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Childhood obesity and adolescent obesity is linked with many serious health issues in adulthood.  Unfortunately, there is little evidence that preventive measures such as lifestyle interventions and pharmacological treatments are effective.  There are several surgical procedures for children and adolescents but the long term effects remain uncertain.

Researchers from University College of Gjovik and the University of Oslo, Norway in a paper “Bariatric surgery for obese children and adolescents:  A review of the moral challenges” concluded that surgery on children’s healthy organs to discipline their eating behavior in order to help them to be socially acceptable or to compensate for poor parenting is ill advised.  There needs to be more evidence on outcomes and risk factors.  There also needs to be a valid consent or assent.

In making a decision on bariatric surgery for children and adolescents, parents need to look at the moral implications with regard to values, viewpoints and arguments before they make the decision to go forward.

bariatric surgery child obesity

Long Term Outcomes and Benefits of Bariatric Surgery for Children

There is little evidence on the benefits of bariatric surgery on youngsters.  The overwhelming research has been on adults and those results don’t necessarily generalize to a children and adolescents.  If, after 100 – 150 procedures there are few complications then it might be permissible to perform this procedure, but only in specialized, high volume centers where the doctors have plenty of experience.

Much consideration needs to be given to how this procedure might affect psychological and social development.  Few studies address these issues.  The other moral consideration is informed consent.  Should a parent make the decision for a child, or is a child or adolescent mature enough to have a say?  Surgery should not replace self discipline.

Studies show that one third of obese adults were sexually abused as children.  So as part of the assessment process for children and adolescents, this should be addressed.

Preconceptions on Bariatric Surgery for Youth

Overweight children and adolescents are often the target of discrimination and prejudice.  And medical practitioners are known to also discriminate against the obese, by assuming they are ill prepared to take care of themselves.  So, few referrals are made for surgery among this population.  But should this social problem be addressed with surgery anyway?

Bariatric surgery poses particular questions for minors because it uses medical interventions to alter everyday behavior when there are other solutions available such as dieting, exercising, and cognitive behavioral therapy that pose no risk to healthy organs in the body.  Also this surgery does not address the many unknown causes of obesity.

In conclusion these researchers posed the following questions that need to be addressed when making a decision such as bariatric surgery for a child or adolescent:

  • Who to operate on
  • When to do it
  • Who is to decide
  • How to decide
  • Who is to operate
  • How best to prepare
  • How to follow-up

 

And the most important question would be how to generate more high quality evidence in a morally acceptable manner.

I would love to know your option on this topic of Childhood Obesity and Bariatric Surgery. Please Comment!

 

 

Gastric Bypass Surgery patients lose more weight over the long them than those who have undergone gastric band operations.

A recent study found that obese patients who’ve had gastric bypass surgery experience changes in their brain which affect how the brain itself responds to food.  The Medical Research Council (MRC) found that this procedure reduces not only hunger, but the drive to eat for pleasure.

This was not found to be true of patients who have undergone gastric banding operations.  Therefore over the long run, gastric bypass patients lose more Gastric Bypass eat lessweight.  The research was published in the journal Gut and the theory is that physical changes made to the gut during surgery somehow have an effect on the drive to eat for pleasure.

Dr. Tony Goldstone from the MRC Clinical Sciences Centre at Imperial College London and consultant endocrinologist at Imperial College Healthcare NHS Trust said that  “Both procedures reduce appetite and have health benefits including long-term weight loss and improvement or even complete resolution of type 2 diabetes. However, gastric bypass surgery appears to be more effective for weight loss and has a more profound effect on the way in which the brain responds to food.”

Magnetic Resonance Imaging (MRI) was used to measure brain activity by scientists from Imperial College London, UK.  They studied 61 men and women who had lost weight using either one of these surgical methods.  21 people had gastric bypass and 20 people had gastric band surgery.  They used a control group of 20 people who had no surgery.

Patients who had gastric bypass surgery had less activity in brain’s reward centers when shown pictures of food, compared with those who had gastric banding surgery.  Gastric bypass patients also rated high-calorie foods as less appealing and as a result ate less fat in their diet than patients having gastric banding surgery or people in the control group.

However compared to the un-operated control group, both groups that had surgery had similarly reduced hunger and seemed unrelated to their psychological traits.

Researchers could not determine what caused these changes in brain activity, but did see differences in the patients’ metabolism which might be a factor.  The gut hormones that make us feel full after a meal were higher in the gastric bypass patients.  Levels of bile, which pay a role in digestion were also higher.

Another factor that was observed was that patients with gastric bypass surgery were physically uncomfortable, even nauseous after eating foods high in sugar and fat.  So this of course influenced their eating habits.

Dr. Goldstone concluded that “These findings emphasize that different bariatric procedures work in different ways to influence eating behavior,” added Goldstone. “This may have important implications for the way we treat patients with obesity and could help pave the way for a more personalized approach when deciding on the choice of bariatric procedure by taking the impact on food preferences and cravings into account.”

 

 

 

 

 

The gastric sleeve procedure has become very common in terms of weight loss surgery.  In spite of its recent popularity among patients and surgeons it’s still controversial, especially regarding bougie size.

 

What is a Bougie?

 The bougie (BOO-zhee) is a measuring device in the form of a long, flexible tube. Surgeons use it to guide them when dividing the stomach.

During the surgery the bougie is inserted through the mouth and guided through the esophagus and stomach to the pylorus.  The tube creates a bulge that the surgeon uses to guide the stapler in dividing the stomach.  After the sleeve is formed the bougie is removed.

Bougies come in various sizes and the unit of measurement is called a French, abbreviated F.  1F = 0.333 mm or 1/3 mm.  A 40F bougie is equal to ½ inch for example. Standard bougie sizes in the U.S. range from 32 – 50F.

Generally, the smaller the bougie used, the smaller the new stomach size.  But the same size bougie doesn’t always create the same size stomach.  A lot depends on the surgeon and whether he/she over sews the staple line, and if so by how much.

There is no unanimous agreement on the ideal bougie size for a given patient.  This is a challenge because each procedure requires the surgeon to find the size that will be the safest, yet allow for the most amount of weight loss.

The smaller the bougie that is used, the smaller the sleeve and the resulting stomach restriction.  But there is a greater risk of leakage and instances of stricture.  A stricture occurs when scar tissue develops and interferes with the normal movement of food and liquids into the stomach.  It can only be corrected with surgery.

On the other hand, if a larger bougie is used, there is less risk but then maybe less weight loss as well.

Gastric Sleeve Surgery

 

2008 Gastric Sleeve Bougie Study

 This study showed a very minor difference in weight loss results when using a 40F bougie vs a 60F bougie.  At 6 months the difference was less than 2% and at 12 months the difference was less than 6%.

Study: Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes. Surg Obes Relat Dis. 2008 Jul-Aug;4(4):528-33. doi: 10.1016/j.soard.2008.03.245.)

2013 Gastric Sleeve Surgery Study on Leaks

The results show that bougies of 40F and larger had incidents of leaks with virtually no change in weight loss.  Pending further research but caution is recommended in using the smallest possible bougie due to the risks outweighing the benefits.

(Study: The Effects of Bougie Caliber on Leaks and Excess Weight Loss Following Laparoscopic Sleeve Gastrectomy. Is There an Ideal Bougie Size? Obes Surg. 2013 Aug 3. [Epub ahead of print])

2012 Gastric Sleeve Study

Surgeons surveyed reported that in the range of 32F – 50F the most common size being used is 36F, (used by 32% of them).  Studies showed that the procedure is relatively safe while there are still variations in bougie size.

(Study: Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg. 2013 Aug 4. [Epub ahead of print])

What is the Best Bougie Size for Gastric Sleeve Surgery

Many variables determine bougie size including patient input, their height and weight and of course the surgeon.  It’s typically smaller when this is a stand alone procedure (32-50F) rather than a duodena switch (50-60F).

Depending on the bougie size the new stomach will be 60-80% smaller.  After surgery the new stomach will hold a meal of ½ cup to 1 ½ cups, rather than the normal 4 – 6 cups.

Before undergoing the sleeve gastrectomy procedure you must discuss bougie size with your surgeon.  You need to understand his reasons for recommending the size he intends to use.  It’s your stomach and you need to be comfortable.

The sleeve will help reduce hunger and limit food intake, but you need to follow a reduced calorie, nutrient-rich diet if you want to be successful.

On September 25th 2013, the Centers for Medicare and Medicaid Services (CMS) has dropped the requirement that bariatric surgery facilities be certified as a Bariatric Center of Excellence.

CMS released this statement on September 24, 2013 giving their reasons:

            “We believe the available evidence is sufficient to determine that the requirement for facility certification/COE designation for coverage of approved bariatric surgery procedures does not provide improved outcomes for Medicare beneficiaries.”

 

Why remove the Center of Excellence requirement?Bariatric Center of Excellence Medicaid

They concluded that certifying these facilities did not improve results.  There was also a downside and this was that fewer people could get the services they needed.  These included mostly the disadvantaged.

 

The Change in Policy

The policy in place since 2006 requiring these facilities be accredited to be covered on Medicare has been reversed.

This National Coverage Determination (NCD) on Bariatric Surgery for the Treatment of Morbid Obesity spelled out certain criteria for patients, procedures that would be covered and specific requirements that bariatric facilities must have in order to have coverage.

At the time every facility performing these services and procedures had to be certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center or approved by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE).

In 2005 the thought was that these certifications were beneficial but since then this has not been proven out.

 

Reconsideration Request

 A formal request to have this 2006 policy lifted was submitted by representatives of the Michigan Bariatric Surgery Collaborative.  The members requesting that CMS consider removing the certification policy were John Birkmeyer, MD, Nancy Birkmeyer, PhD and Justin Dimick, MD.

These doctors spelled out the results of several current studies that showed no real difference in mortality or complications between the centers of excellence and the facilities that were not.

So the CMS opened a National Coverage Analysis (NCA) in January 2013, in order to review the evidence.

They analyzed nine current research articles on the topic, they got input from the public at large and they reviewed professional society position statements.

 

The following groups opposed the new CMS policy removing accreditation:

  • The American Society for Metabolic and Bariatric Surgery (ASMBS)
  • American College of Surgeons (ACS)
  • The Obesity Society
  • Academy of Nutrition and Dietetics
  • American Society of Bariatric Physicians (ASBP)
  • American Association of Clinical Endocrinologists (AACE)
  • Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

 

The issues raised by those commenting had to do with:

  • Access to Care
  • Quality and Outcomes
  • Commitment to Multi-disciplinary Team Approach and Structure
  • Consistency of CMS Policy
  • Medicare Population at Risk
  • Communication with Certifying Organizations
  • Review of the Evidence

 

The major issue was access to care.  One of the studies concluded that “the Center of Excellence requirements have increased the travel distance for Medicare patients”, making it more difficult to access.

 

Bariatric Surgery Accreditation

The American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS) are responsible for carrying out the accreditation.  Last year they joined forces forming the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

This program establishes a national standard for accreditation so that patients have better care before, during and after their procedures.  Across the country there are currently about 750 inpatient and outpatient center accredited by either the ASMBS or ACS.

CMS is the only major insurer to have dropped the certification requirement.  Others still may require accreditation in order to cover bariatric surgery:

 

Before the decision was made by CMS to drop the accreditation Justin Dimick, MD, who was in favor of this decision said:

“There are definitely two points of view on the issue.  There is the professional association point of view, representing the people who perform accreditation, and obviously they support keeping the requirement, which is certainly understandable.  Doctors Birkmeyer and I represent the scientific perspective, which is about what the evidence shows, and we think the evidence does not support the need for mandatory accreditation.”

“We are not against certification,” said Dimick.  “We just don’t think it should be mandatory.”

 

 

Primary Source:  Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity – Facility Certification Requirement (CAG-001250R3), accessed at www.cms.gov.

 

 

Looking for a Type II Diabetes Cure? Many health conferences are starting to talk about the ability of bariatric surgery to improve the symptoms of and cure type II diabetes. For years, it has been known that people who undergo bariatric surgery often seen an improvement in their diabetes long before they start seeing weight loss results. If you have type II diabetes you may want to consider bariatric surgery as a way to improve and cure your diabetes.

Consider some more information about the procedure before you decide to talk with your doctor about undergoing the procedure since all surgical procedures should be carefully considered.

Is Bariatric Surgery Really the Answer for Type II Diabetes Cure?

Much talk can be found online about bariatric surgery as a cure for type II diabetes. In fact, some medical studies have bariatric surgery for type II diabeteseven shown the benefit of bariatric surgery in treating or at the least reducing the symptoms of type II diabetes. Perhaps the best news comes from two new studies published in the New England Journal of Medicine. These new tests were done from a random group of people that compared people with bariatric surgery versus those who received conventional or intense medical treatment for their type II diabetes. Before this, there was no definitive test about the effects of bariatric surgery and type II diabetes.

These two new studies were done in Italy and had the goal of dropping a type II diabetes patient A1C to under 7 after 2 years of treatment. Those who didn’t undergo bariatric surgery underwent lifestyle changes such as a low-fat diet and increased exercise based on the American Diabetes Association guidelines. Both of these studies showed that those who underwent bariatric surgery had lower BMIs, lower A1C’s and other health benefits such as lower blood pressure and lipid levels than those who didn’t undergo the surgery.

In addition, these benefits came from the surgery itself and not from any medication help. This is what many doctors and the press are talking about when it comes to bariatric surgeries ability to be the type II diabetes cure.

While these studies show good results from people with type II diabetes that undergo bariatric surgery. It is important to also keep in mind that people who don’t undergo surgery also see improvements in their type II diabetes with rigorous medical treatments. So it is important to carefully look into bariatric surgery and see if it is right for you. Often if you aren’t obese, a doctor won’t recommend this type of surgery just to help with type II diabetes. However, if you are both obese and suffering from type II diabetes it may be reasonable to talk with your doctor about the benefits of undergoing bariatric surgery.

After undergoing the procedure you need to be prepared to deal with a lifetime of nutritional and dietary changes that must be rigorously followed in order to avoid complications. You will need to be vigilant about taking additional supplements to avoid malnutrition. Tracking your nutritional status is important.

Bariatric surgery is certainly an option for people who are looking for a long term type II diabetes cure. You should carefully consider the information above and talk with your doctor to make sure bariatric surgery is right for you. You may want to schedule a free information session that most bariatric practices offer, so the surgeon can help answer any questions you may have about the procedure.

Knowing how much drinking you are allowed to do is important with bariatric eating. It is essential to follow bariatric nutrition in order to avoid serious health risks. Bariatric surgery can dramatically change your life, but you need to carefully follow your new dietary regime in order to see best results and avoid serious health complications. Before you consider bariatric surgery you want to consider all the risks involved. If you have already had the procedure and want help maintaining a healthy lifestyle you need to know what to do. This article can help you understand the health risks associated with drinking during meals after bariatric surgery.

How to Eat After Bariatric Surgery- Bariatric Eating Guidelines

Bariatric surgery and the resulting nutrition and diet that you follow are a good way to help you stop over eating, but it can also come with home health problems if you don’t follow the proper bariatric surgery eating guidelines. Bariatric surgery will reduce the size of your stomach and therefore, reduce the amount of food that can be contained in your stomach. If is important to eat slowly and carefully chew your food after bariatric surgery.

bariatric eating guidelines

 

Typically, not following bariatric eating guidelines will lead to nausea and vomiting. These symptoms are the same that you would feel if you ate too fast or ate too much food. However, there are other health issues that can occur after bariatric surgery that are easy to avoid if you follow proper eating habits. Let us look at some of these issues.

Some nutritional problems that occur after bariatric surgery include the following:

· Difficulty digesting food – especially red meats, bread products and fruit and vegetable skins.

· Intolerance to certain foods – especially in the few days after the operation.

· Malnutrition as a result of vitamin and mineral deficiencies.

· Changes in bowel habits.

· Dehydration as a result of inadequate drinking.

· Some symptoms to look for after bariatric surgery include the following:

· Dry mouth

· Headache

· Fatigue

· Strong smelling and/or dark urine

· Lactose intolerance

· Gas

· Diarrhea

· Bloating

· Cramping

 

Tips on How Much and When to Drink and Eat After Bariatric Surgery

Following bariatric surgery you will need to abide by some simple bariatric eating guidelines and take daily dietary supplements and a regimen of multi-vitamins in order to avoid malnutrition and get the missing nutrients from you new reduced diet. When you eat less, you will also be consuming less fiber so it is important to drink as much water as possible, exercise regularly and eat natural fiber sources such as oatmeal or applesauce.

Since bariatric surgery is reducing the size of your stomach it is important that you don’t drink too much fluids with you meal because this will over extend your stomach.  This will increase your feelings of nausea and increase your risk of vomiting. Also, drinking with your meals causes the food to travel faster through your stomach, potentially making you hungry sooner. Some foods can also be expanded as a result of mixing with water. Therefore, it is important to drink fluids often, but before and after meals.

 

Bariatric surgery is one of the best procedures to help obese patients lose weight. If you follow the tips above you will be able to reduce your chance of complications that can make the procedure uncomfortable.

Weight Loss Surgery and Gastric Sleeve Dumping Syndrome

 

What Is Gastric Dumping Syndrome

Causes of Gastric Dumping Syndrome

Gastric Dumping Syndrome is a common bariatric surgery issue, specifically with Gastric Sleeve and Gastric Bypass.  After having weight loss surgery the way a person eats changes dramatically.  Gone are the large meals because the stomach is reduced by approximately eighty to eighty-five percent leaving only a sleeve or tube that is the shape of a banana.  The new stomach you have after gastric sleeve surgery does function normally so you do not have as many food restrictions but you just cannot eat as much.

 

What is gastric dumping syndrome and why do you get it?

 

This is the problem that can develop, especially if there are foods eaten that are have a high content of sugar.  It is also referred to as rapid gastric emptying.  It is very common to have this after having gastric sleeve surgery.  Normally a person will experience it after eating but in some cases it will happen one to three hours later.  There are some people who have gastric dumping syndrome at both times.

 

When you have had gastric sleeve surgery the opening that is between your stomach and small intestine has been removed.  The opening at stomach, called the pylorus acted as a brake before surgery to help your stomach empty slowly.  Since there is no longer a “brake” the stomach contents just rushes into your small intestine. As a result your body reacts by adding a big amount of gastric juices to your small intestine.

 

What are the symptoms of gastric dumping syndrome?

 

Gastric dumping syndrome is actually a group of symptoms.  Some of these symptoms can include:

 

  • Gastrointestinal
    1. Nausea
    2. Vomiting
    3. Abdominal cramps
    4. Diarrhea
    5. Fullness feeling

 

  • Cardiovascular
    1. Flushing
    2. Feeling lightheaded and/or dizziness
    3. Rapid heart rate and/or heart palpitations

 

If a person has gastric dumping syndrome one to three hours after eating there are other symptoms that can happen.  These later symptoms are caused by dumping a large amount of sugar into their intestine.  The body responds by releasing a large of amount of insulin which is used to absorb this extra sugar.  This can cause hypoglycemia, which is a low level of sugar in your body.  These symptoms can include:

 

  • Hunger
  • Sweating
  • Feeling lightheaded and/or dizziness
  • Confusion
  • Fainting
  • Rapid heart rate and/or heart palpitations

 

In conclusion

 

Doing a study on more than one thousand people who have had gastric sleeve surgery, all have experienced gastric dumping syndrome at some point in time.  Two-thirds had the early symptoms while the other third had the later symptoms.  There were a few who had both symptoms.  As you can see, it is a common problem after having weight loss surgery.  It is not a life threatening condition and can be easily remedied by changing their eating habits such as

 

  • Eat smaller meals
  • Avoid drinking anything with meals
  • Limit your intake of drinks and food with a high sugar content
  • Increase the amount of fiber in your diet
  • Stay away from foods that are acidic
  • Lie down at least ten to fifteen minutes after eating