Obesity and surgery

Obese patients and their doctors may face special challenges when undergoing and performing surgery. Health experts warn that health care provider should not underestimate the risks but on the other hand, should not dismiss obese patients as hopeless cases. The American Heart Association recently released a new Science Advisory on performing surgery on obese patients Let us look at  some of the issues surrounding obesity and surgery.

Proper evaluation is difficult in obese patients.

Performing an evaluation in highly obese patients can be difficult because of many co-existing conditions. Heart problems in particular are easily underestimated during a physical examination. According to lead author Dr. Paul Poirier,

“A severely obese patient can be technically difficult to evaluate prior to surgery. For example, severely obese people might feel chest tightness that could be a symptom of their obesity or of an underlying cardiac problem. Doctors need to carefully evaluate severely obese patients before they have surgery.”

Surgery can be difficult in obese patients.

Surgeons report that surgery can be challenging in severely obese patients. There was a big scandal in the UK a few years ago when some health care providers refused to perform surgery on obese patients

Obese patients are prone to complications.

Obese patients are more likely to suffer complications after surgery such as infections, and pulmonary embolism, and are more likely to stay on a ventilator and have a prolonged hospital stay.

Obese patients are not at higher risk for death.

Despite of these, the mortality rates during surgery do not depend on body mass index (BMI). According to Dr. Poirier

“Some surgeons are under the impression that severely obese patients are more likely to die in surgery than people who are not obese, and won’t operate on them as a result. This is not true. Severely obese patients are at increased risk for pulmonary embolism, wound infection and other conditions. But they are not more likely than their lower-weight counterparts to die as a result of surgery.”

The AHA advisory recommends the following:

• The recommendations are meant for all health care providers, from cardiologists, to surgeons, to anesthesiologists, providing pre-operative evaluation recommendations, as well as recommendations on management and care for obese patients during and after any type surgery, be it a knee replacement or a heart operation.
• The health care provider should especially pay attention to obesity-related conditions such as:
  • Heart failure
  • Atherosclerosis (thickened or narrowed arteries)
  • High blood pressure
  • Heart rhythm disorders
  • History of blood clots (especially pulmonary embolism)
  • Poor exercise capacity
  • Pulmonary hypertension related to sleep apnea
• The health providers should take into consideration age, gender, as well as the abovementioned conditions as independent factors for mortality or complication from surgery.
• Health care providers should advise patients to be as healthy as possible before surgery. This may include losing weight, keeping blood pressure under control (for those with hypertensiotn, or keeping blood sugar level under control (for those with diabetes).
• Extra, non-invasive tests may be performed if it aid in pre-surgery evaluation, such as ECG or chest X-ray.
• Surgeons should discuss with patients the risks associated with a particular surgery for a patient their size.

In providing this advisory, the AHA aims to give obese patients the best possible care they deserve.

               

Does your BMI really reflect your health status?

Those who are closely watching their weight are familiar with the term BMI, short for body mass index. Body weight in absolute terms cannot be used as accurate measure of obesity for simple reason that there are short people and there are tall people, and weight can therefore vary relative to height. That’s why scientists use BMI, a numerical value of weight in relation to height, calculated as a person’s body weight divided by the square of his or her height, as a diagnostic tool to evaluate weight problems and health status of a person. Weight status based on BMI (usually expressed in terms of kg/m²) is categorized as follows:

• Underweight  - 18.5 and below
• Normal weight - 18.5 to 25
• Overweight - 25 to 30
• Obesity class I - 30 to 35
• Obesity class II - 35 to 40
• Obesity class III - above 40

This has been like this for years but recently, there have been concerns that BMI may not be an accurate way of assessing a person’s true health status.

Based on BMI measurements, almost one-third of the American population is considered overweight, which is the middle range between normal weight and obesity. Excess weight has been identified as a major risk factor in many chronic diseases, including heart disease, hypertension, hyperlipidemia, diabetes, osteoporosis and certain types of cancer.

Several research studies looked at how BMI is related to mortality rates, were surprisingly inconclusive and sometimes contradictory results. Scientists now think that that BMI may not be the right measurement because:

• BMI doesn’t distinguish between different types of fat mass. For example, there is the fat mass which is of important health concerns as it is closely linked to type 2 diabetes. However, there is also lean mass, especially muscle tissue, which reduces health risks.
• BMI does not directly measure the distribution of body fat. Depending on location, fat may have more or less impact on health. Visceral fat or fat at the waist, for example, is more detrimental to health than fat at the hips.

Thus, using BMI as health status indicator does not actually show the complete picture and may miss the health risks that slight overweight may present.

According to lead author Dr. Cora E. Lewis of the University of Alabama at Birmingham

“This larger picture includes important relationships between BMI and other health outcomes, such as cardiovascular disease and its risk factors. Arguably, the most important relationship among the cardiovascular disease risk factors is diabetes, which is significantly more common in overweight than in normal-weight people.”

Considering the increasing number of children who are overweight, health experts are urging researchers and clinicians alike to act now and conduct research that goes beyond just BMI.

Dr. Lewis continues

“Weight gain is progressive and weight loss difficult. Although a young child is unlikely to have a heart attack, overweight children are likely to become overweight or obese adults, which puts them at risk for cardiovascular events as they mature. Achieving and maintaining a healthy body weight is of high importance for all Americans.”

               

Recession obesity: getting fat during lean times

Ever heard of recession obesity? It is getting fat during lean times. This is mainly due to the fact that people tend to cut back on the essential and healthy things (see previous post) during economic downturns such as what we are experiencing now. However, it is only lately that health experts realized how really serious the problem really is - especially among children and adolescents.

Researchers at Duke University looked at a variety of indicators that could assess how children are faring now compared how they fared in the past and how they would do so in the future. This compilation of indices resulted in the “2009 Child Well-Being Index”, which calculates the health and economic status of American children. The Index addresses questions which include:

• Overall, on average, how did child and youth well-being in the United States of America change in the last quarter of the 20th century and beyond? 
• Did it improve or deteriorate? 
• By how much? 
• In which domains or areas of social life? 
• For specific age groups? 
• For particular race/ethnic groups?
• And did race/ethnic group disparities increase or decrease?

A possible scenario that could lead to recession obesity:

Parents opt to feed their children cheap but filling fast food meals and cut down on the relative more expensive fresh fruit and vegetables.

According to Kenneth Land, project director of the Child Well-Being Index and sociology professor at Duke University:

“There is concern with ‘recession obesity’ apart from the general trend toward an increasing number of obese American children. There is a concern that parents will substitute fast food, high carbohydrate and high sugar-content food, for healthy food and that this will cause an uptick in the rate of overweight children and adolescents.”

A study published in the Journal of the American Medical Association last year reported that 32% of American children overweight, while 16% were obese.

Aside from the obesity problem, the researchers also observed the following:

• Mortality rates for children aged 1 to 19 years old increased in previous recessions. This is expected to happen again.
• The rate of violent crimes among teenagers also increased, and is anticipated to occur again.
• The recession is resulting in a housing crisis, uprooting many adolescents.
• A large number of 16 to 19-year olds are out of school but can’t find work, “leaving them particularly vulnerable to delinquency and crime.”

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The link between obesity and food allergies

Overweight children and adolescents are more likely to suffer from food allergies. This is according to a study by American researchers. Here are some of the figures to think about (Source: NY Times):

• Overweight children are 50% more likely to be allergic to milk.
• They are also 26% more likely to be allergic to at least one type of food.

For children as well as for parents, food allergies are a problem that can range from being a mild annoyance (e.g. skin rash) to life-threatening (food related anaphylaxis). According to the Food Allergy and Anaphylaxis Network, 4% of the American population (more than 12 million people) has some form of food allergy. Of these, 3 million are children.

90% of food allergies are due to the following food stuffs:

• milk
• eggs
• peanuts
• tree nuts (e.g., walnuts, almonds, cashews, pistachios, pecans)
• wheat
• soy
• fish
• shellfish.

The current study followed up 4,111 children and teenagers aged 2 to 19 years old and monitored the levels of total and allergen-specific immunoglobulin E (IgE) or antibodies to a wide spectrum of airborne (indoor and outdoor) and food allergens as well as the body weight of the participants. The researchers found that obese or overweight children have higher IgE levels compared to children with normal weight.

According to researcher Dr. Stephanie London, “The signal for allergies seemed to be coming mostly from food allergies. The rate of having a food allergy was 59 percent higher for obese children.”

The study results do not necessarily prove that excess weight can cause food allergies in children. However, the fact remains that there is a strong association between obesity and allergies. This is an association that cannot be simply ignored but should be investigated further.

In recent years, the problem of obesity, especially among children has been on the rise. The same is true with the problem of food allergies.

According to lead author Dr. Cynthia Visness

“Given that the prevalence of both obesity and allergic disease has increased among children over the last several decades, it is important to understand and, if possible, prevent these epidemics.”

The current study was funded by the National Institute of Environmental Health Sciences (NIEHS) and the National Institute of Allergy and Infectious Diseases (NIAID). The results have been published in the May issue of the Journal of Allergy and Clinical Immunology.

Photo credit: Stock.xchng

               

CVD News watch, May 15

Our heart(y) news watch for this weekend is focusing on obesity, a risk factor for cardiovascular disease. Happy reading!

CVD obesity watch

The obesity epidemic in the US is due solely to increased food intake
It’s all about food, according to a study by Australian researchers which was presented at the 2009 European Congress on Obesity in Amsterdam last week. It has always been thought that a sedentary lifestyle (e.g. lack of physical activity) is what is tipping the scales for a large number of Americans. Actually it’s the huge amount of food that they consume that lead to the excess pounds and expanded waistline. It seems that the food intake in the US have been continuously increasing since the 1970s. The study looked into the account energy intake, energy expenditure, and body size in 963 children and 1399 adults. So we just have to cut down, that’s it? It’s not going to be easy, according to the authors. “The food industry has done such a great job of marketing their products, making the food so tasty that it’s almost irresistible, pricing their products just right, and placing them everywhere, that it is very hard for the average person to resist temptation. Food is virtually everywhere, probably even in churches and funeral parlors.”

CVD exercise watch

Get Animated with Anna Kournikova
But even though obesity may be solely due to food intake, there is no denying that physical exercise is beneficial to our health. That’s why tennis star Anna Kournikova has teamed up with Cartoon Network to help Boys & Girls Clubs of America get “animated” e.g. teach kids fun, creative ways to stay healthy and active in any typical indoor classroom. The DVD “GET ANIMATED WITH ANNA KOURNIKOVA” presents new and creative ways for kids to be more active and energetic on a daily basis indoors or outdoors, without being especially proficient in a particular sport. Definitely better than watching cartoons, eh?

CVD health care cost watch

Complications and Costs for Obesity Surgery Declining
On another aspect of obesity, a new study by the Agency for Healthcare Research and Quality (AHRQ) showed that the rate of postsurgical complications for bariatric surgey decline by 21% from 2002 to 2006. The health care costs associated with the intervention dropped as well. The improvements are largely due to improved surgical techniques.

CVD health care reform watch

Building Momentum as Democrats Forge Health Care Reform

They are not yet quite there but they are building momentum. Major organizations that represent American doctors, hospitals, health plans, and medical suppliers met last May 11 with the US President and pledged to do their part to achieve the administration’s goal of reducing by 1.5% annually the growth of health care spending over the next decade - saving an estimated $2 trillion. Truly an important step in US health care reform.

               

Can baby fat predict obesity?

The last three decades have witnessed the rapid increased incidence in obesity and scientists and health experts are scrambling to come up with ways and means to stop and reverse this trend. Recently, more and more evidence points to the fact that the problem of excess weight starts rather early in life. A recent study by Boston researchers suggests that the rate of weight gain during the first months of a baby’s life is a predictor of its risk for obesity later in life.

According to lead author Dr. Elsie Taveras, assistant professor in the Harvard Medical School Department of Ambulatory Care and Prevention

“There is increasing evidence that rapid changes in weight during infancy increase children’s risk of later obesity. The mounting evidence suggests that infancy may be a critical period during which to prevent childhood obesity and its related consequences.”

Dr. Taveras is also the co-director of the One Step Ahead Clinic, a pediatric overweight prevention program at Children’s Hospital Boston.

Previous studies on obesity risk concentrated on infants’ body weights. The current study took into account that weight gain is a dynamic process associated with growth, looked further and measured growth rates, e.g. weight gain, body length, and weight-for-length gain.

The connection between rapid infant weight gain and later obesity was striking, even after adjusting for factors such as premature babies or those underweight at birth. Take for example two infants with the same birth weight who, after six months, weigh 7.7 kg (16.9 pounds) and 8.4 kg (18.4 pounds), a 0.7 kg (1.5 pounds) difference. According to study estimates, the heavier of these two infants would have a 40% higher risk of obesity at age 3 (after adjusting for potential confounders).

Previous studies indicated that there is some confusion from infants’ growth charts, and that parents tend to be wrong in judging their children’s weight. Another study suggested that the “tipping point” for childhood obesity can be as early as age 2. The currents study indicates that weight gain in children should be managed appropriately as early as possible.

“At first it may seem implausible that weight gain over just a few months early in infancy could have long-term health consequences, but it makes sense because so much of human development takes place during that period-and even before birth,” says Matthew Gillman, director of the department’s Obesity Prevention Program. “Now we need to find out how to modify weight gain in infancy in ways that balance the needs of the brain and the body.”

               

Earth Day Special: Losing weight is good for the environment

I know. You have probably heard it all. Losing weight is good for you. And this absolutely true. People lose weight for a lot of reasons.

Weight and looks

For some people, it’s all about looks. They lose weight (or at least try to) because they associate slimness with good looks. Sometimes, however, vanity can have some bad consequences when they take the weight issue a bit too far and fall into the trap of eating disorders instead.

Weight and health

Losing weight is good for the health. After all, obesity is a risk factor for many chronic diseases including heart disease, stroke, diabetes, osteoporosis, and cancer. Keeping fit and healthy is the best reason to lose weight. In the process, you feel good about yourself without being dependent on good looks.

Weight and the environment

Now, it seems there is another compelling reason for us to lose those pounds and manage our weight properly. Low weight is good for the environment and can help slow down climate change. Here are the reasons why:

• Food consumption. Losing weight means low food consumption. It seems that food production contributes extensively to global warning. According to London School of Hygiene & Tropical Medicine’s Department of Epidemiology and Population Health, the population of Vietnam, which is considered to be on the lean side, consume less food resources than say the overweight population of more developed countries such as the US.
• Waste production. Food consumption is, of course, closely related to waste production. Again, according to the researchers, a lean population needs 20% less food resources and produce less greenhouse emissions than an overweight population.
• Transport-related emissions. It is a known fact that energy consumption are related to weight. The more food a population eat, the more energy is needed for cargo transport. In addition, the heavier a population is, the more energy is spent on human transport. And corollary to this, the more transport-related emissions are produced. According to Science Daily

The researchers estimate that a lean population of 1 billion people would emit 1.0 GT (1,000 million tonnes) less carbon dioxide equivalents per year compared with a fat one.

This doesn’t mean that we should blame all environmental problems on overweight people because this is far from fair.

Instead, we should take these findings as a strong incentive to lose weight. And governments and health authorities should put more effort in tackling the obesity problem. For the sake of the population. For the sake of our planet. Happy Earth Day!

Photo credit: stock. xchng

               

7 steps to successful weight loss in children: The CORE Tool

In 2007, American researchers came up with recommendations to fight childhood obesity and they consisted of 4 steps based on “the principle of least intervention.” This year, a group of scientists from the Center of Obesity Research and Education (CORE) proposed that the previous recommendations be expanded to 7 steps in order to achieve more significant improvement.

The new model also proceeds stepwise, each step is more intensive and drastic than the previous one.

The so-called Seven Steps to Success are

1. Medical Management. Seeing your child’s pediatrician regularly will help provide you with feedback about progress and regular evaluations for potential health problems caused by excess weight (e.g., high blood pressure, liver problems, diabetes).
2. Education. Knowledge of the best ways to eat, stay active, and solve problems relating to weight is necessary for successful weight control.
3. Environmental Changes. Making changes in the environment in which your family lives can help (e.g., taking televisions and computers out of bedrooms, eliminating all high-fat food in the house).
4. Support Groups.
5. Cognitive–Behavior Therapy (CBT) I: Clinics or Short-Term Immersion. CBT is a scientifically based approach to helping people improve their motivation, goal-setting, and focusing skills. Professionally conducted CBT programs for overweight children are available (check local hospitals, clinics). Immersion programs focus on CBT full time, for example for 4 weeks in the summer.
6. CBT II: Long-term Immersion. Longer, more intensive, immersion programs are available in therapeutic boarding schools and clinics.
7. Bariatric Surgery +. For some seriously overweight teenagers who have tried the first six steps, specialized surgeries (bariatric surgeries like the gastric bypass) performed in surgical centers that have experience and understanding of this problem are important options.

It is important to know that the model is based on one important assumption – that obesity among children is a family affair. For it to work, the participation and commitment of all family members is essential.

Another review study published earlier this year suggests that family-based lifestyle interventions that include diet modifications, physical exercise and behavior therapy programs were effective in helping overweight children to lose weight. Furthermore, this loss weight was could be sustained for 6 months in young children and up to one year in adolescents.

The CORE tool also recommended several organizations active in the fight against obesity.

Organizations active in education on obesity and proper nutrition:

·        www.healthykids.ca

·        www.cspinet.org

·        www.calorieking.com

Support groups:

·        Take Off Pounds Sensibly (TOPS)

·        Weight Watchers

Clinics for CBT:

·        www.wellspringcamps.com

·        www.camplajolla.com

·        www.zeepreventorium.be

Clinics experienced in bariatric surgery:

·        www.fitprogram.ucla.edu

·        www.cincinnatichildrens.org

You can also download the full CORE tool at

Seven Steps to Success: A Handout for Parents of Overweight Children and Adolescents

               

CVD Newswatch, January 23

Good morning. Here is your news round up for this weekend and it doesn’t include any peanut butter recalls. Happy reading.

CVD innovation watch

Sensor in artery measures blood pressure
No more 24-hour blood pressure readings with electrodes attached all over your torso. The German applied research company Fraunhofer-Gesellschaft announced an innovative technique of monitoring blood pressure. A microimplant with a diameter of 1mm is inserted into the femoral artery. The microsensor “measures the patient’s blood pressure 30 times per second. It is connected via a flexible micro-cable to a transponder unit, which is likewise implanted in the groin under the skin. This unit digitizes and encodes the data coming from the micro-sensor and transmits them to an external reading device that patients can wear like a cell phone on their belt. From there, the readings can be forwarded to a monitoring station and analyzed by the doctor.”

CVD legislation watch

Obesity tax proposal gets mixed reaction
New York State Health Commissioner Richard Daines makes his own YouTube video to campaign for the obesity tax which would place an 18% sales tax on top of prices of fattening drinks such as non-diet cola and sweetened drinks with <70% fruit juice content. The tax will supposedly help curb obesity and raise $400 million that can help out the state deficit. Another supporter is New York Governor Paterson himself. Other leglislators, however, are not as keen.

CVD employment watch

Health care among few bright spots in us employment picture
Unemployment is up, very high up, in fact. But where can we find jobs these days? The health care industry is the way to go, according to the Wall Street Journal. It seems there is a constant shortage of medical professionals especially nurses.

CVD diagnostics watch

New tool could prevent needless stents and save money
We haven’t heard the end of the stents controversy. This study published in the15 January issue of the New England Journal of Medicine says that doctors may be using too many unnecessary stents to open arteries. By using new diagnostic tool called ‘fractional flow reserve,’ or FFR, “which involves inserting a coronary pressure guidewire into the artery, doctors can measure whether blood flow is actually reduced to a dangerous level beyond any apparent narrowing.” In many cases, medication may actually be a better option than the rather invasive stent.

CVD regulatory watch

FDA issues update to safety review on cholesterol-lowering drugs
The US FDA reaffirms its recommendation of cholesterol-lowering drugs and “its position that elevated amounts of low-density lipoprotein (LDL), or “bad cholesterol,” are a risk factor for cardiovascular diseases such as heart attack, stroke and sudden death and that lowering LDL cholesterol reduces the risk of these diseases.” This comes after the regulatory body’s evaluation of the results of the ENHANCE trial.

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Curbing ads to curb children obesity

`Tis the season to be jolly. And ’tis also the season to be eating, drinking, and feasting - and becoming obese in the process. It’s especially difficult for kids who are bombarded with advertisements of goodies right and left.

Now I am not one to scrooge about and say “Bah! Humbug!” every Christmas. I have two little boys who are as keen on Christmas and Christmas treats just like other kids. But just because it’s Christmas, that doesn’t mean we should forget our health - and that of our family. After all, obesity is a major risk factor for cardiovascular disease. In recent years, it has become an epidemic even among children.

It is therefore music to my ears when I heard about the Children’s Food and Beverage Advertising Initiative. Launched by the Council of Better Business Bureau (BBB) in November 2006, it started a bit slow but has gained momentum since then. As of June this year, 13 major food companies have joined the initiative pledged their commitment. Currently there are 15 and these include well-known names such as Coca-Cola, Kraft, McDonald’s, Cadbury Adams, Hershey, and Mars.

But what is the initiative about?

“Under the terms of the Initiative, participating companies agreed to devote at least 50 percent their advertising directed to children under 12 to promote healthier dietary choices and/or to messages that encourage good nutrition or healthy lifestyles. Healthier-product pledges must be consistent with established scientific and/or government standards, including USDA Dietary Guidelines and MyPyramid, and FDA standards for health claims. Each company prepares a Pledge that describes its commitment. This document must be approved by the Initiative staff. The Pledges are available for public viewing on the BBB web site after they have been approved.”

The pledge is voluntary and self-regulated.

This month, another major food industry player finally made a pledge it wasn’t prepared to make earlier - Nestlé. Claiming to be “the world’s leading nutrition, health, and wellness company“, it has been heavily criticized for selling too many junk food. Based on the assessment of the consumer group Center for Science in the Public Interest (CSPI), 93% of Nestle products for aimed children under 12 were “of poor nutritional quality.” Come January 1, 2009, however, Nestlé, the world’s biggest food company will “only advertise foods to children that meet nutritional guidelines.” Also excluded from the under-12 ads is one of the company’s best selling brands, WONKA candies, named after Roald Dahl’s famous chocolate maker in his book “Charlie and the Chocolate Factory.”

While consumer groups are happy with Nestlé’s move, there are still, according to CSPI, many foodcompanies which are not part of the Initiative and these include “Chuck E. Cheese’s, Subway, Yum Brands (KFC, Taco Bell, and Pizza Hut, sponsor of the Book It! Program for schools), Perfetti Van Melle (maker of Airheads candies), and Topps (maker of Baby Bottle Pop and other candies)”.

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