Hunger Hormones May Be Dieters' Worst Enemy - in Primary Care, Obesity from MedPage Today

There could be a REASON why we fail diets. Or -- diets fail us.

One year after initial weight reduction, levels of the circulating mediators of appetite that encourage weight regain after diet-induced weight loss do not revert to the levels recorded before weight loss. Long-term strategies to counteract this change may be needed to prevent obesity relapse.

Ghrelin.  You may have heard of this evil little hormone.

Nature -

Do you follow?

*blink blink*  Wikipedia tells me --

Ghrelin  is a 28 amino acid peptide and hormone that is produced mainly by P/D1 cells lining the fundus of the human stomach and epsilon cells of the pancreas that stimulates hunger.^[1] Ghrelin levels increase before meals and decrease after meals. It is considered the counterpart of the hormone leptin, produced by adipose tissue, which induces satiation when present at higher levels.

In some bariatric procedures, the level of ghrelin is reduced in patients, thus causing satiation before it would normally occur.

Medical News: Hunger Hormones May Be Dieters' Worst Enemy - in Primary Care, Obesity from MedPage Today.

Hormones regulating when a person feels hungry or sated do not rapidly adjust to weight loss, which may be a factor in the yo-yo effect observed among dieters, researchers found.

One year after losing weight, levels of appetite-regulating hormones didn't revert to baseline levels, Joseph Proietto, PhD, of Heidelberg Repatriation Hospital in Australia, and colleagues reported in the Oct. 27 issue of the New England Journal of Medicine.

The findings suggest that the "high rate of relapse among obese people who have lost weight has a strong physiological basis and is not simply the result of the voluntary resumption of old habits," Proietto and colleagues wrote.

It's well established that heavy patients who lose weight dieting often fail to keep the pounds off, the researchers explained.

Studies have shown that restricting calories can lower levels of the hormones leptin -- which tells the brain that the body is full -- and ghrelin -- which stimulates hunger.

Doesn't this also help explain why some forms of weight loss surgery ... work better overall in the long term?  In certain types of WLS -- most of ghrelin producing factor -- is removed. 

Go DS.  Or not. It's up to you.  Surgery flame wars!

DSFacts.com -

Approximately 70% of the stomach is removed along the greater curvature, also called a vertical sleeve gastrectomy (VSG). The remaining stomach is fully functioning, banana shaped and about 3 - 5 oz in size which restricts the amount you can consume. The pylorus continues to control the stomach emptying into the small intestine; as a result patients do not experience "dumping". The upper portion of the duodenum remains in use; food digests to an absorbable consistency in the stomach before moving into the small intestine. This allows for better absorption of nutrients like vitamin B12, calcium, iron and protein when compared to gastric bypass procedures.

A benefit of removing a portion of the stomach is that it also greatly reduces the amount of ghrelin producing tissue and amount of acid in the stomach.

Ghrelin is the "hunger hormone" and by reducing the amount of the hormone produced the appetite is suppressed.

Study -

Sumithran P, et al "Long-term persistence of hormonal adaptations to weight loss" N Engl J Med 2011; 365:1597-1604.

Duodenal switch = more weight lost + more risks?

While the roux en y gastric bypass is the most commonly performed weight loss surgery procedure, many people are choosing other surgeries.  One of them:  the duodenal switch, is often preferred by patients due to the better long term weight loss, and honestly, the dietary restrictions aren't as harsh as other post op weight loss surgery procedures.  (I'd have one if I could.  Just saying.)

But, it's risky.  (They all are.  Don't hit me.)    

SOURCE: bit.ly/mQAUrf 

Annals of Internal Medicine, online September 6, 2011.

NEW YORK (Reuters Health) - A less common form of obesity surgery may spur more weight loss than its far more popular cousin, gastric bypass -- but at the price of greater long-term risks, researchers reported Tuesday.

The study, published in the Annals of Internal Medicine, followed 60 severely obese patients who were randomly assigned to either gastric bypass surgery or a more extensive procedure known as duodenal switch.

Less anxiety after duodenal switch surgery?

Anxiety and depression appear to be somewhat relieved 1-2 years after duodenal switch surgery, a small study shows:

Anxiety and Depression in association with Morbid Obesity: Changes with Improved Physical Health after Duodenal Switch

Posted: 10/06/2010; Health and Quality of Life Outcomes. 2010;8(48) Â© 2010 BioMed Central, Ltd.

Abstract

Background: Patients with morbid obesity have an increased risk for anxiety and depression. The "duodenal switch" is perhaps the most effective obesity surgery procedure for inducing weight loss. However, to our knowledge, data on symptoms of anxiety and depression after the duodenal switch are lacking. Furthermore, it has been hypothesized that self-reported physical health is the major predictor of symptoms of depression in patients with morbid obesity. We therefore investigated the symptoms of anxiety and depression before and after the duodenal switch procedure and whether post-operative changes in self-reported physical health were predictive of changes in these symptoms.

Methods: Data were assessed before surgery (n = 50), and one (n = 47) and two (n = 44) years afterwards. Symptoms of anxiety and depression were assessed by the "Hospital Anxiety and Depression Scale", and self-reported physical health was assessed by the "Short-Form 36" questionnaire. Linear mixed effect models were used to investigate changes in the symptoms of anxiety and depression. Correlation and linear multiple regression analyses were used to study whether changes in self-reported physical health were predictive of post-operative changes in the symptoms of anxiety and depression.

Results: The symptom burden of anxiety and depression were high before surgery but were normalized one and two years afterwards (P < 0.001). The degree of improvement in self-reported physical health was associated with statistically significant reductions in the symptoms of anxiety (P = 0.003) and depression (P = 0.004).

Conclusions: The novelty of this study is the large and sustained reductions in the symptoms of anxiety and depression after the duodenal switch procedure, and that these changes were closely associated with improvements in self-reported physical health.

___________________________________________________________________________

Although - I have to mention my eyes diverted to this while reading the study - click on it to read it - 

Which came first?  Yeah.  Chicken > egg > omelet.

Would she have the DS again?

A video from Lori - several years post op after her duodenal switch - a very realistic view of her feelings of life now.  This is awesome to see - because she's telling the truth.  

If you listen carefully - many of the same foods that bother her as a DS'er are the same issues that bother me as a roux en y gastric bypass post op.  

And, clearly, she's much, much thinner.  ;)

A Typical DS Diet in Pictures

Post by Bronwen, DS Sister -

So, it's the new year, and a lot of people have made resolutions to do something, anything, about their weight.  There are Weight-Loss boards flooded right now with people looking for solutions.  Many people are coming to the end of their collective rope and are contemplating surgery.  It's important to choose your surgery before you choose your surgeon, and also to choose a surgery that will allow you to eat in a way that you are going to be able to maintain.  Be real, people - I knew I could never maintain a low-fat, low-sugar, low-calorie diet in the long run.  Been there, done that, outgrew every size T-shirt on the way up to a 4x.  Melting Mama has chronicled for years what she's been eating.  I figure I'll do the same today, just to show you the differences.

Ok, so I was thinking about trying to explain what it is I can eat, being a 3.5 year DS (Duodenal Switch) post-op, and I thought pictures would be helpful, too.  I took these photos about two weeks ago, so they aren't exactly typical in that I don't eat out every day.  Most of the time, I pack my lunch.  Since I was Christmas shopping, I got to have lunch at an actual restaurant!

So for breakfast:

I hit the Dunkin Donuts and had a large Iced Coffee with cream and sugar, hash browns, and a sausage, egg, and cheese on a croissant.  I threw away the bottom of the croissant because I got the hash browns.  The coffee lasted me most of the morning, as I sipped it as I shopped.

Then, there was a snack that I had when I stopped home to drop off the first round of packages:

It's a piece of homemade peanut butter candy dipped in chocolate that one of my husband's coworkers made.  It was pretty good!

I went back out for more shopping, stashed my purchases in the trunk, and went to Panera for lunch (mmmmmmm!!!!!!).

It was pretty sunny in my window seat.  I got the BBQ Chopped Chicken Salad, a piece of whole-grain baguette (and 7 pats of butter), a diet pepsi, and a shortbread cookie.  It was heavenly!

I got home late in the afternoon and was starving, so I had a snack.  I made iced coffee at home and heated up some party-sized meatballs that I'd had left over in the fridge.

Later, I made a salad for dinner, too.  This isn't really typical of me, either, since I'd normally nom a pot roast waaaaaay before I'd crunch up a salad, but they just tasted good to me.  So here was my Asian Chicken Salad:

I threw a bag of salad in the bowl, chopped up some cilantro and onions, and threw on some chow mein noodles and salted cashews.  Had I had a red pepper in the drawer, I'd have julienned some of it and mixed it in there too, but alas, I was pepper-free.

There was dessert, too.

More homemade candy - a caramel and a piece of toffee, and a Yodel!

About 9:30, my stomach started growling again, so I had my last snack.

Extra sharp cheddar cheese and some whole wheat crackers with the rest of my iced coffee.

It looks like a lot, now that I see it all laid out in pictures.  You certainly would never suspect that I'd had eighty-five percent of my stomach removed.  I take my time eating, but it's not abnormally slow.  I don't have any food intolerances, although I've heard of people that do - lactose intolerance is fairly common after RNY and DS.  I had a cast-iron stomach before my DS.  I suspect that my surgeon had to use a laparoscopic blowtorch to cut through it.

I know a few of you are thinking "Regain?"  The answer is no.  I maintain between 152-157 naturally by eating this way.  If I go above 157, I throttle back on the sweets and my weight drops back into range.  It's also important to note that I didn't start eating cookies and candy until I'd lost the majority of my weight - I lost 145 pounds total, and have maintained that loss.  I weigh every day.  That doesn't work for everyone, but it's what works for me.

I didn't show my vitamins in there - I took 'em, though!  Breakfast, lunch, and bedtime.

So that's my DS Diet in pictures.  Any questions?

/Bronwen's post

MM adds - You know, that intake quantity is about the same as I can eat at five years however many months out now with a RNY.  HOWEVER, we know that eating like that with an RNY = My Ass.

Finding your style post WLS

A long time ago, before I'd even thought about having weight loss surgery, I ran across an article in whatever women's magazine was hanging around at the nail salon on these two women who' made a succesful business out of defining other women's personal style in two words.  Imagine: tow words that completely encapsulate your wardrobe philosophy.  What would they be?

I'm sure these two style mavens also provided recommendations for your style if you wanted to change it up some.  Imagine if you came out with a "dowdy dowager" when you were going for "yummy mummy!"  You'd want some advice, wouldn't you?

Well, that article pinged around my little brain for a bit while I analyzed my big ol' plus-sized wardrobe.  Were I a fashionista armed with a thesaurus, I'd have declared it "frumptastically stodgy."  I've always leaned toward the classics - well-made, fairly conservative investment pieces - and had tried to cobble together a collection of ensembles from Roaman's, Jessica London, and Lane Bryant.  There was no ultra-cool Torrid or chic Igigi when I was plus-sized.  Ultimately, though, I fell short: many of the pieces, though expensive, were ill-fitting or cheaply made. 

Facing facts was hard, too.  I'd never gone into wardrobe planning at a size 24 thinking I was going to stay a size 24.  After all, I was always on some kind of diet.  I'd always seen my clothing as temporary or disposable, so I really didn't invest much thought into them beyond "Does it fit?  Does it cover the bulges?  Is it a dark color?"  Clothes shopping itself was done on a desperation basis - when everything else was either completely unsuitable, too small (again!) or stained/ripped/holey and the choice was between going shopping or calling in to work naked the next day.

After weight loss surgery is when I began seriously thinking about my clothes.  I was shrinking out of them at such a rapid rate, that replacing them often was a priority.  Suddenly, calling in naked was an all-too-real scenario!  Add to that the sudden influx of possibilities in the styles of clothing I could wear, and I was headed out to sea in the misses department.  Remembering that article helped me a lot.

The first thing I did was to try and put the style I admired and wanted to emulate into a two-word capsule.  That forced me out of the "temporary" mindset and to believe that I was going for a permanent change.  I thought about the dainty clothing that I'd always loved - the soft fabrics, delicate lace, and feminine frills - but had felt to awkward and ungainly to wear.  I reexamined how I felt about the solid elegance of the classic pieces I'd always wanted in my closet - the clean tailored lines that flattered the figure.  I wanted to wear both, so I needed a combination that reflected that.  I distilled it down to Modern Romantic.

The next thing I did was to ask my real-life style inspirations where they shopped.  It was so easy!  I've found that almost as soon as you compliment another woman on an article of clothing, they can't wait to tell you where they got it and if it was on sale (and with my friends, it usually was!).  I found a bunch of stores that I'd previously avoided had turned into veritable gold mines of inspiration.

Lastly, after years of watching Trinny and Susannah, and then Stacy and Clinton, I took that advice on the road and "shopped" in these new stores.  I didn't buy anything for the longest time - I was still too large for most of them.  But I'd analyze the clothing according to my new criteria: would it be flattering?  is it a nice color?  would it work with anything else in my closet?  is it a "Modern Romantic" sort of piece?  All those years of What Not To Wear had finally paid off!

I now have a complete wardrobe full of clothes that I've been able to wear for the last two years (sort of - this is the third fall that I've fit into the same clothes, so I suppose it's "going on" three years).  It's got tons of frilly blouses, lacy camisoles, fussy skirts, and delicate accessories combined with the classically-styled staple pieces - the trousers, blazers, and pencil skirts.  I can mix and match with the best of them.  And they last, too!  No longer do I have to throw away my pants because my thighs have rubbed holes in the inseams.  My shirts are no longer irrevocably stained from falling sauce splattering my bounteous bosom.  And nothing has to leave my wardrobe because it's gotten too small.  Fancy that!

There is a downside, however, to having an extensive wardrobe full of clothing that fits you, though: you find yourself getting sick of your clothes long before you'd ever have to get rid of them!  Ah, it's a tough life, sometimes... ;-)

Do you watch Lost?

   

I just finished watching seasons 1-4, hoping to catch up with the story before the last season airs.  My favorite character is Hurley, because I can identify so much with him.  He often doesn't get it right, but always tries hard with the best of intentions.  Money has been a source of sadness and stress for him.  The jolly fat person loved by all, but also universally derided for the weakness implied by being overweight.  And don't forget the stigma of mental illness.

What I'm eating this week

So, I’ve always been a tad anal-retentive about dinner.  I can wing it for breakfast, and lunch is usually leftovers from dinner the night before, but dinner itself?  I’ve planned my dinners a week at a time for the last 16 years, using the market flyer to help me find the bargains.  When my husband and I were first living on our own, I’d print out a monthly calendar and fill it in with all of the scrumptious dinners that I was going to fix that month.  It gave me something to look forward to.

Yeah, foodie much?  Totally.  Unabashedly.  Unapologetically.  I. LOVE. FOOD.

This post brought to you by the letter V...

…for Vitamins!

You know, I’ve never minded taking vitamins.  My stepmother used to set out a Vitamin C tablet for me every morning with my Flintstones when I was little.  In a household with two working parents, they couldn’t afford for my brother or me to be sick.

When I was on one of the Big-Name Diet Plans, I was taking a small handful of vitamins with every meal.  Calcium, Essential Fatty Acids, a Proprietary Mineral blend, and a daily Vitamin supplement, all two or three times daily.  The reasoning was that if one is consuming fewer than 1000 calories a day, then one needs to supplement vitamins, as one is not getting adequate vitamins from one’s food.  Good to know, huh?

I had heard from various sources that I’d be taking small mountains of vitamins after my Duodenal Switch in order to maintain my health.  I figured if I got to trade in prescriptions for vitamins, I’d come out ahead of the game.  You know what?  I totally did.

Here’s what that small mountain of vitamins looks like when I break it down into one week’s worth of doses:

I’ve got Calcium Citrate (6 tablets daily), a multivitamin (one daily), Zinc (3 capsules daily), Vitamin A (one capsule 3-4 times a week), a Probiotic (3 capsules daily), Vitamin D (one capsule daily), and Vitamin K (one capsule daily).

I take the vitamins in the pink container at breakfast.  I toss the purple container in my lunchbag and take them at lunch.  The green container holds my bedtime vitamins.

All that’s left is to now wonder “is that it?!”  I mean, I was totally prepared to be making meals out of vitamins and all I’ve got is a few capsules to swallow before my meal?  That’s not even an hors d’œuvre for crying out loud!  But really, it’s not the number of pills that you take that you should look at – it’s the dosages.

I take some fairly high dosages of the fat-soluble vitamins, as those are the ones that DSers malabsorb the most: Vitamins A, D, E, and K.  Currently, I take 50,000 ius of Vitamin D; 10,000 ius of Vitamin A, and 1000 mg of Vitamin K.  I take more Zinc than the average DSer, too, because apparently, my body doesn’t care for Zinc and eliminates it quite quickly.  Sure, there are some DSers that are taking higher doses of these vitamins than I do.  There are also some DSers that require less than I do.  Really, with any surgery, your level of supplementation is going to vary with your individual body chemistry.  I have a very good friend who has an RNY and is very malabsorptive.  Had she had the DS, she may well have been consuming those small mountains of vitamins.  We’ll never know, happily.

However, with any malabsorptive surgery, be it the Duodenal Switch or the RNY, vitamin and mineral supplementation should be a top priority.  Tums and Flintstones are NOT adequate supplementation, and any bariatric practice that does not require further vitamin supplementation is ignorant at best and criminally negligent at worst.  Whew!  Glad I got that off my chest.  Who knew vitamins came with a soapbox?

As you can see, I’m passionate about those vitamins.  Did you take yours today?

In which I get more than I ever dreamed of.

Last you heard, I had enlisted my husband’s support in my quest to have Weight Loss surgery.  It was given grudgingly and somewhat conditionally.  My husband had quite snarkily asked me what my father would think about that choice, fully expecting my father to come down on the side of “No way, Jose.”

 

Are you glad you did it?

  

By Christina:

There is no simple yes or no answer to this question for me.  Just a few days ago, when I was at the end of my cash and had forgotten to take any meat out of the freezer for dinner, I wished I could fill my belly with a cheap meal of cheesy pasta with tomato sauce.  Unfortunately, my belly has decided that even a small portion of that is evil.  I was mourning the "easy food" days pre-surgery, days when I didn't have to plan what to eat because all food was edible and I didn't have to worry about protein.  I was hating having had WLS.

In which I charge into battle for my choice...

Last season’s cliffhanger ended where my husband challenged me to explain exactly and in detail why I wanted the Duodenal Switch and not the other surgeries available to me.  All I can say is that I was very glad that I’d had all that time to prepare for this argument and that I’d spent all of those lunchtimes eating with my colleague, H.  I’d printed out a list of studies for him and was ready to present the data.

In which I convince my husband that diets don't work

So, last I left off, I’d told you how gung-ho I was on getting weight loss surgery, right? 

Oh no, another DSer ?

From Christina - another switch sistah:

Let me say thank you to Beth for inviting me to add my thoughts here.  I've been quite grateful to have this blog to read because it's let me know that there are people with issues after WLS.  Mine has been seriously increased chemical sensitivities.  I simply cannot tolerate fake foods - artificial sweeteners, protein shakes, microwave dinners, etc. make me bloat up and generally feel awful.

Guess who's coming for dinner?

I know you were expecting Melting Mama, but surprise!  It’s not!  My name’s Bronwen, and Beth has said I can write here for a while.  I’ve had weight loss surgery, too – a Duodenal Switch.  Wait!  Don’t run away!  I don’t bite!