I saw a patient today who has battled with depression intermittently throughout her life and also struggled with obesity. She wonders if the two are related, but also about how she will manage the depression after her weight loss surgery. Is it still possible to take medications should she need them? Might her depression improve if she undergoes weight loss surgery?
Interestingly, the research on depression and obesity shows it is a two way street: depression leads to more obesity, but obesity itself exacerbates depression. It makes sense, if we think about it. Depressive feelings can lead to overeating and loss of motivation to exercise. Likewise, obesity can lead to feelings of lower self-esteem and lower one’s mood.
Research also indicates some people do experience improvement in their depression after weight loss surgery.
Similar data exists about non-surgical weight loss. Of course it is hard to separate out which comes first, better feelings of self-esteem and higher motivation that lead to successful weight loss or some improvements in weight, leading to better body image and some improvement in mood. Ultimately, this chicken and egg question may be difficult to answer, and the most important advice is to seize the day and to work very hard on both problems. By this, I mean that if you struggle with depressed mood then seek help immediately including psychological counseling and visiting with health professionals who may offer effective antidepressant medications and recommend mood elevating activities like exercise. Likewise, if you are overweight or obese, don’t let another day go by without working on this problem too. Seek professional help. Follow the strategies and tips outlined here and in my books and you will benefit with lower weight and an improved mood.
For my patient today, I also let her know that antidepressant medications can be taken and absorbed after Roux-en-Y gastric bypass surgery. We do believe it is best to change from any extending release formulations (for example Effexor XR) to the standard release formulations that usually must be taken two to three times a day rather than only once a day.
Like so many complex facets of human health, depression and obesity are closely linked. One affects the other, but more importantly one is improved by improving the other

Why to people who seem fitter, thinner and healthier also seen to be living with a higher energy level? It’s maddening, isn’t it? These same people who have all the gifts of good looks and skinny bodies also appear to be darting around and living life at a higher more enjoyable velocity than the rest of us. What gives?

There may be more to this question than meets the eye and it may be less clear what is cause and what is effect than may observers might think.

Unquestionably, even as infants, some humans are moving at a slower speed while others faster. Hormone levels like thyroid hormone play a role in dictating wide variations in things like resting heart rate, blood pressure and the speed with which simple behaviors are accomplished. So one theory has always been that those people who are blessed with a higher metabolic rate are first and foremost “high energy” people and they tend to exercise more, expend more energy, live more actively and therefore look fitter, thinner and healthier.

But, the effect may be more powerful when we consider it in the other direction. By this I mean that people who achieve a healthier weight and a trimmer waist line begin to experience a new an higher energy level in their day to day activities. They find joy in physical activity, exercise, competition and the outdoors. They feed off of the enthusiasm of other high energy people around them pursuing similar activities. And perhaps most importantly, the psychological influence on our energy level cannot be underestimated. A person who has “seen the light” and changed eating behavior and lifestyle to become fitter and healthier lives with a sense of purpose and that gusto, that enthusiasm, infects everything the person does so their friends, colleagues and neighbors admire their achievements and note how everything they do is approached with great energy.

I have patient’s who lived for years in a sadly obese state before they made a transformation. They described hours on end sitting, watching television or engaging in other passive activities with little to no physical exertion . They describe how this inertia led to more eating, more of a sense of depression and failure, more weight gain and a cycle of further reduction in energy level. That cycle can be broken. It requires new thoughts, a new commitment and new goals. Those thoughts, commitments and goals must be reaffirmed constantly and once they are, a sense of achievement takes hold and a new higher level of energy is experienced.

Want to experience a higher energy level? Don’t wait for it to come along and bite you. You have to make the change today.

An interesting study just released looks at the long-term remission rates of type 2 diabetes mellitus after laparoscopic adjustable gastric banding.  The study reported by Dr. Samuel Sultan demonstrated that after five years of follow-up 40 percent of previously diabetic patients were now off of all diabetes medicines and had normal blood sugars and normal hemoglobin A1c levels.  In a total of 80 percent of patients the diabetes was improved (as defined by a reduction of diabetes medicine) or was totally resolved.

Not surprisingly the patients in the study who maintained the resolution of their diabetes were the same patients who maintained their weight loss over that time period and who exhibited a greater magnitude of weight loss at the five year mark.

I think what this study says about long-term resolution of diabetes after lap-band surgery is that the key is, in fact maintaining the weight loss for the long-term.  We know that the keys for maintaining that weight loss long-term are committing fully and completely to changing, adapting a new life style, participating in ongoing long-term follow-up with the bariatric surgeons office and continuing to have band fills and adjustments on a regular basis.  We also think that coaching, attendance at a support group and more active participation in activities, such as regular walking groups, contribute to the long-term success that leads to total, long-term resolution of diabetes.

Recently scientists have pointed to some concerning data from the Center of Disease Control in Atlanta, indicating that after swine flu infection, more deaths have occurred in obese individuals than would be expected statistically.  This has led some scientists to opine that overweight or obese individuals may have grater risks when it comes to a serious flu infection.

Based upon the extensive volume of data from many other disease states, it is logical to expect swine flu to carry greater risks for a person who is overweight or obese than a person who has normal weight.  Any adverse health condition must be fought off by the human body with all of its organ systems functioning and coordination to sustain health and rid the body of the disease.

So, if health deterioration has occurred in many other aspects of the body when a new disease strikes, the body is less able to sustain itself and fight off the new problem.  Think of pneumonia (a new infection in the lungs) occurring in an old or disabled person.  This person lacks the strength and robustness of all the organ systems to adequately fight off this disease state that would have been a relatively easy battle in a health twenty-year-old.

This certainly is true for obese individuals facing all kinds of serious illnesses including: cancer, heart disease, diabetes, even an automobile accident or other trauma.  The individual in a car accident who is seriously overweight faces much higher risks because of deconditioning, poor lung function, impaired mechanics of breathing, strains on the heart to pump the blood through the body, liver congestion, kidney impairment and a host of other issues.  All of these other organ problems may have resided under the radar screen until the trauma occurred, but now they serve as an ominous background upon which the disease must play out.  Compared to a normal weight individual, the risks of the body failing to fight off the disease or trauma are significantly higher.

With H1N1 flu, there could also be an immunological affect based upon the increased adipose tissue or fat tissue carried by the individual.  The hormonal changes that we see in obesity (resistance to insulin and leptin along with increased levels of inflammatory cytokines and leptin) could potentially leave the body more vulnerable to attack from the virus.  It might be that these adverse states of relative immune susceptibility only incur a very slight, increased risk of say, one percent over an overweight individual.  If a flu virus like swine flu, afflicts millions of people that one percent increased risk among obese individuals translates to a significant number of victims suffering real and serious consequences from the flu.

Lastly, the findings have increased death rates after swine flu infection among obese individuals could also stem not from a specific cause that is related to the increased fat cells in the body, but rather due to the secondary diseases that we know stem from obesity.  For example: since so many more people with obesity have diabetes and high blood pressure, it is possible that these secondary conditions of obesity are what confers the added risk of swine flu death.  More sophisticated studies that control for these variables would help us understand if indeed that is an independent risk due to obesity and excess fat, above and beyond the associated adverse health conditions of obesity.

What ever the exact cause or mechanism it comes as no surprise that as we head into the swine flu season, overweight and obese individuals face greater risks.

Did you know that lack of sleep leads to more weight gain? As if there weren’t enough things out there to cause us to gain weight, research as shown that a lack of a good night of sleep leads to more wight gain. The mechanism is thought to be related to an increase in hunger and a decrease in some of our impulse control and mindfulness with respect to eating and giving into temptation around food.

I have definitely seen this phenomenon in my own life. After a night on call when I have had very little sleep, I tend to do a very lousy job of eating well the next day. Somewhere in my subconscious I seek to reward myself, or find comfort and pleasure in things like doughnuts and pastry’s in the doctor’s lounge that I would otherwise, usually avoid. I also find that if I have not slept well, or slept enough hours, that it is much harder for me to find the energy or motivation to go for a run or do other exercise. So, none of these are health results from lack of sleep!

So what can you do about it? Well, there are a few, very important practices you can undertake that will maximize better sleeping and therefore help you in your journey to a healthier weight.

• For starters, don’t consume caffeine or other stimulants in the afternoon or evening. Avoid alcohol beyond two or three ounces of wine and avoid eating a late night meal.
• Find 30 minutes for a brisk walk or other exercise in your day or evening and you will sleep much better.
• Establish a routine in which you sleep in a safe and comfortable environment that is controlled to your likings, in respect to the temperature and darkness.
• Establish your bedtime and stick to it every night. Try to minimize emotionally charged events and activities that occur close to bedtime.

Importantly, many of us have un-recognized sleep disturbances that can only be diagnosed by a formal sleep study. The most common among these is obstructive sleep apnea, a very common condition that occurs as a result of weight gain. It results from airway obstruction of some soft tissues.

I am occasionally struck by the comments from medical physicians or from people in the health care community who comment that some of what I do to help people lose weight and solve their diabetes is so “radical”. Usually when they say this they are referring to Roux-N-Y-Gastric Bypass surgery, which does involve a fairly permanent rerouting of the stomach and upper intestinal system. Even though the procedure is done with a laparoscopy, or minimally invasive technique, and usually involves a one hour surgery and overnight hospital stay, I certainly agree that it is a major decision to undergo the procedure and not something to be taken lightly.

I am ,however, troubled by the real lack of understanding of the nature of the diseases of both obesity and diabetes among those making this kind of comment. I have even had, for example, people in my office who were considering weight loss surgery and brought along their skeptical spouse or significant other to talk with me. Here I would be, speaking with a person who has tried for decades to lose weight and is now seriously overweight struggling with insulin shots, umpteen medications, severe pain in the spine and weight bearing joints, high blood pressure, breathing difficulties and yet the spouse or significant other would be very discouraging, saying things like, “the surgery is too radical”. I wonder just what solution would be appropriate given the “radical” nature of the disease that is leading to such diminished quality of life for the person in such a dramatic shortening of life span with early onset of these devastating diseases. What we seek in medicine and all health interventions is proportionality wherever possible. This means that we prefer that the treatments, or intervention, be proportional to the seriousness of the disease. For example, radical brain surgery would only be considered appropriate if the disease being treated was a life threatening brain tumor. We would not recommend craniotomy surgery and its attendant risks and recovery time for a less severe brain condition, like say, headaches.

So, is weight loss surgery a proportional treatment for this disease? I would argue that it is quite acceptable in terms of this concept of being proportional, especially when compared to so many other kinds of treatments across the spectrum of so many other diseases. And especially as weight loss surgery has moved increasingly to the minimally invasive and even to the outpatient realm, it has become far less radical than the disease it treats and in many cases cures.

I recently came across the video I have included in this blog post. I though some of you would appreciate it. It does touch on the enormous problem obesity is in American society today.  It also discusses some of the possible public policies that may be implemented to try to address this trend of increasing obesity amongst America population.

It is imperative to the future of this nations that this problem be addressed. The financial burden alone is crippling our health care system.  And this not even mentioning the personal toll obesity takes on families and loved ones who cannot lead the productive lives they would otherwise be able to pursue.

Earlier this week Health Affairs released the findings of its study on the cost of obesity. Although many of us have been aware of the rising cost of obesity related illnesses, it is still shocking to see that (according to this study) the medical spending on obesity-related conditions is around $147 billion dollars annually as of 2008. This account for almost ten percent of all medical spending in the country. This is further proof that the cost of obesity is not just in the value of lives, but is a hugely significant financial burden as well.

The numbers are further proof that obese individuals should not let the up front costs of beginning a serious weight loss program, with or without a surgical aspect, dictate their decision to begin a weight loss program. The figures will quickly add up in terms of all the medical bills over time when compared to the cost of the tools one may need to maintain a healthy weight and live a healthier and more fulfilling life.

A recent study finished in March of 2009 in surgical endoscopy described the outcomes with surgery in people with a lower Body Mass Index than the current standard widely accepted criteria (normally a Body Mass Index of 35 or greater qualifies people for weight loss surgery at most U.S. centers).

In this study, 53 patients with a Body Mass Index ranging from 28 to 35 underwent laparoscopic adjustable gastric banding surgery.  In the study, the patients lost 69% of excess body weight at six months. This rose to 77% at 12 months and 81% of excess body weight was lost at the two-year mark.  The mean Body Mass Index was 33 at the beginning of the study and then fell to 25.8 at the two-year mark.

Even more importantly, 50% of the patients with diabetes mellitus experienced complete resolution of their diabetes.  (Fifteen patients total started with type II diabetes.)  45% of patients with hypertension experienced resolution of this condition. Similar results were seen with asthma and obstructive sleep apnea.

Over the two-year course of the study, 13% of patients experienced some type of problem or complication including one patient with a band slip, two with fluid causing band obstruction, two with esophagitis and two with port leaks.

This most recent study adds further evidence that weight loss surgery is safe and effective for people with a lower Body Mass Index than is widely accepted.  The implications of this sort of research finding are quite profound.  Many additional tens of millions of Americans and hundreds of millions worldwide would qualify under an expanded BMI criterion.

This study and other like it show that people who are moderately obese stand to improve their health and resolve very serious conditions such as type II diabetes, obstructive sleep apnea, hypertension and asthma with the help of weight loss surgery.  Should the criteria be expanded?  Should health insurance plans pay for this surgery for this vast number of people who would qualify under expanded criteria?

Perhaps it is better to offer the weight loss surgery to people at a lower BMI and take a more proactive or preventive approach to the serious diseases they will soon develop.  One might argue that they might also be expected to have lower risk for surgery at this earlier stage of the obesity disease rather than waiting until they have full-blown obesity with many complications like severe heart and lung disease (which make them higher risk for surgery and anesthesia).

In the future, we will see a debate over whether the current criteria for weight loss surgery need to be expanded and then who would pay for the procedures and programs.

What are the Health Effects? – Complications of Obesity in Adolescents

A recent review by Karam in Pediatric Endocrinology Reviews (August 2008, Volume 5, supplement 4, page 980) discusses the growing problem of type II diabetes among adolescents. Since most type II diabetes (previously referred to commonly as “adult onset diabetes”) is related to weight gain, and since weight gain and obesity continue to rise among children and adolescents, we see a parallel rise in the development of new cases of type II diabetes among children ages 13 to 17. The authors discuss methods to attempt to prevent the onset of diabetes in this patient population chiefly by recognizing when kids become at risk for the disease through weight gain at an early age.

These are the types of efforts that are very difficult, but are the same efforts being undertaken across the country and across the world in school districts and community programs and through nonprofit foundations like the Obesity Prevention Foundation.

Identifying adolescents who are at risk for diabetes involves measuring height and weight, calculating a Body Mass Index, and intervening with counseling and education of both the kids and the parents. The hope is this will lead to improved and healthier eating, reduce calorie intake, increase physical activity and a correction of the weight gain curve toward a more normal Body Mass Index. In this way, it is hoped that some kids will avoid developing early onset of type II diabetes.

Sometimes identifying kids who are overweight and targeting them specifically with counseling and education can seem intrusive or discriminatory. There might also be a perception of being judged or a misplaced focus on appearance and social norms instead of on health and diabetes prevention.

Navigating all of these personal, political and social obstacles is no easy task, but with the rising rates of type II diabetes among our young people, what other choice do we have but to try hard to protect the health of our young people?