Bone Health, Vitamin D, and Obesity - Again!

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

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

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

Reference Article:

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

More References:

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

Support Groups - Do They Make A Difference?

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

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

References:

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

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

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

Super Size Me - the Swedish Experiment

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

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

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

Reference:

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

Economy of Health and Obesity

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

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

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

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

The study in focus:

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

PLoS Med is the Public Library of Science Medicine

Reference:

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

Surgery for Type 2 Diabetes with Obesity?

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

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

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

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

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

References:

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

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

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

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

Abdominal Pain after Gastric Bypass

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

Here are some causes of pain after gastric bypass:

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

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

3. Gallstones and gallbladder disease.

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

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

Hair Loss after Weight Loss Surgery

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

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

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

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

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

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

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

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