Gastric Plication - more to come!

Dr Dan Cottam VIDEO

Don't have to lift heavy weights at gym -Yay!

Lighter Weights are effective

One less barrier to getting in the gym - easier on the joints... also allows some variety!!!

Waist circumference (abdominal fat distribution) articles

German study on Diabetes risk in BMI>25

Double mortality rate in those with "normal" BMI, but thicker waist

BMI not as reliable in elderly (UCLA)

Thicker waist Independent risk factor in Arthritis progression

Evidence at Endocrinology conference - Gastric Bypass Superior

Bariatric Surgery in Diabetic Adults Improves Insulin Sensitivity Better Than Diet, Study Finds

And yet the last paragraph (see link) Dr Korner appears to have an attitude of "well, we will research this" rather that "we need to get THIS tool to the sick people who need it" Maybe I am overly sensitive, likely her statements are very selectively edited (ie., maybe it is the reporter's bias), but where is the call to action for the excellent tool we already have?

Are researchers only interested in supporting the pharmaceutical industry? I honestly don't think so, but you would be hard pressed to show evidence otherwise from this article.

If your endocrinologist, dietitian, insurer, or employer want to ignore evidence, you need to get this article to them by registered mail!

More articles on epigenetics, life expectancy

Intrauterine environment important for later obesity risk

One of many studies showing that it's not just the DNA, but the womb that are important factors in predisposition to obesity.

(and another annoying "headless" photo - dehumanizing heavy people, and making the excuse of privacy)


Below are articles to bring to your HR director at work (especially the last one - shows them they are not just losing money having increased health costs...) Many seem to ignore the fact that newly treated WLS patients are often the most enthusiastic, loyal employees! Also, those who are the sickest are least likely to change jobs, due to worry about any new job not covering pre-existing conditions. Companies need to invest in treating this disease - but they need to be educated, and offered organized programs. To their credit, some insurers are actually working on this (I will deny saying most nice things about insurers, but they are not all bad)

Increasing Loss of Life to Obesity




Obese Employees Take More Sick Leave



Finally, I had a very nice visit tonight with a support group at Virginia Mason, and last night with the group here in Bellingham. Both groups are super impressive - both with good listening leaders, and great sharing, discussions, and real SUPPORT! I certainly felt supported as a patient - thanks!

More evidence on individual vulnerability to obesity

link to report on Science Daily

Tell your skinny friends - we're not all wired the same! This doesn't mean we can stop worrying about lifestyle, food choices, etc - but hopefully will keep people from completely blaming themselves... (see at least 5 posts below for the theme of "taking responsibility without shame/blame"!!!)

SIMPLE Timer tools for Eating, Separating Fluids from Solid

I saw a great timer/ eating utensil set at ASMBS meeting last week - I think they are very useful looking, and sure to get even more refined. I look forward to getting feedback from users.


I haven't had too much problem eating too fast, but know that is a long term issue for patients. Actually, I think many eat so fast in 10 minutes that they can't finish a reasonable amount of food, then get "hungry" an hour later (or spend 20 minutes washing down food with immediate liquids) , then next thing you know, they are "grazers"!!!

This tool for the Treo/Palm platform helped me watch time go by over a 30 minute timer for meals. Kept me pacing my bites, then a followup 45 minute clock reminded me when I could drink after my last bite.

It is very easy to set up all sorts of custom timers - and tickles me that it is borrowed from the meditation world! This is mindfulness! Seriously, though, I do try to meditate, but exercise seems to be my main meditation.


Found a similarly reviewed product for those with an iPhone or iPod Touch - looks to be just as good. I can honestly say this type of tool may save people a lot of painful drift away from healthy habits.

Here are some comments on it



Finally - FOOD LOG, and EXERCISE LOG are critical for me - but I have NO fancy, or even basic software.... Just make an entry every day in my Calendar (on Palm, but will migrate to Google Calendar when get new smart phone..) and put my meal time and a basic description under the "note" attached to the "food Log" event. Super Easy, Super Fast - but totally on the record!

With exercise, I just enter it directly on the Calendar as an event - "Run 30*** Northshore Trail, Lift C/S/T (my abbreviation for Chest/Shoulder/Triceps)*** 6 sets, 15 minutes Weight ___ @ gym

I only put down my weight a couple times a week, but do get on the scale every day. My other "Lifts" are B/B for Back/Bicep, and L/A for Legs/Abdominals. For me, a three way breakdown keeps the lifting brief enough that I get it done in 15-30 minutes, so have very little excuse not to get it in at least 3 times per week. If I try to do it all at once, it gets overwhelming. That's where everyone has to figure out what works for their life and personality.


Keep it simple, but don't try to live totally unstructured!!! We all need SELF support first and foremost.

Infertility, Cardiac risks

Just a quick couple of links to come back to later - want to spend some time on the maternal issue from Quebec data showing improved obesity rates in children born after mom had Bariatric Surgery (duodenal switch in that clinic)

We just had a great lecture two weeks ago from a Seattle OB/Gyn whose clinic has stopped doing IVF in any patient over BMI 50 - looks like those in the article below have even tighter criteria.

In vitro fertilization failure rates in obese moms





Also, this issue is in the news today after a major Diabetes Conference just ended. 100,000 extra heart attacks, failure, strokes, deaths possible with this single drug - wow! It is very commonly used. I don't think we have enough respect for how complex the systems are that we manipulate. Surgery is certain to have risks, but they are not usually so insidious.

Avandia bad outcomes for 100,000 - Event rate more than 1 in 60?

Obesity Action Coalition - new campaign

I just got a paper copy of the magazine yesterday.

Your Weight Matters website

Not sure if it is replacing their regular magazine, or a separate publication, but it is very well written, and I think the campaign is admirable! We have to be empowered as a group, and this is how it happens!

There is a great article about Minorities - covering cultural and genetic issues. The Airline seat policy controversy is thoroughly addressed, and there are other great articles on advocacy, preop anxiety, and postop nutrition and mobility challenges.

I really commend OAC for taking on the controversies of Fattertainment and Childhood obesity also. Bigotry survives in our society by hiding in the shadows - those who struggled against all sorts of discrimination in decades and centuries past are very strong shoulders to stand on, but they have also shown that it requires real courage and active work!

Data doesn't lie, but it can fail to tell the whole story

article about HealthGrades Bariatric report (includes link to report)

These ratings are based on "expected" outcomes, but I can tell you from experience that the heroic Docs who run our University and major referral hospitals are taking care of unmeasurable levels of complexity in some patients. That does not make them automatically the best, but it is worth taking into consideration BEYOND the data.

My own personal care will not be chosen simply on the "star system", but I think these databases will continue to be more useful every year.

Excellent Blog Article from SCOAP

Return on Investment for Quality

This is really worth reading.
See previous post - SCOAP puts Washington State at the forefront of collaborative quality improvement.

Medications have risks, too

Liver Damage in 13 patients with Xenical/Alli

CBS link

This may or may not be the end of this story. We will only have to trust the FDA - Fen/Phen took a few years to have its major risks identified. 36 million people may have had prescriptions, but probably not 1 in 100 are taking it long term. How different would the data look if it ends up with 130, or even 1300 people injured out of 500,000 taking it more than a year? The benefit of taking this drug is not demonstrated to extend life expectancy (no non-surgical method has). What is the risk/benefit calculation if there is only minimal benefit???

I am not terribly worried about this drug, but the "next" med that actually has as much effect as Fen-Phen. Any new really effective med will sell like hotcakes (and be prescribed liberally). Any drug maker is in a huge rush to get to market for the BILLIIONS of dollars they will make with a winner. Just be careful with new things, whether operations or meds.

The sleeve gastrectomy only has a few large groups published more than 5 years out, but has been performed for more than 10 years... We have a lot to learn about exact techniques and effectiveness and patient selection, but the long-term issues seem to be limited to Reflux.

Racism in BMI criteria?- need for new research to be reflected in Access to Care

92 million Diabetics in China

Here is the abstract of the New England Journal article

and even more than that on the borderline (148 million) note that the BMI's are much lower than the 1991 NIH criteria - see Dr Rubino videos below

This uncomfortable question is getting around the surgical community - if there is disease despite lower BMI, does using BMI as an exclusion for coverage constitute racism on the part of of providers and insurers? The NIH criteria were set in 1991 as expert opinion, which should/could be updated now with data from actual additional research (as loudly called for by many on that original panel!)

Washington State should be very proud

Tuesday I was able to attend the annual retreat for hospitals and medical centers involved in a massive coordinated safety and effectiveness group known as SCOAP (Surgical Care and Outcomes Assessment Program).

SCOAP homepage

Surgeons and anesthesiologists have been at the forefront of most major advances in systematic care improvement, from the residency training model, to hospital standards, to outcomes/evidence based care. Dr. David Flum is the brilliant leader of this, but I was just as impressed at the commitment of docs from around the state (from tiny critical access hospitals, to military hospitals, to huge University and regional medical centers) to take the time and contribute in so many ways to make the care of our fellow citizens better every day. It is measurable, and they have the data to prove it! These powerful cooperative tools require a lot from those who already give 110%. I am honored to know them, and hope that my hospital can participate soon.

The famous Atul Gawande MD, MPH was there as the keynote speaker (along with the Washington State Patient Safety Conference group), and gave a great lecture about Checklists in quality care. He stressed that the goal is quality, and the tools should not be confused with the mission. His articles are always insightful, and well written.

My former residency chairman Anthony Senagore MD MS MBA gave an invited lecture about recovery from colon surgery (Enhanced recovery protocol), and a great deal of new research is just starting to be applied - getting people back on their feet quicker, and avoiding costly and dangerous problems during the healing process. Thanks also to Dr Patch Dellinger for making the data on Surgical Site Infection more understandable.

Thanks also to Governor Chris Gregoire for the video greeting, and for funding the Governor's Life Science Discovery Fund that helps support all this.

Diabetes and Vascular disease

It's well known that most death from clinically severe ("morbid") obesity and from diabetes is related to heart and vascular disease - but this is a hint at HOW they are linked beyond just cholesterol and inflammation.

Your arteries may be suffering insulin resistance, too

ScienceDaily (May 4, 2010) — In people with insulin resistance or full-blown diabetes, an inability to keep blood sugar levels under control isn't the only problem by far. A new report in the May issue of Cell Metabolism, a Cell Press publication, shows that our arteries suffer the effects of insulin resistance, too, just for entirely different reasons.

Canadian impressions

I have been attending the monthly lectures at University of British Columbia - and got a chance to talk today with a few key players today in Vancouver. There is strong advocacy for Diabetes and Obesity issues there. Many thanks for the time!



One great piece of info is this: (unfortunately it is likely too late for me to try to get there)

McGill - First Canadian Summit on Surgery for Type II Diabetes

PDF of Diabetes Report

Metabolic Surgery Article Links (from Summit Website)

Dr Christou is the McGill surgeon who is part of the team behind the landmark Quebec study showing tremendous survival benefit with Bariatric Surgery in Quebec. Dr Rubino from Cornell (see other postings below) is co-chair.




Canadians enjoy 2.7 years more (and healthier) life than those in USA
ScienceDaily (2010-04-28) -- Compared to their neighbors south of the border, Canadians live longer, healthier lives. Research has found this disparity between the two countries, suggesting that America's lack of universal health care and lower levels of social and economic equality are to blame.


Some useful links specific for Canadians ----


UBC Department of Surgery

Victoria - Drs Amson and Tang I think this is the only active program doing all types of Bariatric Surgery - but haven't met them personally yet.

BC Association of Bariatric Advocates

Vancouver's Lap Band center (False Creek Surgery Center)

Canadian Center for Functional Medicine

Obesity Help's BC messageboard

Dr Foote's 8 Rules to Success

This is copied from my palm pilot, so
format is rough, but good stuff!!!

1 daily 3 small meals, 1 high protein snack
2 Lowfat solid food, 60 gr protein/d
--- Limit fatty, sugary to 1-2 x/mo
3 Eat slow, chew chew chew (20/bite)
4 NO liquids 15 prior, 45 m after meal
5 Avoid liquid calories
--(incl soups, smoothies, protein drinks, alcohol)
6 Drink 64 oz noncaloric liquids/day
7 Listen to your body (stop B4 pain!)
8 Exercise every day - schedule!

Starting to work toward Bellingham pilot surgical program!

Good news! I am going to be doing more outreach and consultation. We are going to set up some information sessions, and talk to whatever group would like to have more information about Medical and Surgical weight management.

We already have a draft pathway for both medical and surgical approaches.

Also, the Washington State chapter for the American Society for Metabolic and Bariatric Surgery is formally getting under way. We have filed the preliminary application, and will be setting up a charter, etc in the next few months. There is a lot of work to be done for advocacy in Washington State, and I am excited to be part of it!

Since printing materials costs money, and we are just piloting, I am expanding the LINKS to explore to make this a good portal to exploring the world of weight management.


also, this is fairly big news from the ASMBS website...

TWO MAJOR INSURERS NOW COVER LAPAROSCOPIC SLEEVE GASTRECTOMY Aetna, United Healthcare Each Change Policy to Cover Newer Method of Bariatric Surgery

Habits - find ones that work for you. This is a process, one that can be polished with support group attendance, and paying attention to your experience. I found MBSR (mindfulness based stress reduction) to be helpful to have perspective and stay in balance (or keep working toward it!)

link to Dr Kabat-Zinn's program

Duluth Clinic program (where I did training in 2006)

Priorities - we don't always get our way, but the only way to make any progress is to honestly put effort towards our goals. Be honest with your priorities. Examples for me are especially exercise and meal planning.



MEAL REPLACEMENTS were one of the tools from reinforced at the ASBP (American Society of Bariatric Physicians) meeting I just attended in Seattle. They really help with meal planning, and many people ask me what I use - here are some links:

They are not cheap, but much better price by the box.

Genisoy Bars These are very nice chocolate mint, and pretty chewy.



BALANCE BARS in chocolate chip, honey peanut, and sometimes the Balance Bare are favorites for me - they give good satiety, and are tasty without being "irresistable"

Zone Bars - some are stocked at Costco (usually 2 box sets with Fudge and Peanut Butter), but I like the mint ones best. Target and Fred Meyer stores stock them here in Bellingham.



EAS shakes are a good protein source, and great before the gym.

These are just some of the things I use as an example - it takes time to shop around and find what you won't mind using every day, but won't lose control over. There aren't a lot of foods that I can stock up on without abusing, but these don't seem to tempt me much. If you find a food that you can't keep away from, don't try to keep a stock!!!


I don't count every gram of protein, or every calorie, but it is nice to have a label to read, and to have a pre-limited amount.

Will we see more directed care toward patients in hospitals to help shorten future admissions (or prevent them altogether)?

A consultation for smoking cessation or alcohol treatment has been shown to be more effective when initiated during a related illness.


video link - MORE WEIGHT EQUALS LONGER HOSPITAL STAYS


IMPROVED PREGNANCY OUTCOMES AFTER BARIATRIC SURGERY

Quoting from above link...
Bennett says her study suggests that insurance companies "should be covering gastric bypass surgery in women of childbearing age because of the potential to reduce complications if we can reduce their weight before they become pregnant." Treating the obesity before pregnancy, she adds, also has the potential of saving a lot of money on treatment of complications in mothers, fetuses and newborns."

and...

"Prior research has shown that rates of gestational diabetes (which also causes complications in pregnancy) decreases after bariatric surgery, and that weight loss can increase fertility in obese women."