My Favorite WLS in 2011? Sleeve Gastrectomy!

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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?

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

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

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

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

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

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

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

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

The source article:

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

First Heart Attack - How Young?

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

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

Reference:

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

Overweight, Excessive Insulin Secretion and Higher Prostate Cancer Mortality

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

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

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

References:

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


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

Low Serum Vitamin D and Hip Fracture Risk

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

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

Reference:

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

Oxalate Kidney Damage

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

Some definitions:

Nephropathy: A disease or an abnormality affecting the kidneys

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

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

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

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

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

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

References:

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

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

Two Hundred Seventy Five Minutes per Week

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

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

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

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

Reference:

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

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

A Food Diary Works!

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

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

Stay Healthy!

Reference:

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

At what age do we stop being so active?

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

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

Reference:

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

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

Obesity and Weight Loss Surgery in Older Age

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

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

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

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

Stay Healthy!

References:

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

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

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

A Plateau

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

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

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

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

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

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

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

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

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

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

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

Stay Healthy!

More on Fibromyalgia and Bariatric Surgery

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

References:

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

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

Kidney Stones, Obesity and Bariatric Surgery

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

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

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

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

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

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

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

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

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

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

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

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

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


References:

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

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

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

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

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

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

Bone Health, Vitamin D, and Obesity - Again!

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

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

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

Reference Article:

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

More References:

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