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Teaching Our Children Healthy eating Habits

As I am sure you have all heard in the media, the largest group of US population that is getting larger is the youngest member of the society.

There are some common sense reasons why our children are becoming overweight. These include excess calories, sedentary lifestyle (being in front of computer, and video games.) Children however can easily be taught healthy habits. It is much easier to avoid the disease of the obesity, rather than try to correct it later in life. I am not discounting the genetic predisposition to obesity which may be present in some cases.

Looking over some of our very first newsletters I came across the following list that I believe is worthwhile sharing again.

Teaching Kids to Eat Right and Get Moving
Studies cite sedentary pastimes and poor eating habits as the main factors behind childhood obesity. Experts see prevention as the remedy. Much of the latest research on childhood obesity is focused on prevention and intervention: breaking children of their bond to television, guiding them toward more physical
activity and improving their eating habits. Nurturing Good Habits: For a child, family eating patterns and parental pressures can make the difference between a healthy body and a sensible outlook on meals or a lifetime of bad eating habits. Experts recommend that parents establish good habits and pass them on to their kids.

• Don’t restrict eating by making certain foods off-limits
• Don’t tell children to clean their plates.
• Don’t put children on a diet unless recommended by an experienced health professional who realizes that obesity is not all about overeating and lack of activity.
• Don’t use food to regulate moods-reward children with love, attention and parental time.
• DO realize that three meals a day works for adults, but children need healthy snacks too.
• DO try to serve meals to the whole family that meet heart-healthy guidelines-<30% fat.
• DO try to introduce healthy foods to children—they may learn to love it!
• DO become educated about the food types, their nutritional values as well as portion sizes.
• DO make exercise a part of daily life— walk to and from school with them if you can.
• DO limit television viewing, playing video games, surfing the internet, and being on the computer. They will find fun active things to do.
• DO join your children outdoors for fresh air. Once outside stress seems to release easier.
• DO down at dinner with your family— conversations will happen!

Food should be healthy, and be valuable and nutritional. Our children will mimic what we do on daily basis. By making the same changes in our life style, we will set example for our children to follow.

Am I Going Bald?

“My hair is thin. My hair is falling out. My hair is dry and brittle. I just run out of energy…..”These are some of the most common reasons bariatric surgery patients come to see me. Typically they are eating between 2 and 4 of the vending machine peanut butter crackers for one meal and a few noodles at the other meal. Many times they just simply aren’t hungry, and this is a welcome feeling for them. Well, thinner is greater, but thinner hair isn’t usually as well received.

The hair problem is reflective of protein malnutrition, (and possibly vitamin deficiency if the patient is not taking their vitamin mineral supplement as directed.) This can happen several year’s post –op when patients simply stop paying attention to their intake.

Here are some of our suggestions for quick and easy protein:

• Purchase low fat peanut butter and low fat crackers and keep handy in
  your car or desk at work.
• Try hard-boiled eggs—coloring them is helpful in keeping track of each
  batch’s freshness.
• Low fat cheese is a possibility.Watch the portion size.
• Skim milk (or 1% milk) is a great source of protein. Add 1/3 cup of nonfat dry milk powder to 1 cup of milk—this will give you twice the protein. Lactose intolerant? Try Lactaid milk, Lactaid tablets to help
  with the gas, cramping, or diarrhea.
• Beans and bean soup. If gas is a problem try BEANO—this is an enzyme sold over the counter in the drugstore.
• Sliced or shaved deli meat, Teriyaki turkey jerky, sliced almonds are quick protein sources.
• Remember to try and get 80 grams of protein/day.

Trans-fatty Acids

Trans-fatty acids occur in semi artificial fats created by pumping hydrogen through liquid fats. This process adds hydrogen atoms and alters the molecular bonds of fatty acids that are liquid at room temperature. This process was first used to produce margarine, which has the texture of butter. It gives the “crunch” in cookies, and most importantly (for manufacturers)
prolongs the shelf life.

One of the many problem with these acids is that they increase LDL (low density lipoproteins) and lower the HDL (high density lipoproteins) that are good for you. Studies conducted by scientists in the last 25 years confirm that two percent increase in consumption of trans-fatty acids double the risk of developing heart disease.

As much as 25 to 50 percent of the fat in baby biscuits, cookies, chips, croissants and fish sticks contain appreciable amounts of trans-fatty acids.

Many of the major fast food chains have now committed to removing Trans fats rom their menu. Enjoy your dinner.

Cases of esophageal cancer in patients who had been taking oral bisphosphonate drugs for osteoporosis have been reported by an official from the Food and Drug Administration (FDA) in the January 1 issue of the New England Journal of Medicine.

Twenty-three cases (of which 8 were fatal) have been reported in the United States, all of them in association with alendronate (Fosamax, Merck), which was cited as the suspect drug in 21 cases and as a concomitant drug in 2 cases. These reports were received by the FDA in the 12-year period between October 1995 (when alendronate was launched in the United States) and mid-May 2008. No reports were received about esophageal cancer and any of the other oral bisphosphonate products.

A further 31 cases (6 fatal) have reported in Europe and Japan, with lendronate as the suspected drug in 21 cases. Of the remainder, 6 cases were associated with risedronate (Actonel, Procter & Gamble/Sanofi- Aventis), ibandronate (Boniva, Roche/ GlaxoSmithKli ne), etidronate (Didronel, Procter & Gamble), or a combination of these, and 4 cases cited bisphosphonates as concomitant drugs.

Writing in a letter to the journal, Diane Wysowski, PhD, from the FDA, gives few further details but points out that 4 of the patients had Barrett’s esophagus, which is a precursor of esophageal adenocarcinoma. “Physicians should avoid prescribing oral bisphosphonates to patients with Barrett’s esophagus,” she writes.

Dr. Wysowski also points out that esophagitis has been associated with oral bisphosphonates, usually when the drugs are not taken according to directions. “Crystalline material similar to ground alendronate tablets has been found in patients with erosive esophagitis, and persistent mucosal abnormalities have been noted in some of these patients, suggesting a potential for carcinogenic effects,” she writes.

Merck said in a statement that data from its clinical trials and postmarketing reports do not suggest any association between alendronate and esophageal cancer. The company pointed out that alendronate has been marketed for 13 years, during which time more than 150 million prescriptions have been written in the United States alone. Merck also noted that its clinical database includes more than 17,000 patients, of whom about 3000 osteoporosis patients took alendronate for 3 to 5 years and about 800 patients took alendronate for 8 to 10 years.

N Engl J Med. 2009;1360:89
Thank you VICKI BLACKBURN for sharing this information .

What are Biphosphonates?

These drugs are usually prescribed to prevent or treat Osteoperosis, and also to long time steroid users (cancer patients) to prevent bone loss. It is also prescribed to patients suffering from Paget’s Disease. Bisphosphonates are antiresorptive medications, which means they slow or stop the natural process that dissolves bone tissue. Fosamax, a member of this particular group of medications, has recently been linked to a condition called Osteocrenosis of the Jaw (ONJ). Individuals taking Bisphosphonates are also advised to avoid any unnecessary unvasive dental procedures (cleanings are OK).

Biphosphonates have been advocated strongly for treatment or prevention of osteoporosis. It has become evident that there are significant risk associated with this class of medication.

We strongly suggest that patients discuss these with the prescribing physician before taking this class of medication. When it comes to weight loss surgery and Biphosphonates, it is imperative that the patient has a normal serum Ca, PTH, Alk. Phos, before starting on this class of medication.

Newsmaker
The past year has gone by very rapidly. A lot or new changes and improvements were instituted. We continue to make changes and strive to do better. We wish every one a happy and healthy new year.
The staff and Ara Keshishian, MD, FACS

New Anti-cancer Components Of Extra virgin Olive Oil Revealed
Good quality extra-virgin olive oil contains health relevant chemicals, phytochemicals’, that can trigger cancer cell death. New research sheds more light on the suspected association between olive oil-rich Mediterranean diets and reductions in breast cancer risk.

A team of researchers set out to investigate which parts of olive oil were most active against cancer. Their findings revealed for the first time that all the major complex phenols present in extra-virgin olive oil drastically suppress over expression of the cancer gene HER2 in human breast cancer cells.

Extra-virgin olive oil is the oil that results from pressing olives without the use of heat or chemical treatments. It contains phytochemicals that are otherwise lost in the refining process. Menendez and colleagues separated the oil into fractions and tested these against breast cancer cells in lab experiments. All the fractions containing the major extra-virgin phytochemical polyphenols (lignans and secoiridoids) were found to effectively inhibit HER2.

Although these findings provide new insights on the mechanisms by which good quality oil, i.e. polyphenol-rich extra-virgin olive oil, might contribute to a lowering of breast cancer risk in a HER2- dependent manner, extreme caution must be applied when applying the lab results to the human situation. As the authors point out, “The active phytochemicals (i.e. lignans and secoiridoids) exhibited tumoricidal effects against cultured breast cancer cells at concentrations that are unlikely to be achieved in real life by consuming olive oil”.

Nevertheless, and according to the authors, “These findings, together with the fact that that humans have safely been ingesting significant amounts of lignans and secoiridoids as long as they have been consuming olives and extra-virgin oil, strongly suggest that these polyphenols might provide an excellent and safe platform for the design of new anti breast-cancer drugs”.

Fat consumption after Duodenal Switch
The addition of moderate amount of fat in to your diet, after Duodenal Switch operation will result in loose bowel movement. By reducing the fat absorptive capacity in the small bowel after surgery, more fat is found in the colon. This results in loose bowel movements. In some patients who have had problem with constipation before surgery, and continue to have the same problem after DS, addition of some fat can be helpful. Excessive amount of fat however, will create problem.

Types of olive oil
Generally, olive oil is extracted by pressing or crushing olives. Olive oil comes in different varieties, depending on the amount of processing involved. Varieties include:

• Extra virgin – considered the best, least processed, comprising the oil from the first pressing of the olives.
• Virgin – from the second pressing.
• Pure – undergoes some processing, such as filtering and refining.
• Extra light – undergoes considerable processing and only retains a very mild olive flavor.

When buying olive oil you will want to obtain a high quality EXTRA VIRGIN oil. The oil that comes from the first “pressing” of the olive, is extracted without using heat (a cold press) or chemicals, and has no “off” flavors is awarded “extra virgin” status. The less the olive oil is handled, the closer to its natural state, the better the oil. If the olive oil meets all the criteria, it can be designated as “extra virgin”.

What is pure and light olive oil? “Pure” olive oil is made by adding a little extra virgin olive oil to refined olive oil. It is a lesser grade oil that is also labeled as just “olive oil” in the U.S.

“Light” olive oil is a marketing concept and not a classification of olive oil grades. It is completely unregulated by any certification organizations and therefore has no real precedent to what its content should be. Sometimes, the olive oil is cut with other vegetable oils.

Newsmaker
This year has gone by very fast. One of the most significant changes that have taken place is the deployment of our electronic medical record system. We are on schedule to have the medical records of our new patients on a secured server stored electronically. This has been a on-going project and now we are aiming for a January 2009 complete deployment.
Ara Keshishian, MD, FACS

Calcium And Vitamin D May Not Be The Only Protection Against Bone Loss Diets that are high in protein and cereal grains produce an excess of acid in the body which may increase calcium excretion and weaken bones, according to a new study.

The study found that increasing the alkali content of the diet, with a pill or through a diet rich in fruits and vegetables has the opposite effect and strengthens skeletal health. “Heredity, diet, and other lifestyle factors contribute to the problem of bone loss and fractures,” said Bess Dawson-Hughes, M.D., of Tufts University in Boston, Mass. and lead author of the study. “When it comes to dietary concerns regarding bone health, calcium and vitamin D have received the most attention, but there is increasing evidence that the acid/base balance of the diet is also important.”

Average older adults consume diets that, when metabolized, add acid to the body, said Dr.Dawson-Hughes. With aging, we become less able to excrete the acid. One way the body may counteract the acid from our diets is through bone resorption, a process by which bones are broken down to release minerals such as calcium, phosphates, and alkaline (basic) salts into the blood. Unfortunately, increased bone resorption leads to declines in bone mass and increases in fracture risk.

“When fruits and vegetables are metabolized they add bicarbonate, an alkaline compound, to the body,” said Dr. Dawson Hughes. “Our study found that bicarbonate had a favorable effect on bone resorption and calcium excretion. This suggests that increasing the alkali content of the diet may attenuate bone loss in healthy older adults.”

In this study, 171 men and women aged 50 and older were randomized to receive placebo or doses of either: potassium bicarbonate, sodium bicarbonate, or potassium chloride for three months. Researchers found that subjects taking bicarbonate had significant reductions in calcium excretion, signaling a decrease in bone resorption.

“In this study, we demonstrated that adding alkali in pill form reduced bone resorption and reduced the losses of calcium in the urine over a three month period,” said Dr. Dawson- Hughes. “This intervention warrants further investigation as a safe and well tolerated supplement to reduce bone loss and fracture risk in older men and women.”

Other researchers working on the study include Susan Harris, Nancy Palermo, Helen Rasmussen, and Gerard Dallal of Tufts University in Boston, Mass., and Carmen Castaneda-Sceppa of Northeastern University in Boston, Mass.

Bariatric Surgery Before Pregnancy Benefits Moms, Babies

Women who get pregnant after having weight-loss surgery have a lower risk of maternal and newborn complications than pregnant women who are obese, according to U.S. researchers who analyzed 75 studies.

Data from those studies showed that bariatric surgery in the United States increased by 800% between 1998 and 2005 (from 12,480 to 113,500). Women accounted for 83% of procedures among patients ages 18 to 45. Between 2003 and 2005, more than 50,000 women in this age group had inpatient bariatric surgery each year, which accounted for 49% of all bariatric surgeries.

The review authors found that pregnant women who’d had bariatric surgery had lower maternal complication rates than obese women, including gestational diabetes (0% vs. 22.1%) and preeclampsia (0% vs. 3.1%). In addition, maternal weight gain was reduced in women who’d had bariatric surgery.

Newborn outcomes among women who’d had laparoscopic adjustable band surgery were similar or better than outcomes among obese women: premature delivery, 7.7% vs. 7.1%; low birth weight, 7.7% vs. 10.6%; overly large body (macrosomia), 7.7% vs. 14.6%.

The findings were published in the Nov. 19 issue of the Journal of the American Medical Association.

“Research is needed to better delineate the extent to which surgery and subsequent weight loss improve fertility and pregnancy outcomes,” the review authors wrote. “Optimizing success for contraception and producing healthy neonates following surgery will require a multidisciplinary effort by surgeons, primary care physicians, reproductive fertility specialists, obstetricians, and patients.”

Having bariatric surgery during childbearing years may change a woman’s fertility following weight loss, alter nutritional requirements during pregnancy, or impact contraception, the researchers noted. — Robert Preidt

Source: Journal of the American Medical Association, news release, Nov. 18, 2008

Newsmaker
Can I control my appetite and my hunger?
In general appetite is a learned response. It can be adaptive to stimuli and environmental factors and variable. Stress, emotional and psychological variables will result in behavioral changes, thus changes in appetite.
In contrast, hunger is an physiological response. It is an inborn behavior, common to all animals. It is a need based derive.
We can control our appetite, but not our hunger.
Ara Keshishian, MD, FACS

Completely Novel Action Of Insulin Unveiled
A Ph.D. student at Sydney’s Garvan Institute of Medical Research has uncovered an important piece in the puzzle of how insulin works, a problem that has plagued researchers for more than 50 years. The research brings scientists one step closer to explaining exactly how insulin prompts fat and muscle cells to absorb glucose.

“Since the 1920s, when Banting and Best discovered insulin, scientists have been battling to discover how it actually works,” said Professor David James, head of Garvan’s Diabetes Program. “Then along comes Freddy Yip, doing his PhD, who unveils a completely novel action of insulin, one which we believe plays a fundamental role in glucose uptake, a process that is defective in Type 2 diabetes.” There are two processes involved in Type 2 diabetes: insufficient production of insulin in the pancreas after a meal and faulty uptake and storage of glucose in fat and muscle cells, or ‘insulin resistance’.

Freddy’s finding focuses on the intersection between these two processes. “In the cell we have seriesof motor proteins that have the ability to move other molecules from one place to another along intracellular rail road tracks,” he explained. “I have discovered that insulin activates a specific kind of motor protein known as Myo1c, which in turn performs a critical role in glucose uptake.” Insulin controls glucose uptake into our fat cells by moving glucose transporter proteins from inside the cell to the surface membrane so that they can pump glucose into the cell. Myo1c aids in this process by helping the
transporters slide into the surface membrane.

In healthy people, around 80% of the glucose transporters migrate to the cell membrane after a meal, allowing plenty of glucose into the cell. In people with Type 2 diabetes, however, that figure drops to around 10%. Freddy Yip believes his study will create a strong foundation for future diabetes research. “We knew before that Myo1c was somehow involved in the regulation of glucose transport. My research indicates that Myo1c is a major target of insulin action and helps to accelerate the delivery of transporters to the membrane,” he said. “We think there may be blockages in the signal between insulin and myo1c in people who develop insulin resistance. If we’re correct, it should be possible to target that pathway for development of new therapies.”

Professor James sees the finding as a welcome milestone on a very long road of discovery. “While we’re certainly not saying we’ve found a way to cure diabetes, we are saying we’ve found a pretty significant clue.”

Treatment of diabetes and weight gain: A vicious cycle

There is a common concern that some oral agents or insulin can cause weight gain.

What insulin does to the body:

1. Regulates the liver from releasing too much glucose (I like to say that insulin leans up against the door of the liver and only lets a little glucose out at a time).
2. Acts as a “doorman, or key” to open the doors of the cells and allow glucose to enter the cells.
3. Acts as a storage promoter, to store extra glucose back into the liver, along with the muscles, while the excess is stored as fat.

The person without diabetes:
So as a person without diabetes, whenever I overeat, my pancreas automatically releases extra insulin to take care of my extra food intake; if I don’t exercise it off, that excess food gets stored as fat and I gain weight. Remember Rhoda on the Mary Tyler Moore Show? To paraphrase her comment, she said “don’t bother giving me that candy bar-just apply it directly to my hips, since that’s where it will eventually end up!”

The person with diabetes:
In contrast, with diabetes, if you don’t have enough insulin, then when you overeat, not all the food can enter the cells (to store in the liver and muscles, with the excess stored as fat); some of the glucose from your food just piles up in the blood, and gets urinated out-what I call a “false” weight loss/weight control.

What insulin does to the body:
If your diabetes were out of control for awhile, you were losing weight without trying; then as your blood glucose improved from taking diabetes medication, this would mean that instead of urinating out your food/calories, you were now able to retain your food and use it as energy (as well as store the excess in muscle and fat). The long-term studies proving that good diabetes control matters (i.e. the DCCT and UKPDS) also showed that people gained weight as their control improved. Despite the fact that losing weight and exercising are the keys to decreasing the risk of developing type 2 diabetes or to controlling diabetes and decreasing the risk of heart disease, experts have also agreed
that:

1. controlling glucose is important, even if it means gaining some desirable weight (the average weight gain in the DCCT was 10 pounds);
2. certain diabetes medications may not cause as much weight gain as others;
3. careful meal planning and exercise can help to limit the weight gain.

Overeating:
True, if you are overeating and/or not exercising enough, and are thus requiring more oral agents or insulin, then you will gain weight because the diabetes medication is supporting your excess food intake. In the April, 2002 issue of Diabetes Forecast, Sheldon Gottlieb, MD addressed the issue of diabetes medication and weight gain, and commented that some people use insulin as a “carbohydrate credit card.” I hope you get my point that in this instance, the diabetes medication itself did not cause weight gain, but rather the excess calories did.
Insulin sensitizers (Thiazolidinediones) and weight gain:
These drugs (trade names Actos® and Avandia®), which are used in treating insulin resistance, also are associated with weight gain. They interact with a receptor in tissue that may convert it into fat cells, although how this occurs is not yet well understood. Despite the weight gain, this class of drugs is associated with improved cardiovascular function. To limit the weight gain, the drug Metformin (trade name Glucophage®) is often added.
Insulin and weight gain:
Generally, we tend to say that people might be prone to gain more weight on insulin, rather than on oral agents. But in addition to the issues discussed above, another common reason for weight gain is often related to the actual insulin regimen one is oni. e. if you take pre-mixed, intermediate, or long-acting insulin twice daily, you are forced to eat on time, to avoid skipping meals, and to anticipate exercise by taking an extra snack or decreasing your insulin, etc.-and this restricted regimen makes it harder to control weight. Often, using a rapid-acting insulin with each meal, with a bedtime dose of Lantus or NPH, or using an insulin pump, combined with careful diet and exercise, will allow you more flexibility in your lifestyle and an easier time controlling weight.