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?

Times are tough.  A lot of people right now are facing difficult economic circumstances, jobs are scarce, and extra money is not just lying around these days.

With all that’s going on, how can a person manage to focus on losing weight?  The truth is that becoming healthier and skinnier can be economically very beneficial to a person.  However, to focus on weight loss requires some psychological clarity and focus.  It can be difficult when life has become very stressful for economic or other reasons to focus clearly on a goal of changing your life, losing weight and becoming healthier. But it is possible and it may be the best thing you can do to move forward in this area of your life even while  other aspects of life face great challenges due to the economy.

Losing weight and living at a healthier weight can save money for a number of reasons.  First of all, you simply eat less.  If you become disciplined and start cutting out a lot of the high calorie snacks and treats, this not only  helps weight loss but it helps with the pocketbook.  Yummy mochas and cappuccinos, not to mention ice cream and popcorn, are expensive and add unneeded pounds to the waistline. Becoming focused on a weight loss program allows you to save this money.

More importantly, however, if you can lose 10% of your excess body weight that translates into significant health improvements so much so that many people find that they are able to decrease or quit medications they are currently taking for problems like gastroesophageal reflux, painful bones and joints, and even diabetes and high blood pressure. With more significant weight loss, lots of medications and doctors’ visits fall by the wayside.

There are expenses with good weight loss programs. These include reading material, literature, audio programs, protein meal replacement shakes, low carb, low glycemic index snacks and meals, and even medications.  Yet, usually these are cheaper in the long run than eating regular meals.  Sometimes though cheap high calorie food can seem more appealing.

The bottom line is that you and your health are too important to do anything other than focus on losing weight and becoming healthier.

I think just about everyone would agree  that one of our top priorities should be to ensure the health of our nation’s children.   And although some of us point to a failure of personal responsibility as a component of the problem of weight gain and obesity, few can make a compelling claim that our nation’s children bear the responsibly for their own obesity and unprecedented suffering with diabetes (and other obesity-related health problems).

And what of the causes of this devastating increase in childhood obesity and childhood diabetes?  Numerous recent studies have noted the striking rise in obesity related illness among kids.  A disturbing, growing percentage of our nation’s youth have a condition known as “prediabetes” or impaired glucose tolerance that leads to outright diabetes.

The best evidence points to multifactorial causes.  We are a more sedentary society.  Our children spend more time in front of screens than out kicking balls and running through the grass.  Physical education has disappeared from the school curricula.  A greater fraction of the child’s meals are fast foods and prepared foods.  And these same fast foods are more delicious than ever and higher in calorie content than ever.  And finally, our children have exhibited a stunning increase in the consumption of carbohydrate sweets, especially table sugar (sucrose) and high fructose corn syrup, that parallels the epidemic of weight gain and obesity. As a weight loss expert having worked with so many overweight people over the years, the consumption of sweeteners stands out as accounting for a disproportionate amount of the problem of weight gain.

Scientific studies further link the consumption of high fructose corn syrup-laden beverages and increasing rates of childhood obesity.

In 1970, the average per capita consumption of soft drinks, sodas, in the United States was 28 gallons per person per year.  In 2008, it was 56 gallons per person per year (of beverages usually sweetened with high fructose corn syrup).  Over the same period of time, the rate of obesity (Body Mass Index greater than 30) has increased from around 5% to over 15% among children and adolescents in this country.  Between 1970 and 1990, the US per capita consumption of high fructose corn syrup has increased tenfold or more than 1000%.  According to a comprehensive review undertaken by the American Journal of Clinical Nutrition in their article published in 2006 (American  Journal of Clinical Nutrition, Volume 84, page 274-288), the comprehensive review of all of the clinical trials and evidence-based, peer-reviewed studies demonstrates that “the weight of epidemiologic and experimental evidence indicates that a greater consumption of sugar sweetened beverages is associated with weight gain and obesity”.

So how do we as individuals, as communities, as governments, as schools, and as corporations lead, protect and nurture our young people?  How do we, as the adult stewards of our young people, prevent them from suffering the scourge of obesity, type II diabetes and its complications (blindness, amputations, stroke, kidney failure)?

My belief is that the solution lies in every community in the country, every government chamber in the country, every school in the country, every corporate boardroom, and every home.  It will take all of us working on many solutions to fix a problem that is so widespread and so damaging to kids.

When tobacco was shown to cause health problems (cancer, heart disease, birth defects), initially the tobacco industry dug in and created an advertising, public relations response that tried to deny the science.

Now we see the same head-in-the-sand response by the makers of high fructose corn syrup. Instead of acknowledging the obvious role of sweeteners in fostering childhood obesity, diabetes and disease, the industry is mounting a public relations campaign to dispel the science.

Instead of stepping up and taking responsibility, the industry is putting out spin with ads like these from the corn council.

Sure, there are differences among tobacco, alcohol and sweeteners. But if we are to reduce the alarming rates of childhood diabetes, it is undeniable that we must find a way to reduce consumption of these high calorie, high carbohydrate sweeteners.

As a physician and parent, I would appreciate industry taking a leadership role in educating kids and parents about the damaging aspects of high fructose corn syrup. Imagine a responsible corn industry running ads that say that consumption of this sweetener needs to be limited in kids and overweight adults. Consuming too much of this sweetener leads to weight gain which causes real health problems for kids, like diabetes. So enjoy our delicious sweeteners, but do so in moderation, and make sure your child is staying on a healthy growth curve and not gaining weight beyond a healthy level.

I suspect it is a matter of time before governments force the Corn Council to step up and act responsibly. Based on this sad spin campaign that ignore our childrens’ health and serves only to promote more profits for the purveyors of high fructose corn syrup, it does not appear that the corn industry is prepared to act responsibly on its own.

There is no question that losing weight successfully is a complex undertaking.  There is no question there are many elements to it.  But awareness has to be one of the first steps and helping make children aware will help them later in life as they work to maintain a healthier weight.  For a surprising number of adults and kids, there is not a really clear understanding of the link between high calorie, high carbohydrate foods and soft drinks, and painful joints, difficulty breathing, insulin injections, and obesity.  So if there were a motivational breakdown, it might look something like this.

1.    Identification of the problem:  “I’m overweight”.

2.    Fuller understanding of the ramifications of the problem: “My weight is causing me pain, impairing my health, shortening my life expectancy, and reducing my quality of life.”

3.    Recognizing what causes the problem:  “I’m consuming far too many calories, high carbohydrate foods and drinks, and burning too few calories with too little exercise.”

4.    Define your goals:  What you personally hope to gain or experience:  “I want to play with my children outside and experience less pain in my knees and back.”

5.    Define specific weight loss goals:  “I want to lose 50 pounds in 12 months.”

6.    Make a specific plan:  “I am enrolling today in the medically supervised weight loss program with IMetabolic.”

7.    Start today.  No delays, no waiting.  No excuses.  Just start.

One of the keys to staying on track with your personal weight loss goals is to continue to write down why you want to achieve the goals you have set.  What personally, most deeply affects you and your loved ones, your health, and your quality of life.  Write down the goals, such as, “I want to lose weight so I can never take another insulin shot again.”  Or, “I want to lose 30 pounds so I can resume skiing again.”

What are your goals?  What do you want to achieve?

I saw a patient in my office recently who has a very important concern: Nearly everyone in his family has diabetes. He himself is quite overweight and has not developed diabetes but is only in his 30s. He wants to have weight loss surgery to lose weight and feel better, but also to prevent diabetes.

Should he undergo weight loss surgery? Which procedure would be the best?

I think there is little question that the roux-en-Y gastric bypass operation has proven to be the most effective procedure at eliminating diabetes once it has been diagnosed. There is also very little question that weight reduction helps prevent the onset of type 2 diabetes. But in this particular man there is probably no clear-cut, single correct answer. Certainly if my patient succeeds and really puts his mind to it, he will have a high chance of preventing the development of diabetes with either procedure. I suspect the success rate may be even higher with gastric bypass surgery, the more invasive procedure. But whether a higher rate of prevention success warrants a more invasive procedure will not be decided in the same manner by each person.

In the future, better studies will help us quantify the risk of diabetes for individuals and provide more detailed answers about the best preventive strategies. But it is noteworthy that more and more people are thinking about prevention and taking a proactive stance against diabetes and other complications of obesity.

A major problem with weight gain among kids is that it produces serious health problems and sets the stage for early development of even more serious disease. For example, kids who gain weight develop what is called “impaired glucose tolerance”, meaning that they have a type of pre-diabetes condition. This means that the overweight, or obese child does not process ingested sugars easily and the serum blood sugar level rises. There are also problems with insulin production and resistance of the tissues to insulin, both critical factors in the development of diabetes.

In addition, the circulating blood lipid levels rise in overweight kids and they develop early plaques on the inner lining of the arteries, known as atherosclerosis.

The combination of an expanding waistline together with high lipid levels and elevated blood sugars are the core findings of the metabolic syndrome, a collection of serious cardiovascular abnormalities associated with early heart attacks, strokes and death.

The kids who start out on this path at such an early age have a poor chance of living a normal, long life. Many of the metabolic results of weight gain as a child are well described in a volume by Weiss called The Metabolical Consequences of Childhood Obesity (Best Practice and Research Clinical Endocrinology and Metabolism, volume 19, issue 3, page 405).

The connection between being overweight as a child or adolescent and then later having adult obesity and cardiovascular disease is made clear in a study by Srinivasan in the journal Metabolism (volume 45, issue 2, page 235, February 1996). In this study, 783 subjects surveyed first as adolescents and then again as young adults age 27 to 31. They found that the excess weight present in the adolescents persisted into young adulthood and had a strong and negative impact on health as measured by multiple cardiovascular risk factors (high blood pressure, elevated cholesterol, adverse lipid profile and diabetes).

So, unfortunately, while we would like to think of some of the youngsters as still retaining some of that “baby fat” and hoping that it will melt away as they age into adulthood, the facts speak otherwise. Childhood weight gain and obesity lead to adult obesity and disease.

We cannot afford to neglect childhood weight gain and adolescent obesity as serious problems and as an important opportunity to intervene for improved long-term health.

Did you know that a 20-ounce soda, like a Pepsi, has 69 grams of carbohydrates and 250 calories! This astounding fact, these astronomical amounts of carbohydrates and calories in just one soda, is both very good news and very bad news.
The very bad news is that millions of people are drinking soft drinks and consuming unprecedented amounts of calories in the form of carbohydrates, sugars, and high fructose corn syrup. These drinks have zero nutritional value. Some of the doctors I work with in the field of weight loss and obesity refer to them as “diabetes delivery vehicles”. How many people do you know who drink two or three or four or even five or six Cokes or other soft drinks a day? The harm that consuming that much carbohydrate brings is quite substantial. Massive carbohydrate calorie intake quickly leads to the metabolic syndrome, obesity, elevated blood pressure and the onset of diabetes. Those conditions bring about early and very serious health problems including heart attacks, strokes and other deaths.

Wow! So what’s the good news?

Well, the good news is that if you currently are in the habit of drinking soft drinks, fruit drinks, even fruit juices on a regular basis every day, then you have an amazing opportunity to very quickly and very successfully lose weight and become healthier by making one single change in your routine: Eliminating high carbohydrate drinks.

But wait, some people say, “I’m totally addicted”, and, “I can’t stop drinking my favorite soda pop”, and “I love it, it helps me get through the day.”

Let’s face it, no change is easy. All of the behavioral, activity based, and overall lifestyle changes that I write and speak about to my patients are more difficult than this one single change of eliminating high calorie soft drinks from your diet. In other words, there is no single change that is easier and that has a greater impact on your health and weight than this.

Our rule at iMetabolic is all drinks must be zero calorie. (The only exception for this is children who may choose milk or water as their beverage).

But how do I Eliminate High Carb, High Calorie Drinks?

If you really feel like you can’t live without your high calorie, full sugared, high fructose corn syrup laden beverage, first consider the harm it is doing to your body. If you are trying to lose weight and become healthier, adding in 200, 300 or 400 calories per drink several times a day is immediately leading you absolutely no room to consume any good quality calories. The soft drinks are typically high in sodium which can lead to elevated blood pressure, but the killer is really the carbohydrate calories. This is a highly effective way of tacking on pounds and pounds of fat and developing diabetes, high blood pressure, metabolic syndrome and obesity.

Now is the time to switch from high sugared, high carbohydrate drinks to equally delicious zero-calorie beverages. That’s right, equally delicious. It just takes a little time and there is a little pain involved in the transition, but you will be completely and equally satisfied with one of the many zero-calorie drink options available today. These include all kinds of energy drinks, non-carbonated beverages and “diet” sodas and soft drinks.

One of the things that my patients consistently tell me is that they seem to be sleeping more poorly than ever.  I hear many versions of this, but the common thread is that as my patients gained weight over the years they have had a harder time falling asleep and had a much more difficult time obtaining restful sleep through the night.  The partners of my patients report increased snoring and wakefulness, as well as early waking in the wee hours of the morning, and somehow it is just too hard to get back to sleep.

Why should sleeping become so difficult?  There may be quite a few reasons as sleep disturbances are truly multifactorial problems.  Part of the problem stems from the impaired mechanics of breathing that occurs with weight gain.  With weight gain we snore more, we have more soft tissue obstruction in the mouth and throat, and it takes more effort to move the “bellows” of our chest and achieve good full breaths.  But there are lots of other factors at work here.

As most of us know, there is a strong psychological aspect of sleep.  If we are more stressed or more depressed, more anxious, more upset, we tend to sleep poorly.  And  weight-related health problems play a role. Pain from degenerating joints can keep us awake. Some medications interfere with good sleep.

How can weight loss help?  Successful weight loss improves all the mechanical factors and physiological factors that impair sleep.  Some of these are “diseases” in their own right such as obstructive sleep apnea (OSA).  Others are just a milder form of sleep disturbance.  But what also happens is perhaps more amazing:  people who begin to feel better about themselves physically and see themselves as working toward an important purpose of weight loss and health improvement, feel better about themselves psychologically as well. And this has tremendous positive impact on sleep and restfulness.

With weight loss, often the physical and psychological aspects of sleep improve. And better sleep means feeling better throughout the day.

In our practice, we developed a sense that all problems resolve after weight loss surgery. I bet if you polled the nurses, the nurse practitioners, office staff, physician assistants and the doctors at Western Bariatric Institute, you would find that through the experience of thousands of patient having undergone weight loss surgery, our clinical staff has come to believe that most health problems fade away and disappear.

This is not hubris; it is just the impression one gets from seeing people in follow up who gradually reduce the number of medications they are on and show up years later looking like an entirely new, and healthier, person. It is very common for people to have been on eight or twelve medications plus CPAP machines for their obstructive sleep apnea, only to return a year or two or three later not only looking like an entirely different person, but also having stopped all their medications and their CPAP.

This impression may be accurate for many people. However, there is some concern among the sleep specialists that obstructive sleep apnea may be a bit more complex disease than we have imagined. In the world of medically supervised weight loss and in bariatric surgery, we tend to view all diseases as being purely weight-related or obesity-related. But that of course is not entirely true.

Around 25% of people with obstructive sleep apnea are not obese. Their risk factors may be more of an anatomic one, having to do with the shape of their mouth and jaw and pharynx. So if a normal weight person has obstructive sleep apnea and then goes on to gain weight, you can imagine that the sleep apnea becomes more severe. Once the weight is lost through bariatric surgery or medically supervised weight loss, the structure of the face and throat has not really changed, so it stands to reason that some degree of obstructive sleep apnea would continue.

As weight loss doctors, we have not taken a highly sophisticated approach to the long-term follow up of obstructive sleep apnea. We probably thought that if the patient reported they were sleeping better and feeling better, and they had lost weight, then what would be the reason for more studies of their sleep?

Well, although there is not much long-term data out there on this question, it may be the case that people with obstructive sleep apnea do need long-term follow up and many of them do need ongoing CPAP. Most of the people who lost weight and kept it off do not need the same level of CPAP. For example, they do not need the pressure settings to be as high as 15 or 18 cm, but rather they can use CPAP more comfortably at 7 or 8 cm. But the big reason to continue with CPAP and to continue visiting the sleep doctors is that independent data shows that untreated sleep apnea carries its own risks of mortality and contributes to other health problems including hypertension and daytime sleepiness.

We see such dramatic resolution of patient’s health conditions like high blood pressure, diabetes and high cholesterol that we naturally lump in obstructive sleep apnea in the same categories and expect its complete and total resolution after weight loss surgery. The truth is probably a bit more complicated. Patients with obstructive sleep apnea undergo weight loss surgery, lose weight and markedly improve or resolve their sleep apnea, but many patients will benefit from ongoing CPAP at lower pressures to avoid the long-term risks and adverse effects of untreated obstructive sleep apnea.

One future study we may undertake at Western Bariatric Institute will be a long-term observation of obstructive sleep apnea over the course of ten years and beyond after their weight loss surgery. This would provide really meaningful data on the need for ongoing sleep studies and titration of CPAP.