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Results for : "Vitamin A"

Enhanced Cognitive Function after Bariatric Surgery

March 18, 2016 6:51 am

The adverse effects of obesity reduce the body’s natural potential of optimal physical, mental health and cognitive function. Obesity is associated with a greater risk of health problems such as hypertension, stroke, diabetes, and sleep apnea. These issues attribute to an increased risk of dementia and cognitive dysfunction.

Glucose homeostasis plays a key role in the neural mechanisms of the brain. Insulin signals nutrients by circulating within the body in proportion to body fat mass. In addition to other regulatory mechanisms, this allows the brain to control feeding behavior by stimulating energy storage and metabolic homeostasis. Metabolic imbalances modify insulin sensitivity and lead to impaired glucose output inhibition [Qatanani and Lazar et al., 2007 (1)].

System effects of free radicals
System effects of free radicals

Free radicals are formed when weak molecular bonds are split. Their instability causes them to attack neighboring stable molecules and lead to a chain reaction of disturbing living cells. Antioxidants, such as vitamins C and E, defend the body from the damaging effects of free radicals by acting like scavengers. They protect cells from tissue damage that can potentially lead to disease.

Moreover, insulin resistance links oxidative stress, which is the continuous imbalance between free radical production and the body’s antioxidant defenses to detoxify its harmful effects. Enhanced oxidative stress is a result of accumulated fat, which impairs the secretion of insulin and damages glucose uptake in muscle and fat. Increased oxidative stress is the underlying cause of pathogenesis in vascular cell walls that lead to the development of cardiovascular problems, plaque formation. Data suggests, in a study conducted by Dr. Convit (2) in 2002, that management of blood sugar levels may enhance memory and possibly decrease the risk of Alzheimer’s disease.

In congruence with these findings, added stress due to excess weight can negatively affect the anatomy and physiology of the body. A study in 2010, led by Dr. Thompson (3), concluded that obesity is associated with “atrophy in brain areas targeted by neurodegeneration: hippocampus, frontal lobes, and thalamus” [Raji et al., 2010 (3)]. These brain regions play a critical role in the maintenance of memory, executive function, and sensory interpretation, respectively.

Central respiratory function is also disrupted by the mechanical effects of obesity. Reduced lung expansion is especially destructive during sleep. Obstructive sleep apnea is a disorder where breathing stops for brief periods because of an obstructed upper airway. Excess weight and increasing body mass index (BMI) restricts expansion of the chest wall and increases airway resistance, which decreases lung volume [Zammit et al. 2010 (4)]. This boosts respiratory muscle workload for consistent breathing. Complications of sleep apnea include fatigue, heart problems, metabolic syndrome, and more.

Cognitive impairments lead to deficits in executive function, response, reflex time, planning, and memory [Spitznagel et al. 2013 (5)]. Blood sugar levels, oxidative state, respiration and other mechanisms influence our cognitive abilities. Weight loss from bariatric surgery may reduce the comorbidities of an obese patient. The primary outcomes are improvements with diabetes, blood pressure, glucose levels, sleep apnea, BMI, and excess weight resolutions.

Schematic of how cognition is effected by obesity. Source (1)
Schematic of how cognition is effected by obesity. Source (1)

Weight loss surgery reverses the stressors of the body to permit the development and preservation of cognitive function. By improving anatomical aspects of physical health, the overall mental well-being of patients is remarkably enhanced.

A number of studies have looked at the short [Gunstad 2011(6)] and intermediate  [Alosco 2013, (7)] term improvement in memory function after weight loss surgery

Thank you to Contributor: Mariam Michelle Gyulnazaryan

References for Cognitive Function

  1. Qatanani M, Lazar MA. Mechanisms of obesity-associated insulin resistance. Genes & Dev. 2007; 21: 1443-1455.
  2. Convit A, Wolf OT, Tarshish C, de Leon MJ. Reduced glucose tolerance is associated with poor memory performance and hippocampal atrophy among normal elderly. PNAS. 2013; 100 (4): 2019-2022.
  3. Raji CA, Ho AJ, Parikshak N, Becker JT, Lopez OL, Kuller LH, Hua X, Leow AD, Toga AW, Thompson PM. Brain structure and obesity. Hum Brain Mapp. 2010; 31(3): 353-364.
  4. Zammit C, Liddicoat H, Moonsie I, Makker H. Obesity and respiratory diseases. Int J Gen Med. 2010; 3:335-343.
  5. Spitznagel MG, Alosco M, Strain G, Devlin M, Cohen R, Paul R, Crosby RD, Mitchell JE, Gunstad J., Cognitive function predicts 24-month weight loss success following bariatric surgery. Surg Obes Relat Dis. 2013; 9(5): 765-770.
  6. John Gunstad, Gladys Strain, Michael J. Devlin, Rena Wing, Ronald A. Cohen, Robert H. Paul, Ross D. Crosby, James E. Mitchell, 2011, ‘Improved memory function 12 weeks after bariatric surgery’, Surgery for Obesity and Related Diseases, vol. 7, no. 4, pp. 465-472
  7. Michael L. Alosco, Mary Beth Spitznagel, Gladys Strain, Michael Devlin, Ronald Cohen, Robert Paul, Ross D. Crosby, James E. Mitchell, John Gunstad, 2013, ‘Improved memory function two years after bariatric surgery’, Obesity, vol. 22, no. 1, pp. 32-38
  8. Furukawa S, Fujita T, Shimabukuro M, Iwaki M, Yamada Y, Nakajima Y, Nakayama O, Makishima M, Matsuda M, Shimomura I. Increased oxidative stress in obesity and its impact on metabolic syndrome. J Clin Invest. 2004; 114(12): 1752-1761.
  9. Mitchell JE, de Zwaan M. Psychosocial assessment and treatment of bariatric surgery patients. 2011;6: 103-109.
  10. Nguyen JCD, Killcross AS, Jenkins TA. Obesity and cognitive decline: role of inflammation and vascular changes. Front Neurosci. 2014; 8: 375.
  11. Chan JSY, Yan JH, Payne VG. The impact of obesity and exercise on cognitive aging. Front Aging Neurosci. 2013; 5: 97.

Acanthosis Nigricans

November 16, 2015 9:28 am

There are a a number of skin conditions that are associated with the disease of obesity. Acanthosis Nigricans is characterized as areas of thickened, dark, velvety discoloration in body folds and creases. Usually seen in the armpits, neck, under the breasts, in the skin folds of the abdomen and groin. The exact cause of it at the molecular level is not clear other than seen frequently with insulin excess in the case of benign conditions. This symptom can give a warning about health conditions that require further investigation.

Patients may assume excessive sweating and poor hygiene are the causes of this condition- both of which are incorrect.

Screen Shot 2015-11-15 at 8.36.13 PM

Acanthuses Nigerians is caused by acanthosis and papillomatosis of the epidermis (the outer most layer of the skin)  pigmentation is usually not in this area,  rather than pigment-producing cells. The skin proliferation abnormalities in acanthosis nigrcans are frequently associated with hyperinsulinemia and insulin resistance. This probably presents the best understanding of the pathology behind it. It suggests that the layer of  skin gets thicker probably caused by some stimuli- as indicated above seen with insulin excess.

There are two forms of this condition: Benign and Malignant.

Benign forms are associated with obesity, insulin resistance, and type II diabetes.

Insulin resistance: Insulin is a hormone secreted by the pancreas that allows your body to process sugar. Resistance predisposes to type II diabetes.

Hormonal disorders: Hypothyroidism, Polycystic Ovarian Disease, and other endocrine disorders of adrenal glands are ovaries

Drugs: Certain drugs and supplements such as high-dose niacin, birth control pills, steroids, may cause acanthosis nigricans.

Malignant forms may be an indication of Gastro-intestinal cancer such as stomach, colon, or liver cancer.

Treatment: No specific treatment is available for acanthosis nigricans. Treating the underlying conditions may restore some of the normal color and texture to affected areas of skin.

Bowel Length in Duodenal Switch

November 09, 2015 6:25 am

Malnutrition is one of the most feared complication of the duodenal switch operation. It may present years after surgery. What is common is a mix of nutritional deficiencies which include fat soluble vitamins, and protein calorie malnutrition. These all point to possible excessive shortening of the common channel. In my practice we have seen patients that have had lengthening of their common channel to improve their metabolic picture. What is very obvious to us, is that we see disproportionately higher number of cases coming to us for revision from practices where the common and alimentary lengths are done as a “standard” numbers with no specific adjustments made for the patient, their anatomy and situation. I have said for years, that the length of the bowel that is measured to be become the common and the alimentary limb should be a percentage of the total length of small bowel, rather than a pre-determined measurement. Here is a visual description of how this works.

If a common channel and the alimentary limb is measured to be a percent of the total length then the chance of protein calorie malnutrition is minimized since this will take into account the bowels absorptive capacity which is being reduced. This decrease in the absorption is done as a fraction of the total length.

Raines et al. published  a study in 2014, that showed how small bowel length is related more closely to a patient’s height and not weight.  And yet, some surgeons totally based the length of the common channel and the alimentary limb arbitrarily based on the patient pre operative BMI and nothing else. Could this be the cause of why I see some patients coming to us for revision of their duodenal switch for malnutrition?

Staying on Track and Surviving Halloween

October 27, 2015 6:07 am

happy-halloween-clipart_3

Halloween is the start of  temptations during the holiday season and surviving Halloween is possible. It’s a time of high carbohydrate treats that can turn into a nasty trick of regain or slowed weight loss. Halloween is a fun holiday that you can participate in with some foresight and planning.  Sugar and simple carbohydrates are easily absorbed and can decrease weight loss or regain. The following are some helpful tips to keep you on track.

  • Stay steady with high protein, hydration, vitamins and minerals.  Protein and hydration will keep you full and help curb the carb cravings.
  • Make you own high protein treats.  There are so many great recipes out there.
  • If you give out candy don’t buy candy that you like.  In fact, do the opposite and buy candy you dislike.
  • Don’t give out candy at all. Instead opt to do a non-candy type item, stickers, pencils, rings, trinkets, easers, small coloring books, or other small items.
  • Keep a list of your goals posted in a visible place.
  • Make a picture collage of your goals, achievements you want, and non-scale victories you’d like to achieve posted in a high visibility location.

Stay strong and avoid the pitfalls of temptation.

Coping Skills after Bariatric Surgery

June 02, 2015 7:23 am

For many people, food can become a coping mechanism and a way to self sooth or comfort themselves. After weight loss surgery the ability to use food in this manner is disrupted due to the smaller portions and in some cases food intolerances. Developing alternative and healthy coping skills is an imperative step after weigh loss surgery.

Obesity is a multifactorial process that has many contributing aspects. Although, obesity is not entirely the result of poor eating behavior, and lack of exercise. After weight loss surgery, we should appreciate the importance of healthy dietary choices; being sure that volume and frequency is not driven by emotion or emotional eating.

The mental aspect of weight loss surgery should not be ignored. Developing healthy coping skills can be a large part of dealing with the changes that take place. Some people go through a mourning period for the loss of the foods that once gave them comfort, made them part of a group, or the feeling of their best friend. In some cases, there may be a need to seek the assistance of a mental health care provider to be able to work through some of the issues and feelings. Never hesitate or be afraid of contact a mental health care professional.

Learning and practicing effective coping/soothing techniques can be started prior to weight loss surgery. The following are some coping skills that can be effective for some to adopt into their daily lives.

coping-skills1
nature

1. Nature – Get out into the great outdoors and into the sunlight. The sounds and sights of nature have a way of energizing the body and calming the mind. Sunlight is excellent for increasing Vitamin D levels which can help elevate mood and general well being.

2. Exercise – The mental and physical effects of exercise are paramount after weight loss surgery. The natural chemical release from exercise is a calming effect and gives a sense of well-being. In addition, the physical aspects of increase weight loss and change in body contour have positive mental and emotional effects.

3. Music- There are many research articles regarding the positive effects on both metal and physical aspects of music. Music has a way of soothing or energizing the soul. Turn up loud or keep it soft. Sing along. Dance it out if you need to.
4. Journaling – We always suggest to people prior to weight loss surgery to start journaling. It can give you perspective when you look back at entries. We also suggest to journal body measurements, pictures, and weights so that you might look back at how far you’ve come from your starting point.

5. Mindfulness – Using all five sense to experience life and food. Take your time to take everything in and experience the full effect. Be present in all life experiences. Ask yourself: Am I enjoying this? Does this feel like what I need? Is this getting me to where I want to be? Is this healthy for me?

6. Support groups of peers- There is nothing like having a group of people who have been there or know exactly how you may be feeling to be able to talk, share or vent. There are so many support groups that can be taken advantage of in either face to face or cyber groups.

7. Treat yourself- Treat yourself and practice self-care by doing something that you find relaxing, gratifying or energizing. Massage, manicure, an outfit, shoes, an outing, or a class.

8. Distraction- Hobbies, new skills, reading, games, bubble bath, or anything that get you out of the same mental spot can help with calming and soothing.

9. Talking- There is great value in having a close friend or trusted therapist to be a sounding board and give you an opportunity to unload some of the challenges you’ve been carrying.

Changing habits and coping skills takes practice and patience. It is not something that is easily changed over night. Focus on small steps, goals and achievements. Give yourself time and credit for the accomplishments that you’ve made. Always look at how far you have come and the positive lifestyle changes you’ve made. There may be set backs but don’t beat yourself up about it, move on and continue to take steps toward your goal.coping-skills1

https://www.counselorlady.com

Shared Success Story- Dr. D. Brown

April 13, 2015 11:38 am

I had Roux-en-Y (RNY) gastric bypass surgery in February 2004. I was told it was the “Gold Standard” procedure and it was the only one my insurance would approve (according to the surgeon’s office). I lost around 130 pounds with some minor bounce back. Kept it off for 7 years. I had so much energy; I decided to go back to school to become a doctor.

In medical school I really began to regain, for a total of 75 pounds over 5 years. I tracked food and found that if I ate more than 1300-1400 calories daily, I was gaining. I had absolutely no sugar dumping or satiety or restrictive effects left from the RNY Gastric Bypass, only my metabolism’s memory of starvation mode.

In fact, I never had one incident of dumping syndrome; I only felt satiety for the first 2 years and was able to eat well over 2 cups of food per meal by year 7. Lack of dedicated exercise, extreme stress (time, financial & academic) as well as poor food choices all contributed to my regain. However, the RNY Gastric Bypass surgery only has an average long-term excess weight loss of around 50%, so that still makes my weight regain close to the acceptable range.
Finally, I looked into revision surgery. Not only is surgery always a major decision, but also a revision to a DS is a very technically complicated surgery. I extensively researched all the options to make the right decision. The Duodenal Switch surgery has the best long-term statistics for maintained weight loss in all the medical studies (close to 75% excess weight). The major feature is nutrient malabsorption. The amount is dependent on an individual basis but most fat and some protein calories are not absorbed. There is an initial restrictive component as well. With the nutrient malabsorption also comes vitamin/mineral malabsorption. However, RNY also causes vitamin malabsorption and I was already taking vitamins, so what’s a few more? I am just 4 weeks post-op now and am still in trial-&-error mode, but I have found a safe plan for returning back to work. I really could not have afforded any complications and am so glad that I placed my trust in Dr. Keshishian.
Dr. D. Brown

Starting wt: 274.0

Vitals for 4-16-15 (4 weeks post DS)
wt = 249.0
T = 97.7
P = 88
BP = 108/80

Hyperparathyroidism and Weight Loss Surgery

March 13, 2015 5:57 pm

Hypoparathyroidism refers to elevated level of parathyroid hormone levels (elevated or high PTH).  Parathyroid glands are two small glands that are located behind the thyroid gland.  The primary function is regulation of the calcium level in the bloodstream. Parathyroid levels may be abnormally elevated for a number of reasons.

1-Primary Hyperparathyroidism

There may be abnormalities within the parathyroid glands themselves including benign and malignant tumors.    Laboratory studies to assist in identifying Parathyroid hyperplasia are calcium, phosphorus, magnesium, PTH (parathyroid hormone), Vitamin D and possibly a 24 hour urine, kidney x-ray, and Dexa scan. The calcium levels in parathyroid hyperplasia are usually elevated and Vitamin D levels low. Patients can present with hypercalcemia symptoms such as kidney stones, nausea, vomiting, peptic ulcer, constipation, bone pain, bone weakness, depression, lethargy, fatigue. There are two types of Primary Hyperparathyroidism parathyroid hyperplasia and parathyroid adenomas.  These both can at times be genetically linked.

Once the cause of elevated parathyroid hormone has been identified as primary hyperparathyroidism, the treatment involves surgical removal of one or more of the adenoma(s) or removal of 3.5 off all of the parathyroid glands if hyperplasia is diagnosed.

Parathyroid hyperplasia: When the growth involves all 4 of the glands.  These may effect either one of the glands or all 4 of them.  Majority of these are benign.

Parathyroid adenoma(s) refers to the abnormality or benign growth of one or more of the parathyroid glands.

2- Secondary Hyperparathyroidism

This is probably the most common cause of hyperparathyroidism imposed on a  weight loss surgical patient.  The elevated parathyroid hormone is the physiologic response all of the parathyroid glands to low calcium level.  The parathyroid hormone is elevated in order to favor bone breakdown and make available for calcium to be circulating in the bloodstream.  Parathyroid hormone also facilitates reabsorption of the calcium from the urine and improve absorption of the calcium from the GI tract.

The most common causes of secondary hyperparathyroidism is Vitamin D deficiency, weight loss surgery, kidney failure, Celiac or Crohn’s Disease.  Lower levels of Vitamin D decrease the intestinal calcium absorption and thereby increasing PTH secretion. Vitamin D is the transport molecule for calcium. Symptoms may include bone or joint pain, muscle weakness, osteomalacia,  low to normal blood calcium levels. The treatment of secondary hyperparathyroidism is correction of the underlying low calcium, low vitamin D levels. We have our Duodenal Switch patients take calcium citrate and  dry water miscible type of Vitamin D3.  Some people may require vitamin D injection in order to overcome deficiencies. You can find a list of supplements on our website and/or our starting point supplement recommendation in our patient workbook

Hyperparathyroidism and Weight Loss Surgery

Laboratory Blood Specimen Collection Change

October 30, 2014 5:20 pm

Older and Newer Blood Specimen Tubes

No one likes surprises at the lab when you are about to get your blood drawn. The picture above is of the older vacutainers blood specimen tubes and a new type of tube that is being introduced. There is currently a change over of blood specimen tubes in laboratories across the country.  Locally we are seeing the use of SARSTEDT tubes/syringes.  This change over is for several reasons. First and foremost is to reduce blood bourne pathogen exposure due to needle sticks and tube breakage. However, these blood specimen tubes offer some additional benefits, especially to people who frequently have lab draws. One of which is the ability to use aspiration of the specimen to decrease the incidence of hemolysis.  Hemolysis skews laboratory studies and damages the red blood cells in the collected specimen causing the need for repeated testing.  Aspiration is also easier on fragile veins due to the decrease pressure versus vacuum. The SARSTEDT tubes are versatile in that they can also be used as a vacuum tube if needed.

Hope this knowledge will alleviate at least some anxiety on your next trip to the lab for your blood draws.  Remember that follow up laboratory studies after weight loss surgery is a lifetime commitment that ensures your health and adjustment of vitamins and supplements.

Angular Cheilitis

October 04, 2014 2:35 am

Cracked corners of the lips is know as Angular Cheilitis (AC). This is a condition that is not uncommon. It has been contributed to a lowered immune state caused by multiple factors. The underlying lowered immune state may predispose a patient to an infection which can cause the AC. These infections can be caused by bacteria or fungus that is normally present in healthy individuals, but with any level stress placed on the immune system, they are able to spread.

This condition can surface with minimal weakening of the immune system. Possible contributing factor of weakened immune system may be stress (physical and psychological), trauma, malnutrition, and extreme fatigue. Vitamin B and Iron deficiency was also suspected to be a cause of AC. The  Vitamin B or iron deficiency may be contributing factor of weakened immune state and not directly causing AC. It is however important to correct all possible contributing causes including Iron and vitamin B deficiency.

Angular Cheilitis
Angular Cheilitis