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  • Emperor penguin (Aptenodytes forsteri) are the largest of all penguins up to 3 feet, 9 inches tall, weighs up to 65 pounds. Monogamous. Males and females similar size. Nearly all arctic animals head south for the winter, needing open ocean to feed. But the EP uses this time to breed and hatch its young. After a courtship of several weeks, the couple mate, and the female lays a single egg. Female lays a single egg at the start of the Antarctic winter, March, then goes off to sea, as much as 50 miles over ice to find open ocean in which to feed. Male incubates in by keeping it warm on his feet, in a “brood pouch” for 72 days during the coldest part of the Antarctic year. He feeds the chick with a “milk” produced by a gland in the esophagus and loses about half his body weight during this time. During this time of cold, the males huddle together for warmth, rotating from the inside to the outside to warm themselves. The mother returns after 2 1/2 months or so, bringing with her food which whe regurgitates for the chick to eat. The males leave for their own fishing session at sea, while the mothers take over care of the chicks. The youngsters stay sheltered by their mothers in their brood pouches for two months. If a young chick falls out of the warm spot it can freeze to death in as little as two minutes. As they grow, their parents leave them in creches while they leave to fish, returning with food to regurgitate. By December the chicks have reached the age of independence as the ice has broken up. And the upper angle and
  • Emperor penguins Ave height 45 inches, weight 65 pounds, largest of the 17 species of penguin One of 17 species of penguin Live only in southern hemisphere Unusual in that mother lays only a single egg, which broods on the males feet. The male will stand in one place, clustered for warmth, until the mom returns in 65-72 days, losing 1/2-1/3 of his weight during this time. Mom travels up to 50 miles over the frozen ice looking for food.
  • Multivariate Relative Risk of Death from Cardiovascular Disease, Cancer, and All Other Causes among Men and Women Who Had Never Smoked and Who Had No History of Disease at Enrollment, According to Body-Mass Index. The reference category was made up of subjects with a body-mass index of 23.5 to 24.9. From:   Calle: N Engl J Med, Volume 341(15).October 7, 1999.1097-1105
  • We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative. About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.
  • We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative. About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.
  • Source: Mokdad et al., Diabetes Care 2000;23:1278-83; J Am Med Assoc 2001;286:10 .
  • Source: Mokdad et al., Diabetes Care 2000;23:1278-83
  • And next year we will weigh more
  • Young woman with 2 children, husband died 2 years ago from sleep apnea and obesity. She is 200 lbs overweight.
  • Hippocrates who stated that "sudden death is more common in those who are naturally fat than in the lean." Many writings describe fat men. Hippocrates, known as the father of medicine, wrote in 500 B.C. that obese people who wanted to lose weight could do exercise before eating and eat while still panting. He also advised a high fat diet as he considered people would get tired of fat and would eat less. (Sounds like the Atkins Diet.) Fat people should eat only once a day, sleep on a hard bed, and walk naked often. Galen believed in exercise, wiping off perspiration, then massage while deep breathing and bathing often. Food should be of 'little nourishment'.
  • After obese subjects lost weight by caloric restriction, follow-up for over 9 years was associated with the return of weight to pre-weight-loss levels in 95% of individuals. The 102 subjects were predominantly men (93%) who underwent severe caloric restriction or therapeutic starvation for morbid obesity, resulting in a mean weight loss of 28.6 kg over a minimum of 8 weeks. Of this group, only 7 remained below their initial weight for the entire follow-up period. A unique aspect of this study is the length of follow-up and the notable fact that no better outcome has been established by other studies conducted for varying times of follow-up. [22] Modified from Drenick and Johnson. [23] From:   Schwartz: Arterioscler Thromb Biol, Volume 17(2).February 1997.233-238
  • 45. Wadden TA, Sternberg JA, Letizia KA, Stunkard AJ, Foster GD. Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five-year perspective. Int J Obes. 1989;13(suppl 2):39-46. 89 women treated for 16 weeks with or without behavioral therapy.
  • An extra live-saver a day is 10 pounds in ten years; an extra slice of bread a day is 100 pounds in 10 years.
  • From:   Rosenbaum: N Engl J Med, Volume 337(6).August 7, 1997.396-407
  • From:   Rosenbaum: N Engl J Med, Volume 337(6).August 7, 1997.396-407
  • From:   Rosenbaum: N Engl J Med, Volume 337(6).August 7, 1997.396-407
  • *Figure 1. Body mass index (BMI) of men and women before, during, and after their stay in Biosphere 2, demonstrating the significant decrease in BMI caused by weight loss that occurred during the period of restriction of energy intake. Data are means, and error bars indicate SE.*
  • Diet-induced weight loss decreases REE, which contributes to weight regain. This phenomenon has led to the "set-point theory," which proposes that body weight is predetermined so that weight loss (or weight gain) will decrease (or increase) metabolic rate, to return body weight to a preset value [ 74 ]. Hypocaloric feeding in either lean or obese persons causes a 15 to 30 percent decline in REE, which cannot be explained completely by the concomitant decrease in body size or lean body mass and is part of the normal metabolic adaptation to energy restriction [ 75 ].
  • Very high levels in Prader-Willi
  • Faced with stairs or escalator, use the stairs. Faced with a choice of an easy food or difficult food, choose the more difficult food (pictures of peanuts in the shell, peaches canned and whole, whole wheat berries vs bread)
  • Every patient is somebody’s child. Remember how they feel.
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    1. 1. Emperor Penguin
    2. 2. The Penguin Diet – Lose 1/3 of your weightLose 1/3 of your weight in 10 weeks!in 10 weeks! Without exercise!Without exercise! The Penguin WayThe Penguin Way
    3. 3. Why store calories as fat? Fat 9 kcal/gm Protein 4 kcal/gm Sugars and carbohydrates 4 kcal/gm
    4. 4. Evolution and weight . . .
    5. 5. Is obesity bad for you? • Diabetes • High blood pressure • Sleep apnea • High cholesterol • High triglycerides • Coronary artery disease • Congestive heart failure • Cancer • Gallbladder disease • Joint disease • Gastroesophageal reflux disease • Stress urinary incontinence • Fatty liver disease • Infertility • Pseudotumor cerebri
    6. 6. Body Mass Index (BMI) = wt (kg) /Ht (m) 2 -- 5 ft 6 in – 100 lbs → BMI 16 – 150 lbs → BMI 24 – 217 lbs → BMI 35 – 248 lbs → BMI 40 – 300 lbs → BMI 48 – 450 lbs → BMI 73
    7. 7. Mortality associated with obesity “Ideal” weight BMI 20-25 “Overweight” BMI 25-30 “Obese” BMI > 30
    8. 8. Of Apples and PearsOf Apples and Pears • Body types more strongly predict comorbidities of weight. • Body type more strongly inherited than weight.
    9. 9. Diabetic Not Diabetic 6’3” 373 lbs, BMI 48.5 5’9” 559 lbs, BMI 82
    10. 10. We have successfully evolved…
    11. 11. Overweight (BMI > 25) 2/3 of US adults Obese (BMI > 30) 15% obese 1980 23% obese 1990 > 31% obese today At least 3-5% > 100 pounds overweight
    12. 12. Obesity Trends* Among U.S. Adults BRFSS, 1985(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%
    13. 13. Obesity Trends* Among U.S. Adults BRFSS, 1986(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%
    14. 14. Obesity Trends* Among U.S. Adults BRFSS, 1987(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%
    15. 15. Obesity Trends* Among U.S. Adults BRFSS, 1988(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%
    16. 16. Obesity Trends* Among U.S. Adults BRFSS, 1989(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%
    17. 17. Obesity Trends* Among U.S. Adults BRFSS, 1990(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%
    18. 18. Obesity Trends* Among U.S. Adults BRFSS, 1991(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
    19. 19. Obesity Trends* Among U.S. Adults BRFSS, 1992(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
    20. 20. Obesity Trends* Among U.S. Adults BRFSS, 1993(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
    21. 21. Obesity Trends* Among U.S. Adults BRFSS, 1994(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
    22. 22. Obesity Trends* Among U.S. Adults BRFSS, 1995(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
    23. 23. Obesity Trends* Among U.S. Adults BRFSS, 1996(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%
    24. 24. Obesity Trends* Among U.S. Adults BRFSS, 1997(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%
    25. 25. Obesity Trends* Among U.S. Adults BRFSS, 1998(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%
    26. 26. Obesity Trends* Among U.S. Adults BRFSS, 1999(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%
    27. 27. Obesity Trends* Among U.S. Adults BRFSS, 2000(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%
    28. 28. Obesity Trends* Among U.S. Adults BRFSS, 2001(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    29. 29. (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    30. 30. Obesity Trends* Among U.S. Adults BRFSS, 2003(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    31. 31. Obesity Trends* Among U.S. Adults BRFSS, 2004(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    32. 32. Obesity Trends* Among U.S. Adults BRFSS, 2005(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
    33. 33. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1990 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    34. 34. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1991-92 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    35. 35. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1993-94 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    36. 36. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1995-96 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    37. 37. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1995 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    38. 38. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1997-98 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    39. 39. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1999 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    40. 40. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 2000 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    41. 41. Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 2001 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    42. 42. One third of US children born 2000 predicted to become diabetic • African Americans – Females 49% – Males 40% • Hispanic – Females 53% – Males 45% • White – Females 31% – Males 27% Center for Disease Control, June 2003 Life expectancy to decline in coming generations from obesity related illness.
    43. 43. Where are the Weapons of Mass Destruction?
    44. 44. Obesity is not . . . • An eating disorder-- – Bulemia, anorexia not more common among obese
    45. 45. Obesity is not . . . • A psychological disorder -- – Psychological interventions (psychotherapy) largely ineffective at producing weight loss.
    46. 46. Obesity is . . . • A consequence of progress. – Obesity is more prevalent among the richer countries than the poor. • Rapid increases in China and India
    47. 47. Obesity is not a choice
    48. 48. Obesity is not a choice.
    49. 49. Are we just not trying? • 30% of men and 45% of women claim to be dieting
    50. 50. 50 Billion dollars spent yearly on weight loss programs
    51. 51. Obesity increasing in all ages (No, we don’t mean exercise.)
    52. 52. Are we just not trying? • Initial dietary diary
    53. 53. Are we just not trying? • Weight Watchers twice yearly x 20 years, max 100 lbs weight loss • Physician supervised liquid protein diet • Jenny Craig • Phen-Fen • Meridia • Single mother, children ages 12 and 14 • Husband died of obesity and sleep apnea 2 years ago.
    54. 54. Are we just not trying? • Follow up diary – Or have we just given up?
    55. 55. Hippocrates’ diet prescription • Exercise and eat while panting. • Perform hard labor. • Eat a high fat diet once daily. • Sleep on a hard bed. • Walk naked as much as possible. ”. . . sudden death is more common in those who are naturally fat than in the lean.”
    56. 56. Weight maintenance following diet alone . . . 102 patients undergoing supervised mean weight loss of 28.6 kg over 8 or more weeks. Only 7/102 remained below their starting weight for 9 years. From: Schwartz: Arterioscler Thromb Biol, Volume 17(2).February 1997.233-238
    57. 57. Diet and behavioral therapy . . . Wadden, et al. Int J Obes. 1989;13(suppl 2):39-46.
    58. 58. Drug therapy -- Orlistat . . . Two year prospective, randomized, placebo-controlled trial of Orlistat From: Davidson: JAMA, Volume 281(3).January 20, 1999.235-242
    59. 59. Obesity -- is it genetic? • Twin studies suggest that about 60- 80% of obesity is genetic.
    60. 60. Obesity: Is it Genetic? • Obese -- leptin • Diabetes -- leptin receptor • Fat • Tubby • Agouti yellow • Mahogany Over 200 genes implicated in humans so far. . .
    61. 61. Obesity: Is it Genetic?
    62. 62. Obesity: Is it Genetic?
    63. 63. Diabetes and insulin resistance -- common molecular defects
    64. 64. The Common Sense Diet One pound = 3,500 Calories Calories in - Calories out = weight gain or loss Eat less +Exercise more Perfect weight control
    65. 65. But, it’s hard to fool mother nature . . . The “Set-Point Theory” of Weight Control
    66. 66. The “Barostat” ↑ 24 hour energy expenditure ↑ Exercise expenditure ↑ Thermic effect of eating ↑ Thyroid function ↑ Heart rate, blood pressure ↓ Ghrelin Elevated body weight Usual body weight
    67. 67. The “Barostat” ↓ 24 hour energy expenditure ↓ Exercise expenditure ↓ Thermic effect of eating ↓ Thyroid function ↓ Heart rate, blood pressure ↑ Ghrelin Reduced body weight Usual body weight
    68. 68. The “Barostat” ↑ 24 hour energy expenditure ↑ Exercise expenditure ↑ Thermic effect of eating ↑ Thyroid function ↑ Heart rate, blood pressure ↓ Ghrelin ↓ 24 hour energy expenditure ↓ Exercise expenditure ↓ Thermic effect of eating ↓ Thyroid function ↓ Heart rate, blood pressure ↑ Ghrelin Elevated body weight Reduced body weight Usual body weight
    69. 69. Changes in Plasma Lipids and Lipoproteins in Humans During a 2-Year Period of Dietary Restriction in Biosphere 2 Archives of Internal Medicine Volume 158(8) April 27, 1998 900-906. Verdery, Roy B., PhD, MD; Walford, Roy L.,MD
    70. 70. Biosphere 2 Subjects • All subjects lost weight during study • Weight stabilized during second year • All weight regained following study
    71. 71. What happens when we lose weight with a diet? Leibel, Rosenbaum, Hirsch, NEJM 1995
    72. 72. Can surgery provide safe, effective weight loss? • Alter ability to eat volume of food--operations on stomach. • Alter ability to absorb food -- operations on small bowel. • But its not neurosurgery!!!!!
    73. 73. Adjustable Gastric Banding • Relatively safe operation • Adjustable depending on weight loss or side effects • Weight loss variable but very good in some patients • Weight loss strongly dependent on regular follow up with surgeon
    74. 74. Sleeve Gastrectomy •Weight loss may be similar to band •Lack long-term follow up •Greater early side–effects •Greater early complications •Fewest late complications •Not covered by insurance
    75. 75. Distal Gastric Bypass with Duodenal Switch • Riskiest of the weight loss operations. • 75% of stomach removed • Food bypasses about ½ of small intestine • Decreases food intake • Decreases absorption • Gas and loose stools • Significant risk of malnutrition
    76. 76. Roux Y Gastric Bypass • Food bypasses stomach, eliminating reservoir • “Dumping syndrome” with sweets • Hormonal changes may diminish hunger • Bypasses stomach -- watch for B12, iron, calcium deficiency • Recommended by National Institutes of Health
    77. 77. Gastric Band •Slower weight loss •Fewer major surgical complications. •Requires more intensive followup and band adjustments. •Mechanical complications and pouch dilation may occur late. Gastric Bypass •Faster weight loss and resolution of diabetes. •More major surgical complications. •Longterm risk of vitamin deficiency, ulcers and intestinal obstruction. •Weight loss may be more reliable.
    78. 78. 14 Year Followup in 608 Patients After Gastric Bypass Mean Wt % Excess Body Mass Index (lb) Wt Loss Preop 304.4 (198-615) 49.7 (33.9-101.6) 1 year 192.2 (104-466) 68.9 (10.3-124) 31.5 (19.1-69.3) 5 years 205.4 (107-512) 57.7 (-14.6-115.9) 33.7 (19.6-7.16) 10 years 206.2 (130-388) 54.7 (-0.9-103.1) 34.7 (22.5-64.7) 14 year 204.7 (158-270) 49.2 (7.2-80.9) 34.9 (25.9-54.6) Poiries, 1995
    79. 79. LAP-BAND Outcomes Author Year # patients BMI Follow-up %EWL O’Brien 2001 700 45 6 yr 53% Cadiere 2000 652 45 2 yr 62% Fielding 1999 335 46 1.5 yr 62% Dargent 1999 500 43 3 yr 64% Belachew 1998 350 43 4 yr 64% Total 2537 53%-64%
    80. 80. A Well-Adjusted Band • Weight loss • 1-2 pounds per week • Calories from solid foods • Thick breads and thick meats may be difficult • Eat slowly • Chew thoroughly • Comfortably eat a small selected solid meal • Liquids go down easily • Don’t drink with solids • No high calorie liquids
    81. 81. Diabetes following bypass • 608 patients – 146 patients diabetic – 152 patients IGT • At four months: • 83% of diabetics normal glucose, insulin, A1C • 98.7% of IGT normal glucose, insulin, A1C • Similar benefits from lap band – just slower Poiries, 1995
    82. 82. Measuring Success -- • 70-90% of diabetics in remission • Significant improvements in sleep apnea, hypertension, lipid disorders, joint disease But most patients are still overweight . . .
    83. 83. Significant decrease in deaths due to heart disease, diabetes, cancer • 1. Sjöström L et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741-52 • 2. Adams TD et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357:753-61 • 3. Sowemimo OA et al. Natural history of morbid obesity without surgical intervention. Surg Obes Relat Dis. 2007;3:73-77 •Swedish Obese Subjects (SOS) study: 31.6% reduction in adjusted overall mortality rate in surgical groups vs. conventional treatment (1) •A collaborative research project in Utah: 40% mortality reduction in gastric bypass patients vs. controls (2) •Social Security Death Index and office records: 50%-80% mortality reduction benefit with surgical intervention (3)
    84. 84. Are there risks we haven’t anticipated? • WLS patients had 58% greater death rates from non- disease causes (e.g. accidents, suicide, drug overdose) vs control Adams, et al. N Engl J Med. 2007;357:753-61 – Unrecognized presurgical mood disorders, post-traumatic stress disorder, victims of childhood sexual abuse? – Changes in alcohol/drug metabolism? • Teenage girls undergoing WLS have high risk of unplanned pregnancy. Inge, et al
    85. 85. One year later . . .
    86. 86. Who is a candidate for surgery? • BMI > 40 • BMI 35-40 with significant comorbidities – Diabetes – Sleep Apnea, hypoventilation syndrome – Heart disease – Joint disease requiring prosthetic replacement – Severe gastroesophageal reflux Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991 Mar 25-27;9(1):1-20
    87. 87. Insurance Issues • Some but not all insurance carriers cover Weight Loss Surgery – check your plan. • “Centers of Excellence” may be centers of cheapness. • Questions to ask: – Is weight loss surgery a covered benefit? – Are there pre-requirements? – Can I have my surgery at Community Hospital? • Get it in writing. • Document your conversations: time, person, conversation.
    88. 88. QuickTime™ and a DV/DVCPRO - NTSC decompressor are needed to see this picture. Laparoscopic surgery speeds recovery
    89. 89. Preoperative Evaluation • Primary care referral – Mammograms? – Colonoscopy? – Health maintenance? • Laboratory, cardiovascular testing • Dietary evaluation and counseling • Psychiatric evaluation • Please complete your packet!
    90. 90. How long does it take? • Surgery – 45-90 minutes • Hospital stay – 1-2 days (sometimes outpatient) • Preparation for surgery – 6 weeks -? • Results – a minimum of 5 years, but in truth, forever . . .
    91. 91. Who is not a candidate for surgery? • Patient doesn’t want it • Patient doesn’t need it. • Medically unstable -- no such thing as an emergency weight loss operation. • Serious psychiatric illness, substance abuse, poor impulse control • Noncompliance. • Age
    92. 92. Ghrelin • Produced in fundus of stomach • Rises during weight loss and fasting • Stimulates appetite and fat accumulation
    93. 93. Ghrelin variation abolished by gastric bypass Plasma Ghrelin Levels after Diet-Induced Weight Loss or Gastric Bypass Surgery Cummings, David E., et al. N Engl J Med 2002 346: 1623-1630
    94. 94. The “Good Diet” Menu: • Breakfast – Oatmeal or All Bran or Kashi Go Lean cereal with nonfat milk • Lunch – Spinach salad with tuna, beans, or grilled chicken • Dinner – Broiled fish or poultry breast – Steamed vegetables or spinach salad – Wild rice, beans or lentils • If you get hungry in between, consider: – Fresh vegetables > berries or fruit (not juice) – Nonfat mozarella – Soy nuts
    95. 95. Side effects • Pain • Difficulty swallowing • Vomiting • Nausea • Hair loss • Diarrhea or constipation • Depression
    96. 96. Complications I • Bleeding • Infection • Phlebitis or pulmonary embolus • Heart attack or stroke • Coma or death -- roughly 1/200 patients undergoing weight loss surgery will die from procedure related complications. • Surgical complications less with band than bypass
    97. 97. Bypass Complications II • Anastomotic leakage • Anastomotic obstruction • Intestinal obstruction/internal hernias • Gallstone formation • Reoperation
    98. 98. Complications Gastric Banding • Band erosion • Ulcer formation • Gallstones • Port malfunction • Device malfunction/deterioration
    99. 99. Complications Gastric Banding • Pouch dilation Gastric prolapse
    100. 100. Complications III • Psychological adaptation • Iron deficiency • Other nutrient deficiencies • Excessive weight loss • Weight regain or inadequate weight loss
    101. 101. What happens if you don’t take your vitamins?• Your hair will fall out. • You will develop dry, flaky skin and sores in your mouth. • You may feel more tired than you should. • Your spine can gradually collapse, leaving you hunched over and in pain. • You can break your hip with a minor fall and require surgery. • Your feet and hands may go to sleep or burn so badly that you cannot stand or wear socks or shoes. • You can lose your ability to walk. • You can lose your sense of balance. • You can go blind. • You can develop cancer. • You can develop heart failure. • You can lose your ability to understand speech. • You can require a blood transfusion. • You can develop dementia. • You can die.
    102. 102. Weight loss and conditioning before surgery?!? • Weight loss surgery is elective surgery. • Improves safety. • Speeds postoperative recovery. • Psychological preparation.
    103. 103. If I don’t want surgery, what? • Choose your parents carefully. • Turn back the clock: – Decrease access to food – Fewer carbohydrates – Fewer processed foods – More sidewalks – Fewer cars, TVs, computers • Nutrition Services at CHOMP
    104. 104. •Approved by the American Heart Association as a heart healthy food. •110 calories and 27 gms simple carbohydrates per 8 oz serving – more than most soft drinks! Brought to you by Coca Cola . . Trust no one . . .
    105. 105. Because we love them we will not allow our children to . . . • Play in the street • Do without seat belts • Go to bed without brushing their teeth • Play with knives • Smoke • Use drugs • Drink soft drinks • Eat fast food If you want to use drugs or eat fast food, don’t do it in front of your children.
    106. 106. What about our kids? Diets don’t work. Lifestyle modifications might: – Don’t use food as reward. – Be aware of eating. – Eat dinner together. – Teach nutrition. – No kids’ meals – Kill the TV

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