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)