• Adolescent Bariatric Surgery
• Genetic and Biochemical Response to Obesity
• "Understanding" Nutrition
• American Heart Walk

Adolescent Bariatric Surgery
By SHERYL WILLIAMS

Introduction and Background

Americans are gaining weight at an astonishing pace. Obesity is swiftly becoming an epidemic in this country. According to findings based on a national survey conducted in 2003-2004 and reported in the April 5 issue of The Journal of the American Medical Association, seven out of ten U.S. adults are overweight or obese.¹ This trend is magnified in our children. According to www.actionforhealthykids.org, 19 million children between the ages of six and 19 are overweight. The incidence of childhood obesity has doubled for children and tripled for adolescents.² It is estimated that 80 percent of overweight children become obese adults.³ Development of co-morbid conditions such as Type 2 Diabetes, heart disease, sleep apnea, osteoarthritis, high blood pressure, elevated cholesterol, metabolic and hormonal syndromes, and depression; once mostly prevalent in overweight adults, are now being seen at alarmingly increasing rates in children.

Obesity has reached prevalent proportions and health care costs associated with weight-related illnesses have skyrocketed. A sedentary life combined with access to an abundance of energy-dense food has lead to an increase in this chronic disease with national health care costs reaching $70 billion per year.⁴ It is interesting to note health care dollars are consumed with the treatment of weight-related diseases and not primarily focused toward research and prevention. The best, most effective intervention for the treatment of obesity is prevention. At risk of stating the obvious, prevention implies it is to be implemented before the onset.

The definition of obesity as used in this paper reflects a medical diagnosis generally indicated by an individual’s body mass index (BMI), a height to weight ratio. Adults are classified as overweight when their BMI is between 25-30, and classified as obese when it is above 30. Children and Adolescents are deemed overweight when their Body Mass Index is greater than the 95^th percentile when compared to a mean value of other children of the same age and gender. A child is defined as “at risk for overweight” if their weight-to-age percentile is greater than 85 percent and less than 95 percent. The term obesity is not used as a means for judgment or as a physical observation. The World Health Organization, the American Medical Association, the National Institute of Health, the American Dietetic Association, and the Internal Revenue Service identify obesity as a disease. Obesity develops from a complex interaction between genetic and environmental factors and therefore is a multi-factorial chronic disease.⁵

Behavior Component

Behavior, in the case of morbid obesity, relates to food choices and portion sizes, and to what degree of physical activity one participates. Americans are consistently consuming more calories. The increased consumption of fast, processed, ready-made foods not only contribute to the increase in caloric intake, it also correlates to a decrease in overall nutritional quality. We are a nation of over fed, under nourished people. The ever increasing portion sizes while dining out directly correlates to increased portion sizes while eating at home. Learned behaviors from parents are another major contributor dictating whether a child is overweight or obese.

The influence of television, computers and other technologies discourage physical activity and add to the problem of obesity in our society. While Americans are consuming more calories, they are expending less by decreasing physical activity. Today’s society has developed a more sedentary lifestyle. Walking has been substituted with driving cars, physical activity has been replaced by technology and nutrition has been overpowered by convenience foods.

Genetic Component

Evidence for a strong genetic contribution of human obesity comes from a variety of sources. Twin and familial aggregation studies suggest that genetic factors account for 60 to 80 percent of the predisposition to obesity.⁶ Biological relatives are apt to resemble each other in numerous ways, including body weight. Individuals with a family history of obesity may be predisposed to gain weight. Family history is used to identify at risk individuals, especially children, for integrated prevention efforts. The risk of obesity is doubled if a child has a parent who is overweight, tripled if the parent is moderately obese and five times greater if the parent is severely obese.^a,b,d The number of genes, markers, and chromosomal regions associated with obesity phenotypes is currently well over 400.^7,a In fact, the 2000 human obesity gene map includes genes on every chromosome except the Y chromosome.⁸

There is no magic bullet to fight obesity. In an environment that sustains a readily available resource for a vast array of food, individuals will respond differently to this stimulus. Some individuals store fat more readily in an environment of excess, others lose less fat in an environment of famine. It has been suggested that obesity is so heterogeneous and polygenic that there will be no major genes; rather, 20 or more common gene variations may each contribute their part in the genetic burden of obesity.⁹ Seldom do people have a mutation in a single gene that causes severe obesity. However, research is providing valuable insight into the complex biological pathways that regulate the sensitive balance in relation to energy input and energy output. Obese individuals have similar genetic profiles that may open the doors to understanding the biological differences that predispose some individuals to gain weight. Continued research will be extremely beneficial in the treatment of obesity in these at risk individuals.

Environmental Component

Moreover, while genes appear to enhance the vulnerability toward obesity, other determinants must be present for obesity to occur. It is important to recognize that the genetic expression of obesity and the biochemical regulations occur more readily in an environment that enables the body the opportunity to accumulate excessive food intake and more efficiently store fat. Simply stated, if one cannot find it or cannot get it, one cannot eat it! Environmental influences and technological advances include an overall decrease in physical activity while at the same time provides an increase in food availability, directly proportionate to the increase in consumption of more calorie dense, readily available and thus extremely easily obtainable foods. Our lifestyles have become increasingly more stressful while at the same time we have become increasingly more sedentary. Environmental factors can be magnified in adolescents. Teens eat with their families and they eat what is served, but are also able to purchase food on their own and consume it when they wish.

Just as the disease of obesity is multi-factorial, so the discovery for a cure will have to be also. Just as there is no one, singular cause for obesity, it is quite doubtful that there will be only one, singular gene, biochemical or environmental aspect that will ultimately bring an end to this epidemic. However, current research continues to substantiate that obesity is not simply a matter of willpower or lack thereof.

According to the National Institute of Health, diets for the purpose of sustained and significant weight loss have a 98 percent failure rate. We have become a nation of veteran dieters. If one diet actually achieved what it promised to do, wouldn’t we have found it by now? Honestly, it’s not in finding a diet that works because all of them work to some degree – one loses weight. However, the true test is in finding a diet that works for good.

With ever increasing food portion sizes, eating out more frequently, changes in the overall composition of the food we eat, our increase in overall daily calorie consumption, and the steadily decrease in physical activity; the fueling of the obesity epidemic will continue to blaze. For individuals who are genetically predisposed to weight gain, prevention is the best course of treatment. Genes are not destiny. The management of obesity, though proven more difficult for some than others, is possible. Gastric bypass surgery is considered to be the most effective “tool” available for the management of this chronic disease. Morbid obesity is not simply the result of overeating. It is a serious disease that needs to be prevented and treated. Obesity is a complex problem related to a multitude of contributing factors including our genes, environment, biology, actions, and our attitudes.

Obesity Stigma

The startling rates of obesity have brought extensive awareness to the medical consequences of this public health problem. Often unnoticed are the social and personal obstacles that overweight and obese individuals face. Bias, stigma, and discrimination due to weight are common experiences for many obese individuals. Discrimination against the morbidly obese individual is the last socially acceptable form of prejudice in our society. This discrimination has grave consequences on personal and social well being as well as overall health. Weight stigma plays a part in daily life, including work, school and healthcare settings.

Perceptions about the causes of obesity contribute to weight stigma and bias. The severely obese person faces a hostile public attitude that begins with the assumption that obesity is solely brought on by a lack of willpower. Assumptions that obesity can be prevented by self-control, that individual non-compliance explains failure at weight-loss, and that obesity is caused by emotional problems, are all examples of attitudes that contribute to this negative bias.¹⁰ Because of society’s misperception, little sympathy and often times open ridicule is expressed and the morbidly obese person is viewed as being exclusively responsible for his or her own grief. An obese individual is more likely to be stigmatized if their obesity is perceived to be caused by controllable factors such as personal choices rather than caused by uncontrollable factors such as a thyroid condition.¹¹

The obese adolescent faces multiple forms of weight stigmatization, the most prevalent occurring in school. They face various obstacles in the educational setting, ranging from pestering and rejection from peers, to biased attitudes from teachers. Negative attitudes have been reported as early as among pre-school children, ages three to five, who associated overweight peers with characteristics of being mean, stupid, ugly, lazy, and having few friends.¹² At least 30 percent of overweight girls and 24 percent of overweight boys report being teased by peers at school.¹³ Teachers report that obese students are perceived as untidy, more emotional, less likely to succeed at school, and more likely to have family problems.¹⁴

The consequences of weight related bias can have serious and negative impact on an individual’s quality of life. Weight bias can have psychological, social and physical health consequences. Psychological consequences from weight stigmatization can include depression, anxiety, low self-esteem and poor body image. Social consequences from weight stigmatization can include rejection by peers, poor quality of interpersonal relationships, and the potential negative impact on academic performance. Physical health consequences from weight stigmatization can include unhealthy weight control practices, binge-eating, and avoidance of physical activity.¹⁵ The cost of this discrimination can acutely impact an individual’s quality of life, from early childhood through adulthood, and only further strengthen the negative stigma associated with obesity.

Bariatric Surgical Intervention

Pediatric obesity has serious health consequences and is now considered the most pressing nutritional disorder among children and adolescents.¹⁶ Surgical treatment of obesity is an option for those who are medically classified as morbidly obese. Morbid obesity is defined as a patient having a BMI of 40 or greater or weighting more than 100 pounds over their ideal body weight. A patient with a BMI between 35 and 40 with one or more obesity-related diseases is also medically classified as morbidly obese and meets the generally accepted criteria for surgical intervention.

Gastric bypass surgery is considered to be the most effective “tool” available for the management of this chronic disease. It is not a cure. After weight-loss surgery, individuals must still modify their lifestyle habits, adjust their diet and increase their physical activity. Weight loss surgery is considered when the risks of the obesity and its corresponding co-morbidities (diabetes, high blood pressure, heart disease, strokes, osteoarthritis, sleep apnea, some cancers, liver disease, acid reflux disease, menstrual irregularities, etc.) outweighs the risk of not having surgery. Surgery is a powerful means to reduce weight and related co-morbidities. Behavioral, physical and psychological changes are also required to maintain a healthy quality of life.

The BMI criteria for surgical intervention for adolescents are based upon the same criteria for adults. Using the currently utilized growth chart standards, an adolescent with a BMI over 40 surpasses the 95^th percentile. However, the timing of surgical treatment for adolescents is controversial and in most cases depends on each individual’s physiological factors and health needs, as well as their decision-making capability. Physiological maturation is generally complete by sexual maturation and is normally attained by age 13-14 in girls and age 15-16 in boys.¹⁷

The adolescent represents a vulnerable and challenging population, whose varying stages of cognitive development and propensity for risk-taking behavior can present high risks for weight regain and consequences of noncompliance with medical and lifestyle recommendations. Some surgeons are reluctant to promote weight loss surgery to patients of this age group because of concerns about intellectual maturity and the ability of adolescents to fully comprehend and comply with the recommended postoperative requirements. Close long-term follow up is of utmost importance in the adolescent population.

Emerging data has demonstrated that weight loss surgery, particularly laparoscopic Roux-en-Y gastric bypass, is a safe and effective means of treating obesity-related co-morbidities in the adolescent patient.¹⁸ The scientific literature on pediatric obesity presents strong arguments for encouraging methods to prevent the

onset of obesity in youth.¹⁹ Unfortunately, for the 19 million children in the United States who are already classified as overweight, prevention is not an option.

Research

Similar to the adult obesity epidemic, a new adolescent obesity epidemic is on the rise. The younger the obese patient, the greater the loss in terms of life expectancy.²⁰ Childhood obesity might further increase the health burden on an already strained healthcare system. Bariatric surgery has proved to be safe and effective in adults, achieving long-term weight reduction and maintenance and reducing obesity-related co-morbidities.²¹ Data regarding surgery for obesity in adolescent patients is scarce. At a recent conference of the American Academy of Pediatrics, bariatric surgery has been advocated as an effective tool to treat severely obese adolescents, in particular, Roux-en-Y gastric bypass and adjustable gastric banding.²² Bariatric surgery in adolescents represents only a small proportion of all bariatric operations performed in the United States; however, bariatric surgery in this age group is increasing.

Perioperative outcomes of bariatric surgery in adolescents compared with adults at academic medical centers²³

J. Esteban Varela, M.D., M.P.H., Marcelo W. Hinojosa, M.D., Ninh T. Nguyen, M.D., F.A.C.S.

Research article and oral presentation from the 2007 annual meeting of the

American Society of Bariatric Surgery, San Diego

Esteban Varela, MD, MPH – Study’s lead author and director of

Minimally invasive surgery, VA North Texas Health Care System and Assistant Professor of Surgery, University of Texas Southwestern Medical School, Dallas.

Using the International Classification of Diseases, 9^th Revision, Clinical Modification diagnosis and procedural codes, data was obtained from the University Health System Consortium for 55,501 morbidly obese patients, 309 adolescents and 55,192 adults, who had undergone gastric bypass or gastric banding surgical procedures from 2002 to 2006. The outcome measures included demographics, length of hospital stay, intensive care unit stay, 30-day readmission, morbidity, and observed and expected mortality.

Of the adolescents studied the mean BMI was 42-51 kg/m², 231 or 75% were female, and 75% were white. The severity of illness as classified from the ICD (International Classification of Diseases, 9^th Revision) codes ranked 58 percent as minor, 38 percent as moderate and 4 percent at major. Adult rankings were 48 percent each for minor and moderate, and 4 percent for major. The overall 30-day complication rate was significantly lower in the adolescent group (5.5% adolescents and 9.8% adults). In adolescents, the 30-day morbidity and mortality rate was 0%.

Bariatric surgery in adolescents represents a small subset of all bariatric operations performed, although the number has increased threefold since 2002. Gastric bypass is the most commonly performed bariatric procedure in adolescents. The outcomes of bariatric surgery in adolescents appear to be as safe as those in adults.²⁴

“Bariatric surgery in adolescents has been controversial. We now know that it is as safe as in adults, with fewer complications,” Stated Dr. Varela. The study shows that the number of teenagers undergoing bariatric surgery has dramatically increased since 1999.²⁵ Bariatric surgery among adolescents has tripled in the last five years, although teenagers comprise still only a small portion of the overall bariatric population. Bariatric surgery has a high safety record in children. No American teenager is known to have died from complications related to a bariatric procedure.²⁶ Though Dr. Varela was encouraged by the results, he cautioned that more studies are needed to define the long-term effects of surgery in teenagers.

Discussion of Study

The increasing incidence of obesity in pediatric populations is especially startling because of the substantiated belief that there will be consequential increase of obesity-related morbidity and mortality as adolescents mature. Surgical therapy for obesity is extremely effective in terms of weight reduction and decrease or reversal of co-morbidities. Nutritional monitoring and supplementation among bariatric programs has been widely variable, so much more so within the adolescent population due to its small division of the overall surgical population. Maturity compliance issues also contribute to a variable degree of care. The long-term nutritional effects and recidivism of chronic food restriction and nutrient mal-absorption in growing and developing adolescents still needs to be determined, studied and addressed.

The focus should be on the value for the patient over the lifetime of care not just on whether the patient lived or died or did or did not have a medical complication. In addition to morbidity and mortality, life-long measurements of adherence to and effectiveness of recommendations for nutritional supplement intake needs to be monitored and reported. Adolescents have more of their life still remaining to be lived. Nutritional, psychosocial, and emotional implications as well as degrees of recidivism after adolescent bariatric surgery should also be monitored.

Weight loss surgery should be considered as a viable and safe operation for severely obese teenagers who have tried and failed to lose weight with diet and lifestyle changes. The earlier the intervention the better the chances are to avoid future health problems and improve quality of life.

Research continued

Initial outcomes of laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents²⁷

Joy Collins, M.D., Samer Mattar, M.D., Faisal Ureshi, M.D., Juanita Warman, M.S.N., C.R.N.P., Ramesh Ramanathan, M.D., Philip Schauer, M.D., George Eid, M.D.

The influence of laparoscopic bariatric surgery in adolescents is not as well identified as in adults. For this reason, assessment of the short-term outcomes of adolescents undergoing laparoscopic Roux-en-Y gastric bypass were evaluated. Medical records of patients under 18 years of age who had undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity from 1999 to 2005 were reviewed. The resulting variables examined included preoperative body mass index, percent of excess weight lost for those with at least three months of follow-up, length of hospital stay, postoperative morbidity and mortality, changes in co-morbid conditions, and effect of surgical weight loss on quality of life.

Eleven patients (seven girls and four boys) had undergone laparoscopic Roux-en-Y gastric bypass. The mean follow-up was 11.5 months. The average patient age was 16.5 years. The average body mass index was 50.5 kg/m². The average number of co-morbidities was 5.3, 70% of which improved or resolved postoperatively. No mortalities resulted. The quality-of-life surveys obtained from nine patients reflected an overall improvement in self-esteem, social functioning, and productivity in school or the workplace.

Obese adolescents experience adverse social and psychological effects that can contribute to a sense of isolation and rejection, with later disturbances in body image and difficulty forming social relationships. In addition, obese adolescents frequently have associated co-morbidities that are often progressive and potentially life-threatening.²⁸ The approach in this study involved a multidisciplinary team of practitioners with experience in dealing with individuals of this age group. The parents or legal guardians were included in every evaluation and all visits. A special protocol using guidelines recognized by the American Society of Bariatric Surgeons and the American College of Surgeons was developed. The program protocol involved a team of expert bariatric surgeons, anesthesiologists, adolescent bariatric medicine specialists, bariatric clinicians, bariatric nurse specialists, and adolescent psychologists, nutritionists, and exercise physiologists.

A nutritional evaluation took place and focused on detailed weight and dietary histories, the identification of environmental cues that encouraged or promoted inappropriate eating behavior, screening for protein and vitamin deficiencies, and education regarding the appropriate postoperative nutritional and exercise programs required for success.²⁹ A psychological evaluation was also conducted by an authority in adolescent development. To be considered for surgery, the adolescent was required to demonstrate reasonable expectations of the surgery, an understanding of the possible outcomes, and the motivation and ability to comply with postoperative follow-up regimens and recommendations.³⁰ The additional goals of the psychological evaluation were to provide counseling and education concerning the lifestyle changes required after bariatric surgery and to determine the existence of social and family support structures.

The conclusions from this study suggest that laparoscopic gastric bypass is an effective weight loss treatment for morbidly obese adolescents. The patients in this study had substantial weight loss and improvement in overall health and self-reported quality of life after bariatric surgery. No mortalities occurred. The co-morbid conditions in this study correspond to those reflected in adult obese patients. Data has suggested that such improvements in hypertension and diabetes that can be either improved or resolved after weight loss surgery, can lead to salvage of potentially lost years of life.³¹

Discussion of Study

Again, issues with patient compliance with respect to the required vitamin, dietary, and exercise regimens are difficult to ascertain. Enhancement of postoperative compliance is best improved through extensive preoperative patient screening and education. Intensive follow-up protocol involving the surgeon and members of the multidisciplinary team is equally necessary. The involvement, support, and cooperation of parents and family members are essential. A more aggressive patient and family educational protocol regarding the importance of follow-up care was a direct result of this study.

In the adolescent population, long-term compliance with postoperative recommendations, dietary and exercise programs, and follow-up visits may be difficult to monitor. Adolescents being considered for bariatric surgery should be able to adapt to new situations and solve problems, understand the consequences of taking or not taking nutritional supplements, and understand the importance of following and adhering to the prescribed medical and nutritional course of therapy. Therefore, a dedicated team of practitioners committed in a multidisciplinary approach to the life-long treatment of adolescent patients is crucial.

Conclusion

In two studies published in The New England Journal of Medicine, evidence is offered that it is safer to have bariatric surgery than to remain morbidly obese. Obese individuals who undergo bariatric surgery to lose weight will add years to their lives. The Journal cites 15,000 Americans and 4,000 Swedish obese individuals who underwent surgery have at least a 30% lower risk of dying over a 10-year period than a group of similarly matched obese people who did not have surgery.³² How much so will these years matter, when the length of life remaining is greater than the number of years currently lived?

Obesity is a complex disease with genetic, hormonal, neurological, psychological, nutritional, social, metabolic, physical and environmental causes. Only within the past 15 years has obesity been medically recognized as a chronic (persistent) disease having complex origins, affecting most, if not all aspects of life. Simply decreasing caloric intake and increasing energy expenditure does not always result in significant or sustained weight loss for every individual. Each individual is unique and each individual stores and burns fat differently.

The current obesity epidemic does not spare adolescents. The need to prevent obesity from an early age is critical. Preventing obesity needs to be a population-wide initiative, not merely one focused on obese children. Obesity is one of the most common metabolic disorders. The increasing prevalence of obesity in pediatric populations is especially alarming because of the probability that there will be consequential acceleration of obesity-related morbidity and mortality as adolescents mature. Surgical intervention for obesity is extremely effective in terms of weight reduction and reduction or reversing co-morbidities. Without effective behavioral and/or dietary programs to treat severe obesity among adolescents, increasing numbers of surgical weight loss interventions are being performed within this young age group.

Adolescent bariatric surgery requires an extended methodology of success and its proper value should be based on longer-term outcomes. Comparative measurements of overall weight loss and even longer term measurements of possible weight regain also need to be studied. Nutrition outcomes related to this life-long surgical procedure, as well as noncompliance issues, risk-taking behaviors, and improved health-related overall quality of life, are all areas requiring further documentation and research. Of special interest for the adolescent would be insights and measures of compliance with not only nutritional supplement intake and outcomes, but with follow-up visits and adaptation of healthier lifestyle behaviors.

A life-long multidisciplinary, integrated, family-oriented approach is of utmost importance when providing surgical options to the adolescent. Adolescent bariatric surgery must bring together medical specialists, surgeons, endocrinologist, nutritionists, behavioral specialists, and lifestyle coaches. The involvement, support, and cooperation of parents and family members is essential. An aggressive patient and family involved educational component is equally critical. Additionally, it is vital for this life-long follow-up to consistently include every member of the multidisciplinary team.

Obesity is a multi-factorial chronic disease. We eat for a thousand different reasons and the least of those reasons is nutrition. After surgery the relationship with food needs to change. One does not choose to have gastric bypass surgery because they wish to stay the same. One chooses to have gastric bypass surgery because they are ready to change their life. Making the decision to undergo gastric bypass surgery is taking a courageous stride toward changing one’s life forever. Only when a healthy lifestyle change occurs will any eating plan work. Gastric bypass surgery is not a miracle nor is it a cure for obesity. It is a tool – a very powerful tool. Changing one’s lifestyle after gastric bypass surgery can be an amazing adventure. A multidisciplinary team helps pave the road to this adventure. It must be realized that gastric bypass surgery is not the end of the adventure. It is the beginning. Know what that adventure is called? It’s called life!

“Overcoming my obesity has given me opportunities that I would have never had. It has given me hope and a determination that I have not ever known before. I made the greatest decision of my life…I choose life! I chose to get help and the surgery has changed my life forever! No regrets, no looking back, no more being the fat kid. No more standing on the sidelines. No more feeling hopeless and depressed. I have a future and I am walking on sunshine!”

John Edgar, postoperative adolescent
underwent surgery at age 17, preoperative weight of 406 pounds, BMI 66.
Postoperative weight loss 221 pounds as of 2006.³³

###

The following article was published in the April 2007 edition of Beyond Change.

Genetic and Biochemical Responses to Obesity
By SHERYL WILLIAMS

Americans are gaining weight at an astonishing pace. Obesity is swiftly becoming an epidemic in this country. According to findings based on a national survey conducted in 2003-2004 and reported in the April 5 issue of The Journal of the American Medical Association, seven out of ten U.S. adults are overweight or obese.¹ This trend is magnified in our children. According to www.actionforhealthykids.org, 19 million children between the ages of six and 19 are overweight. The incidence of childhood obesity has doubled for children and tripled for adolescents.² It is estimated that 80 percent of overweight children become obese adults.³ Development of co-morbid conditions such as Type 2 Diabetes, heart disease, sleep apnea, osteoarthritis, high blood pressure, elevated cholesterol, and depression; once mostly prevalent in overweight adults, are now being seen at alarmingly increasing rates in children.

Obesity has reached prevalent proportions and health care costs associated with weight-related illnesses have skyrocketed. A sedentary life combined with access to an abundance of energy-dense food has lead to an increase in this chronic disease with national health care costs reaching $70 billion per year.⁴ It is interesting to note health care dollars are consumed with the treatment of weight-related diseases and not primarily focused toward research and prevention. The best, most effective intervention for the treatment of obesity is prevention.

The definition of obesity as used in this paper reflects a medical diagnosis generally indicated by an individual’s body mass index (BMI), a height to weight ratio. Adults are classified as overweight when their BMI is between 25-30, and classified as obese when it is above 30. The term obesity is not used as a means for judgment or as a physical observation. The World Health Organization, the American Medical Association, the National Institute of Health, the American Dietetic Association, and the Internal Revenue Service identify obesity as a disease. Obesity develops from a complex interaction between genetic and environmental factors and therefore is a multifactorial chronic disease.⁵ It is this genetic component and related biochemical physiological responses to this complex multifactorial chronic disease that is to be the focus of this paper.

Evidence for a strong genetic contribution of human obesity comes from a variety of sources. Twin and familial aggregation studies suggest that genetic factors account for 60 to 80 percent of the predisposition to obesity.⁶ Biological relatives are apt to resemble each other in numerous ways, including body weight. Individuals with a family history of obesity may be predisposed to gain weight. Family history is used to identify at risk individuals, especially children, for integrated prevention efforts. The risk of obesity is doubled if a child has a parent who is overweight, tripled if the parent is moderately obese and five times greater if the parent is severely obese.^a,b,e The number of genes, markers, and chromosomal regions associated with obesity phenotypes is currently well over 400.^7,a In fact, the 2000 human obesity gene map includes genes on every chromosome except the Y chromosome.⁸

Approximately 30 years ago, two genes believed to be a factor in the development of obesity were discovered. They were called the ob and the β3-adrenoreceptor genes. The β3-adrenoreceptor gene, located primarily in adipose tissue, is thought to regulate the resting metabolic rate (RMR) and fat oxidation. It is speculated that persons with a mutation of this gene may have an increased ability to gain weight by increasing the body’s efficiency to store fat. Fat stores are regulated over long periods of time. Overweight and obesity can come about from only a minute positive energy intake imbalance over an extended period of time.

With regard to the ob gene however, mice lacking the ob gene developed severe obesity.⁹ This gene in mice is considered to be identical in its correlation to humans. Leptin was later discovered as the protein coded for by the ob gene that acted as a satiety factor. Leptin receptors in the hypothalamus augment the negative feedback mechanism signaling to the brain the feeling of fullness (satiety) resulting in a reduction in energy (food) intake. The critical differentiation between the experimental leptin-deficient mouse and the obese individual is the absence of leptin in letpin-deficient mice versus high levels of leptin in obese patients. This yielded the conclusion that morbidly obese patients (BMI > 40) are leptin-resistant rather than leptin-deficient.

As the study of genes lead to the study of leptin, the study of leptin has lead to the study of ghrelin. Ghrelin is a gastric hormone regulated by the hypothalamus by which production is increased by lack of food in the stomach. Leptin and Ghrelin are reportedly opposing metabolic counterparts, regulated reciprocally by alterations in energy balance.¹⁰ In people, ghrelin concentrations increase abruptly before and decrease rapidly after each meal. Ghrelin and leptin, are both satiety regulatory hormones. Current genetic and biochemical research leads to the perception that in morbidly obese patients, the signaling functions of both hormones are considered to be defective. Gastric bypass patients are less hungry post-operative because the portion of the stomach that signals ghrelin production no longer receives food and therefore it is expected to see low levels of ghrelin in these individuals¹¹.

Last year another gene was associated with obesity, as published by the genetics and genomics department at Boston University’s medical school. This new study ascertains that five percent or one in every ten people, including children, has a gene variant pattern (mutation) linked to obesity. At present, the report only suggests an “association” between the gene variant and obesity. The researchers of this study found that when two copies of a particular gene variant were present, people had a higher BMI and were more likely to be obese.¹²

There is no magic bullet to fight obesity. In an environment that sustains a readily available resource for a vast array of food, individuals will respond differently to this stimulus. Some individuals store fat more readily in an environment of excess, others lose less fat in an environment of famine. It has been suggested that obesity is so heterogeneous and polygenic that there will be no major genes; rather, 20 or more common gene variations may each contribute their part in the genetic burden of obesity.¹³ Seldom do people have a mutation in a single gene that causes severe obesity. However, research is providing valuable insight into the complex biological pathways that regulate the sensitive balance in relation to energy input and energy output. Obese individuals have similar genetic profiles that may open the doors to understanding the biological differences that predispose some individuals to gain weight. Continued research will be extremely beneficial in the treatment of obesity in these at risk individuals.

Moreover, while genes appear to enhance the vulnerability toward obesity, other determinants must be present for obesity to occur. It is important to recognize that the genetic expression of obesity and the biochemical regulations occur in an environment that increases the ability of the body to accumulate excessive food intake and more efficiently store fat. Environmental influences and technological advances include an overall decrease in physical activity while at the same time provides an increase in food availability, directly proportionate to the increase in consumption of more calorie dense, readily available and thus extremely easily obtainable foods. Our lifestyles have become increasingly more stressful while at the same time we have become increasingly more sedentary.

Just as the disease of obesity is multifactorial, so the discovery for a cure will have to be also. Just as there is no one, singular cause for the obesity epidemic, it is quite doubtful that there will be only one, singular gene or biochemical aspect that will ultimately bring an end to this epidemic. However, current research continues to substantiate that obesity is not simply a matter of willpower or lack thereof.

According to the National Institute of Health, diets for the purpose of sustained and significant weight loss have a 98 percent failure rate. We have become a nation of veteran dieters. If one diet actually achieved what it promised to do, wouldn’t we have found it by now? Honestly, it’s not in finding a diet that works because all of them work to some degree – one loses weight. However, the true test is in finding a diet that works for good.

With ever increasing food portion sizes, eating out more frequently, changes in the overall composition of the food we eat, our increase in overall daily calorie consumption, and the steadily decrease in physical activity; the fueling of the obesity epidemic will continue to blaze. For individuals who are genetically predisposed to weight gain, prevention is the best course of treatment. The management of obesity, though proven more difficult for some than others, is possible. Gastric bypass surgery is considered to be the most effective “tool” available for the management of this chronic disease. Genes are not destiny. Obesity is a complex problem related to a multitude of contributing factors including our environment, our biology, our actions, our attitudes, and our genes.

###

References: 

¹ Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM, Prevalence of Overweight and Obesity in the United States, 1999-2004; JAMA. 2006;295:1549-1555.

^2-3 Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity Among US Children, Adolescents, and Adults, 1999-2002. JAMA. 2004;291:2847-2850

⁴ Wolf AM, Coldtiz GA, Current Estimates of the Economic Cost of Obesity in the United States, JAMA. 1999; 282: 1530-1538

⁵ National Institute of Health and National Heart, Lung and Blood Institute. Clinical Guidelines on the identification, Evaluation, and Treatment of Over-weight and Obesity in Adults – The Evidence Report. Obes Res. 1998: xi

⁶ Maes HH, Neale MC, Eaves IJ, Genetics and Environmental Factors in Relative Body Weight and Human Adiposity. Behav Genet. 1997; 27: 325-335

^7-8 Perusse L et al: The Human Obesity Gene Map: the 2000 update, Obes Res 9:135, 2001

⁹ Nijhuis J, Van Dielen FMH, Buurman WA, Greve JWM, Review Article-Leptin in Morbidly Obese Patients: No Role for Treatment of Morbid Obesity but Important in the Postoperative Immune Response. Obes Surg 2004: 14, 476-483

¹⁰ Fruhbeck G, Diez-Caballero A, Gil MJ, Montero I, Gomez-Ambrosi J, Salvador J, Cienfuegos J, The Decrease in Plasma Ghrelin Concentrations Following Bariatric Surgery Depends on the Functiona Integrity of the Fundus. Obes Surg 2004: 14, 6006-612

^11,iiNijhuis J, Van Dielen FMH, Buurman WA, Greve JWM, Ghrelin, Leptin and Insulin Levels after Restrictive Surgery: a 2-Year Follow-up Study, Obes Surg, 2004:14:783-787

¹² Herbert A, Obesity Epidemic Balloons to New Girth, News Release, Science, Harvard School of Public Health. April 14, 2006; Vol. 312: 279-283

¹³ Shuldiner AR, Sabra M: TRp64Arg β3-Adrenoceptor: When Does a Candidate Gene Become a Disease-Susceptibility Gene? Obes Res 9:806, 2001

Additional References:

Bray GA, Contemporary Diagnosis and Management of Obesity. Health Care Co: Newtown PA; 1998:35-67

iKoza RA, Mikonova , Hogan J, Rim JS, Mendoza T, Faulk C, Skaf J, Kozak L, Changes in Gene Expression Foreshadow Diet-Induced Obesity in Genetically Identical Mice. PloS Genetic. 2006:2: 769-780

Website References:

^aOffice of Genetics and Disease Prevention, Center for Genomics and Public Health, University of Washington, Public Health Perspectives:  What We Know, What We Don’t Know and What it Means

^bCDC Public Health Perspective

^cObesity Gene Map

^dCenter for Nutrigenomics at UC Davis

^eAmerican Dietetic Association

^fAction for Healthy Kids

The following article was published in the November 2004 5th Anniversary "Special" Edition issue of Beyond Change.

"Understanding" Nutrition
By SHERYL WILLIAMS

A recent telephone call started me thinking...

Over the past several months my office has been receiving an increasing number of telephone inquiries from post-operative patients. Most calls are from individuals whose surgeons “made” them call, others are from those referred simply by word-of-mouth. These inquiries are from patients who are around two-to-three years post-op who received inadequate, very little, or no nutritional counseling. Consequently, they are re-gaining significant weight or they never quite lost what they wanted to lose in the first place. They feel like their surgery failed or worse, they’ve failed – again.

Considering...

Three years ago it wasn’t a requirement from many insurance companies as well as from the surgeon’s office for patients to received nutritional support before or after gastric bypass surgery. Any nutritional information provided from the surgeon’s office was considered, by the patient, as the basic information needed to get through the first three months after surgery and therefore most likely wasn’t incorporated into life-long, lifestyle changes. Three years ago very few nutritionists were knowledgeable about bariatric surgery except in the case where it was their job to “save us from ourselves” and “talk us out of obesity surgery.”

Even still today, I meet individuals who tell me of their negative experiences when they picked a nutritionist from the yellow pages and were treated with disrespect. They speak of arriving at an office where there wasn’t one chair that would accommodate their size so they sat quietly, politely, albeit uncomfortably, at an angle in a chair with arms. They speak of feeling “less than human” because the consultant kept looking them in the stomach instead of in their eyes. They express how they felt they were spoken “at” instead of listened “to”. And, heaven forbid if the counselor smiled!

In all fairness, many dietitians are very over worked and underpaid, especially those working within their internship requirements before becoming a registered dietician. Speaking as one who still has her internship to look forward too, I am fully aware how difficult it will be to take up to a year out of my life, put in long hours for little or most likely no pay, and still work fulltime elsewhere because you simply have too; not to mention balance all that, in my case and many others too, with being a wife and a mother.

However; still in all fairness, I too was one of those individuals sitting at a nutritional consultation where another chair had to be brought in to accommodate my 300 pound size. I know how it feels to have someone talk to your stomach instead of to your face. I can’t tell you how many copies of the Food Pyramid I’ve received – for goodness sake, I remember when we only had the Four Food Groups! I still remember the words spoken in frustration and yes, disgust by my last nutritional support counselor, “I cannot understand why ‘you-people’ don’t simply push yourselves away from the table and jog around the block.” To which I replied, “You wanna go jogging? Let’s go! But, you’ve got to wear a backpack filled with 155 pounds of bricks.” After the uncomfortable, confused pause and the statement from the counselor, “Why on earth would I want to do something like that?” I continued, “Because, that’s what I carry over and above what you carry, every day, from the moment I wake up until the moment I go to bed at night.” I think, I hope, for a brief moment, maybe the lights came on for this counselor.

I fully understand the reservations gastric bypass individuals have when required to see a nutritionist either pre-surgically or post-surgically, hopefully both. I promise not to give you a copy of the Food Guide Pyramid and tell you to eat six to eleven grasses a day. Because I know, after surgery, you’ll have a hard enough time eating six grapes! (Assuming you’re off of clear liquids then!) I won’t even give you a diet because we know, diets don’t work. Diets have a 98 percent failure rate. If we went to a podiatrist with an in-grown toenail and asked the doctor for help only to discovered that doctor had a 98 percent failure rate – we’d run outta that office as fast as our in-grown toenail would take us! However, another diet comes along and we think, “Maybe this one…maybe this time.”

Haven’t we tried all the diets known to humankind? Many we’ve even made up ourselves. Have you tried the Pork-rind and Fresca diet? Honestly, haven’t we learned something from every diet we’ve tried? We’ve learned something even if it’s what not to do or what didn’t work. The deception is in not only finding a diet that works – but in finding one that works for good. Obesity is a multifactorial disease. We eat for a thousand different reasons and the least of those reasons is nutrition. Gee, Hello! That’s my job! My personal favorite reason to eat even surpassing “because it tastes good” is simply “because it’s there!” If there was only one thing to fix regarding obesity and overeating – don’t ya think we’d have fixed it by now?

I go to the movies because I can get a huge sack of popcorn and I can get it refilled if I eat the first one fast enough! I go to the family reunion or the church potluck because “all my favorites are gonna be there!” We have so many traditions, social events, entertainment factors, habitual and emotional reasons surrounding food and the reasons why we eat. Truthfully, we don’t give it too much thought especially on a daily basis because these reasons have been instilled in us ever since we were children. Now, we have this major event in our lives and it’s called “MY GASTRIC BYPASS SURGERY!” and everything regarding food after surgery can be magnified and brought to the surface. Yes, sometimes we look back on our surgery and honestly give it credit for helping us make better choices. Or, sometimes, we blame it for making us change our choices! It’s been said, gastric bypass surgery is stomach surgery, not brain surgery. The greatest percentage of our success with gastric bypass surgery is mental. Don’t we eat most of the time with our heads rather than with our stomachs?

After surgery our relationship with food needs to change. Now we go to the movies because we want to spend an evening with family or friends and actually watch the show. Now we go to the family reunion not because “all my favorites are going to be there”, but because “all my favorite people are there.” We do not have this surgery to stay the same. We have this surgery because we’re ready to change our lives. In that same respect, we don’t have this surgery to eat for who we used to be. We have this surgery to eat for who we want to become.

As I share with all my friends – yes, I say “friends”, because they might start out as clients, but we always end up as friends – we know diets don’t work. Only if a healthy lifestyle change occurs will any eating plan work. Let’s face it. We’re smarter than our stomachs and if a healthy lifestyle with a healthy relationship with food doesn’t take place after gastric bypass surgery – the surgery then becomes the 365-day gastric bypass diet. We’ve heard it said and it needs to be said again, gastric bypass surgery is not a miracle nor is it a cure for obesity. It is a tool – a very powerful tool. My surgery is every bit as much of a tool for me this very moment as it was over eight years ago. It remains my tool because I have taken the responsibility to make the right choices that keeps this surgery my tool. And it will be my tool for the rest of my life – and that’s a good thing!

So, back to the telephone call

The response I received was…

“No offense, but I don’t think you’re gonna do if for me.” You know what? She was absolutely right. But I wasn’t the one who was supposed to “do it” – she was.

When your surgery becomes your tool then you take the credit for every single pound you lose and you take the credit for how you have changed your life. We’ve got this amazing adventure ahead of us. We must realize that gastric bypass surgery is not the end of the adventure. It is the beginning. Know what that adventure is called? It’s called life!

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American Heart Walk
By SHERYL WILLIAMS
September 20, 2003

The American Heart Association's American Heart Walk took place at Woodward Park. Teams and informational booths were sponsored by several local organizations.

Together with the American Heart Association, the First Annual "Walk from Obesity" formed a team in support of the American Society of Bariatric Surgeons.

A team of 51 walkers was assembled. Overall efforts throughout the morning were expected to serve over 1,500 participants and volunteers, raising upwards of $160,000 for the American Heart Association alone!

Both two-mile and four-mile walks began shortly after 8:00 a.m.

My nine-year-old son, Jacob, and I tackled the two-mile course. Before the walk began I made a deal with Jacob, if he went most of the way at a steady pace, I’d carry him over the finish line on my shoulders. Silly me, I should have defined the word "most".

At the half-way mark I was bombarded with, "Is this far enough yet, Mommy?"

During the last quarter mile, I kept my promise. As we crossed the finish line I made the comment to the water-boys, "Next year, he's carrying me!"

We must have looked a sight. We were filmed by the local news!

There was an obstacle course, antique fire truck rides, bounce house and face painting for the kids. In keeping with the theme of the festivities, most children were getting variations of hearts painted on their faces. Jacob chose the blue alien.

The morning was enhanced still further when we received our goodie bags! In addition to our really cool t-shirts, the goodie bags included a water bottle, a sun visor that matched our t-shirts, a talking pedometer, a Frisbee, sunscreen, note pads, pens, pencils, emery boards and candy.

We left this event around 10:30 a.m. We were so motivated; we headed off to the gym for more exercise!

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