Now a new study out of Columbia University and The City College of New York has found that the obesity epidemic poses an equal or greater threat to health- related quality of life than smoking². Published in the American Journal of Preventive Health, the study analyzed data of more than 3.5 million adults according to the Behavioral Risk Factors Surveillance System. The findings showed that the quality-adjusted life years, or QALYs, lost to obesity are equal to or greater than lose due to smoking. Over the past 15 years, the number of adult smokers decreased 18.5 percent while the number of obese Americans increased 85 percent.

The same week as this research was published, a study in the New England Journal of Medicine, reported that if both smoking and obesity rates in the United States go unchanged than the life expectancy in American will be reduced by nearly nine full months³. However, if all U.S. adults become non-smokers of a normal weight by 2020, life expectance could increase by 3.76 years of life.

For those who are morbidly obese, losing the weight can be as difficult as quitting smoking if not harder. Weight loss procedures available at St. Vincent’s Medical Center can help. Visit our site to learn more about bariatric surgery, read success stories or attend a free seminar and learn how this year you can accomplish a New Year’s Resolution that will benefit your health and overall well being.

1. Jia H, Lubetkin EI. Trends in quality-adjusted life-years lost contributed by smoking and obesity. Am J Prev Med 2010; DOI: 10.1016/j.amepre.2009.09.043
2. CDC: “Overweight and Obesity: Health Consequences”. Available at http://www.cdc.gov/obesity/causes/health.html
3. Stewart, S.T., Cutler, D.M., & Rosen, A.B. (2009). Forecasting the Effects of Obesity and Smoking on U.S. Life Expectancy. New England Journal of Medicine. Vol361:2252-2260

Although you may face challenges, most people, even the morbidly obese, can perform some sort of physical activity. The government recommends at least 30 minutes of moderate-intensity physical activity each day. This can include walking. In fact, when they are first starting out, many patients look for ways to simply increase their steps each day. You can purchase a pedometer at a local sporting goods store to measure your steps and keep track of your progress. At first, 30 minutes may seem like a lot, but consider the following, simple ways you can increase the amount of steps you take each day:

• If you work in an office building, take the stairs instead of the elevator
• Park your car far away from the store’s entrance
• Carry one grocery bag at a time from your car to your house
• Walk a lap around the mall for every store you visit
• Lift weights or walk in place while watching TV

Walking may not be what we think of when we think of “working out” but it is a trusted exercise with many benefits. Walking works your heart, lungs and the large muscle groups in your legs and will help you gradually build up your endurance. Then you can consider including different types of activity into your routine. For example, the President’s Council on Physical Fitness and Sports recommends that an exercise program include each of four basic fitness components:

• Cardiorespiratory Endurance – the ability to perform repetitive activities that increase oxygen demand on your heart, lungs and body tissues. Water aerobics and bicycling are two alternatives to walking that will get your heart rate up without putting pressure on your joints.
• Muscular Endurance – the ability to repetitively exert force on a physical object. Lifting hand weights or doing pushups are examples of muscular endurance exercises.
• Muscular Strength – the ability to exert force on a physical object for a brief period of time. As you practice muscular endurance you will be able to lift heavier weights.
• Flexibility – the ability of your joints to move through their full range of motion. Yoga and tai chi are two types of stretching exercises but you can also set aside time to stretch at home or even while sitting at your desk.

More often than not, the toughest part of an exercise routine is not the physical exertion but the ability to stay motivated. Setting goals, tracking your progress and rewarding yourself are great ways to encourage yourself. Set both short-term and long-term goals. A short-term goal may be to go for a walk on your lunch break every day, while a long-term goal maybe to participate in a 5K charity walk. Tracking your progress lets you see how your short-term goals are helping you reach your long-term goals and allows you to see how far you’ve come. Record your goals and keep an exercise journal. Then, when you’ve accomplished one of your goals, give yourself a reward such as new walking shoes, some new music or even an hour of peace and quiet. You deserve it!

Exercise can be an intimidating concept. We often equate “working out” with the extreme, such as marathon runners, body builders, competitive sports etc. Don’t let this stop you. Any post-bariatric physical activity can make you healthier and is important toward an improved lifestyle. Start increasing your activity and logging your success today!

Sources: Weight Control Information Network (WIN). (2007, January). Activity at Any Size. Available at http://win.niddk.nih.gov/Publications/active.htm. Accessed Nov 30, 2009.
The president’s Council on Physical Fitness and Sports. (2009, November).Fitness Fundamentals: Guidelines for Personal Exercise Programs. Available at http://www.fitness.gov/fitness.htm. Accessed Nov 30, 2009.

What is sleep apnea? According to the National Sleep Foundation, sleep apnea is a chronic disorder wherein the breathing is repeatedly interrupted for brief moments while sleeping. This happens because the soft palate in the back of the mouth falls down and blocks the airway.

The good news is that reduction in just 10 percent of body weight in obese people, who suffer from sleep apnea, can lead to a significant improvement in the condition. Weight loss surgery can help you achieve weight loss much greater than 10 percent.

Gary Foster, director of the Center for Obesity Research and Education at Temple University in Philadelphia, and colleagues from six other universities recently completed the largest randomized study on the effects of weight loss on sleep apnea in patients with type 2 diabetes. The new study, called Sleep AHEAD, looked at 264 obese men and women between 45 and 75 years old. The researchers found that 87 percent of obese patients who suffer from Type 2 diabetes had sleep apnea and were not even aware of it.

During the study, the 264 participants were broken into two groups: the first received a intensive behavioral weight loss program developed especially for obese patients with type 2 diabetes, portion-controlled diets, and a prescribed exercise regimen of 175 minutes per week. The second attended three group informational sessions over a one-year period that focused on diabetes management through diet, physical activity and social support.

After one year, those who were part of the intensive program lost an average of 24 pounds. More than three times as many participants in this group had complete remission of their sleep apnea and also had about half the instances of severe sleep apnea as the second group. The study results were published in the Sept. 28 issue of the Archives of Internal Medicine.

Any amount of weight loss proved to be beneficial, but those who lost about 10 percent of their original body weight saw the greatest effect. “These results show that doctors as well as patients can expect a significant improvement in their sleep apnea with weight loss,” said Foster, the study’s lead author.

Sources: Renee Cree, Temple University. “Temple-Led Study Finds Weight Loss Has Significant Impact On Sleep Apnea.” Oct 29, 2009. Available at http://www.medicalnewstoday.com/articles/165536.php. Accessed Nov 16, 2009.

“Weight loss can help you sleep better.” Oct 29, 2009. Available at http://topnews.us/content/27438-weight-loss-can-help-you-sleep-better. Accessed Nov 16, 2009.

The better you understand your emotions – your eating history, trigger points, needs and response to stress – the better you are likely to do. “If you have ‘learned’ maladaptive or destructive eating behaviors that have contributed to weight gain,” Mary says, “you can also ‘unlearn’ these behaviors and ‘relearn’ new ones that help you keep the weight off after bariatric surgery.”

The first step is getting to know yourself on a deeper level. Tune in to your feelings to tell you what’s going on and to help you figure out what to do. Better yet, start a journal and write about your day every day for a couple of weeks. Ask yourself these questions before you have a meal:

• Why am I eating? Am I hungry or thirsty? Am I upset or emotional? Do I feel stressed? The only good reason to eat is for the nourishment of the body when you are truly hungry, so if you think you are eating for any other reason, make a note of this.
• When and where am I eating? What triggers my eating? Am I at work, at home, at a restaurant? Is there a recurring event or a person that triggers me? Identify and write down all of the cues, triggers and associations between your internal world (thoughts and feelings) and external world (people, places, times of day, etc) to allow you to see what pushes your brain’s eating buttons.
• How do I manage stress? Do I relax and meditate when I am under pressure? Do I get enough sleep? Or do I often find myself smoking, drinking or eating comfort foods when stressed? In modern society stress is a fact of everyday life, so learning to handle it in healthy ways is key to successful weight loss and maintenance – and your overall well-being.

Keep your journal for two weeks and then read your entries. Do you see a pattern in your daily bariatric diet? This information will help you assess your eating behavior and identify where and how to make changes. For example: should you clearly see from your logs that being alone at home at night is almost 100% associated with eating ice cream, you now know that you must address what’s going on under these circumstances.

Mary Ziller has seen time and time again, based on years of experience with bariatric patients, how this approach helps them keep the weight off and become more confident. “Once you’ve discovered what triggers you, learn to recognize and overcome it rather than act on it,” Mary advises. “Or come up with a change in your routine that will break the habit – like calling a friend, getting outside for a walk, or meditating. Get to know what you do and don’t like. Speak up for yourself – let yourself and other people know what you need.”

Getting to know yourself can be very rewarding. After all the work you’ve done, you may find that you’ve become an emotionally balanced, positive person who can control your weight and your life!

The JECM study researchers looked at 49 mothers and their 111 children. Some of their children were born before the mother had bariatric surgery and others were born after. The research found that children born after their mother had weight loss surgery were three times less likely to become severely obese. Additionally, the children born after their mother’s surgery had obesity related health risks such as reduced insulin resistance and lower cholesterol levels.

“Our study confirms previous research showing that the interuterine environment may be more important than genes and the post-natal environment when it comes to the association between maternal obesity and childhood obesity,” said the lead author of the paper, Dr. John Kral, of the State University of New York, Downstate Medical Center, Brooklyn, in a news release.

A similar study was presented at the American Society of Metabolic and Bariatric Surgery meeting in Dallas, TX, June 2009. The study population consisted of 76 children born before their mothers’ bariatric surgery and 73 born after the surgery. Compared with children born to the same mother before surgery, those born after bariatric surgery had a lower birth weight, the researcher Picard Marceau, MD, PhD, of Laval University in Quebec, Canada, said. As the children grew older, those born after their mothers’ obesity surgery had blood glucose, insulin, and insulin resistance values that were 30% lower than those of the before-surgery siblings. Triglycerides were 20% lower, HDL was 12% higher, and total cholesterol/HDL ratio was 13% lower.²

Dr. Marceau credited the surgery for improving the mothers’ internal metabolic environment, which was mirrored in their offspring. “Transmission of obesity is cumulative through generations,” he said. “Morbid obesity is a congenital and treatable condition. To curb the obesity epidemic, the focus must be on pregnancies. Medical or surgical treatment for obesity before pregnancy is salutary for offspring.”

Obese women already have an increased rate of infertility and a greater chance of birth defects and other pregnancy complications, such as gestational diabetes.³ These studies show that obese women who are planning to have children should make an effort to lose weight through weight loss surgery or behavior modification before becoming pregnant.

1. Stanford University: “Childhood Obesity Prevention.” Available at http://feeding.stanford.edu/facts.html. Accessed Sept 2, 2009.
2. Marceau P, et al “Successful bariatric surgery in the mother improves health of offspring” Surg Obesity Related Dis 2009; 5(35 Suppl): Abstract PL-110.
3. Boyles, Salynn (February 3, 2006). “WebMD.” Available at http://www.webmd.com/diet/news/20060203/obesity-increases-risks-in-pregnancy, Accessed Sept 2, 2009.

Let’s start with the number of meals per day. To optimize your weight loss, Lynn recommends continuing to eat just 3 meals daily. (If you drink a protein shake instead of breakfast, you’ll eat just 2 meals.) Instead of between-meal snacks, use liquids to meet your fluid goal of 60-70 oz, including protein drinks.

Now, how much should you eat per meal? According to Lynn, by 2-3 months after your surgery, your stomach will hold about 1/3 cup (about 5 tablespoons) of well-chewed food per meal. By 4-6 months after surgery, your stomach will reach its maximum capacity of about ½ cup (4 oz). Remember, the most important part of your diet is protein, and you should aim for 60-80g of protein per day.

At Home: Measure or Weigh Your Food

The easiest way to make sure you don’t overeat is to actually measure your prepared food. “Measuring cups and spoons are your new best friends when it comes to getting used to new portions,” Lynn Holmberg says. Use the measuring cups and spoons that you cook with, and if you don’t have those buy them before your surgery so that you’re well prepared when you need them.

Weighing food is another option, which may be easier than measuring for some foods such as meat. Try out the different kinds of food – meats, grains, cheese, purees, salads – until you can eyeball the right servings quickly.

Remember to watch your protein intake with each meal. “By 4-6 months post-op, you may find you can manage 1-1/2 to 3 oz. protein food per meal,” Lynn advises. “If you’re able to eat more protein at mealtime, you may be able to decrease your protein drink now. Your dietitian can help ensure you continue to meet your protein goal.”

At a Restaurant: Order Small Portions or Split the Meal

Here are three tips on how to be smart about your portions when you’re eating out and cannot measure or weigh your food:

Order an appetizer instead of a full meal, or order from the kids’ menu.

Tell your waiter or waitress that you had weight loss surgery and cannot eat very much.

Split your meal with your spouse or friend, or cut it in half/thirds right away and bring the rest home.

Lynn’s final advice on food servings: “It is very important to learn to eat slowly, and not overeat. You don’t want to have food blockage problems, feel sick, or stretch your new small stomach. If you are a LAP-BAND® patient and find that you can eat more than ½ cup of food without problems, it’s probably time to get a band fill (adjustment)!”

“Bariatric surgery in the older population is underutilized because of a misperception that old age alone puts patients at higher weight loss surgery complication risk and mortality,” said Joseph Kuhn, MD, co-author and director of General Surgical Research at Baylor University Medical Center in Dallas, TX. “We found seniors can benefit just as much as younger people from bariatric surgery without taking on additional risk.”

Researchers from Baylor University Medical Center analyzed a prospective database of 100 patients over age 65, who had laparoscopic gastric bypass between January 2005 and July 2008, and compared safety and outcomes to a younger population. This is the largest reported study to date of laparoscopic gastric bypass surgeries performed on elderly patients.

Prior to surgery, older patients had a higher operative risk profile compared with their younger counterparts, including sleep apnea (45% vs. 34%), Type 2 diabetes (65% vs. 33%) and hypertension (81% vs. 57%). Two years after surgery, however, elderly patients had similar weight loss surgery results and low complication rates and short hospital stays compared with younger surgical patients.

Patients over age 65 showed 75.5 percent excess weight loss after two years, while patients under 65 showed 79.2 percent excess weight loss after two years. Post-operative complication rates were low in older patients compared to younger patients, including bleeding (1% v. 1.3%), pulmonary infections (3% v. 1.3%), cardiac (2% vs. 0.36%) and wound infections (1% v. 1.7%). No patents died in the two year follow-up period. Due to the age and overall health status of patients over age 65, researchers noted it was particularly interesting that length of hospital stay (1.9 vs. 1.3 days) and 30 day readmissions rates (6% vs. 7.4%) were also comparable.

About 26 percent of people 65 and older in the U.S. are obese and another nearly 40 percent are overweight (1), putting them at a higher risk for Type 2 diabetes, high blood pressure and heart disease. Since 1990, the prevalence of obesity has increased more than 50 percent in the elderly (2).

“The population is getting older and unfortunately more obese, so we will see a corresponding increase in the number of patients over 65 who are eligible for bariatric surgery and surgery needs to be an option for them,” said Christopher Willkomm, MD, study co-investigator from Baylor University Medical Center.

1. Rhoades, J. Overweight and Obese Elderly and Near Elderly in the United States, 2002: Estimates for the Noninstitutionalized Population Age 55 and Older. Statistical Brief #68. February 2005. Agency for Healthcare and Research Quality, Rockville, Md. http://meps.ahrq.gov/mepsweb/data_files/publications/st68/stat68.pdf.

2. Physical Activity and Older Americans: Benefits and Strategies. June 2002. Agency for Healthcare Research and Quality and the Centers for Disease Control. http://www.ahrq.gov/ppip/activity.htm.

Source: American Society for Bariatric Surgery (ASMBS), New Study Shows Similar Benefits, No Additional Risks for Seniors Who Have Gastric Bypass, news release, June 25, 2009. Available at http://www.asmbs2009.org/.   Accessed June 29, 2009.

After your bariatric surgery, inevitably you will have both good and bad days, successes and setbacks. Your mind may become preoccupied with thoughts such as “I feel depressed so eating a cookie will make me feel better” or “I am not meant to lose weight” or “I hate to do exercises”, etc. If these negative thoughts keep you from reaching your weight loss goal, you are certainly not alone.  But instead of giving in to your personal triggers, you can learn to recognize them, tolerate and overcome them, and develop alternative coping mechanisms.

Mary starts working with bariatric patients by helping them actively identify the triggers of their negative thinking and replacing them with alternative, positive responses. Simply having a positive attitude can make the weight loss challenge easier. According to a 2003 study in the Journal of the American Dietetic Association, as self-efficacy improved in young adults, eating habits improved and weight loss increased.

“Self-efficacy is positive psychology, when you believe that you are capable of achieving your goal,” Mary says. “Ask yourself – what do you own that you feel good about? What positive qualities do you have that will help you achieve your weight loss goal? The better you feel about yourself, the less likely you are to overeat or otherwise sabotage yourself, which brings you closer to reaching your goal.”

With time and effort, you can change how you think. Try these tips to learn to feel good about yourself:

Meditate and relax. Meditation can help reduce stress, focus your mind, control your thoughts, keep things in perspective, and even unlock your creative potential. Step back, meditate, then take action.

Focus on what makes you feel good. Imagine how your greatest strengths bring you to success. Remember a great experience or a nice day that you had recently. Visualize feeling good using positive affirmations, such as “I enjoy being healthy” or “My body is getting stronger, slimmer, and healthier every day.”

Steer clear of triggers that are not in your best interest. If a certain place, time or event causes you to feel negative or eat foods not recommended for your bariatric diet, do your best to avoid them for a while. Pick a different place to go to, re-arrange your schedule, or try a new routine – it’s worth it! And remember to steer clear of negative people who bring you down.

Develop new interests. New hobbies and interests can help you rewire your brain and create a new routine for yourself. They can also help you meet new friends, boost your creativity, and – who knows! – maybe even discover a new talent!

First things first – here are a few rules of eating after bariatric surgery:

• Eat just 3 meals a day, give yourself 20-30 minutes per meal, and choose small portions.
• Drink liquids between meals – 15-30 minutes before, or 30 minutes after a meal. Aim for 60-70 oz of fluid daily.
• Take your daily multivitamin with iron, calcium, and other supplements as directed by your healthcare team.

Because you will be eating a small amount of food at a time for the rest of your life, you’ll want to stick with “super,” protein-rich foods, fruit and vegetables. But there is no need to feel limited – there are plenty of great-tasting choices you can select from. You can also add seasoning, mustard, chilis, curry or hot sauce to your meals to spice them up. Here is our bariatric diet shopping list to help you out:

Protein

• Lean skinless chicken breast, leg meat,lean skinless turkey, lobster, pork tenderloin – not fried chicken, poultry skin, ground meat less than 90% lean, sausage, hot dogs, corned beef
• Fish, scallops, shrimp, crabmeat, canned fish in water – not fried fish, fish in batter, canned fish in oil
• Beans like chickpeas, lentils, black beans – not beans cooked with fatty meat
• Eggs, egg whites, Eggbeaters prepared without added fat – not fried eggs
• Cottage cheese 0 or 1% fat, reduced fat cheese, low fat or fat free ricotta – not 2-4% cottage cheese, full fat cheese and ricotta

Fruit and Veggies

• Cooked tender green beans, carrots, spinach, beets, zucchini, squash, mushrooms, tomatoes – not corn, popcorn, tough broccoli stems, stringy green beans
• Peeled cooked potatoes, sweet potatoes – not chips, fries
• Canned, stewed or baked peeled fruit without added sugar (apples, apricots, peaches, pears, plums, pineapple) – not canned fruit in syrup
• Peeled fresh apple, peeled ripe pear, melon without seeds, banana – not orange or grapefruit membrane, cherry or apricot pits
• Try new salad vegetables and fresh fruit to see which ones you can tolerate and like best. To start, try grating or dicing raw veggies like carrots or cucumbers.

Beverages

• Calorie-free, non-carbonated beverages (water, coffee & tea without sugar) – not carbonated water & drinks, soda, diet soda, alcohol

Sauces and Dressing

Yes, you can have sauces and salad dressing, too! Use low-fat and fat-free mayo or dressing to moisten salads and meals. Lynn Holmberg also advises to check out lower-calorie – and delicious! – options like lemon, balsamic vinegar, or home-made salsa. Make a protein- and calcium-rich dip for veggies using nonfat yogurt or fat-free ricotta. “If you find grilled meats too dry,” Lynn says, “try baked or stewed meat with vegetables. Low-fat mushroom or red pepper soup make great cooking sauces. You can also add low-fat sauces like tomato sauce, or create your own using low-fat mayo or 0-2% fat Greek yogurt.”

This list should set you off to a great start on your nutritious journey after weight loss surgery. When in doubt, always check with your surgeon or dietitian – they can offer additional advice on meal planning, cooking, eating out, shopping, and meeting your protein and supplement goals.

The findings from the study by the U.S. Agency for Healthcare Research and Quality (AHRQ), “Recent Improvements in Bariatric Surgery Outcomes” published in the May 2009 Medical Care, are based on an analysis of more than 9,500 patients under age 65 who had weight loss surgery at 652 hospitals between 2001 and 2002 and between 2005 and 2006.

Results of the study showed that the bariatric surgery complications dropped from approximately 24% to roughly 15%, driven primarily by a reduction in the post-surgical infection rate by 58% and a reduction in abdominal hernias, staple leakage, respiratory failure and pneumonia by 29% to 50%. Rates for other complications, such as ulcers, dumping (when sugars go directly from your stomach pouch into the small intestine causing heart palpitations, nausea, abdominal pain and diarrhea), hemorrhage, wound reopening, deep-vein thrombosis and pulmonary embolism, heart attacks and strokes, remained relatively unchanged.

Between 2001 and 2006, hospital costs for bariatric surgery patients as a whole fell from $29,563 to $27,905. For patients who experienced complications, this number dropped from $41,807 to $38,175. Hospital costs for the most expensive patients—those who had to be readmitted because of complications—fell from $80,001 to $69,960.

Among the other findings:

• Complications fell even though there were more older and sicker patients undergoing surgery. During the study period, the proportion of patients over age 50 having surgery for obesity increased from 28% to 44%, and the average number of weight-related health conditions – such as diabetes, high blood pressure, and sleep apnea – in bariatric surgery patients more than doubled.

• The six-month post-surgical death rate remained at about 0.5% during the study period.

• Hospital readmissions due to complications fell from 10% to 7%, and complication-caused, same-day hospital outpatient visits fell from 15% to 13%.

According to the researchers, the improvements are largely due to a combination of three factors—increased use of laparoscopy, a technology that allows physicians to operate through small incisions; increased use of banding procedures without gastric bypass, such as the LAP-BAND® System; and increased surgeon experience arising from the growth in the number of bariatric surgeries performed by hospitals.

Source: U.S. Agency for Healthcare Research and Quality, news release, April 29, 2009. Available at http://www.ahrq.gov/news/press/pr2009/barsurgpr.htm. Accessed June 2, 2009.