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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!

ww_dieting

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

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.

GB Obesitas -now also working on behalf of Region Skåne!

By | News | No Comments

Our personnel and surgical team at GB Obesitas Skåne -under the leadership of Dr. Gislason and Dr. Broden -worked for many years at Aleris Obesitas in Malmö and Kristianstad. This included private and public funded surgery. Last spring, our team and Aleris went separate ways when Aleris ended its public obesity surgery business (post operative check-ups at Aleris will take place another six months, but no new publicly funded operations are performed).

During the summer, Region Skåne issued a new tender for publicly funded obesity surgery, for which we submitted an ambitious and serious offer on 12 September. The analysis and decision-making process is now completed and GB Obesitas Skåne won the contract. Earlier this week we could formally sign the agreement with Region Skåne -so now we can release the news:

GB Obesitas Skåne works on behalf of Region Skåne from 1 January 2020!

This agreement applies to public obesity surgery and runs until 31 December 2025, with the possibility of extension after that for another two years.

The following is clear: GB Obesitas becomes a direct referral body, a doctor’s referral letter or patient’s own referral letter must no longer go through the surgery clinic in Landskrona. We will follow Region Skåne’s guidelines for obesity surgery, that document you can find on the Region Skåne official website. In short, the indications for a publicly funded operation are the following;

  • 18 – 65 years of age> with BMI 40
  • 18 – 65 years of age> with BMI 35 and a co-morbidity linked to the obesity disease; such as Type 2 diabetes, sleep apnea, severe osteoarthritis of weight-bearing joint, and more.

The procurement includes on-call preparedness for possible complications after the procedure and one year of medical follow-up. All of our patients have access to the digital support tool Baribuddy, and are continuously reported to the Swedish Obesity Surgery registry SOReg.

 

The procurement also has a “secondary care chain”

This means that a referral can be made to the assessment of long-term problems after previous obesity surgery. We will set up a structured care package for this. The procurement allows for everything from out patient visits to diagnostic laparoscopy and renewed surgical procedures. We will return with more details.

Operations at the Centralsjukhuset in Kristianstad, CSK

As with previous procurements (which were previously won by Aleris), GB Obesitas Skåne will have access to the ward and operating room at CSK in Kristianstad. This allows for safe surgery even in more complex patient cases, with the backing of the hospital’s other resources when required. We will start by calling those to preoperative checklist that are already in the existing public queue to obesity surgery. You who belong to this group will be contacted by us in due time. Many details remain to be solved. Keep an eye on our digital platforms and we will provide more information on an ongoing basis!

Our private obesity surgery and obesity care continues as before

-with procedures includinggastric bypass, sleeve gastrektomy, SASI, revisional surgery, distal gastric bypass and medical packages. Read more in the section packages and prices. Our information meetings can be found here.

We are now taking the next step towards our high set goals for GB Obesitas Skåne -to become a complete center for advanced Obesity Care: with educational initiatives for the public including lectures on Best Weight, lectures for health care professionals, primary obesity surgery including complication management and follow-up, secondary care chains with care for those with long-term problems after previous surgery, as well as active clinical research.

Many details remain, and it is still too early to send your referral letters directly to us. But follow us on our platforms and we’ll keep you updated -we’re also on Facebook and Instagram.

Yours,

Dr Hjörtur Gislason, Dr. Carl-Magnus Broden and the entire GB Obesitas team