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Mental Health and Bariatric Surgery - Canadian Data

>> Monday, September 18, 2017





We know that there is a relationship between mental health and obesity, with mental health issues such as depression being associated with an increased risk of obesity, and with the risk of mental health issues developing increasing as weight increases. In people with more pronounced obesity who are considering bariatric surgery as a treatment option, it is important to consider how mental illness may impact the efficacy and safety of surgical treatment for obesity.

These issues were beautifully summarized in a recent review by Val Taylor and colleagues, published in the Canadian Journal of Diabetes, with a focus on Canadian data.

Here are a few of the highlights:

1. How common are mental health issues in Canadian bariatric surgery patients? 

Over half of patients presenting in Ontario for bariatric surgery had a history of mental illness (most commonly depression). Neither a history of depression nor bipolar disorder seem to be associated with success of weight loss with bariatric surgery, but stability and control of mental health issues preoperatively is important to optimize success.  The prevalence and severity of depression in the bariatric population are consistently decreased after surgery – but there is a risk of development of depression for some people as well, which may be related to some of the psychological challenges that can present after surgery.  Many people with mental health issues are taking medications to treat these conditions, and absorption of these meds may be affected after surgery, so close monitoring to ensure good control of the mental health issue after surgery is important.

2. Eating disorders:

Binge eating disorder (BED) has a prevalence of up to 30% in people presenting for bariatric surgery, with the data conflicting on whether BED reduces the success of weight loss with bariatric surgery. Management of the feeling of loss of control and regulation of emotions in these individuals are important factors to help reducing binge eating in this group.

Active bulimia is a contraindication to bariatric surgery.

3. Suicide risk:

While depression usually improves after surgery, the risk of suicide is increased after bariatric surgery, with a multitude of possible reasons/contributors behind this fact.  The risk of self harm seems to be increased at least 3 years after surgery, so long term psychological follow up and support of bariatric patients is essential.

4. What if there is a past history of sexual abuse?

A history of sexual abuse is present in 21.5% of people in the Ontario Bariatric Surgery Registry.  While this does not appear to influence the success of surgery, these individuals are at a higher risk of mental health issues such as depression, speaking to the need for proper assessment and follow up.

5.  Substance use/abuse:

A history of substance use (alcohol, tobacco, or recreational/illicit drugs) seems to be correlated with a risk of substance use after surgery, particularly if the substance use history is near to the time of surgery.  Alcohol abuse is a particular risk, as alcohol hits harder and fasterafter surgery.  A ‘transfer’ of addictions from one thing to another (eg, from food to gambling) after surgery has been described, and should be discussed and managed ahead of time.


Most often, mental health issues can generally be well managed to optimize success of the individual undergoing bariatric surgery.  Identifying and managing these issues before surgery is essential, and long term support after surgery is key as well.


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017


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Blood Sugar and Insulin Levels As A Biomarker For Weight Loss Success?

>> Monday, September 11, 2017





To date, no particular diet composition has been shown to be superior to another for weight loss success in the general population.  However, we haven't yet ruled out that some types of diets may work better for certain specific groups of people.  For the first time, a new study suggests that people with prediabetes or diabetes, and people with higher fasting insulin levels, may have better weight loss success with either a lower glycemic load diet, or a diet containing a large amount of fiber and whole grains.

The study, published in the American Journal of Clinical Nutrition, evaluated data from three studies and stratified weight loss results by fasting blood sugar and insulin levels.

The first trial, called the DioGENES study (as blogged previously), looked at the ability to maintain weight loss using a high vs low glycemic index and high vs lower protein diet.   The results of this study overall showed that a low GI, higher protein diet was superior to a high GI, lower protein diet to maintain lifestyle-induced weight loss.  In the current analysis, they found that people with prediabetes regained 5.83kg more on a high GI diet than a low GI diet, whereas people with normal blood sugar regained only 1.44kg more on a high GI diet than a low GI diet.

The second study, called the SHOPUS study, was designed to test the New Nordic Diet, which is high in fiber and whole grains. People with prediabetes lost a mean of 6 kg on this diet, whereas people with normal blood sugars lost only 2.2kg.

Finally, in the NUGENOB study, which was designed to test nutrient-gene interactions in obesity, people with diabetes lost a mean of 2kg more on the high fat/low carb diet than on the low fat/high carb diet, whereas people with normal sugars lost only 0.43kg more on the above comparison.

When the authors incorporated fasting insulin levels into these analysis, the associations above were strengthened further.  Some interesting phenotypes were also revealed:

  • people with lower fasting blood sugar and high fasting insulin levels responded equally on all 3 pairs of diets 
  • people with high fasting sugars and low fasting insulin levels did better on diets with a lower glycemic load and more fiber and whole grains
  • people with lower blood sugar and lower fasting insulin did better on a low fat/high carb diet. 


We often talk about precision medicine - customization of health care decisions based on each individual's genetics, lab results, hormone levels, and so on; yet in obesity medicine, we have very little routinely measured information that can help us determine what type of management program may be best for our patient.  Finally we have some data, using easily measurable blood tests, that may help to guide us.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017




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Obesity, Addiction, Alcohol and Bariatric Surgery Part II

>> Tuesday, September 5, 2017





We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors.  We are also learning increasingly that there are many areas of neurophysiologic (brain), psychological and behavioral overlap in the realms of obesity and addiction.

In part I of this two-part blog post, we discussed some of the changes that happen after bariatric surgery, as discussed in a recent review.

Now, some threads that weave a connection for some people between obesity and addiction: 

1.  For some people, food is an addictive substance.  People who have high scores on food addiction questionnaires have similar patterns of brain activation as in people with other addictions.  Also, overconsumption of certain nutrients (eg sugar) elicits chemical responses in our brains, similar to those that result from consumption of drugs or alcohol.

Some people think that combatting a food addiction is no different than trying to quit smoking.  But remember, a person who quits smoking can (and ideally will) lead their life without ever touching another cigarette.  But the person battling a food addiction can't stop eating - they have to continue to eat for the rest of their lives, while controlling the addictive component that leads to overeating: a very, very difficult thing to do. 

2.  Some people with obesity have more 'turbo-charged' food reward circuits in their brains, which results in a powerful drive to seek high calorie food.  Obesity can also be accompanied by a reduced brain-driven ability to resist temptation and control impulses to eat, with data suggesting that there is a genetic component to these differences.  After gastric bypass surgery, research has identified some changes in this brain activity, and these changes may be associated with the amount of weight lost after surgery.

Know that feeling of: I am so hungry I don't care what it is it just has to happen RIGHT NOW...?
For some people, this feeling may come only if meals are skipped for many hours, or after a fierce workout.  For others, they may feel like this until their body is at a higher body weight 'set point'.  The level of energy reserves, or time from last meal that contributes to the threshold for this feeling to set in, is very different from person to person.

So for people who have a food addiction, as well as for people who have a more powerful reward circuitry, weight management will be difficult, but not impossible - having a psychologist with professional training in obesity management is an important part of the team to help manage their weight struggles.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017








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Obesity, Addiction, Alcohol and Bariatric Surgery Part I

>> Monday, August 28, 2017







We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors.  We are also learning increasingly that there are many areas of neurophysiologic (brain), psychological and behavioural overlap in the realms of obesity and addiction.  A recent review draws on our knowledge of alcohol use after bariatric surgery to help us understand these connections.

After gastric bypass surgery:
  • 9.4% of patients who have had gastric bypass surgery report a period of excessive alcohol intake at some point after surgery
  • 7% of patients with no preoperative history of excessive alcohol intake develop a problem after surgery
  • middle aged females seem to be at higher risk
  • post bariatric surgery addiction problems seem to be fairly specific to alcohol (though addictions to other substances, or activities such as gambling are also seen - see 'addiction transference' below)
  • when a person who has had gastric bypass surgery drinks alcohol, there is a faster rise, higher peak, and longer duration of blood alcohol levels 
Interestingly, some people who were frequent alcohol consumers before surgery actually have a decreased enjoyment of alcohol after surgery, which may be mediated by an increase in the gut hormone GLP-1, and a decrease in the hunger hormone ghrelin.

Psychological and social factors can also have a big influence on alcohol consumption after surgery.  As blogged previously, food addiction seeking a new outlet (called 'addiction transference') may be a factor for some people.  A need for a coping mechanism as a person watches their body change after surgery may be involved.   Some may reach for alcohol as a way to manage the complex psychological issues that can arise after surgery. 

Stay tuned for the next blog post, where I'll discuss some of the parallels between obesity and addiction that may be relevant for some people, discussed in this review. 


Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017




  


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Por-Puffed Wheat Squares

>> Monday, August 21, 2017





So I'm sure you're already wondering... what on earth is a PorPuffed Wheat Square?

A couple of weeks ago, I wandered into a local cafe in Calgary, and found these enormous puffed wheat squares staring me in the face:



I bought one of these mammoth creations.... and before digging into it, I decided to cut it up just to see how many appropriately (in my opinion) portion-sized squares it would make.  I thought maybe 4, 5, 6.....

Sixteen.

SIXTEEN!!

I cut it up into 16 pieces and brought them to work to share with my work family.

(And yes ok maybe I caved and bought a Rice Krispie square too.)



ONE Rice Krispie square is cut up in the bag on the left.
ONE Puffed Wheat square is in the bag cut up on the right.

So the teaching today is about portions: sadly, portion sizes have grown by 3-4x (and in this case, 16x!) compared to what portion sizes were in the marketplace 30-40 years ago.  This is a problem especially out of control in North America (travellers may notice that portions are usually smaller on other continents).

So here's my recipe for PorPuffed Wheat Squares (short for Portioned-Puffed).  There are many permutations on this out there - this one is chocolaty, delightful, and will make a square that stays fairly soft for several days, if you follow my guidance below.

Disclaimer: the ingredients are high glycemic index and not healthy (though puffed wheat squares will have a lower calorie bill than something more dense like a brownie or granola-based bar), but portioned appropriately, they are a delectable and very reasonable little treat once in a while.

INGREDIENTS:

  • 1/2 cup corn syrup
  • 1 cup brown sugar
  • 1/2 cup margarine
  • 5 tbsp cocoa powder
  • 8 cups puffed wheat

DIRECTIONS: 

1.  Melt the first 4 ingredients under low-medium heat until the mixture just starts to boil.  (don't wait any longer or the squares will be too hard)

2.  Remove from heat and fold in the puffed wheat.

3.  Press into a 9x13" pan, lightly greased with margarine. 

That's it!  Super easy. 

Makes 20 squares. Per square: 
  • Calories: 135
  • Carbs: 21g
  • Fat: 4.8g
  • Protein: 1g

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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A HEARTFELT WELCOME!

I am excited that you have arrived at my site, and I hope you are too - consider this the first step towards a Healthier New You!! As a medical doctor, Endocrinologist, and obesity specialist, I am absolutely passionate about helping people with weight management. Though there is certainly no magic cure for obesity, there IS a successful treatment plan out there for you - it is all about understanding the elements that contribute to your personal weight struggle, and then finding the treatment plan that suits your needs and your lifestyle. The way to finding your personal solution is to learn as much as you can about obesity: how our toxic environment has shaped us into an overweight society; the diversity of contributors to obesity; and what the treatment options out there are really all about. Knowledge Is Power!!


Are you ready to change your life? Let's begin our journey together, towards a healthier, happier you!!




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