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Aug 30 2021
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Obesity Part 5: the GB Obesitas Action List

By About obesity, Body weight regulation, News, Obesity prevention, Online resources

In our blog series “Obesity -who is to blame?” in Part 1, we have talked about how obesity is a disease, in Part 2 how we move around, in Part 3 processed food and the term “bliss point” and in Part 4 the costs of obesityand an example from Chile of what can be done about the problems in real life. We have now put together a variety of measures that have been tried or proposed in different places around the world.

The idea behind this is this: Obesity is not the fault of the individual – it is obesity-sensitive genes plus our obesogenic environment that creates the disease. Dealing with obesity as the “responsibility of the individual” is therefore both unfair and ineffective. As far as prevention is concerned, society is already acting in situations which in principle are similar: traffic, alcohol, tobacco. We have traffic rules, car testing and driving licences; alcohol tax, age limits and warning labels. Now we need the same in our “obesogenic” society.

Preventing overweight and treating obesity are different things

Preventing overweight and obesity from occurring (=primary prevention) is just as important as treating obesity disease in those already affected (=obesity care) -but the two situations require completely different measures. Primary prevention requires preventive community intervention, obesity care requires medical intervention. Measures in the list that are preventive are labeled “(PR)” as in primary, measures related to the care of already established obesity are labeled “(HC -health care)”.

Medical decisions and measures (HC)

  • Obesity should be considered a common, chronic and serious disease
  • Obesity disease is thus a central and mandatory subject in all healthcare educations, this needs to include knowledge about how the disease occurs, its physiology plus nutritional education. (All these things are completely underdeveloped in Swedish healthcare education today).
  • Evidence-based national guidelines
  • Patient follow up database for non-surgical obesity treatment, corresponding to the surgery registry SOReg. (We must document what care measures we do, which ones work and which do not, etc. In spite of the fact that the weight management industry in Sweden alone has a turnover of SEK 300 million per year, there is currently no patient follow up register in place.)
  • Drug subsidy for modern obesity drugs. If obesity is a common chronic and serious disease, then of course the medicine costs must be treated as all other medications -with subsidy.
  • All children with isoBMI > 30 are referred to an obesity-competent team (mandatory for the caregiver, children with obesity risk living 14 years shorter lives than their normal weight friends), these children’s parents should be involved and supported (not blamed).
  • Activities suitable for FAR (physical activity on prescription) – procured by Sweden’s regions from gyms, wellness and fitness centers and associations and then offered subsidized to those prescribed FAR by the healthcare system

School and Youth (PR)

  • “Walking school buses” under municipal authority
  • Ban on fast food restaurants, soft drink vending machines etc. within 500 metres of and within schools
  • Mobile phone ban in school during all school hours including breaks (probably positive for both studies and activity).
  • Subsidies for ourdoor kindergartens and preschools
  • Guidelines+control of served food at preschool and school: -educational meals, nutritional content and portion sizes; and training in nutritional science for all staff.
  • Playgrounds with roofs that are a little more comfortable when the weather is bad.

Society (PR)

  1. Sugar tax (18% tax on high sugar drinks in Chile),
  2. Black Dot labels on foods high in sugar, salt, calories or saturated fats (i.e. up to four black “dots” per food). Foods with several Black Dot labels are sold in separate sections inside the stores.
  3. Ban on ads for high-processed junk food and sweets aimed at children, ban all TV advertising for this type of product from 06:00 to 22:00 every day.
  4. Prohibition of mascots or toys for children associated with junk food, e.g . Tony the tiger at Kellogg’s or KinderEgg.
  • Ban on sweets, soft drinks and unhealthy snacks within 15 feet of the checkouts in shops
  • Water dispensers outside all grocery stores
  • Accessibility requirements for stairs (not just escalators and elevators) in all public environments (“points of decision prompts” -signs showing the way to the right choice).
  • Guarantee of at least five public areas for physical activity within a 500 metre radius of housing in all urban areas.

Do “everything at once”

None of the above listed measures alone will have a sufficient effect on society to make a difference. We need to implement many of the measures in parallell at the same time and on a large scale. Different actors in society need to work together, led and supported by policiesand legislation. We need to monitor which measures are effective (and which are not)but avoid getting “stuck” in decision making regarding what should be prioritised or not before we even get started. The efforts will, of course, in several cases cost money. At the same time you can expect society to also save the money from increased public health – and consider that overweight and obesity already cost Sweden a staggering SEK 48.6 billion per year and 3400 deaths.

Can you come up with more smart measures to prevent obesity? Get in touch with us and we can update the list!

Feel free to share!

Aug 30 2021
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Food labelling Chile

Obesity -who is to blame? Part 4

By About obesity, Body weight regulation, Food and drink, News, Obesity prevention, Online resources No Comments

In Sweden we have laws and regulations!

We have traffic legislation: we drive on the right, we have to take a test for a driving licence, have the car inspected regularly, drive sober, wear a seat belt and comply with speed limits. We even have special traffic police. The cars themselves are made increasingly safe, they are also crash tested.

We also have alcohol legislation; with age limits, Systembolaget, alcohol tax, warnings in alcohol ads. Tobacco is the same: age limits, warnings on packaging, tobacco tax and recent ban on smoking in outdoor dining areas. Drugs are completely criminalized.

 

Why do we have all this?

Couldn’t people just “take responsibility” and discipline themselves?

We have it because we know that without all this, people would be in harm’s way:

In Sweden, 324 people died and 2195 were seriously injured in traffic in 2018 (Swedish Transport Agency). Approximately 12,000 people die from smoking each year, while 100,000 fall ill with smoking-related disease (National Board of Health and Welfare/Public Health Agency of Sweden). About 2,000 people die as a direct effect of alcohol per year, in addition, alcohol caused just over four percent of the total burden of disease in 2017 (data from the international global burden of disease(GBD) project).

Society/the government thus chooses to take responsibility for the population as a group through legislation, to steer it in the right direction. One can have political opinions on the details of the above, but no one would want to abolish all the laws and regulations. Right?

 

How much does overweight and obesity cost? More than you know

At the same time, obesity disease causes at least 3,400 deaths in the country per year. The total cost of overweight is SEK 23.4 billion per year, obesity an additional SEK 25.2 billion (report IHE). Every other adult Swede is currently overweight or has obesity(Public Health Agency of Sweden).

In response to this overweight and obesity epidemic, Swedish society is currently doing -what?

Almost nothing. (Well, we have a 15-year age limit if you want to buy a can of Red Bull and there are certain rules for what advertising to children may look like.) If we translate this approach to traffic, it would be equivalent to having right-hand traffic -but forget the rest (driving licence, speed limits, alcohol, seatbelt, traffic lights)…

We have petrol, alcohol and tobacco taxes. “Fetmainitiativet” (the obesity initiative) proposed a Swedish sugar tax, but this was dismissed by the then responsible minister,who instead wanted to see a “holistic approach”. There is still no sign of this “grip”.

On the contrary, we are unbridledly exposed to advertising of high-processed foods, snacks and sweets almost everywhere. (Public service even allowed Melodifestivalen to have pure junk food as its main sponsor this year). In my large supermarket at home you have to step 20 steps(!) from the checkout to get out of the “zone” with nothing but sweets, chocolate, chips and snacks -there is now even a mini shelf at the checkout between the merchandise band and the customer with small pieces of chocolate (just at eye level for accompanying children). No warnings, no age limits. Nothing.

The same government and society that otherwise impose traffic rules, age limits, extra taxes and warning labels choose to watch passively while the population becomes increasingly exposed to highly processed foods that we know lead to obesity disease. So now we as citizens are suddenly supposed to “discipline ourselves” and take responsibility ourselves, apparently?

This is unreasonable and in every way illogical. In addition, the problem already costs us 3400 deaths and SEK 48.6 billion every year. (Let that sink in).

 

Then why doesn’t anyone do anything?

No one “knows” exactly, but let’s speculate:

Do people realise that obesity is a disease, or do they think it is a poor lifestyle choice made by the patient? Considering Swedish healthcare professionals are basically not educated about obesity disease at all, then how much do our politicians and decision-makers know? Do they think high-processed food is harmless? How strong is the food industry’s own lobbying (quite strong, one might suspect)? How much public opinion is there to help people avoid overweight or obesity?

 

The Four Black Dots

In the next part of the series we will list our proposals for society measures, but you will get a little sample here: in Chile you have a pronounced overweight and obesity problem (75% of the adult population is overweight or obese). Since 2016, there has been an action plan in place to tackle this at the community level. The reason for this: Senator Guido Girardi, who is also a trained physician.

Chile has introduced a number of interesting reforms in this area:

Soda tax: sweetened beverages have an 18 percent tax.

The four Black Dots. If a food item is unhealthy in terms of sugar, salt, caloric content or saturated fat respectively, each of these categories results in a black stop-shaped label being put on the packaging. The customer can thus directly see if an item has zero, one, two, three or, in the worst case, four black dots. The effect is obvious and immediate: no more guessing what the small print in the table of contents really means, and extremely difficult for the producer to get around the problem via misleading advertising or the like.

Result: accompanying children often point out to mom or dad themselves that they don’t want food with black stop signs on -and the industry self-adapts to avoid the black labels. (Read more in the New York Times atricle.)

– ban on junk food advertising on radio and television between 6 a.m. and 10 p.m.

– ban on mascots and cartoon characters linked to junk food (e.g. Tony the Tiger at Kellogg’s).

So it is possible to make changes -if only the will to do so is there.

In the next blog section we will list our suggestions for action – follow us!

/Carl-Magnus

Aug 28 2021
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Obesity -who is to blame? Part 3

By About obesity, Body weight regulation, Food and drink, News No Comments

On a normal day…

On the burger joint’s drive-thru: the taste of hot fresh grilled burger, a little sweetness from the dressing and bread, salty fries, bubby cola flavor from the soda -just what I needed now! (This is what a bliss point tastes like, see below!)

At the same time, at one of our info meetings: “obesity is of course my own fault, no one has forced me to eat this much…”

Meanwhile, in a social media comment field: “fat people have themselves to blame, no one has forced them to put all that rubbish in their mouths…”

At the same time, in a boardroom: “… we see excellent growth in all markets, especially the Nordic market has developed favourably since we…”

Is all this connected? And if yes, then how? We’ll talk about that today.

 

Bliss Point

Let’s start with the meal we descibed. Now it was a Burger Meal of some kind, but might as well have been a microwave lunch, sweetened drinking yogurt or a Friday snack in front of the TV: here we need to learn about the term “Bliss Point”. The following quotes are from Svenska Dagbladet’s article series on obesity the other week:

“Bliss point is a term that describes the proportion of sugar but also fat, salt and other flavors, which is maximally alluring to our reward system. If the point is exceeded, we feel disgust because it becomes too sweet or too salty. But all the way up to the “disgust point”, the product gradually becomes increasingly attractive. The term bliss point has been used in the food industry since the 1970s when it was explored in detail.

An important discovery was when sugar, fat and salt are combined, the respective disgust point is raised and the product instead becomes super rewarding. For children, the disgust point is just over 25 per cent sugar, for some up to 36 per cent. That’s just over twice as high as for adults, and explains why products aimed at children are often made sweeter.

In addition, some ingredients can shift the disgust point upwards for other ingredients, thus increasing consumption, such as sugary soft drinks together with salty snacks.”

 

Bliss Point: the perfect combination of sweet, salty, fat

So it’s no coincidence that a Burger Meal looks the way it does – it’s the perfect, super rewarding, combination of sweet, salty and fat that releases the most rewarding neurotransmitters (endorphins, dopamine) in our brains. Once there, the various companies have gradually increased portion sizes and thus the profits – compare a burger meal in 1950 against today in the first picture, or how, among other things, our “Friday in front of the TV” habit has increased Swedish potato chip sales in the second picture:

And so the “no one has forced me” reasoning tags along, doesn’t it? This food is scientifically expert designed to produce as much reward hormones as possible in our brains every time we eat(!).

 

Study: High processed food -weight up

This spring, a very well-crafted study on just that was published by Kevin D. Hall in Cell Metabolism (“Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain…”). 20 adult participants, weight stable with BMI around 27, were stayed at the clinic for two weeks. They were randomized to either eat high-processed food or unprocessed food. They could eat as much or as little as they wanted. The result? Those who lived on high-processed food ate an average of 508 kcal more per day than the others, through eating more fat and carbohydrates, but not protein. After the study period, those who ate high-processed food had gained an average of 0.9 kg, those with unprocessed instead lost an average of 0.9 kg! See also the chart in the title image of the blog here above.

The study has, quite rightly, already received a great deal of attention. And note that these were weight-stable study subjects who did not have obesity, yet it becomes so obvious in just two weeks.

So you see, it’s all connected! Developing overweight/obesity is not the individual’s “fault”, our food society is today like an ingeniously rigged minefield with “bliss points” everywhere. (And so far, the government is doing nothing about this basically, but more about their responsibilities in the next blog section).

 

Big business

So to the boardroom we mentioned in the beginning: who are these companies?

Well, it’s Nestle (including Mövenpick and Dreyer’s ice cream, PowerBar, NesQuick, KitKat, Smarties), Pepsico (including Tropicana, Mtn Dew, Gatorade, 7Up, Pepsi, Pizza Hut, KFC, Taco Bell), Unilever (including GB Glace Group, Ben&Jerry, Knorr, Becel), Coca Cola (Fanta, Sprite, Monster, VitaminWater, etc.) -add the companies Mars, Kellogg’s, Kraft, McDonald’s, Restaurant Brands Int groups (including Burger King and Tim Horton’s), Orkla Foods (OLW m.m.) and a couple more and you have the majority of all processed foods in your own store at home.

This is big business –nothing is left to chance. Including our taste buds and reward systems.

A hefty cynicism can be found in these large companies’ product ranges: the same companies that have had full control of “bliss points” since the 1970s, and are actively contributing to our ongoing obesity epidemic, are engaged in -you guessed it! -the weight loss industry: a quick Google search shows a market report on the globalWeight Loss and Obesity Management marketand finds some familiar companies listed there -Coca Cola Co., Nestle, Pepsico, Unilever, Kellogg’s…

So the same companies that create our highly processed, bliss point-optimized foods make sure to then also offer weight loss methods and make money off us once more, so to speak.

We can only imagine how perfectly orchestrated these companies feel that it is, when the consumers who suffer healthwise from weight gain only blame ourselves -or each other..!

The next section will be about society, government and politics. What should they be able to do to help us out of this? What have other countries already done and succeeded in? Follow us!

Aug 28 2021
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How does our way of getting around affect our health?

Obesity -who is to blame? Part 2

By About obesity, Body weight regulation, Obesity prevention No Comments

In Part 1 of our series, we talked about why the individual with overweight or obesity is constantly held personally responsible for their situation -even though obesity is a geneticly and hormonally controlled disease and not a of lack of character, or poor personal lifestyle choice. If you missed the part 1, you’ll find it here. In short: genes sensitive to obesity are the prerequisite for developing obesity, our community environment determines how many of those with sensitive genes then develop the disease.

If our increasing problems with obesity in society are not the fault of the individual, but the result of how we created our society – who or what is it that contributes to this? We’re going to start unraveling that now, starting with how we get around in everyday life:

Transport from A to B

When I went to school in the ’70s and ’80s, 90% of the pupils walked or bicycled to our school. Nothing strange about that. These daily movements burned perhaps 300-600 kcal per day. Spread over 38 school weeks of 5 days, it was actually 57,000 – 114,000 kcal in a year – just this little everyday routine. Kids don’t really do this today, do they?

We don’t see the road to school as really safe anymore – so schoolchildren today are increasingly being given a ride by mom and dad. Safer -yes maybe -but thereby you miss the 300-600 kcal listed above. If we add that during breaks or leisure time you don’t automatically play football, climb around at the playground or chase each other in general – we’ve invented smartphones and tablets with games and social media in it – then we’re starting to have a very passive everyday life for our children.

The Public Health Agency of Sweden and Generation Pep presented data on the subject at Almedalen Week last year: obesity prevalnece today is 20% among children in Sweden, the proportion of children cycling to school has halved since 1990 -while average caloric intake has increased by 200 kcal per day (!).

Microtransports

On to youth and adulthood. The same phenomenon can be found here, but in partly different guises: what was before natural was to walk -run if you were in a hurry! Or cycle distances in everyday life of 500 meters to a kilometre or two has today been given the trend term “microtransport”. The technology behind it is efficient rechargeable batteries that power Hoverboards, Segways, electric skateboards, electric mopeds, electric scooters and e-bikes – the latter, as you know, even had government subsidies until very recently(!). What they all have in common, of course, is that they are new, cool, easy to get around with, often have quite impressive both maximum speed and range -but you burn zero or minimal calories.

“Riding is easy and fun. It’s easier than learning how to ride a bike, and more fun than walking on tiny feet… Get the App”

The quote is borrowed from one of the most common electric scooter companies, many of you see these every day in our cities. Their slogan is ‘catchy’ isn’t it? ‘Tiny feet’ suggests that you can probably try it at early ages..?

Any of you who have continued (like me) to be childish enough to like animated movies? Remember humanity in Pixar’s (amazing but dystopian) Wall-E? If not, check the clip here,you’ll soon understand where I’m going with this.

What should we do to combat overweight and obesity?

Society itself must do more. There are very good examples of organised projects, such as the “walking school bus” in France where children are accompanied to and from school, or here at home by the fantastic work that is already taking place in Friskvårdsgruppen Halland – read more here!

But otherwise, we probably can’t expect smartphones, tablets or electric small vehicles to disappear -of course they won’t. They’re great -sometimes!

But they have physical inactivity – and therefore the risk of weight gain – as an obvious side effect. We need to understand that. We need to make our children understand that. Just because something exists, and can be used, doesn’t mean we have to do it all the time, does it? Next time – take a walk from A to B instead, all changes start there, with the first step you take.

/Carl-Magnus

In the next part,we knock on the door of probably the biggest culprit in our obesity epidemic – the food industry. Follow us!

 

Aug 28 2021
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Obesity -who is to blame? Part 1

By About obesity, Body weight regulation No Comments

I have been meeting patients with obesity for many years and talked to several thousand patients with obesity or overweight. What strikes you consistently, both in the affected individual and in the reactions they tell you about from their environment or previous healthcare experiences -is the discussion of guilt.

Whose fault is it… and why is it so important?

Whose fault is it that you suffer from overweight/obesity? Whose fault is it that you don’t fix the problem yourself by “moving more and eating less”? Why do patients, their surroundings and healthcare (!) over and over again fixate on the issue of who is to “blame for the problem” of overweight/obesity? We never do it in other situations?

Someone who falls, has a fracture and has to be treated in the hospital – doesn’t get cross-examined about “risky behavior” by their loved ones or their treating orthopaedic surgeon before the fracture is even casted? Someone who is stressed at work, regularly drinks alcohol, doesn’t have time to exercise -and now develops angina; the environment does not point the finger at him/her for the “sloppy lifestyle”, delaying or even refusing(!) treatment for the person to first “get their act together”..? No, the heart disease patient immediately gets the proper examination and then the most modern medications. A conversation about the alcohol, stress and lifestyle choices during the care period, too, of course, but not with a “blame yourself” attitude linked to it. And why? Because both fractures and coronary artery disease are diseases. And we have the right to treatment for our diseases, right?

Now it is just that obesity is also a disease, classified as such by, among others, the United Nations. WHO and American AMA. It’s not a poor lifestyle choice by a less intelligent person who lacks character, it’s a disease.

Who is at risk of developing obesity, and how many people are affected?

Obesity in society develops in two stages: the first step is whether you are at risk of getting the disease obesity at all or not – this is determined by your genes. If you have genes that are sensitive to our obesogenic (obesity-inducing) environment, then you are at risk. Step two is how many of those with sensitive genes who then develop the disease. It is determined by our daily environment – that is, our community. More about this in part 2 of the blog series.

Time to wake up – the earth is round, not flat -obesity is disease, not laziness

Why do we continue to stigmatise, discriminate and bully people with obesity? A strong part-explanation is ignorance. Obesity is a complex, hormonally controlled disease – but very few know about this.

Within Sweden’s healthcare educations – including the medical program! Nothing is basically being taught about obesity. Zero. Nothing. Let that sink in.

And if you don’t know anything about a condition and then meet this particular condition every day, what are you going to do? Well, you have to make something up. Hence the most common prescription “you have to move a little more and eat a little less, so…“. The idea behind this phrase is that the body is like an unintelligent machine without built-in defense mechanisms – if you feed the body with less energy but burn more, it shrinks -as simple as that.

The problem is that science has known since at least the 1990s that it is not that simple – the body has its own idea of what weight it wants, a so-called “set point for body weight” in the brain. If you starve your body, it still remembers what the set point was before you lost weight and now your body is defending itself! (if you want to know more -read here,look here or here). It’s 100% biology. 0% morality, will or character.

The earth is round, not flat. But society or health care has not understood that. -yet.

Time for change!

If you’re suffering from obesity, hear this! It’s not your fault. You’re a perfectly normal person! You live in a large body because you have genes sensitive to obesity. Need support? Contact the National Association of HOBS – they will be happy to help you.

You who bully others for their obesity –stop immediately! Have a close look in the mirror instead: what makes you bully others? What right do you have to judge someone for a disease? Do you also judge other people for other diseases?

If you work in health care, you know what a ghrelin or leptin molecule is, or what they do? No? Then you need to do your homework -it is not acceptable to be ignorant of something as common and serious as obesity. Have you ever prescribed “move more and eat less”, or “you have to lose weight”? That is not evidence-based care. You must read up – feel free to contact us if you need help to move forward.

Next part of the blog series

… it is about who can actually be held responsible for us having an obesity epidemic on our hands. And it’s not individual people with obesity – it’s completely different factors. Follow us!

Dec 29 2020
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obesity-surgery-diabetes-type-2

Can bariatric surgery cure type 2 diabetes?

By Obesity surgery - health and diseases

How and why can bariatric surgery cure type 2 diabetes?

In this blog post we will talk about how obesity surgery can cure type 2 diabetes for most patients. But what exactly is type 2 diabetes?

What is type 2 diabetes, what is insulin and how does it relate?

Type 2 diabetes is a chronic disease in which the affected person has a blood sugar level that is not regulated well enough due to partial or complete insulin resistance and excretion. That the disease is chronic means that it is long-lasting[1]. But what is insulin and how does it work?

Insulin is a hormone that plays a crucial role in the absorption of glucose (sugar). Simply explained, when we eat, the carbohydrates in food are converted into glucose which is absorbed into the bloodstream. However, glucose does little good in the bloodstream, we want the glucose into the body’s cells where it functions as fuel. Insulin acts as a key in the cells’ “keyholes” that are found in the surrounding membrane. Insulin (key) opens the door for the glucose do it can enter the cell[2].

If you have type 2 diabetes, as mentioned, you are less sensitive to insulin or maybe you do not secrete enough or no insulin at all. This causes the glucose to stay in the bloodstream and not enter the cells, which results in a too high blood sugar level. This can be measured with a blood glucose meter.

Having an elevated blood sugar level over a longer period of time increases the risk of various other diseases, which is why it is important to lower the blood sugar levels to a normal level.

What is the likelihood of my diabetes being cured?

First of all, we need to define what is meant by cured. When we talk about the patient being cured of type 2 diabetes (sometimes also called diabetes remission), it means that the patient has a normal blood sugar level and no longer needs to take any antidiabetic medication.

It is not possible to predict what the likelihood of diabetes remission is on an individual level before obesity surgery. There are several factors that affect the outcome. Bodies react differently to treatment, just as it does with other medical treatments.

However, it is of course possible to say something about it in general and talk about the average likelihood. Most studies show that 70-89% of patients who have type 2 diabetes prior to surgery are cured after undergoing obesity surgery[3],[4],[5],[6],[7].

In addition, you are more likely to experience complete remission of your diabetes if you have had the disease for a shorter period of time (under 5 years), have a milder degree of diabetes and have a large weight loss after surgery. For example, if you have had diabetes for less than 5 years there is a 95% probability of diabetes remission. Whereas if you have had the disease for 6-10 years, the probability is 75% and if you have had diabetes for more than 10 years, the probability of being cured is 54% [8].

Why can obesity surgery cure type 2 diabetes?

There are several factors that contribute to the fact that an obesity operation can cure type 2 diabetes, but there is not complete agreement on these mechanisms. One of the simple factors is weight loss itself, which increases insulin sensitivity. However, for example, gastric bypass surgery improves diabetes already within days after surgery and thus there are mechanisms other than weight loss that come into play[8].

For example, one hypothesized (the “Hindgut hypothesis”) explains that since food more quickly affects the distal (later) part of the intestines after surgery, there is an increased excretion of the hormones GLP-1 and peptide YY, which causes both increased insulin excretion and sensitivity[9].

Another hypothesis (“Foregut”) related to bypass is that the exclusion of the proximal (first) part of the small intestine on the food’s path through the intestinal system avoids the excretion of a suspected (and not yet clarified) signal that otherwise promotes insulin resistance[10].

In general, calorie restrictions (less than 1100 kcal/day) will result in increased liver insulin sensitivity within 2 days, as there is less insulin in the bloodstream and insulin-producing (beta) cells can rest because they therefore do not have to produce as much insulin [11],[12].

A very small Swedish study with 9 patients has shown that 90% of what affects the insulin mechanisms related to the hormorers GLP-1 and GIP are created by the dietary changes. They believe the same effect is experienced as if the patient had surgery, if the patient is on a powder diet and consumes less than 1000 kcal/day . However, the researchers behind the study find that weight loss is stronger and more permanent in surgery rather than on diet alone [13]. The results are very new and further research on the new findings must be conducted to support the theory.

Summary

In short, obesity surgery fixes the problems you have with insulin that cause elevated blood sugar when you are affected by type 2 diabetes through various mechanisms. These mechanisms are related to weight loss, increased insulin excretion and sensitivity and avoidance of insulin resistance.

Type 1 diabetes cannot be cured as this disease is caused by the destruction of the insulin-producing cells in the pancreas.

 

If you want to know more about overweight surgery, you can read about it here and here. Contact usif you consider that surgery could be beneficial for you!

But. till exempel.

[1] https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/endokrinologi/tilstande-og-sygdomme/diabetes-mellitus/type-2-diabetes/ But. till exempel.

[2] https://endocrinology.dk/nbv/diabetes-melitus/behandling-og-kontrol-af-type-2-diabetes/

[3] https://diabetes.dk/aktuelt/nyheder/nyhedsarkiv/2019/fedmekirurgi-faar-type-2-diabetes-til-at-forsvinde-hos-3-af-4.aspx But. till exempel.

[4] https://pubmed.ncbi.nlm.nih.gov/19272486/

[5] https://pubmed.ncbi.nlm.nih.gov/15479938/ But. till exempel.

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234815/

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360104/

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3102524/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936261/

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856597/ But. till exempel.

[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202361/

[12] https://www.gastrojournal.org/article/S0016-5085(09)00150-4/pdf

[13] https://www.medicin.lu.se/article/strang-diet-forklarar-fetmakirurgins-magi-0

Dec 10 2020
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Covid-19 infection in people with obesity -how dangerous is it?

By News

The Corona virus, or Severe Acute Respiratory Syndrome Coronavirus-2 (Sars-cov-2) as the real term is, is an RNA virus that causes the disease Covid-19 (Corona virus disease 2019). The current epidemic is the third with a coronavirus in the 21st century and by far the most severe.

Society, media, politics, health care and research are now fully focused on covid-19 and the virus Sars-cov-2. From the statistics updated daily from the Swedish Intensive Care Register we see that in Sweden 75% of those admitted to IVA with Coivid-19 are male, the median age is 61 years and 73.9% have a risk factor. Dominant risk factors in the registry are high blood pressure (34.9%), diabetes (25.3%), heart and lung disease (23.6%). Obesity is seen here only to be around 3% -but this is tricky, because the registry here reports only “extreme obesity”, i.e. BMI > 40, and we know that BMI well below 40 often results in high blood pressure, type 2 diabetes and cardiovascular disease (obesity is defined as BMI > 30).

Recent research studies

Furthermore, if you look more specifically for obesity versus Covid-19 (here you have to remember that this field of research is completely new and new studies are published all the time), then you will find a study from France (Simmonet et al). A hospital has studied 124 patients admitted to ICU due to Covid-19. 68.6% of these patients required respiratory care. Patients with BMI > 35 were more than 7 times more likely to need respiratory care compared to those with normal weight (regardless of age, diabetes or high blood pressure).

A recent study from New York (Petrilli et al) has followed more than 4,000 patients with Covid-19. Among other things, risk factors were analysed vs. a/ needing hospital treatment and b/ becoming “critically ill” (critical illness, defined as need for ICU care, discharge to hospice or death). The factors most strongly associated to the need for hospitalization were in descending order age > 75 years, age 65-74 years, BMI > 40, heart failure, BMI 30-40, age 55-64 years, chronic kidney disease, diabetes and male sex.

Risk factors for critical illness in Covid-19 were in descending order age > 75 years, age 65-74 years, BMI > 40 and BMI 30-40. (For those of you in health care: lab-wise CRP > 200, high D-dimer and oxygen saturation < 88% upon arrival at the health care department were the strongest factors related to the risk of developing critical illness).

Obesity as a risk factor in Covid-19

It seems, therefore, that obesity disease is a clear risk factor associated with Covid-19, perhaps BMI > 40 is the main risk factor after increasing age(?). This is something that needs to be researched more, but also highlighted better –the latter ASAP, as the epidemic is already in full swing.

SUPPLEMENT: On Friday, April 17, the National Board of Health and Welfare announced that obesity disease with BMI > 40 is an independent risk factor for Covid-19 disease, read the report here.

In depth reading on corona, ARDS and obesity

The following are things that we don’t know everything about yet, so they are hypotheses rather than proven facts. The research on this has not yet “caught up” with the situation we are in with the epidemic in society. But with this said, if you want to immerse yourself then this is for you: What distinguishes the coronavirus Sars-cov-2 from the common flu or cold virus is that it not only infects the upper respiratory tract (and causes a sore throat, etc.) but in some cases also infects deep into the lungs and at the far end of the alveoli. Here, this infection causes alveolar cells to be destroyed, but also gives a reaction from the body itself: our immune system reacts, sometimes even too much. This gives the risk of acute respiratory distress syndrome (ARDS). ARDS is caused by a hyperactive immune system, sometimes called cytokine storm. The body’s attempts to repair the damage result in fibrosis formation and worsened oxygen saturation. What distinguishes this from a common pneumonia is that the body itself exacerbates the problem because the immune system overreacts.

Where could obesity come into this? Well, research has shown that adipose tissue is much more than just an energy deposit, it is also a hormonally active organ. Fatty tissue produces, among other things, cytokines, hormones, growth factors and prostaglandins, which have effects on organs such as the liver, pancreas, muscles, kidneys, brain and immune system. Obesity has been shown to increase activation of pro-inflammatory substances released from adipose tissue (e.g. interleukins, interferon and TNF-alpha). Thus, many people with obesity have an incorrectly overactivated immune system already normally. If this affects the risk of getting ARDS from the corona virus, future research will show. Other factors that can come into play here are that we know that obesity can contribute to so-called increased coagulability (increased risk of blood clots), other concomitant obesity-related diseases, and the risk of ventilating one’s lungs less effectively at high BMI than at normal weight.

How much risk do you have?

How are we going to deal with all this new information? How “big risk” do you have if you are reading this and living with a large body? I understand if you worry, this is an epidemic that we are not used to.

What can probably be concluded from the study from New York above, is that the combination age >55 years at the same time as BMI > 30 increases the risk of needing hospital care at Covid-19, and that age > 65 years at the same time as BMI > 40 greatly increases the risk. Note that all “risk” is relative, each individual has his or her own unique conditions.

What can you do to reduce your risk?

Follow the recommendations of the authorities including social distancing, hand sanitizing, etc. A general recommendation if you are worried about Covid-19 and are in a probable risk group –test yourself. Hopefully, tests will become more available in Sweden now and people with obesity are very likely a risk group that should be prioritized. (In particular, it applies to those of you who have BMI > 40.) Try to work out even if you are at home -physical activity is positive for the immune system.

I have had bariatric surgery -is that an increased risk?

There is no indication that this in itself would increase the risk. Vitamin or mineral deficiency, on the other hand, is negative for the immune system – so take your vitamins after surgery!

If you need more support or have questions, please contact the National Association HOBS , they are there for you!

Dec 10 2020
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Dieting -warning issued..!

By About obesity, Best Weight, Body weight regulation, Food and drink, News

Virtually all our patients have tried to lose weight at some point before they eventually come to us. The stricky thing about all the calorie counting/dieting (“just move more and eat less…”) is that it seems to work at the beginning -you lose weight the first 1-2-3 weeks. Then sooner or later there will be a plateau phase, followed by a gradual weight gain, as a rule, to a higher final weight than the one you started at. The biological cause is the body’s internal weight thermostat (“set point”), which we told in more detail about in previous posts (see, for example, this blog from us, this article from Baribuddy or this information film). The result is that the risk of weight gain within five years after a diet is 95-97%. (This risk is something that the dieting industry never tells you about. And for obvious reasons: they have a turnover of 300,000,000 SEK per year in Sweden alone.).

Yo-yo dieting

The end result, weight down and then up again, is what you call “yo-yo-dieting”. But is it that simple? “Yo-yo” indicates that you easily regain your weight after a diet, but also suggests that you may not have very much to lose – the worst thing that can happen is that you are back on “square one”. Or?

… set point up

Unfortunately, it’s not that simple. What typically happens after a failed diet is that the brain’s set point is elevated by 2-5-8 kg (you regain more than what you lost in the beginning). Thus, the dieting triggers the brain to want to weigh even more. Most patients we meet describe how the first half of their gained weight probably came from genes + environment + a trigger (knee injury, smoking cessation, disease, etc.) -but that then the repeated yo-yo diets themselves pushed up the brain set point the remaining extra kilos. A diet risks triggering the body’s defense against starvation, and afterwards the set point is even higher. (It would therefore have been better to avoid the diet and instead accept the original weight.)

Permanently altered biology à la Biggest Loser

The next problem is that several of the mechanisms that counteract weight loss never disappear – even though you regain weight. The most famous study of this was done in the United States on a season of Biggest Loser participants. The study measured the contestants’ metabolism as well as various weight hormones before competition (when they had a large body), at the end of the competition (when they had done massive weight loss) and six years later (when all but one had regained all the weight again). Results: metabolism and the saturation hormone leptin were -as expected -clearly lowered immediately after the competition. What surprised however was that six years later, despite weight regain, the participants still had a lowered metabolism and lowered leptin(!). Dieting had thus permanently impaired the weight physiology of the participants.

Yo-yo dieting causes a change in body composition

For example, if you lose 10 kg with any traditional diet, you have not lost 10 kg of adipose tissue; you have probably broken down 7-8 kg of adipose tissue but at the same time 2-3 kg of muscle mass. Less fat is good, but less musculature is definitely not good. When you then regain the kilos back, let’s say 12 kg up, then in the worst case it is 12 kg of adipose tissue –no muscle mass. Failed dieting thus remodels the body’s composition for the worse. If you imagine that a person living with a large body makes repeated diets maybe 5-10 times in life, then you understand better why muscle pain, fatigue and impaired strength is so common -the person has lost more and more muscle mass.

… and lower self-esteem

In the end, we have the psychological aspect: repeated failure at weight loss is extremely psychologically stressful for the person himself. Most people blame themselves for weight failure (you have “lack of character” and so on) and people around them (often including health care staff) indirectly confirm this by agreeing, or not contradicting.

Dieting -warning issued!

Thus: one can defend the idea of one serious weight loss attempt through changing lifestyle habits or some type of diet program. This is to see what your particular set point for weight in the brain “accepts” regarding weight loss: 3-5% of us have a set point that is more flexible (and one can then imagine that weight loss can persist even in the long run). The other 95-97% will have a fixed set point corresponding to their higher starting weight -thus it will be a yo-yo effect. If you experience this, repeated new dieting attempts are potentially dangerous to your health: set point will be pushed upwards more and more, the body metabolism will be lowered and the level of saturation hormones will be lower, your body will be remodelled to less muscle mass and you will feel worse and worse psychologically. Better if possible to accept the weight you have and instead try to avoid further weight gain (here the concept “Best Weight” can be used, read more about this here). The alternative will be to choose treatment methods that lower the brain’s set point, i.e. medical treatment or obesity surgery.

What we are strongly opposed to is the almost reckless view of diets as something where the customer has “nothing to lose”: weight loss advertising and products are marketed through pharmacies, tabloids, commercial operators online, apps on the phone – but also by the health care system itself. This as a rule without the slightest warning about the risks we reported above, and never ever with information about what set point is. This problem needs to be highlighted and discussed more in society in general. Feel free to share!

Dieting

Aug 02 2020
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How does the anaesthesia work during an obesity operation?

By News, Operating methods

Our anaesthesiologist Magnus explains

The purpose of the anaesthesia in bariatric surgery – in addition to making it possible to operate – is to help you feel as good as possible after surgery taking into account pain, nausea, mobilization and temperature control.

When you enter the operating room, you have probably already received a peripheral venous catheter in one arm, at the ward. We will carry out an additional verification of your identity and confirm the type of operation that is planned. In the room there are some people who all have a specific role during the operation: we are 2-3 surgical nurses, 2 surgeons, 1-2 anesthesiology nurses and one anesthesiologist.

You lie down on the operating table and some of the operations team work around you, connect you to surveillance equipment and start preparing the operation. There will be no stings or other painful things that are done in the operating room while you are awake. We also connect our drug pumps to the venous catheter and soon start giving you a small dose of medicine to help you relax before you go to sleep.

Anaesthesia with intravenous drugs in gastric bypass and sleeve gastrectomy

In the pumps there are 2 different medications, propofol (sedative agent) and remifentanil which is a strong analgesic medicine akin to morphine. In some patients, a burning sensation is experienced during the infusion into the vein that goes away with local anesthesia. It is not dangerous and does not indicate that the venous catheter is in the wrong place. Before you fall asleep completely, you breathe pure oxygen through a mask. This is a safety measure. If you experience the mask very unpleasant, we can in most cases lighten some on the mask so it does not close too tightly.

While you’re asleep, we’ll tilt the whole table in the way that we elevate the head end. To ensure that you do not slip during the operation, there is a footplate that you should lie close to with your sole and we also put a seat belt around your legs.

FREQUENTLY ASKED QUESTIONS:

Will I be in pain after surgery?
Most of our patients feel pretty good when they wake up after surgery and some even ask if we should not start operating soon! We will transfer you in a bed to the recovery area and you will be monitored for 1-2 hours before you can get to your room. Approximately 15-20 minutes after the end of surgery, most of the anesthesia has lost its effect and you can expect discomfort similar to post exercise muscle aches in the abdominal wall, as if you had done too many situps the day before. Many also experience pain in their shoulders. This is explained by irritation of the diaphragm and abdominal cavity after the laparoscopic surgery and that these organs share sensorics with the shoulders – so we have done nothing with the shoulders. Some patients have an experience of suction high up in the middle of the abdominal cavity. Often it is effective pain relief to change position and rise up to reduce these discomforts.

You don’t have to worry about suffering from severe pain. You should be so well pain-relieved that you can draw deep breaths, cough, be able to move in bed and relax. Please also see our information video about general anesthesia.
You will get extra pain relief if necessary – but the goal of pain relief is to make your discomfort manageable, not to make you painless! If we were to be too generous with pain-relieving drugs (morphine-like agents), it would greatly contribute to increased nausea, lower your ability to breathe and make you very lethargic. The goal is to help you move as soon as possible and stand up on your feet. This is to reduce the risk of blood clots and lung complications and to get the small intestine up and running again.

What pain killers will I receive?
Pain relief consists of different parts. By default, paracetamol and anti-inflammatory medicine (eterocoxib) are given in tablet form at the ward. During the operation we also give you oxycodone, clonidine and local anesthesia in the abdominal wall where the peepholes will be.

Am I going to feel sick after the surgery?
It’s individual how likely you are to feel sick after surgery. Patients who suffer from motion sickness and have felt ill during previous anaesthisia have an increased risk of nausea. Sleeve gastrectomy patients feel to some extent more ill the first hours after surgery than other types of surgery. In any case, this will pass, usually the first hours or before evening. To reduce the risk of nausea, we provide preventive medicines as a standard, in addition to that we avoid all anesthetic gases and instead sedate using propofol.

Am I completely sedated during the operation?
Yes, it’s the only way to perform laparoscopic operations safely.

Can I wake up during the operation?
No. We constantly monitor you during the operation and would notice if something did not look right a long time before you would be conscious. The medicines we use have been used for a long time and we have performed thousands of these operations without it ever happening. Among other things, we monitor heart rate, blood pressure, oxygenation, body movements, breath size, pressure in the airways and your eye movements.

When do I wake up?
You wake up from the sedation to the degree that you can breathe yourself and we can communicate with you in simple sentences immediately after completing the operation when you are still on the operating table. In most cases, patients do not remember these first few minutes afterwards. However, you will be tired in the first few hours after surgery when you are in the recovery unit and most fall asleep for shorter periods there.

Do I get a tube in my throat?
Yes, but only while you’re asleep. You won’t be awake with a tube in your throat.
We use a tube to help you breathe and it is called an endotracheal tube. It goes down the trachea. A second tube goes down the esophagus. In some cases, patients may subsequently experience discomfort in the throat, similar to the onset of tonsillitis. It usually goes over in 1-2 days.

When can I see my relatives?
After you leave the recovery department. Since there are other patients who are waking up in the room, we are not able to receive relatives there. Most often you can call your relatives from the recovery department.

May 25 2020
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Gastric bypass surgery, pros and cons

By Body weight regulation, Operating methods

The gastric bypass (GBP) operation has actually been around for more than 50 years, the American surgeon Edward Mason published “Gastric bypass in obesity” in 1967. The first decades this was open surgery, nowadays it is always laparoscopic. We have gained the most knowledge about the long-term effects of the operation from the Swedish SOS study (Swedish Obese Subjects study). In SOS, a small proportion of patients had gastric bypass surgery, the rest had had gastric banding surgery or a VBG. Gastric banding and VBG (vertical band-reinforced gastroplasty) both had the same principle in common, so-called “restriction”. In plain language: make the stomach smaller, so the person with obesity is forced to eat less and lose weight.

Now, however, gastric bypass proved to be in every way superior to banding and VBG in SOS and upcoming studies; it produced better weight loss and more other positive effects on health: including highly effective treatment of type 2 diabetes (even at BMI less than 35).

Gastric bypass effective

Why was gastric bypass more effective than the older methods of banding and VBG? All three procedures give the operated person a smaller stomach, but gastric bypass is different as it at the same time fundamentally counteracts the body’s own defense against weight loss: a GBP leads to the body’s so-called set point for weight (our “weight thermostat”) in the brain being lowered towards normal levels. This is achieved via a variety of positive hormonal effects in the body, which in itself come out of the intestinal bypass that is done during a gastric bypass (but not during banding or VBG). You could say that the operation has its main effect on the brain – even though you only operate in the abdomen!

Gastric bypass benefits

What are the benefits of a gastric bypass operation? It is extremely well proven and over the years refined. We know very well how a GBP should be performed technically by the surgeon. The operation provides very effective weight loss and it lasts a lifetime. You get health effects at all levels (life is extended on average 6.7 years, it is effective treatment of type 2 diabetes, sleep apnea syndrome, osteoarthritis, PCOS, high blood pressure, cardiovascular disease, fatty liver disease, gout and more. In women, the risk ofdying from a cancer ishalved .).

… and cons

What are the disadvantages? Yes there is initially about 3% risk of serious complications (mainly bleeding and leakage). These can be remedied but often require new surgery. The long-term surgical risk is ileus (in this case also called mesenterial herniation) which comes from changing the anatomy of the small intestine during bypass surgery. Ileus results in acute blockage of the intestine and one must seek emergency medical care. They can be cured, but require a new operation. In the past, this was relatively common, the risk was 5-10%, while today it is prevented at the initial operation (one “closes the mesenterial defects“). Today, the risk is instead 1-3% approximately. Other more medical disadvantages are the risk of dumping (lowering of blood sugar and blood pressure after eating certain foods), increased sensitivity to alcohol and impaired vitamin uptake. The latter is easy to prevent with vitamin supplements -but studies prove this to be difficult to maintain for life for patients (who otherwise feel excellent as a rule and perhaps have lost their previous medicines…). More about both pros and cons can be found in the annual report from the Swedish Obesity Surgery Register SOREG.

Gastric bypass or gastric sleeve?

In recent years, gastric bypass has had a “cousin” namely sleeve gastrectomy (SG). We will talk more about this in the upcoming blog. Which of the two is best? Well, both are excellent, both have disadvantages. Exactly when which of them is “best” … we actually don’t know for sure. This is being studied in Sweden via the BEST study (where GB Obesitas is involved).

Want to know more? Join us for the next information meeting!