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?)

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)

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)

Super Size Me - the Swedish Experiment

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

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

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

Reference:

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

Surgery for Type 2 Diabetes with Obesity?

For inquiries: Contact Form

Schedule of the free no-obligation educational seminars

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)

Urinary Incontinence & Weight Loss Surgery

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]

Gallbladder, stones, sludge, and Gastric Bypass

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.

Just to be thinner?

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.

Vitamin D supplements and Obesity

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]

Does fibromyalgia improve after weight loss surgery?

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.