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Month: July 2009

Longer Life For Milk Drinkers Lactose Intolerance

July 27, 2009 9:56 pm

ScienceDaily — Research undertaken by the Universities of Reading, Cardiff and Bristol has found that drinking milk can lessen the chances of dying from illnesses such as coronary heart disease (CHD) and stroke by up to 15-20 %.

In recent times milk has often been portrayed by the media as an unhealthy food. The study, led by Professor Peter Elwood (Cardiff University) together with Professor Ian Givens from the University of Reading’s Food Chain and Health Research Theme, aimed to establish whether the health benefits of drinking milk outweigh any dangers that lie in its consumption.

Importantly, this is the first time that disease risk associated with drinking milk has been looked at in relation to the number of deaths which the diseases are responsible for. The review brought together published evidence from 324 studies of milk consumption as predictors of coronary heart disease (CHD), stroke and, diabetes. Data on milk consumption and cancer were based on the recent World Cancer Research Fund report. The outcomes were then ompared with current death rates from these diseases.

Professor Givens explained: “While growth and bone health are of great importance to health and function, it is the effects of milk and dairy consumption on chronic disease that are of the greatest relevance to reduced morbidity and survival. Our review made it possible to assess overall whether increased milk consumption provides a survival advantage or not. We believe it does.

“Our findings clearly show that when the numbers of deaths from CHD, stroke and colo-rectal cancer were taken into account, there is strong evidence of an overall reduction in the risk of dying from these chronic diseases due to milk consumption. We certainly found no evidence that drinking milk might increase the risk of developing any condition, with the exception of prostate cancer. Put
together, there is convincing overall evidence that milk consumption is associated with an increase in survival in Western communities.”
The reviewers also believe that increased milk consumption is likely to reduce health care costs substantially due to reduced chronic disease and associated morbidity.

“There is an urgent need to understand the mechanisms involved and for focused studies to confirm the epidemiological evidence since this topic has major implications for the agri-food industry,” added Professor Givens.

  • Lactose intolerance is the inability or insufficient ability to digest lactose, a sugar found in milk and milk products.
  • Lactose intolerance is caused by a deficiency of the enzyme lactase, which is produced by the cells lining the small intestine.
  • Not all people with lactase deficiency have digestive symptoms, but those who do may have lactose intolerance.
  • Most people with lactose intolerance can tolerate some amount of lactose in their diet.
  • People with lactose intolerance may feel uncomfortable after consuming milk and milk products. Symptoms can include abdominal pain, abdominal bloating, gas, diarrhea, and nausea.
  • The symptoms of lactose intolerance can be managed with dietary changes.
  • Getting enough calcium and vitamin D is a concern for people with lactose intolerance when the intake of milk and milk products is limited. Many foods can provide the calcium and other nutrients the body needs.
  • Talking with a doctor or registered dietitian may be helpful in planning a balanced diet that provides an adequate amount of nutrients—including calcium and vitamin D—and minimizes discomfort. A health professional can determine whether calcium and other dietary supplements are needed.
  • Milk and milk products are often added to processed foods. Checking the ingredients on food labels is helpful in finding possible sources of lactose in food products.

Revision of Gastric Bypass

July 20, 2009 10:02 pm

Terry had the gastric bypass operation 3 years ago in an a major referral center by an established surgeon. The surgery went well, and lasted about one hour. The postoperative course was uneventful, and the patient was discharged home on post op day 2. The 3-6 month post-op period was complicated by a stricture at the gastro-jejunostomy anastomosis. An upper endoscopy and dilation. He continued to loose weight as expected. He attended the support meetings early on and then ended up missing some of them after the third year. The follow up appointments with the surgeon were all kept. The episodes of dumping syndrome, the feeling of passing out, diarrhea, high heart rate, nausea amongst others were scary early on. They became less frequent but not any less concerning. He was told by the surgeon that it s a part of the gastric bypass operation. In fact someone at the surgeons office told him that “ hope you have it, since it will help you with your diet and prevent weight regain..”

He started feeling weak and tired at times after the second year. He also gained about 50 pounds back after the third year. The weight gain did not stop till I was within reach of my pre gastric bypass operation. What is worse is that he had to use CPAP machine for sleep apnea that had gone away with weight loss. He also was started back on some of his medications including those for diabetes. He went back to his surgeon, whose first reaction was that “….You must be doing something wrong…”

He was then referred to see the nutritionist, had an upper endoscopy, and an upper GI series. When he went back, he was told that there is nothing wrong and that he should eat correctly and exercise more.

This is not a story but a real example of many more patient that I see in our office all the time. As the facts are pretty accurate, clearly the name, and the specific details have been altered in this article.

What this patient has experienced is what I hear in the office all the time from patients who had the gastric bypass and they “….did not know….” about any other weight loss surgical procedure. After the surgical “honey moon” period of about 2-3 years (much longer than my real honey moon) the reality sets in. Weight regain, inadequate weight loss, nutritional deficiencies, dumping syndrome, and solid intolerance are examples of problems which will direct a patient to seek a solution.

The published data show that the small size of the pouch, in gastric bypass, does not predict excess weight loss (O’Connor SOARD 4, 2008, 399-403), (Nishie, Obesity Surgery 17, 2007, 1183-1188). The size of the gastrojejunostomy anastomosis also does not assure adequate weight loss (Cottam Obesity Surgery 19, 2009, 13-17). Dumping syndrome does not improve gastric bypass surgery outcome. And the incidence of resolution of the obesity related illnesses is significantly better with duodenal switch operation that the gastric bypass or the adjustable gastric banding procedure. Patients with diabetes or cholesterol and triglyceride problem, in my opinion, should not have gastric bypass or adjustable gastric banding done.

A review of the published scientific articles in JAMA, shows that the outcome of Duodenal switch operation is far better than the alternatives with all measured parameters of excess weight loss, diabetes resolution, and improvement of hyperlipidemia.

Let me pose a question. If a patient is told that there are two antibiotics and one of them will treat the urinary track infection in 83.7% of the time and the alternative will treat it in 98.9% of the time, which one would you like to be treated with, if the overall risks all the same?

Table 1
Significant Hyperlipidemia Improvement Diabetes
Weight Loss
Duodenal Switch 99.50% 98.90% 70.10%
Gastric Bypass 93.60% 83.70% 61.60%
Gastroplasty 80.90% 71.60% 68.20%
Gastric Banding 71.10% 47.90% 47.50%

Source:JAMA, review of published data based on more than 22000 patients outcome.

As a Duodenal switch surgeon the answer is clear. I am only trying assure that no patient ever goes to the operating room without having all their options entertained. An informed consent is only valid if all the information was presented. Too often the alternative are either never discussed or barely discussed. A review of the websites demonstrates this point. Very few surgical practices that do not offer the duodenal switch operation discuss this alternative.

And to those that ask, “Why are there more surgeons doing the duodenal switch operation?” I think this a question that needs to be posed to those that do not do it. Here are some of the reasons:

  1. The perceived malnutrition is usually given as a reason. There is a large body of published data in the literature that documents the incidence of malnutrition to be significant in gastric bypass operation. In fact, because of the dietary restriction after gastric bypass there are as many if not more nutritional deficiencies that develop after this operation than the duodenal switch operation.
  2. The need for follow up. I am not clear as to why would this be a reason not to offer a surgery. The scientific evidence again shows that the more structured the follow up the better the outcome. Obesity is a chronic disease, that has a surgical, medical and maintenance phase. The broad picture of treatment plan for obesity in my opinion is no different than that of a cancer patient, who may need surgery, followed by chemo-radiation, and routine follow up.
  3. Last, and most vividly discussed is the issue of increased flatus, and loose bowel movements. There is no dispute that the duodenal switch operation does cause increase in flatulence and loose bowel movement. But here are the facts- in my more than 10 years in private practice, in an office that at times the waiting room is full of pre and post op patients, we have never had to evacuate the building because someone let one go! It has been my experience that that in overwhelming number of cases that have problem with significant gas and diarrhea the problem is easily corrected with minor changes in diet. Polish sausage, bagel and cream cheese for breakfast, deep dish pizza for lunch, and deep fried turkey may give some patients increased gas and diarrhea! With this said however, I have had patients in whom after exhausting all non surgical options (dietary modifications, medications etc) revision of the duodenal switch operation has been done.

In my opinion, the best patient is the most knowledgeable patient. Please make sure that you have taken the time to investigate not only the the surgeon, but also the available procedures.

What is Osteoporosis

July 06, 2009 8:32 pm

Osteoporosis in epidemic in the U.S. Bariatric patients can be even more prone than the average American. Both RNY/GB and DS patients have issues with calcium absorption. DS patients also have issues with absorption of vitamin D. Both populations must be compliant in supplementation on both. Calcium Citrate is the preferred form as it is far more absorbable than the carbonate form. This is not new news to most of us. Calcium absorption is also greatly enhanced by adequate vitamin D. This is also not new to the average bariatric patient. What is relatively new news is that current information is that some laboratory testing methodology has yielded false high readings in the past leading many to falsely believe their level of supplementation was adequate. In addition to false high level’s in previous lab testing procedures the “normal” ranges have been increased recently. Many now believe 50ng/mL should be looked at as a minimum. My most recent labs came back with the form showing a “normal range” of 5-58ng/mL. Recent publications show that our D levels are vitally important to immune function in fighting any number of conditions from flue (swine flue?) to cancers. I personally am making a concerted effort to raise my D value to at least 50ng/mL before next flue season.

A new and emerging factor in combating the osteoporosis epidemic is the awareness of the importance of vitamin K-2. This is not exactly the same thing as the K we all know. There are two primary forms of vitamin K, K-1 and K-2. Most bariatric supplements, even the very best,supplement only our K-1 levels. K-1 has long been known for it’s involvement in blood clotting. K-2 however is very important for Calcium metabolism. This is relatively new research coming out of Japan.

This vitamin has three very powerful effects on our Calcium metabolism. It minimizes the loss of Calcium in the urine thereby keeping what Calcium that is absorbed “on board” for recycling back into constructive purposes. It stimulates the deposition of Calcium in the bone matrix by increasing the levels of a specific hormone which “turns on” the cells that do this job. K-2 also helps regulate the deposition of Calcium in inappropriate tissues such as the walls of arteries and in ligaments.

Research out of Japan has shown increased bone mineral mass in post menopausal women. A group of women were divided into 4 sub groups. The “control” group (who added nothing to their diet) lost 1% bone mineral mass per year. At the other end of the spectrum a group using Calcium Citrate, D3 and K2 (MK-7) gained 1.5%. The most recent information regarding this very important vitamin has shown that a very specific form of the vitamin is by far the most beneficial. As I noted before this research is coming out of Japan. This form of K-2 was first observed in a traditional Japanese food. Natto is a fermented soy product that is very high in Menaquinone-7 (MK-7). This form is very important. The less advantageous and and more common form MK-4 is less well absorbed and has a “half life” (the time it takes for the blood levels to fall by 1/2) of approximately 90 minutes. The MK-7 is more easily absorbed and has a half life of well over 24 hours.

Caution must be used for patients using “blood thinners”. This vitamin will have a direct effect on their clotting time. Research shows that this can be off set by adjusting the levels of medication. Once these levels are adjusted they tend to be much more stable due to the long half life of the MK-7. One of the side effects of these blood thinners is the loss bone mineral mass. Consult your physician before starting.

Editors Note: It is worthwhile to address a few issues raised in this article by Dr. Caya. The first issue is related to the efficacy of the types of calcium. This issue is addressed extensively in our website and summarized in a table at the FAQ section. The summary of the above table is that, Calcium Citrate is absorbed easier, but more of it needs to be takes to get the same amount of elemental calcium. Less of Calcium Carbonate is needed to get the same amount of elemental calcium, however the absorption is less efficient. A search of the medical literature will provide supporting data for recommending one or another type. I believe that most people at least in the beginning could take either type. The decision of which one to take should be based of which is tolerated better. Later on recommendations for changes will be made.

The other point to remind every one is that this information is not static and continuous to change. It is important the patients stay well informed.
Ara Keshishian, MD