Bariatric Surgery Has Adverse Effects in Winter

A study of nearly one million patients who underwent bariatric surgery found that both seasonality and latitude were associated with health outcomes following surgery.

Bariatric surgery provides a weight loss option for individuals with severe obesity who have been unable to lose weight using other methods. The surgery causes weight loss by limiting the amount of food the stomach can hold.

Side effects of bariatric surgery may include infection, diarrhea, nutritional deficiencies, gallstones, hernias and dehiscence. Dehiscence refers to a ruptured wound along the surgical incision. These side effects may occur right after surgery, causing a prolonged length of stay (LOS) in the hospital, or the side effects may occur later.

As the obesity epidemic continues to rise, bariatric surgery will likely become more common. Thus, it is critical to optimize the results of these surgeries by managing modifiable risk factors.

In a past study, researchers discovered that 80% of patients who underwent gastric bypass were considered vitamin D deficient a year after surgery, despite all patients receiving vitamin D supplementation after surgery.

Vitamin D strengthens the immune system by increasing the production of antimicrobial proteins, which aid in fighting off infections and disease. Furthermore, research has found low vitamin D status is associated with increased LOS and increased incidence of hospital mortality. Because of these findings, researchers recently became interested in the relationship between vitamin D status and adverse outcomes following bariatric surgery.

In a recent study, researchers assessed proxies of vitamin D status and outcomes after bariatric surgery of 932,091 patients. The researchers used both seasonality and latitude to estimate vitamin D status. Those who live near the equator have more opportunity to synthesize vitamin D from the sun, and therefore, patients who attended hospitals located at or above 37° North were considered to have lower vitamin D levels on average compared to those located below 37° North.

In a separate analysis, the researchers compared seasonality of the surgery to adverse health outcomes. During the summer (July to September), vitamin D status is highest; whereas, during the winter (January to March) vitamin D status is the lowest. Vitamin D status is considered moderate during both fall and spring.

The study presents promising findings for the role of vitamin D in bariatric surgery. The large sample size increased the strength of the findings. Furthermore, the significant relationships between proxies of vitamin D status and adverse outcomes of bariatric surgery remained after adjusting for several confounding factors.

On the other hand, the study did not directly measure vitamin D status. Instead, the researchers looked at latitude and seasonality to represent vitamin D status. The vitamin D status of the patients could be significantly higher than expected based on latitude or season if they supplemented with vitamin D. Lastly, due to the observational design, the study does not prove that Northern latitude or surgery conducted during winter causes adverse outcomes for bariatric surgery patients, but rather, these proxies for low vitamin D status are linked to adverse outcomes.

Please read the full article here.

Stigma Keeps Obese Elders Away from Medical Care

Older adults with obesity may avoid health care due to the stigma associated with excess weight. This explains a lot of what happens by the elderly. I am different and being overweight hasn't stopped me, even with needing to put up with snide comments from a few doctors. I no longer see one doctor, but because of the way I turn some of the snide remarks back on the doctors, I have also had one doctor refuse to see me.

I admit that I ask the doctors if that comment was really necessary and if they felt that this was the unprofessional way they treated all patients. Sometimes there are a few more comments made by both the doctor and myself, but this is seldom.

Previous studies suggest that obesity is associated with weight stigma and lower rates of some preventive care. However, the effect of BMI on care and health-seeking behaviors among older adults has not been thoroughly investigated. Now, a new study looking at adults aged 65 years and older has found that obesity itself may be significantly associated with the predilection to avoid medical care. The findings, which were presented at Obesity Week 2016, also suggest that this predilection is not explained by functional impairments.

“The study found that people with a higher BMI (greater than 30) have an increased association with having an adverse perception of their physician's interpersonal manner and reporting the predilection to avoid care,” said study investigator Janet Ho, MD, Beth Israel Deaconess Medical Center in Boston.

Dr. Ho, who presented the study findings, said given the prevalence of older adults with obesity in the United States, this adverse perception or predilection to avoid care may translate into significant clinical effects. The study focused on patient perceptions of primary care providers because they traditionally have longitudinal relationships with patients.

“The findings could pertain to endocrinologists, who also often times become the primary health care provider for their patients,” Dr. Ho told Endocrinology Advisor. “Endocrinologists should care about the study findings, because patients with higher BMI who report a predilection to avoid care are the very ones who may need additional specialist support.”

Dr. Ho reports that prior research has shown that being overweight or obese may be a barrier to health care access, utilization, and quality. For example, patients with obesity have been shown to have lower rates of health care maintenance, diabetes screening, and recommended cancer screenings. She also shares that prior research has also found that provider attitudes and interactions with stigmatized groups can contribute to health care access disparities, and that said health care professionals may sometimes hold strong negative opinions about people with obesity.

Dr. Ho noted that stigma may not just affect quality of care, but also affect appropriate and timely care. To better understand the association among adults aged 65 and older who are overweight or obese, and in whom the effect of this stigma is less known, Dr. Ho and her colleagues Long Ngo, Wenxiao Zhou, and Christina Wee looked at surveys of a nationally representative sample of Medicare recipients between 2002 and2012. For this investigation, Dr. Ho and her team accounted for various demographic and clinical factors.

“The most important take-home message is that medical stigma can be implicit and insidious, and that patients with higher BMI may perceive such stigma in their interactions with health care providers, environments, and systems. As providers, especially endocrinologists who may interact frequently with patients with higher BMI, becoming aware of these biases and actively combating its effects in ourselves, colleagues, and interactions with patients is the first step towards improving care for these patients,” said Dr. Ho.

She said while it is possible to conceptually appreciate downstream effects of avoidance of care on health outcomes and costs, it is too early to report on those effects. However, examining the association between this self-reported predilection to avoid care or adverse perceptions of physicians and downstream consequences on health will be the next step in the team's research efforts. Dr. Ho said further studies may help elucidate what the best approaches for addressing this issue are.

Dietetic Associations Around the World Are More Monopolistic

Australia and South Africa are just a few of the places around the world that is creating problems. Great Britain and the USA are also being affected by self-serving members of the dietetic organizations.

Eddie, who writes for Low Carb Diabetichas an excellent article about the British Dietetic Association (BDA). At every opportunity the BDA and it’s members quote the term “Trust A Dietitian.” To me that implies others cannot be trusted to give sound dietary advice, it could mean, or imply, many do not trust a dietitian, but please trust us.

Here in the U.S., the Academy of Nutrition and Dietetics (AND) is pushing hard to expand their monopoly to more states and force all nutritionists to join their organization. The AND is becoming less transparent in showing who is contributing to their cause, especially the beverage companies and other food organizations.

The AND is a member of the International Confederation of Dietetic Associations (ICDA). ICDA is a confederation of national dietetic associations that together represent more than 160,000 dietetics professionals worldwide. International Confederation of Dietetic Associations supports national dietetic associations and their members beyond national and regional boundaries by achieving an integrated communications system, an enhanced image for the profession and increased awareness of standards of education, training and practice in dietetics. The Academy sits on the Board of Directors.

This means that they have some influence on dietetic organizations around the world. In both Australia and South Africa, it was dietitians that started both incidents and in Australia, barred one of their own for even mentioning low carb to a patient.

Many dietitians around the world have only a bachelor's degree and call themselves experts in nutrition. Yet they don't understand why most nutritionists do not respect them and most have a master's degree or higher degree and work with diabetes patients at the level of nutrition the patients' desire. Most dietitians do not work well with diabetes patients, over emphasize carbohydrates, and still promote low fat.

If you stop and think about this, this is what the last about 46 years has been and why obesity has climbed in the world. The wisdom of the crowd is starting to change and those dietitians that refuse to change will find themselves without a job and will become the joke of other professionals. At least more physicians in the United States are promoting other food plans and not high carb/low fat.

AHA Treats Press with Poor Food

I needed to reread this article a second time. While this is not meant to be funny, I did laugh out loud and basically at the American Heart Association.

At the recent American Heart Association meeting the press room was well stocked with margarine, skim milk, and sugar. This alone does not say much for the dietary advice the cardiology doctors promote. Most of the time it is very confusing and much of the time it has been wrong.

The author of the article clearly suggests that the health reporters at the AHA meeting in New Orleans may end up as collateral damage. Larry Husten, writer for Medpage Today said, “Breakfast this morning included low-fat cream cheese, margarine, and preserves.”

You won't find much saturated fat. But there's plenty of sugar around. And don't think about putting whole milk or half-and-half into your coffee. So, what's the problem here? It's important to remember that, in its earlier dietary advice, the AHA played a big role in elevating margarine and other trans-fat products over butter and saturated fats, though they are now completely against them. So, the presence of margarine and low-fat cream cheese is a sign of the long-lingering effect of the AHA's past bad advice.

The AHA continues to label saturated fats as "bad" and you won't find butter or whole milk or half-and-half in the pressroom. This decision, the food services people told me, came directly from the AHA. The food service employees were specifically ordered not to serve half-and-half during this meeting. A kind food services employee surreptitiously smuggled out a few half-and-half containers stowed away in the back for the duration of the meeting. The main point here is that there is considerable scientific controversy about this topic, and many nutrition experts now believe that saturated fats pose no danger at all and may even be beneficial.

And then there's the sugar. Many believe the big jump in sugar consumption was an inevitable consequence of the war against saturated fat. More recently, the AHA has focused some of its attention on the dangers of sugar, and it is supporting efforts to tax sugared soda. So, it seems a bit crazy to me that the pressroom bans whole milk and butter but has sugary desserts. (Please note that I am not suggesting that the AHA ban desserts.)

(I'm also told by confidential sources within the AHA -- for now I'll just refer to them as "Deep Stent" -- that there is a secret resistance network active at AHA headquarters in Dallas involving furtive smuggling of half-and-half and butter into the building.)

Note that meat, cheese, butter, and other saturated fats are labelled as "bad." Along with exercise, saturated fats raise HDL, the so-called good cholesterol, although there's a lot of controversy right now about that term.

The Holidays Often Bring Added Stress

How many of you dread the holidays? I know I used to, before diabetes, as I detested the constant hassles of the holidays with a certain relative. If there was something I had said or done, I was sure to hear about it three times over and in a negative manner, even if it had been something positive to begin with.

I also have a friend that presently will avoid family gatherings during the holidays, just to avoid food and the lectures he receives about not eating enough. He was diagnosed with prediabetes five years ago and because he started to ask questions, he had been able to learn and not develop diabetes. His wife is very upset because he will not go to holiday events when the families are in attendance. He finally told her that his mother was the reason and kept demanding that he eat more than he wanted and would pester him in the days leading up to the gathering and for days after if he did not eat all that she put on his plate.

So this year his wife finally agreed that they should not go to any events that his family would be attending and did convince her family that they would not attend any family event where his family would be present. Her family did trick them and when they arrived, and saw his family, they left immediately. And when the phone calls started from his mother, she finally understood the stress being placed on him by his mother. She even told her family to forget them coming to any holiday gatherings because of their trick.

When I last saw him, he said they were actually looking forward to starting their own holiday traditions. Whether her family or his family was invited would depend on how they treated them and the grandchildren. When his mother insisted on loading the plates and distributing the food at their place, she would never be allowed to come back and this was carefully explained to her, as they did not want the stress she was putting on the family. He told me that she told him and his wife they should be thankful that she did not want them to starve and to eat more food than they were eating.

He said he asked her if she wanted the entire family to develop diabetes. She said she was not putting sugar in their food. At that point, he said he did try some education and she would not believe that diabetes was caused by anything but sugar. He said he finally told his mother that until she talked to a doctor about diabetes and learned that carbohydrates were converted by the body into glucose, she would not be welcome in their home. His wife said she would not because she knew it was sugar that caused diabetes and carbohydrates were necessary for our bodies to remain strong and healthy.

At that point, she asked her family what they knew about diabetes and both my friend and his wife were surprised that they actually knew and she was told that one of her father's brothers had type 2 diabetes. She then told her parents why they did not want to spend any of the holidays with his parents and it was because his mother only believed sugar caused type 2 diabetes and loaded up the plates with carbohydrates. Her parents said they would not trick them in the future and now understood why they did not appreciate his mother loading the plates when he was trying to limit the carbohydrates.

Diabetes - Role of Dairy Products

Dairy products are slowly being recognized again as being good for you, even for people with diabetes. Dairy foods such as milk, cheese, and yogurt are great sources of protein, carbohydrates, and fat. The also contain a good amount of calcium and vitamin D. making them good for bone health. Dairy foods also have a role in diabetes prevention.

For people with diabetes, dairy is good for you, too. While milk and yogurt contain lactose, a kind of milk sugar or carbohydrate, they won’t spike your blood glucose.

Anthropologists think that people have been drinking and eating dairy products for 9,000 years. But today this important food group is often forgotten: 80% of adults don’t get their recommended three servings /day and that’s not counting those who suffer from lactose intolerance, especially Asian Americans and Latinos. If you’re one of the 80%, now is a good time to reconsider.

One of diabetes’ day-to-day challenges is sticking to your meal plan. Dairy can help. In addition to being great sources of protein, milk, yogurt and cheese can help you to feel full longer. That’s because dairy food offer a great combination of protein, low-glycemic carbohydrate, and fat.

Joslin says interesting research is coming out showing that the type of saturated fat in dairy foods may not be as harmful as we once thought. In fact, it seems to have a relatively neutral effect.

While there may not be specific benefits to dairy saturated fat, it does not seem to be harmful. However, if you’re watching calories, the low-fat or non-fat varieties of milk and yogurt may still be the best choice since 1 gram of fat contains 9 calories, which is far more than 1 gram of protein or carbs, which contains 4 calories. This is carb counting with dairy.

Most people with diabetes think first about carbohydrates and plan meals based on a certain allowance of carb servings (measured in grams). Often people avoid dairy because they want to “spend” their carb allowance on other foods. However, given all the good reasons why dairy foods should be a regular part of your meal plan, here’s how to carb count them into your meal planning.

A cup of milk (no matter if it is whole or skim or in-between) will have 12 grams of carb (or you can round that up to 15 grams if you’re estimating). A cup of yogurt can be variable – based on if it is plain, flavored, fruited or Greek. Check the nutrition facts label. But in general, one cup of plain yogurt will also have about 15 grams of carb.

Cheese contains only very small amounts of carbs but it is mostly fat, which is why most people with lactose intolerance can still eat it, especially hard cheese. (Keep in mind that not all “milks” are alike. Rice “milk” drink, almond milk, and soymilk don’t have the same nutritional profile as dairy milk.)

This is the important information on the advantages of milk. Emerging research from multiple different countries is showing some consistent results. People who eat dairy foods more frequently, particularly yogurt and some fermented cheeses like blue cheese, appear to have a lower incidence of diabetes.

Why is this? We don’t know yet. Perhaps it has to do with their probiotics, which can affect the microbiome – or the healthy bacteria that live in your gut. Stay tuned — more research is being done on this. Joslin’s research into dairy foods is underway and maybe available in the near future.

USDA guidelines recommend low fat dairy products. However, it is not clear if high fat or low fat dairy have different effects on glycemic control and other cardiovascular risk factors in patients with type 2 diabetes.

Two research studies have recently launched at Joslin that will help us better understand the role of fat in dairy foods in diabetes – particularly as it relates to weight management.

In a randomized prospective clinical study, Dr. Osama Hamdy and Dr. Joanna Mitri are evaluating the effect of high-fat dairy and low-fat dairy on glycemic control, body weight, and cardio-metabolic risk factors.

Please read the full article by Joslin.

Berries Are Good, But Watch Carbs – P2

This is a continuation of the previous blog.

#6. Berries May Help Lower Cholesterol Levels: Berries are a heart-healthy food.

Important point - berries have been shown to lower LDL cholesterol levels and help protect LDL cholesterol from becoming oxidized.

#7. Berries May Be Good for Your Skin: In addition to their many other health benefits, berries may help reduce skin wrinkling. This makes sense, given that the antioxidants in berries help control free radicals, one of the leading causes of skin damage that contributes to aging.

Important point - berries contain the antioxidant ellagic acid, which may help decrease wrinkling and other signs of skin aging related to sun exposure.

#8. Berry Antioxidants May Help Protect Against Cancer: Several antioxidants in berries, including anthocyanins, ellagic acid and resveratrol, may reduce the risk of cancer. Specifically, animal and human studies suggest that berries may help protect against cancer of the esophagus, mouth, breast and colon.

Important point - berries have been shown to reduce markers associated with tumor growth in animals and people with several types of cancer.

#9. Berries Can Be Enjoyed on Nearly All Types of Diets: Fortunately, berries can be included in many kinds of diets. Although people on low-carb and ketogenic diets often avoid fruit, they can usually enjoy moderate amounts of berries. For example, a half-cup serving of blackberries or raspberries contains less than 4 grams of digestible carbs.

Liberal amounts of berries can be incorporated into the paleo, Mediterranean, vegetarian and vegan diets. For people who want to lose weight, the low calories in berries make them ideal to include in meals, snacks or desserts.

Organic and wild berries are now widely available in many parts of the world. When they are not in season, frozen berries can be purchased and thawed as needed.

The only people who need to avoid berries are those who require a low-fiber diet for certain digestive disorders, as well as individuals who are allergic to berries. Allergic reactions to strawberries are most common.

Important point - berries can be enjoyed on most diets because they are low in calories and carbs and widely available in fresh or frozen forms.

#10. They May Help Keep Your Arteries Healthy: In addition to lowering cholesterol, berries provide other benefits for heart health. One of these is better function of your arteries. The cells that line your blood vessels are called endothelial cells. These cells help control blood pressure, keep blood from clotting and perform other important functions.

Excessive inflammation can damage them, inhibiting proper function. The term for this is endothelial dysfunction, and it’s a major risk factor for heart disease.

Berries have been shown to improve endothelial function in studies in healthy adults, individuals with metabolic syndrome and smokers.

Important point - berries have been found to improve arterial function in several studies of healthy people, those with metabolic syndrome and smokers.

#11. Berries Are Delicious Alone or in Healthy Recipes: Berries are undeniably delicious. They make a wonderful snack or dessert, whether you use one type of berry or a mixture of two or more. Although they are naturally sweet and require no additional sweetener, adding a bit of heavy (double) or whipped cream can transform them into a more elegant dessert.

For breakfast, try berries topped with either plain Greek yogurt, cottage cheese or ricotta cheese, along with some chopped nuts. Another way to include berries in your diet is as part of a salad.

Important point - berries are delicious when served alone, with cream or in healthy recipes.

Take Home Message:

Berries taste great, are highly nutritious and provide many health benefits. By including them in your diet on a regular basis, you can improve your overall health in a very enjoyable way.

Franziska's full article with all information/research links is here.

If you may have any food allergies, or underlying health issues these must always be taken into account. If you are a diabetic and not sure how certain foods may affect your blood sugars, test is best, i.e. use your meter.