: Greek)

Bile: A fluid that is produced and secreted by the liver. It travels down the bile ducts to end in the duodenum, the upper-most portion of the small intestine. If the gallbladder is still in place, it normally concentrates the bile, stores it, before squeezing it into the duodenum. The bile is yellow-green in color, alkaline in reaction and is very bitter. The bile helps with the digestion and absorption of fat.

Biliopancreatic diversion (BPD): A bariatric operation originally described by Dr. Nicola Scopinaro in Italy in 1979. It is a predominantly malabsorptive operation. It also has a modest restrictive component. The stomach is reduced to a 200-500 mL pouch, after removing the distal part of the stomach (hemigastrectomy). The small intestine is divided into an alimentary limb and a biliopancreatic limb. The proximal end of the alimentary limb is attached (anastomosed) to the remaining proximal stomach. The lower end of the biliopancreatic limb is then anastomosed to the terminal ileum within 50 to 100 cm distance from the ileocecal valve (the end of the small intestine, where the colon starts). Therefore, the intestinal tract is reconstructed to allow only a “common channel” of the distal 50-100 cm terminal ileum for absorption of fat and protein.

Biliopancreatic diversion with a duodenal switch (BPD/DS): See "Duodenal Switch"

Biliopancreatic limb: In Roux-en-Y configuration, this is the length of small intestine that includes the duodenum and the upper jejunum, and ends at the Y-junction. Distal to that, the small intestine is called "the common channel". The biliopancreatic limb is given that name because the common bile duct and the pancreatic duct open into the second (descendind) part of the duodenum, which is part of the biliopancreatic limb. Bile and pancreatic juices flow through the biliopancreatic limb and meet with food (that traveled down the alimentary limb) in the common channel.

Bioring Band: A type of adjustable gastric bands that is made by "Cousin Biotech", France. It is not available in USA.

Body Contouring: (also known as "body lift", "body shaping" or "body reshaping") This is a group of plastic surgery procedures performed after massive weight loss, to manage hanging excess skin. Patients have to have reached a stable plateau weight before any such plastic surgery procedures. The person should have achieved a stable weight after the maximum weight loss, and be in good health and not planning on becoming pregnant.

Body Mass Index (BMI): The weight in kilograms divided by the height in meters squared. Using pounds and inches, the formula is BMI = (weight in pounds x 703)/squared (height in inches). The Body Mass Index(BMI) formula was developed by Belgian statistician Adolphe Quételet (1796-1874), and was known as the Quételet Index. BMI Categories: Underweight less than 18.5; Normal from 18.5 to less than 25; Overweight from 25 to less than 30; Obesity Class I from 30 to less than 35; Obesity Class II from 35 to less than 40; Obesity Class III from 40 and above. Calculate your BMI.

Brachioplasty: Also called "Arm Lift" is a plastic (cosmetic, aesthetic) surgical procedure that involves removing excess or loose skin and fat from the upper arms.

Cholecystectomy: An operation to remove the gallbladder. It is most commonly performed with the laparoscope, in which case it is called "laparoscopic cholecystectomy" . See also "Laparoscopic Surgery"

Colon: Also called the "large intestine" or "large bowel" is the part of the intestines that extends after the small intestine and ends at the rectum. Its parts, from proximal to distal: the cecum, the ascending colon, the transverse colon, the descending colon, and the sigmoid (pelvic) colon.

Comorbidities (Co-morbidities): In the context of obesity, means medical conditions that a patient may have, and that are either caused by, or are made worse by, obesity. Examples include diabetes type 2, hypertension, sleep apnea, gastroesophageal reflux disease (GERD), hyperlipidemia/dyslipidemia (elevated total cholesterol, low density lipoprotein, triglycerides or low high density lipoprotein), musculo-skeletal problems, shortness of breath, heart disease, and certain types of cancer.

Desirable Body Weight: These weights are derived from the tables of the best weight for each height for longevity, based on collected insurance data, released in 1959 by the Metropolitan Life Insurance Company released. They are outdated. In 1993, the Metropolitan Life Insurance Company released the "Ideal Body Weight". The reference for the Desirable Body Weight tables: Metropolitan Life Insurance Company: New weight standards for men and women. Stat Bull Metrop Life Insur Co 1959; 40: 1-10.

Duodenal Switch: The full name is "Biliopancreatic diversion with a duodenal switch" (BPD/DS). This is a surgical weight loss procedure utilizing both restrictive and malabsorptive methods. The malabsorption element in this surgery is more significant than proximal Roux-en-Y gastric bypass. The BPD/DS procedure involves the reduction of the stomach to a tube (called the sleeve) gastric pouch of 100 to 150 mL volume. The pyloric valve is left intact. The duodenum is divided a short distance below the pyloric sphincter. More distally, the small intestine is divided, thus an alimentary limb and a biliopancreatic limb are created. The alimentary limb is brought up and is connected to the duodenum and, thus, to the stomach tube. The biliopancreatic limb is attached to the distal intestine, to form a common channel that leads to the colon.

Dumping Syndrome: A group of symptoms that result from the quick "dumping" of food into the small intestine. The most typical forms may occur after gastric bypass, following the ingestion of liquid diet that is rich in refined sugar or glucose. One form (Early Dumping) occurs shortly after such a meal, and consists of any combination of lightheadedness, flushing, diarrhea, and extreme weakness. Transient hypotension may contribute to the symptoms. Another form of the dumping syndrome (called "Delayed Dumping") may occur an hour or later after a meal, and is believed to be a result of hypoglycemia. Not all gastric bypass patients develop dumping syndrome.

EasyBand Gastric Banding System: This Telemetric Adjustable Gastric Band (TAGB), uses remote controlling electronic technology to adjust the inner diameter of the band without the need for a needle access. The access port is replaced by a simple electronic receiver, through which a telemetric signal is directed to achieve an adjustment. EasyBand Gastric Banding System was approved by the European Commission for use in Europe in mid-2006. It is not available in the USA. Allergan anticipates seeking U.S. Food and Drug Administration (FDA) approval of the device following completion of clinical studies that will be conducted in the United States. As of September 2007, the "EasyBand GOAL Trial" study is not yet open for participant recruitment. On 2/22/2007, Allergan Inc. announced the completion of its acquisition of the Swiss medical technology developer EndoArt SA.

EGD See "Esophagogastroduodenoscopy"

EndoBarrier: The EndoBarrier™ is a gastrointestinal tube liner that acts as an impermeable barrier. Food travels down the tube liner without touching the wall of the the duodenum and proximal jejunum parts of the small intestine. This may limit the patient's absorption of nutrients. The EndoBarrier™ is, therefore, a sort of bypassing the absorption capability of the upper small bowel. The EndoBarrier is placed and removed endoscopically. It is a reversible procedure. The EndoBarrier™ is an investigational device. It is not yet commercially available in the USA. It is produced by GI Dynamics, Inc., Lexington Massachusetts, USA.

Endoscopy: Visual examination of the inside of the body, using a tube that has light and camera in it. Examples are EGD, colonoscopy, etc. The term is also used to include "laparoscopy"

Enterra Therapy : See Implantable Gastric Stimulator. Produced by Medtronic, Minneapolis, Minnesota. Enterra Therapy is indicated for use in the treatment of chronic, intractable (drug refractory) nausea and vomiting secondary to gastroparesis of diabetic and idiopathic etiology.

Esophagogastroduodenoscopy (EGD) is an examination of the inside of the esophagus, the stomach, and the upper part of the duodenum. An endoscope (that is, a flexible tube with a camera at the end) is inserted down the throat, and is advanced under vision to the esophagus, stomach and upper duodenum. Typically, the procedure is done under sedation (that is, an intravenous medication that makes the patient sleepy and forgetful). Patients typically go home the same day, when awake enough.

Excess Weight: The individual's current weight minus the ideal body weight for the height, gender and body frame.

FDA: U.S. Food and Drug Administration

French Band: The following are the types of adjustable gastric bands produced in France in alphabetical order: the Bioring band, the Heliogast Band, and the Midband.

Gallbladder: This is a sac that receives the bile secreted from the liver, concentrates it, and then squeezes it to the duodenum. This function is not essential, and removing the gallbladder (an operation called cholecystectomy) does not cause a loss of an essential function.

Gastric: (Greek) Related to the stomach

Gastric Balloon: See "Intragastric Balloon"

Gastric Bypass: A type of bariatric (weight loss) surgery. A surgical procedure that includes stapling (usually, with dividing)the stomach into a small part called the "pouch", to separate it from the rest of the stomach. The intestine is divided, attached to the pouch, and re-arranged in a Y-shaped configuration (Roux-enY). The final result is that the majority of the stomach, and the uppermost portion of the small intestine, are bypassed.

Gastric Electrical Stimulation (GES): See Implantable Gastric Stimulator. Also called Gastric Pacemaker.

Gastric Pouch: In different bariatric surgery operations (eg, gastric bypass, adjustable gastric banding), the "pouch" is the upper-most part of the stomach that remains attached to the esophagus, and serves as a limited-size reservoir for ingested food. The small pouch helps in achieving weight loss by making it easier for the patient to limit the size of the meal (portion control)

Gastric Pacemaker: See “Implantable Gastric Stimulator”.

Gastric Stapling: This is a generic inaccurate name sometimes used by media. Although stapling techniques are used in several bariatric and non-bariatric operations, the term "gastric stapling" is usually applied to a particular bariatric surgical procedure, that is "vertical banded gastroplasty" (VBG). The procedure includes warding off a small portion of the top-most part of the stomach (called the pouch) from the rest of the stomach, usuing surgical staplers. The pouch opens to the rest of the stomach via a very small opening (ostium). Notice that the term "gastric stapling" is also used currently for Gastric Bypass. Due to its lack of definition and accuracy, medical professionals generally avoid use that term.

GastroBelt II Band: A type of adjustable gastric bands, produced by Tyco Healthcare in Europe. It is not available in the USA. Rather than fixing the band in place using gastro-gastric sutures, the band is fixated to the wall of the stomach itself, to minimize the incidence of slippage. Also it has 2-step locking mechanism.

Gastroparesis: A condition in which the stomach loses, partially or completely, the ability to contract and empty. The mainstay of the diagnosis is a delayed gastric emptying. The most common causes are diabetes and idiopathic (of unknown cause). Lines of treatment include medications that attempt to stimulate the gastric motility (prokinetic agents), and gastric electrical stimulation (Enterra Therapy). Studies are underway as to the role of a Ghrelin agonist as a novel prokinetic agent.

Gastroscopy : See "Esophagogastroduodenoscopy"

Ghrelin: A "gut hormone" or "gastrointestinal hormone" that is also commonly called the "hunger hormone". Most of the cells that express ghrelin are located in the stomach. Fasting increases stomach ghrelin expression. Circulating levels of ghrelin in humans increase before, and fall after, food ingestion. These findings strongly suggest a role for ghrelin in appetite regulation. There are ghrelin receptors in the hypothalamus in the brain. Structurally, ghrelin is a 28–amino acid growth hormone–releasing factor. Ghrelin antagonism is being studied as a way to suppress appetite and try to help with weight loss. On the other hand, Ghrelin agonists (that is, stimulating the effects of Ghrelin), are being studied as a novel treatment for gastroparesis.

Heliogast Band: A type of adjustable gastric bands, manufactured by Hélioscopie, Vienne Cedex, France. It is not available in USA.

Hunger Hormone: See "Ghrelin"

Ideal Weight: See "Ideal Body Weight"

Ideal Body Weight (see also "Desirable Body Weight"): The ideal weight tables were released in 1983 by the Metropolitan Life Insurance Company in New York. These were based on the Build Study of 1979, determined by the Society of Actuaries in Chicago. The data represented 4.2 million insured individuals. Using the Ideal Body Weight to categorize weight and obesity has been largely superseded by the Body Mass Index (BMI) concept. Still, the Ideal Body Weight is used to calculate the "Excess Weight". One of the outcome mesaurements of weight loss surgery is to monitor the weight loss as a percentage of the excess weight. (Reference for the Ideal Body Weight data: 1983 Metropolitan Height and Weight Tables. New York: Metropolitan Life Foundation. Statistical Bulletin 1983; 64(1): 2-9)

Implantable Gastric Stimulator (IGS): Also called "Gastric Pacemaker". A device that is implanted to generate electric stimulation to the stomach wall. Historically, the first gastric stimulator for the treatment of morbid obesity was implanted by Dr. Valerio Cigaina in Italy, in 1995. The Enterra Therapy System (Medtronic, Minneapolis, MN) is currently the only gastric electrical stimulator that has received approval from the U.S. Food and Drug Administration (FDA). Enterra Therapy is indicated for use in the treatment of chronic, intractable (drug refractory) nausea and vomiting secondary to gastroparesis of diabetic and idiopathic etiology. There is no available FDA-approved obesity treatment gastric stimulation in the USA. Medtronic acquired Transneuronix company which manufactured the Transcend II Gastric Stimulator. On Dec 8, 2005, Medtronic, Inc. announced that the preliminary results of the Screened Health Assessment and Pacer Evaluation (SHAPE) trial, , did not meet the efficacy endpoint of a difference in mean excess weight loss at one year. Medtronic has indicated that it will continue following patients enrolled in the SHAPE trial through 24-months of follow-up. The company is not making the IGS available for obesity surgery world-wide. On the other hand, the results of the "Appetite Suppression Induced by Stimulation Trial" (ASSIST) study which evaluates Medtronic's IGS therapy in obese patients with type 2 diabetes are not out yet. Study completion date was February 2008.

Intragastric Balloon: The BioEnterics® Intragastric Balloon (BIB®) System is manufactured by Inamed, a division of Allergan, Santa Barbara, California, USA. It is designed to provide short-term weight loss therapy. BIB is placed endoscopically and is inflated with saline. It is made of silicone, and contains no latex. The concept is to partially fill the stomach to help with portion control. The BioEnterics® Intragastric Balloon (BIB®) System is not currently approved for sale in the USA. It is exported to the global market, though.

Lap Band: A type of adjustable gastric band that is manufactured by Inamed Health (formerly BioEnterics®) which is now a wholly owned subsidiary of Allergan, Santa Barbara, California, USA. The Lap Band was approved by the FDA in June 2001. A laparoscopic surgical procedure, it was initially implanted by an open surgery when invented by Dr. Lubomyr Kuzmak (New Jersey) in the 1980's. Drs. Mitiku Belachew and M. Legrand from Huy, Belgium, developed the laparoscopic application of the same. For a while, the Lap Band had been the only commercially available gastric band in the USA. However, the REALIZE (Swedish Adjustable Band) has recently been approved by FDA for marketing in the USA. The Lap Band is also the standard in Australia, and is very popular in Europe.

Laparoscopic Cholecystectomy: See "Cholecystectomy"

Laparoscopic Surgery: also called "Minimally Invasive Surgery", is a way of performing abdominal surgical procedures through multiple small holes or incisions, which allow the introduction of the visualizing telescope (so-called camera) and multiple long instruments. The surgeons see by looking at monitors (like TV screens) which project the pictures from the camera.

Laparoscopy: The visualization of the inside of the abdomial cavity using a tube (laparoscope) that has a camera or a visualizing system at its tip, as well as a light-emitting mechanism. In its most typical form, the patient is under anesthesia, and the abdominal cavity is insufflated with air or CO2 to tent the abdominal wall up, and allow for a clear field of visualization.

Large Bowel: Same as "Large Intestine" and "Colon". See "Colon"

Liposuction: A plastic (cosmetic, aesthetic) surgical procedure that involves suctioning out a varying amount of fat from under the skin (subcutaneous fat). Liposuction is not a type of "Weight Loss Surgery" as defined by the surgical community.

Lower Body Lift: A plastic (cosmetic, aesthetic) surgical procedure that involves a combination of an abdominoplasty, plus a thigh and buttock lift. It requires a large incision around the belt line to lift the lower body.

Malabsorptive Surgery: A type of weight loss surgery (bariatric surgery) that works by bypassing a portion of the small intestine. The small intestine is the organ that performs almost all of the absorption of nutrients. By bypassing a portion of the small intestine, the absorption becomes incomplete, and patients lose weight. Gastric bypass is a combined restrictive and malabsorptive procedure, but the malabsorptive component in the "proximal" gastric bypass (the most common version, with Roux limb up to 150 cm length) is significantly less than that of the biliopancreatic diversion (BPD) operation. Biliopancreatic diversion is another combined restrictive and malabsorptive surgery, but the restriction is less, and the malabsorption is much more than proximal gastric bypass. So, in general, biliopancreatic diversion (BPD) is considered to be primarily malabsorptive. Jejuno-ileal bypass is a purely malabsorptive procedure that has been abandoned.

Mastopexy: Same as "Breast lift".

Midband Band: A type of adjustable gastric band that is manufactured by the French company, Médical Innovation Développement, Limonest, France. It was designed with the advice and guidance of Dr. Vincent Frering of Lyon, France. The Midband is not available in USA.

Minimally Invasive Surgery: See "Laparoscopic Surgery"

MiniMizer Band: A type of adjustable gastric band that is manufactured by HospiMedical GmbH, Switzerland. The MiniMizer Regular gastric band has no retaining loops. Therefore, gastro-gastric sutures are required. The MiniMizer Extra has retaining loops that are designed to be sutured to the stomach wall itself, rather than placing gastro-gastric sutures. Both types incorporate a 2-phase closure mechanism. The HospiMedical MiniMizer bands are not available in USA.

Morbid Obesity: The old definition used to be: having 100 pounds above the "Ideal Body Weight". This definition excluded many patients as it does not take the height into consideration. A more widely accepted definition is: having a body mass index (BMI) of 40 or above (also known as Obesity Class III). It is described as "morbid" because of the higher likelihood of having comorbidities.

Obese: Having a Body Mass Index (BMI) of 30 or above. Obesity Class I from 30 to less than 35; Class II from 35 to less than 40; Class III from 40 and above

Obstructive Sleep Apnea: See "Sleep Apnea"

Obstructive Sleep Hypo-pnea: Same as Sleep Apnea. See: "Sleep Apnea"

Oesophagogastroduodenoscopy (OGD) same as "Esophagogastroduodenoscopy"

OGD Oesophagogastroduodenoscopy same as EGD see "Esophagogastroduodenoscopy"

Overweight: Having a Body Mass Index (BMI) of 25 to less than 30.

Panniculectomy: A plastic (cosmetic, aesthetic) surgical procedure that involves excising the "pannus", which is the excess hanging skin that is present below the belly-button. Panniculectomy is not a type of "Weight Loss Surgery" as defined by the surgical community.

Peptide YY (PYY): One of the gut hormones. It is 36 amino acids in length, naturally produced by specialized endocrine cells (L-cells) in the gut in proportion to the calorie content of a meal. PYY is located in enteroendocrine cells of the ileum and colon and nerves of the enteric nervous system. It modulates appetite circuits in the hypothalamus and, therefore, reduces appetite and food intake.

Peptide YY3–36: See Peptide YY (PYY)

Pouch: See "Gastric Pouch"

PYY: See Peptide YY

REALIZE Adjustable Gastric Band: See also Swedish Adjustable Band. This is one of two adjustable gastric bands that are approved by the FDA for marketing in the United States. Realize is produced by Ethicon Endo-Surgery, Inc. (a subsidiary of Johnson & Johnson). Compared to Lap-Band®, the most important difference according to the official website http://www.realizeband.com/ is the Realize mySuccess™ program, which is implemented to answer questions, listen to concerns, and provide support.

Restrictive Surgery: A type of bariatric surgery that induces weight loss by making only a small portion of the stomach (the pouch or, in the case of sleeve gastrectomy, a tube) available to receive food from the esophagus. Typical examples of pure restrictive operations are: Adjustable Gastric Banding, Sleeve Gastrectomy, Vertical Banded Gastroplasty (VBG). The Intragastric Balloon is not a surgical procedure, although it also produces restriction.

Roux-en-Y: A way of surgically dividing and re-arranging the intestine in a Y-shaped configuration, rather than the linear configuration. The three limbs of the Y configuration are: the "biliopancreatic limb", the "alimentary limb" and the "common channel". It was first described by the Swiss surgeon César Roux (1857-1934), as a means to bypass gastric outlet obstruction. The same concept or configuration has been employed to reconstruct the intestine as part of the bariatric surgical procedure "gastric bypass". Hence the name :"Roux-en-Y Gastric Bypass"

Roux limb: See "Alimentary limb"

Satiety: The dictionary definitions vary. The definition that I prefer is "feeling satisfied", and I use this as a different term than feeling "full"

Sleep Apnea: A medical condition that causes patients to stop breathing or to have very poor respiratory ventilation during deep sleep. The "obstructive" type of sleep apnea is one of the typical comorbidities that may be associated with obesity. It has been reported that obstructive sleep apnea was resolved in 85.7% of patients after bariatric surgery, and was resolved or improved in 83.6% of patients.

Sleeve Gastrectomy: Also called Vertical Sleeve Gastrectomy. A type of weight loss surgery that produces weight loss because of limiting how uch can be eaten (see "Restrictive Surgery"). There is evidence that it may do more than restriction. By removing the fundus of the stomach, the main source of Ghrelin is removed. So, there may be also a benefit related to a hormonal effect. It is generally performed laparoscopically. The surgeon removes approximately 60 % of the stomach so that the stomach takes the shape of a tube or "sleeve." Classically, this operation is performed on superobese or high risk patients as a first-stage procedure, with the intention of performing gastric bypass or duodenal switch later on. There is growing trend to consider this surgery as a stand-alone operation. So far, long-term (≥ 5 yr) weight loss and comorbidity resolution data for sleeve gastrectomy are not available.

Small Bowel: Same as "Small Intestine". See "Small Intestine"

Small Intestine: The part of the gut (gastro-intestinal tract) that starts from the end of the stomach, and ends with the start of the large intestine. Its parts are: Duodenum, Jejunum, and Ileum in that order.

Soft Gastric Band®: See "A.M.I. Soft Gastric Band"

Stapling: See "Stomach Stapling"

Stoma: In the narrow context of bariatric surgery, it is the opening between two connected hollow structures. Typically, used to describe the opening (mouth) between a pouch and the rest of the stomach (after placing an Adjustable Gastric Band) or between a pouch and the intestine (for example, after a Gastric Bypass). The origin if Greek (stoma = mouth).

Stomach Stapling: See "Gastric Stapling"

Swedish Adjustable Band: An adjustable gastric band that is manufactured by Obtech Medical AG of Switzerland (not Sweden!) It was invented by Professor Dag Hallberg, from Sweden, in 1984. Although the patent was awarded in 1985 in Sweden , Denmark and Norway, the product was manufactured in Switzerland. On September 28, 2007, Ethicon Endo-Surgery, Inc. (a subsidiary of Johnson & Johnson) announced that the U.S. Food and Drug Administration (FDA) approved for marketing their product, the REALIZE™ Adjustable Gastric Band. The REALIZE™ Band, has been marketed under the name Swedish Adjustable Gastric Band (SAGB) outside the U.S., and has been commercially available outside the U.S. since 1996. It is probably the most commonly used band in the UK, Scandinavia and Mexico.

Upper Endoscopy Same as "Esophagogastroduodenoscopy"

Vertical Banded Gastroplasty (VBG): The procedure includes warding off a small portion of the top-most part of the stomach (called the pouch) from the rest of the stomach, using surgical staplers. The pouch opens to the rest of the stomach via a very small opening (ostium)that is surrounded with a band, to prevent dilation of the ostium. Before the era of the adjustable gastric bands, VBG was the most common restrictive operation for surgical weight loss.

Vertical Sleeve Gastrectomy: See "Sleeve Gastrectomy"

Weight Loss Surgery: Also called "Bariatric Surgery". A discipline of surgery on the alimentary tract, that includes surgical procedures that lead to weight loss. Generally, the procedures produce restriction of the ability to eat, malabsorption of nutrient, or a combination of those two mechanisms. Plastic surgery procedures (including liposuction and the different "lift" surgeries) are not considered types of "weight loss (=bariatric) surgery" by definition. Bariatric surgery is considered a long-term therapy for morbid or severe obesity. It is not considered a cosmetic surgery.

(This Bariatric Surgery Glossary is a work-in progress with on-going updates. First prepared by Hanafy M. Hanafy, MD on October 11, 2007. Last updated on October 15, 2008)

The Paradox

2007-10-09T20:22:00.000-07:00

Restaurant (A) presents food items that are advertised as being healthy choices, and has even caused some people to lose serious weight. Restaurant (B) was the topic of an entire movie (Supersize Me) which focused on unhealthy eating. Could someone possibly think that eating huge portions at restaurant (A), and picking up choices that were not advertised in their health menu, would still be healthier than eating anything at Restaurant B? Aha, it is the branding thing, again. You remember, we touched on that once before. And here is a very elegant study, actually four studies in one report, that is an eye opener. The article title is “The Biasing Health Halos of Fast-Food Restaurant Health Claims: Lower Calorie Estimates and Higher Side-Dish Consumption Intentions”, that appeared in the October issue of the Journal of Consumer Research.

Study 1: “Calorie Estimations by Subway and McDonald’s Diners” concluded that branding Subway as the healthier choice leads people to believe that Subway meals contain 21.3% fewer calories than same-calorie McDonald’s meals.

Study 2: found that even consumers who are "familiar" with both restaurants estimate that Subway sandwiches contain much less calories than McDonald’s sandwiches containing the “same” number of calories.

Study 3 is the real kicker. Participants were given Subway sandwiches that contained 50% “more” calories than the “unhealthy” Big Mac. In addition to a serious underestimate of the calories in the Subway sandwich, participants who ate the Subway sandwiches ended up ordering higher-calorie drinks and cookies. It is as if those who thought that they ate healthier main-dishes, tended to reward themselves by eating higher calorie side-dishes or drinking more calorie-rich drinks. As you can imagine, they consumed many more calories because of the double mistake (underestimating the main meal calories, and taking richer side orders)

Study 4 actually proved the influence of marketing and branding. When consumers were presented with arguments contradicting the health claims, the “halo effects” mentioned above tended to disappear.

What a fascinating research, and no doubt one that will become a classic. The series of studies were designed to help finding an answer to a question, as stated by the authors: Why is America a land of low-calorie food claims, yet high-calorie food intake?

Source:

Chandon P, Wansink P. The Biasing Health Halos of Fast-Food Restaurant Health Claims: Lower Calorie Estimates and Higher Side-Dish Consumption Intentions. Journal of Consumer Research. Vol. 34 · October 2007

Pierre Chandon, Ph.D. is Associate Professor of marketing at INSEAD, France. Brian Wansink, Ph.D. is the Chair of Marketing and of Nutritional Science in the Applied Economics and Management Department, Cornell University, NY. The data in these studies were collected at the expense of the authors, and the studies were not sponsored by any outside source.

Alcohol after Gastric Bypass

2007-09-30T19:04:00.000-07:00

A glass of wine or two. A beer. A little mixed drink. Would that be OK after a gastric bypass? Well, early after the surgery, while the stomach is healing, you really want to avoid the irritant effect of alcohol. You want your pouch to heal well. So, the answer, as far as we know, is "no". But, what about drinking, let's say 6 months, a year, or more after the surgery? A very interesting study confirmed the previous opinion, that is, alcohol levels go higher after gastric bypass than people who had no such surgery. In a study published in the September issue of the journal "Surgery for Obesity and Related Diseases" (SOARD), researchers from Stanford School of Medicine, Stanford, California, concluded that the gastric bypass patients had a greater peak alcohol level and a longer time for the alcohol level to come back down to zero than the individuals who did not have gastric bypass. A particularly interesting finding was that the gastric bypass patients did not feel that alcohol influenced them any more than the no-surgery group. Could that explain why there are reports of post-gastric bypass patients who were cited for driving under the influence (DUI) after a small social alcoholic drink? Maybe. But also remember that there are other complications related to alcohol intake. Liver disease from alcohol is well-known. To develop alcoholic liver disease on top of the known obesity-related liver disease can be particularly dangerous. Alcohol is not good for peptic ulcers, either. Alcohol calories are empty calories, which is not what gastric bypass patients want to ingest. Also alcohol drinking has been linked to vitamin B1 deficiency. Severe vitamin B1 deficiency can lead to serious nerve damage, that is, Wernicke’s encephalopathy. So far, we do not have a perfectly scientific answer to the question: Is it OK to drink, in moderation, if you are not driving, several months or years after gastric bypass? We just do not have the final answer, and prefer to err on the cautious side. Better be safe than sorry.

References:
Klockhoff H, Naslund I, Jones AW. Faster absorption of ethanol and higher peak concentration in women after gastric bypass surgery.Br J Clin Pharmacol. 2002 Dec;54(6):587-91.

Hagedorn JC, Encarnacion B, Brat GA, Morton JM. Does gastric bypass alter alcohol metabolism? SOARD. 2007 Sept;3(5):543-8. (Note: This is the study quoted above)

Gallbladder, stones, sludge, and Gastric Bypass

2007-09-23T17:22:00.000-07:00

Formation of gallstones or sludge in the gallbladder is known to increase with obesity and with rapid weight loss. According to one report, at 6 months, gallstones had developed in 36% and gallbladder sludge in additional 13% of patients

But another question is: What percentage of patients will actually develop symptoms or problems from gallstones or sludge after bariatric surgery? Well, reports quote anywhere from 3% to 30%.

There are different ways of dealing with the gallbladder, in relation to gastric bypass, and all of them are acceptable. A new trend in recent reports concluded no need to screen for gallbladder disease, based on the low incidence of patients who will actually have symptoms from gallstones after gastric bypass. Some reports will even not consider it necessary to remove a gallbladder with stones during a gastric bypass, because the majority of those with no symptoms before, will not develop symptoms after gastric bypass.

Many surgeons, however, still routinely order an ultrasound of the gallbladder before a gastric bypass. If abnormal, the gallbladder may be removed the same time of a gastric bypass. Surgical removal of the gallbladder is called "Cholecystectomy". Also, if a patient has symptoms of typical biliary pain, even if the ultrasound appears normal, a cholecystectomy may be considered.

Other surgeons routinely recommend the removal of the gallbladder at the time of a gastric bypass surgery, particularly with the open technique. If it is chosen that the gallbladder not be removed at the time of a gastric bypass, most will wait until symptomatic gallbladder disease develops, at which time the gallbladder would be removed (cholecystectomy). Some surgeons will ask patients to take a medication, Ursodiol (Brand Name: Actigall) to help lowering the chance of developing gallstones. One report documented a decrease in the incidence of development of gallstones from 32%, with no treatment to 2%. As you realize, there is no one unified approach.

The symptoms of gallstones or sludge after gastric bypass are not different from the general. In the most typical form, right upper quadrant pain in the abdomen, radiating to the back. However, there are so many variations of this typical picture.

Doing a cholecystectomy after a patient loses weight may be technically easier than during maximum obesity, and will almost always be covered by insurance companies when performed for symptoms. But, notice that treating gallstones, if they migrate to the common bile duct, is much more challenging after gastric bypass. The reason is that, after gastric bypass, patients can no longer have an endoscopic retrograde cholangiopancreatography (ERCP) performed in the usual manner. ERCP is a procedure performed using an endoscope, and allows the extraction of those migrating stones from the common duct, without a need to do surgical cutting into the abdomen. The procedure becomes much more difficult or impossible because the stomach has been completely divided, so the endoscope can no more be guided in the usual way from the stomach to the duodenum. Alternatives do exist, but none of them is that easy, nor the necessary set-up and expertise may be available. Therefore, after gastric bypass, a bigger operation, that is an open common bile duct exploration may be needed. Although the incidence of this particular challenging situation is low, it is still a significant occurrence for the individual unfortunate patient. This possibility needs also to be factored when deciding, weighing the benefits vs. the risks of removing the gallbladder along with a gastric bypass.

Life Expectancy - again

2007-09-05T19:08:00.000-07:00

A very good article reporting and commenting on the 2 studies from the August 23 issue of the New England Journal of Medicine (NEJM), appeared in the Independant Weekly of Lafayette, Louisiana. It is titled "Life Expectancy - New studies show bariatric surgery patients are living longer." By following this Link, you can access the article. This "Bariatrics Lounge" blog reported on the NEJM article on August 22, so our readers were among the first to be informed. You can go back to that blog entry by clicking this Link.

Just to be thinner?

2007-09-03T18:22:00.000-07:00

I read a statement like "It's sad what some put themselves (or their kids) through, in order to be thin." Of course, referring to going through bariatric surgeries like Lap Band, gastric bypass, etc. This statement shows a major misconception as to what bariatric surgery is all about. The name "weight loss surgery" is correct in that bariatric surgery is designed to lead to weight loss. That is true. But the above statement implies that the entire reason for the weight loss is for a "thin" image. Here comes the misunderstanding. Although many patients like being thinner, which is a bonus result of the surgery, the real reason to have the surgery is for health purposes. Morbid obesity leads to three categories of major problems: (1) Life expectancy may be shortened (2) Co-morbidities may get worse, and certainly would not be cured (please, see note below) (3) Quality of life may deteriorate. Those are the real reasons why someone should consider bariatric surgery. Patients do not come and say, "I need weight loss surgery because I want to be thinner." They say things like "I want to get my [type 2] diabetes cured", "I want to be able to play with the kids", "I have many in my family who died from heart disease, and I am still young and would like to prevent that", "my orthopedic surgeon wanted me to lose weight before he replaces my bad knees", "I have sleep apnea, and my doctor said if I lose weight, I may be able to come off the CPAP machine." You've got the picture. So, my counterstatement to the first line here would be "It's sad what some put themselves (or their kids) through, by not controlling their weight and allowing an unhealthy life style to continue." And, as an aside, yes, weight loss will also lead to being thinner. Remember, bariatric surgery is not for everyone who has a problem with weight or obesity. In well-selected patients, the risk of bariatric surgery is, statistically, less than the risk of morbid obesity itself. It is an option if non-surgical weight loss fails to achieve a sustained healthy weight.

Note: "Co-morbidities" is the term given to describe medical problems that are either caused by, or made worse by, obesity.

Plastic Surgery after Massive Weight Loss

2007-08-27T23:44:00.000-07:00

This posting is in response to a request to comment on cosmetic surgery for excess skin in the abdomen and other places, after weight loss surgery.

Body contouring, body lift, body shaping or body reshaping are alternative terms used to describe a group of plastic surgery procedures performed after massive weight loss, to manage hanging excess skin. Patients have to have reached a stable plateau weight before any such plastic surgery procedures. The person should have lost at least 100 pounds or achieved the target or maximum weight loss, had a stable weight for a good length of time after the weight loss surgery, and be in good health and not planning on becoming pregnant. Good candidates for a body lift should also have no medical problems that prevent them from going under general anesthesia for major surgery, and should not smoke. Smoking decreases blood flow to the tissues and, therefore, may slow healing.

Plastic surgery procedures after weight loss surgery include the following:

1. Panniculectomy: This is excising the "pannus", which is the excess hanging skin that is present below the belly-button.

2. Abdominoplasty (Tummy Tuck): Includes dissection and preservation of the umbilicus itself, and a more extensive skin mobilization and more aggressive skin removal than panniculectomy. A complete abdominoplasty also includes tightening of the abdominal wall muscles. Abdominoplasty and incisional hernia repair can be combined into a single procedure.

3. Arm lift or brachioplasty.

4. Breast lift or mastopexy.

5. Lower body lift is a combination of an abdominoplasty, plus a thigh and buttock lift. It requires a large incision around the belt line to lift the lower body.

6. Liposuction uses small, narrow tubes to remove fat and is often used in combination with other lifting procedures to help achieve better contouring in various parts of the body.

Combining multiple "lifts" entails longer operative time, and more potential blood loss, but is very appealing to many patients, from the stand-point of time off work and out-of-pocket costs. Combined procedures are avoided if there is active smoking history or medical problems that make a longer operation a particularly risky undertaking.

Insurance coverage varies from carrier to carrier, and a carrier may have different plans with different provisions. Almost all insurance carriers specify that coverage of aesthetic (cosmetic) surgery is excluded. Definition of medical necessity, that is essential for coverage, is variable.

Possible complications after body-contouring surgery include seroma (collection of thin serous or serosnaguineous fluid), hematoma (collection of blood), wound separation (usually minor), swelling and scarring. All patients will have scars, and basically the surgery trades excess skin for scars. For a small number of patients, scars can be excessively thick or inflamed. Before going for body contouring surgery, any nutritional deficiencies (as protein malnutrition, anemia, loss of muscle mass, and osteopenia/osteoporsis) need to be addressed and corrected.

Body contouring is considered major surgery. The outcome of body shaping is generally extremely satisfying to patients. It may take several months to see the final results of the procedure.

Obesity Rates - still on the rise :(

2007-08-27T19:48:00.000-07:00

I thought the obesity epidemic is plateauing. Well, News Flash! Obesity and overweight rates continue to rise. A new report by Trust for America's Health (TFAH) showed that in 31 states, obesity rates got worse in the past year. State of Washington is actually one of them. Moreover, all states fail to meet the national goal of reducing adult obesity levels to 15 percent by the year 2010. The adult obesity rate of the State of Washington is 22.4 percent, ranking it the 31st heaviest in the nation, according to TFAH's report titled "F as in Fat". Mississippi is top of the list. Colorado continues to be the leanest.

The report noticed that 16 states and Washington, D.C. have passed taxes on junk food or sodas, including Arkansas, California, D.C., Illinois, Indiana, Kentucky, Maine, Minnesota, Missouri, New Jersey, New York, North Dakota, Rhode Island, Tennessee, Texas, Virginia, Washington, and West Virginia.

The full report with complete state rankings in all categories is available on TFAH's Web site at http://www.healthyamericans.org/. The report was supported by a grant from the Robert Wood Johnson Foundation.

Vitamin D supplements and Obesity

2007-08-26T19:00:00.000-07:00

Did you know that there is a high incidence of vitamin D deficiency with obesity? The reason is probably that vitamin D is fat-soluble, so it deposits in the fat stores, and becomes less available to the body. There is a possibility that lack of adequate sun exposure, which is common in Seattle area and in the Northern regions, could contribute to a baseline vitamin D deficiency. This means that a typical patient most likely has a deficit of vitamin D before bariatric (weight loss) surgery. A study from the University of Maine, that was recently published in the journal "Surgery for Obesity and Related Diseases" (1) , showed the results of evaluating how adequate the correction of vitamin D deficiency is, one year after gastric bypass surgery. Before 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. Remember, nutritional supplements after weight loss surgery are not optional, they are a must. The researcher recommended higher doses of vitamin D than the average.

Vitamin D is essential for bone health. Calcium absorption requires vitamin D. Lack of calcium leads to osteopenia and osteoporosis. So, when you take your supplements, particularly after bariatric surgery, make sure that they include calcium and vitamin D. Actually, it may be better to start before having the surgery. Notice, though, that there are medical conditions in which taking extra calcium may be contraindicated. Therefore, make sure that your physician is OK with it. Also, after gastric bypass, the general recommendation is to take the calcium supplements in the form of calcium citrate, not carbonate. There is some controversy in that issue, but taking calcium citrate will keep you on the safer side, with regards to calcium absorption.

So, make sure that you take your nutritional supplements regularly, and stay healthy.

Reference:

(1) 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]

Can TV ads influence our kids' taste buds?

2007-08-25T16:03:00.000-07:00

This is not exactly a bariatric surgery topic, but, nevertheless, a very interesting one. Does advertising/branding affect children's taste? Well, we know that TV ads do influence kids, who, as a consequence, keep begging and nagging for an advertised product. The pressuring will intensify, once other parents provided your kids friends with the product. What standing do you have when you stick to the hated "No", while the attractive TV ads say "yes", and peers' parents have given the sign of approval?

A very interesting study came from Stanford Prevention Research Center and Stanford University School of Medicine. It was published in the August, 2007, issue of the "Archives of Pediatrics & Adolescent Medicine." (1) Kids aged 3-5 years (yes, that young!) were entered into a food tasting game, where they were given 2 identical food items, one wrapped in a McDonald's typical wrapping, and the other wrapped in a plane white wrapping. Items included not only hamburgers, fries and chicken McNugget's, but also baby carrots, which are not even sold at McDonald's, but were placed on top of a McDonald's french fries bag and on top of a matched plain white bag. McDonald's was chosen because it is a good example of a well-branded and heavily marketed source. Guess what? There was a statistically significant higher taste preference for the foods associated with the branded wrappings. This study is remarkable for its hypothesis, and the results that came out of it.

The authors concluded that branding of foods and beverages influences young children's taste perceptions. The authors also suggested that branding may be a useful strategy for improving young children's eating behaviors.

No wonder, a report of a joint "WHO/FAO Expert Consultation" indicated that: "Heavy marketing of fast-food outlets and energy-dense, micronutrient-poor foods and beverages" is a "probable" cause of excess weight gain and obesity. There has been strong evidence of a relationships between television viewing and obesity in children. Could that be, at least partially, due to the food advertising to which they are exposed? You bet.

(1) Robinson TN, Borzekowski DL, Matheson DM, Kraemer HC. Effects of fast food branding on young children's taste preferences. Arch Pediatr Adolesc Med. 2007 Aug;161(8):792-7. PMID: 17679662

Bariatric Surgery Lowers Long-Term Mortality

2007-08-22T22:40:00.000-07:00

More data to support that bariatric surgery may improve mortality. Two new studies are published in the August 23, 2007 issue of the New England Journal of Medicine, indicating that bariatric surgery resulted in decreased overall mortality, in addition to the known effective long-term weight loss. One study came from Utah (Adams et al.). The other came from Sweden (Sjöström, et al). In an Editorial in the Journal, Dr. George A. Bray of the Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, commented that those articles "may provide the missing link between intentional weight loss and lives saved for obese patients"

The Utah study is a retrospective study that aimed at determining the long-term mortality among more than 9000 patients who had undergone gastric bypass and a comparable number of severely obese persons who applied for driver's licenses. During follow-up averaging 7 years, mortality in the surgery group decreased by 56% for coronary artery disease, by 92% for diabetes, and by 60% for cancer. On the other hand, mortality from accidents and suicide, was 58% higher in the surgery group than in the control group. All in all, there was a survival benefit from bariatric surgery.

The other article titled "Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects" reports a prospective, controlled Swedish Obese Subjects study involving more than 4000 obese subjects. The study reports on the overall mortality during an average of 10.9 years of follow-up with an impressive follow-up rate of 99.9%. The study concluded that bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality.

References:

Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, Lamonte MJ, Stroup AM, Hunt SC.Long-term mortality after gastric bypass surgery.N Engl J Med. 2007 Aug 23;357(8):753-61. PMID: 17715409 (Full Text)

Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Agren G, Carlsson LM; Swedish Obese Subjects Study.Effects of bariatric surgery on mortality in Swedish obese subjects.N Engl J Med. 2007 Aug 23;357(8):741-52. PMID: 17715408 (Full Text)

Does fibromyalgia improve after weight loss surgery?

2007-08-18T20:36:00.000-07:00

Well, there are not too many studies that specifically address this issue. Of course the medical literature is full of evidence that musculoskeletal painful conditions in weight-bearing joints do improve with weight loss surgery in the vast majority of patients. However, when it comes to non-weight-bearing joints, and to fibromyalgia in particular, such information is scarce.

However, a study from the University Hospitals of Cleveland that was published in January 2007 did, indeed address that issue. (1)

Fibromyalgia syndrome (FMS) is one of the most common musculoskeletal diseases. Patients have fatigue, chronic diffuse musculoskeletal pains, poor sleep, and stiffness. There is no blood test to diagnose fibromyalgia. To make a diagnosis of FMS, widespread pain symptoms must exist for at least 3 months. The diagnosis is confirmed by finding at least 11 of 18 specific areas of point tenderness. Almost 9:1 patients are females.

In the study from Cleveland, FMS decreased by an impressive 90% after bariatric surgery. As for upper extremity pain, that is, of course,non-weight-bearing, 79% of patients had pain before surgery, compared to 40% after bariatric surgery.

References:

(1) 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.

Pregnancy and Bariatric Surgery

2007-08-13T00:02:00.000-07:00

A recent article from the University of Texas at Houston, TX (1), that appeared in the August issue of the Archives of Pediatric and Adolescent Medicine, reported that the mothers of offspring with some important birth defects (including spina bifida and heart defects) are more likely to be obese than mothers of offspring who do not have any of those defects. The authors admitted that the mechanisms are unknown, but a relationship to undiagnosed diabetes was proposed.

Is it good to have low birth weight? The answer is, generally, No. Studies of populations in the United States and Europe have indicated a significant increase in the incidence of certain diseases in adulthood (coronary artery disease, stroke, and type 2 diabetes) among the low birth weight. This is interesting because the same adult diseases have higher incidence with adulthood obesity. So, does low birth weight correlate with obesity later on? A study about a famine in the Netherlands in the 1940s (2) did show that at the age of 19, the offspring of mothers exposed to the famine during the first half of pregnancy did have higher incidence of obesity.

Previous reports concluded that fetal exposure to diabetes in the uterus is an independant risk for the development of diabetes later in life. Pregnancy in patients with morbid obesity may lead to higher incidence of gestational diabetes and hypertension, preeclampsia, large-for-age fetus, preterm labor, and antepartum stillbirth. (3,4)

So, is it good to be pregnant after bariatric surgery? A review article that appeared in May 2007 in the journal "Medical Clinics of North America" (5) concluded that pregnancy after weight loss surgery is safe and has good outcomes. Cesarean deliveries occur more frequently in all of the reports of pregnancies after bariatric surgery when compared with the general population. Interestingly, there is also a higher incidence of cesarean section deliveries with obesity (3)

In general, it is recommended that pregnancy be avoided during the period of maximal weight loss, typically the first 18-24 months after a gastric bypass. When pregnancy does occur, there is a risk of malnutrition and anemia if ntritional supplements are not taken as advised. With that precaution in mind, studies of pregnancy after gastric bypass (6) and Lap Band (7) showed normal and healthy outcomes. A study from Australia (6) reported that pregnancy outcomes after Laparoscpic Adjustable Gastric Band Placement (Lap Band) are consistent with general community outcomes rather than outcomes from severely obese women.

A word of warning. There have been reports of rare incidences of internal herniation causing dangerous bowel obstruction late in pregnancy after laparoscopic gastric bypass. Though rare, such a possibility should be kept in mind if a pregnant develops acute abdominal pain or signs of bowel obstruction late during pregnancy.(8-10)

References:

(1) Waller DK, Shaw GM, Rasmussen SA, Hobbs CA, Canfield MA, Siega-Riz AM, Gallaway MS, Correa A; National Birth Defects Prevention Study. Prepregnancy obesity as a risk factor for structural birth defects. Arch Pediatr Adolesc Med. 2007 Aug;161(8):745-50. PMID: 17679655

(2) Ravelli GP, Stein ZA, Susser MW. Obesity in young men after famine exposure in utero and early infancy. N Engl J Med. 1976 Aug 12;295(7):349-53. PMID: 934222

(3) Hall LF, Neubert AG. Obesity and pregnancy. Obstet Gynecol Surv. 2005 Apr;60(4):253-60. PMID: 15795633

(4) Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol. 2004 Feb;103(2):219-24. PMID: 14754687

(5) Patel JA, Colella JJ, Esaka E, Patel NA, Thomas RL. Improvement in infertility and pregnancy outcomes after weight loss surgery. Med Clin North Am. 2007 May;91(3):515-28, xiii. PMID: 17509393

(6) Dao T, Kuhn J, Ehmer D, Fisher T, McCarty T. Pregnancy outcomes after gastric-bypass surgery. Am J Surg. 2006 Dec; 192(6):762-6. PMID: 17161090

(7) Dixon JB, Dixon ME, O'Brien PE. Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstet Gynecol. 2005 Nov;106(5 Pt 1):965-72. PMID: 16260513

(8) Ahmed AR, O'Malley W. Internal hernia with Roux loop obstruction during pregnancy after gastric bypass surgery. Obes Surg. 2006 Sep;16(9):1246-8. PMID: 16989713

(9) Baker MT, Kothari SN. Successful surgical treatment of a pregnancy-induced Petersen's hernia after laparoscopic gastric bypass. Surg Obes Relat Dis. 2005 Sep-Oct;1(5):506-8. PMID: 169252793

(10) Charles A, Domingo S, Goldfadden A, Fader J, Lampmann R, Mazzeo R. Small bowel ischemia after Roux-en-Y gastric bypass complicated by pregnancy: a case report. Am Surg. 2005 Mar;71(3):231-4. PMID: 15869139