Bariatric Surgery Procedures

Obesity as a Chronic Disease

noreply@blogger.com (Unknown) — Fri, 07 Sep 2018 16:14:00 +0000

Obesity has been recognised by the World Health Organisation (WHO) as a chronic disease and is now included as a diagnosis in the International Classification of Diseases (ICD).

Overweight and obesity lead to secondary diseases, depending on the severity, duration of the disease and individual predisposition. In addition to cancer, lung and joint diseases, the development of cardiovascular risk factors such as diabetes mellitus type 2, high blood pressure and lipid metabolism disorders should be mentioned in particular.

Conservative therapies of severe obesity for weight reduction usually fail, which is why bariatric surgery is often the only treatment option for many patients, which not only leads to sustained weight loss, but also to a better quality of life, an improvement in the following diseases of obesity and an extension of life expectancy.

In many countries, obesity and metabolic surgery are therefore among the established medical procedures for weight reduction due to their proven effectiveness. Not, however, in Germany. There are two main reasons for this. Currently, only about 12,000 bariatric operations per year are performed in Germany, although around 4 million patients are eligible for bariatric surgery. If they were all to undergo surgery, the german health system would collapse economically. On the other hand, obesity and its treatment by surgery are stigmatised due to a lack of knowledge - also among doctors and other therapists. The patient's decision to undergo bariatric surgery is often ridiculed as his own failure, lack of willpower and a convenient alternative to exhausting, conservative weight loss.

However, the fact that conservative measures for weight reduction - a change in diet, exercise and behavioural therapy - fail in many cases is usually not due to unwilling patients, but rather to the sophisticated defence strategies of the human body when it comes to protecting existing fat reserves in the event of a negative energy balance (e.g. diet) and thus preventing a sustained reduction in weight.

Bariatric operations are often regarded as serious, high-risk procedures in which healthy organs are mutilated and the patient is crippled. In Germany, however, bariatric interventions are carried out under the eyes of medical associations. According to the quality procedures of the German Society for General and Visceral Surgery, the procedures should only be performed at certified clinics or centres. The procedures are performed at these facilities in a standardised manner with low complication rates using the so-called minimally invasive technique.

And the effect of bariatric interventions is now well documented, as the New York Times commented in February 2017 as follows:

"Bariatric surgery is probably the most effective intervention we have in health care."

For patients with severe obesity, it is worth taking a closer look at bariatric surgery. On the following pages, patients will find everything they need to know about obesity, its development, conservative and especially surgical treatment.

Bibliographical sources:

Adams TD, Davidson LE, Litwin SE et al (2017) Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med 377:1143–1155

Adams TD, Davidson LE, Litwin SE et al (2012) Health benefits of gastric bypass surgery after 6 years. JAMA 308:1122–1131

Augurzky B, Wübker A et al (2016) Barmer GEK Report Krankenhaus 2016

Arnold M, Pandeya N, Byrnes G et al (2015) Global burden of cancer attributable to high body-mass index in 2012: a population-based study. Lancet Oncol 16:36–46

Arterburn DE, Olsen MK, Smith VA et al (2015) Association between bariatric surgery and long-term survival. JAMA 313:62–70

Brody JE (2017) Why Weight Loss Surgery Works When Diets Don’t. The New York Times

Dietrich A (2018) AWMF S3-Leitlinie Chirurgie der Adipositas und metabolischer Erkrankungen

Driscoll S, Gregory DM, Fardy JM et al (2016) Long-term health-related quality of life in bariatric surgery patients: a systematic review and meta-analysis. Obesity (Silver Spring) 24:60–70

Sjöström L, Peltonen M, Jacobson P et al (2012) Bariatric surgery and long-term cardiovascular events. JAMA 307:56–65

Sundstrom J, Bruze G, Ottosson J et al (2017) Weight loss and heart failure: a nationwide study of gastric bypass surgery versus intensive lifestyle treatment. Circulation 135:1577–1585

Trainer S, Benjamin T (2017) Elective surgery to save my life: rethinking the “choice” in bariatric surgery. J Adv Nurs 73:894–904

Definition and Classification of Obesity

noreply@blogger.com (Unknown) — Thu, 06 Sep 2018 16:14:00 +0000

Obesity is defined as an abnormal increase in body fat, which usually leads to pathological changes. The so-called Body Mass Index (BMI) is usually used for classification:

According to the World Health Organization WHO, a BMI of 25.0-29.9 kg/m² is called pre-adipositive. As of a BMI of ≥ 30 kg/m² an obesity disease is present, which is divided into different degrees of severity.

Classification	BMI [kg/m²]	Risk of second diseases
Under weight	< 18,5
Normal weight	18,5 - 24,9
Overweight/Preadipositas	25,0 - 29,9	slightly increased
Obesity grade I	30,0 - 34,9	increased
Obesity grade II	35,0 - 39,9	significantly increased
Obesity grade III	≥ 40	greatly enhanced

The BMI is quickly determined and thus allows a quick assessment of the nutritional status. However, it is not very meaningful for assessing the extent to which obesity leads to secondary diseases. Obesity alone is not decisive for secondary diseases, but also for the localisation of excessive body fat. Two patterns of fat distribution are distinguished in obesity:

1. Visceral obesity

In visceral form, also known as abdominal or central obesity, excessive body fat is located in the abdominal cavity. For a better visual understanding, this fat distribution is also called "apple type". The increase of visceral fat masses is a decisive risk factor for the development of cardiovascular diseases.

2. Subcutaneous obesity

In this form of obesity there is an increase in subcuteanous fat mass mainly in the area of the hips, buttocks and thighs, therefore the term "pear type" is used here.

Apple Pear

The fat distribution pattern in obesity can be determined by circumferential measurements. If the ratio of waist to hip is greater than 0.85 in women and greater than 0.90 in men, abdominal obesity is present; if the ratio is lower, peripheral obesity is assumed.

Bilbiography sources:

Lean ME, Han TS, Morrison CE (1995) Waist circumference as a measure for indicating need for weight management. BMJ 311: 158–161

Robert Koch-Institut (2014) Übergewicht und Adipositas. Faktenblatt zu GEDA 2012: Ergebnisse der Studie „Gesundheit in Deutschland aktuell 2012“.

Wirth A, Hauner H (2013) Adipositas Ätiologie, Folgekrankheiten, Diagnostik, Therapie. Springer, Berlin Heidelberg

Ng M, Fleming T, Robinson M, et al. (2014) Global, regional, and national prevalence of overweight and obesity in children and adults during 1980 – 2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384: 766–781

WHO Global InfoBase team (2005) The SuRF Report 2. Surveillance of chronic disease risk factors: country-level data and comparable estimates. World Health Organization.

Obesity - a Global Tsunami

noreply@blogger.com (Unknown) — Wed, 05 Sep 2018 16:35:00 +0000

A study published in 2014 revealed that around one-third of the world's population is overweight or obese, which is why the World Health Organization WHO is right to use the term "global epidemic of obesity".

In 1980, the total number of overweight or obese people worldwide increased from 875 million to 2.1 billion. According to the above-mentioned study, most obese people live in a total of 10 countries, including the USA, China, India and Germany. Extreme values are reached on the southern and western Pacific islands. In Micronesia, Tonga or the Cook Islands, for example, around 70% of the population is obese.

The Robert Koch Institute published a study in 2012 according to which 67% of all men and 53% of all women in Germany are overweight or obese. Between 2008 and 2011, 23% of German men and women have a BMI above 30 kg/m² and are therefore considered obese. The situation among children and young people has worsened considerably. Another study conducted by the Robert Koch Institute found that 15% of all children and adolescents are overweight or obese, which corresponds to around 800,000 obese children and adolescents in Germany.

If normal weight becomes a state of exception in some countries, obesity is no longer just a disease affecting an individual, but also a social problem with catastrophic consequences. While life expectancy is declining, mortality is increasing. The causes are the secondary diseases of obesity such as diabetes mellitus type 2, cardiovascular diseases, sleep-related respiratory disorders, tumour development and infertility.

The economic burden on health systems from the obesity epidemic is also enormous. For example, in a study conducted by management consultants McKinsey in 2015, the costs of the epidemic are estimated at 1.6 trillion euros per year. Statistics on the incidence of overweight and obesity provide impressive evidence of the dramatic development of the disease in many parts of the world. Obesity is increasing rapidly in Asia, for example. As children and young people, in particular, are affected, the social threat posed by obesity is increasing massively.

Bilbiography sources:

Bleich S, Cutler D, Murray C, Adams A (2008) Why is the developed world obese? Ann Rev Public Health 29: 273–295

WHO Global InfoBase team (2005) The SuRF Report 2. Surveillance of chronic disease risk factors: country-level data and comparable estimates. World Health Organization

Wirth A, Hauner H (2013) Adipositas Ätiologie, Folgekrankheiten, Diagnostik, Therapie. Springer, Berlin Heidelberg

McKinsey Global Institute (2014) Overcoming obesity: An initial economic analysis. http://www.mckinsey.com/mgi.

Why are we getting fatter?

noreply@blogger.com (Unknown) — Tue, 04 Sep 2018 16:39:00 +0000

Obesity is a chronic disease. The reason for this is a disturbed energy balance in which the energy intake through food outweighs the energy consumption.

Food and eating habits

With the beginning of the industrial revolution, our eating habits and food composition have changed. Food is more or less always within reach and relatively inexpensive. It is also becoming more and more energy- and calorie-rich.

Data from the National Health and Nutrition Examination Survey in the USA show that men increased their energy intake by 5 % and women by 15 % between 1976 and 1991, a development that was by no means limited to the USA but was also observed in other countries. Total daily energy intake from food also increased by almost 600 kcal between 1977 and 2003, due to the increase in the number of meals per day and portion sizes.

The increase in sugar consumption, primarily from fruit juices and soft drinks, is particularly problematic. Traditional dietary patterns are no longer practised, more and more meals are taken outside the home and the consumption of high-calorie convenience meals is increasing.

Lack of exercise

In addition to changing our eating habits, physical activity has led to a significant decline in energy consumption. For example, the number of daily steps under modern living conditions is declining by around a third. A study of the Amish faith community in the USA as an example of a traditional way of life showed that women take an average of 15,000 steps and men approx. 21,000 steps per day. In a control group for modern lifestyles, the average number of steps per day was only 6,600 for women and around 7,000 for men, reducing energy consumption by around 500 kcal per day.

Changes in working conditions - less physical work, more sedentary work - and changes in leisure behaviour - television and computer behaviour - also result in a reduction in calorie consumption.

Genetic causes

The tendency to obesity may be due to genetic causes in individual cases. Obesity then already occurs in childhood, occasionally in combination with physical stigmata, hormonal disorders and occasionally also mental disability. The importance of genetic causes of obesity should not be overestimated.

Psychological causes

The development of obesity favoured by dietary and the lack of physical activity habits is further exacerbated by psychosocial causes. The disintegration of family structures (isolation) and changing demands in the job (work consolidation, unemployment) increase the feeling of stress, whereby the above-mentioned increase in energy supply can be intensified.

Hormonal causes

Hormonal disorders that lead to obesity, such as hypothyroidism or excessive cortisone production due to adrenal diseases, are usually overestimated. Appropriate blood tests can bring clarity.

Medications

Adipogenic drugs primarily include drugs that have an effect on the central nervous system, such as antidepressants. They stimulate hunger and appetite and can lead to considerable weight gain. Other drugs with similar effects include cortisone and insulin.

Bilbiography sources:

Bassett DR, Schneider PL, Huntington GE (2004) Physical activity in an Old Order Amish community. Med Sci Sports Exerc 36: 79–85

Briefel RR, McDowell MA, Alaimo K, et al. (1995) Total energy intake of the US population: the third National Health and Nutrition Examination Survey, 1988–1991. Am J Clin Nutr 62 (5 Suppl): 1072S–1080S

Bleich S, Cutler D, Murray C, Adams A (2008) Why is the developed world obese? Ann Rev Public Health 29: 273–295

Duffey KJ, Popkin BM (2011) Energy density, portion size, and eating occasions: contributions to increased energy intake in the United States, 1977–2006. PLoS Med 8: e1001050

Hussain SS, Bloom SR (2013) The regulation of food intake by the gutbrain axis: implications for obesity. Int J Obes 37: 625–633

Konturek SJ, Konturek JW, Pawlik T, Brzozowski T (2004) Brain-gut axis and its role in the control of food intake. J Physiol Pharmacol 55: 137–154

Kumar R, Simpson CV, Froelich CA, et al. (2015) Obesity and deep brain stimulation: an overview. Ann Neurosci 22: 181–188

Nielsen SJ, Popkin BM (2003) Patterns and trends in food portion sizes, 1977–1998. JAMA 289: 450–453

Rindi G, Leiter AB, Kopin AS, Bordi C, Solcia E (2004) The „normal“ endocrine cell of the gut: changing concepts and new evidences. Ann NY Acad Sci 1014: 1–12

Schwartz MW, Woods SC, Porte D Jr, Seeley RJ, Baskin DG (2000) Central nervous system control of food intake. Nature 404: 661–671

Stengel A, Taché Y (2011) The physiological relationships between the brainstem, vagal stimulation, and feeding. In: Preedy VR, Watson RR, Martin CR (Hrsg) Handbook of Behavior, Diet and Nutrition. Springer, New York Dordrecht Heidelberg London, pp 817–828

Wiegand S, Krude H (2015) Monogene und syndromale Krankheitsbilder bei morbider Adipositas. Internist 56: 111–120

Wyatt HR, Peters JC, Reed GW, et al. (2005) A Colorado statewide survey of walking and its relation to excessive weight. Med Sci Sports Exerc 37: 724–730

Diseases caused by Obesity

noreply@blogger.com (Unknown) — Mon, 03 Sep 2018 16:46:00 +0000

Obesity can lead to numerous diseases, including joint and lung diseases, cardiovascular problems, diabetes mellitus type 2, high blood pressure and lipometabolic diseases. Obesity also plays a role in the development of cancer. The life value of a 40-year-old obese person is shortened by 7 years on average.

Metabolic syndrome

Besides smoking, metabolic syndrome is regarded as a decisive risk factor for diseases of the arterial vessels, especially coronary heart disease. The so-called "deadly quartet" of metabolic syndrome includes:

Obesity, especially visceral type
High blood pressure
Lipometabolic disorders
Insulin resistance or impaired glucose tolerance, the main cause of diabetes mellitus type 2

Other common diseases in metabolic syndrome are hyperuricemia (increase in uric acid levels, gout) and hyperandrogenemia in women, i.e. an increase in androgen levels (male sex hormone). Blood clotting disorders are also more common, which increases the risk of thrombosis in obese people.

Visceral obesity is an important factor in insulin resistance, in which the cells react less to insulin supplied from the body and from outside. Affected are mainly muscle, liver and fat cells. A study from 1997 showed a 6.2-fold increased risk of developing diabetes mellitus with an abdominal girth of more than 96.4 cm compared to less than 71 cm within 8 years. Conversely, even moderate weight loss in obesity can significantly reduce the risk of diabetes. This correlation does not apply to autoimmune diabetes mellitus type 1.

The most common consequence of obesity is high blood pressure, which occurs 5 times more frequently in obese people than in people of normal weight. Here, too, weight loss leads to a reduction in elevated blood pressure values. Obesity leads to an increase in triglycerides with simultaneous lowering of HDL cholesterol in the blood, which is called dyslipidemia. It is a precursor of arteriosclerosis (arteriosclerosis).

Obesity is an independent risk factor for cardiovascular diseases. These include heart failure, heart attack and sudden cardiac death as well as strokes.

Fatty liver

Visceral obesity can lead to liver obesity, which can range from inflammatory hepatitis to cirrhosis. Cirrhosis is a risk factor for the development of hepatocellular carcinoma. Insulin resistance also plays an important role here.

Sleep-related respiratory disorders

Obesity can lead to the development of sleep apnoea syndrome, which is characterized by nocturnal breathing stops that can last for several minutes. Untreated, it leads to high blood pressure, heart problems, heart attacks, depression and stress disorders such as stomach ulcers, tinnitus and hearing loss. There too is a connection with the insulin resistance mentioned above.

Men are 4 times more likely to suffer from sleep apnoea syndrome than women. From a neck circumference of more than 43 cm in men and 40.5 cm in women, the risk of apnea syndrome increases significantly. The first sign of sleep apnoea syndrome is increased tiredness during the day.

Musculoskeletal system

Degenerative joint diseases occur more frequently and early in obesity. This often blocks the desired increase in physical activity during the treatment of obesity. Premature wear mainly affects the knee and hip joints, but spinal problems also increase.

Cancers

The risk of developing carcinoma is increased in obese people. The probability of developing a carcinoma is 12 - 50 % per increase in BMI of 5 kg/m², depending on the type of cancer.

A link between obesity and tumours is known for colon, kidney, oesophagus, stomach, pancreas, liver and prostate cancer. Adipose women also have an increased risk of gallbladder and bile duct carcinoma, breast, ovarian and cervical cancer.

Bilbiography sources:

Alberti KG, Zimmet P, Shaw J (2005) The metabolic syndrome-a new worldwide definition. Lancet 366: 1059–1062

Borel JC, Borel AL, Monneret D, et al. (2012) Obesity hypoventilation syndrome: from sleep-disordered breathing to systemic comorbidities and the need to offer combined treatment strategies. Respirology 17: 601–610

Carey VJ, Walters EE, Colditz GA, et al. (1997) Body fat distribution and risk of non-insulin-dependent diabetes mellitus in women. The Nurses’ Health Study. Am J Epidemiol 145: 614–619

Deutsche Gesellschaft für Kardiologie, Deutsche Hochdruckliga e.V. DHL (2013) ESH/ESC Pocket Guidelines. Leitlinien für das Management der arteriellen Hypertonie. http://www.hochdruckliga.de/

Flier JS, Maratos-Flier E, Elbelt U, Scholze JE (2012) Adipositas. In: Longo DL, Fauci AS, Kaspar DL, et al. (Hrsg) Harrisons Innere Medizin, 18. Aufl. ABW Wissenschaftsverlag, Berlin, S 665–672

Haslam DW, James WPT (2005) Obesity. Lancet 366: 1197–1209

Kerner W, Brückel J (2015) Definition, Klassifikation und Diagnostik des Diabetes mellitus. Diabetol Stoffwechs 10 (Suppl 2): S 98–S 101

Knowler WC, Barett-Connor E, Fowler SE, et al. (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346: 393–403

Kushner RF, Elbelt U, Scholze JE (2012) Diagnostik und Management der Adipositas. In: Longo DL, Fauci AS, Kaspar DL, et al. (Hrsg) Harrisons Innere Medizin, 18. Aufl. ABW Wissenschaftsverlag, Berlin, S 673–681

Nimptsch K, Pischon T (2014) Adipositas und Krebs. Adipositas 8: 151–156

Tuomilehto J, Lindström J, Eriksson JG, et al. (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344: 1343–1350

Obesity and Psyche

noreply@blogger.com (Unknown) — Sun, 02 Sep 2018 16:54:00 +0000

Obesity is often associated with mental disorders. Among the German general population, 38% say they have suffered from a mental disorder in their lives to date, and around 48% of obese people. It is unclear whether obesity is the cause of mental illness or vice versa, but it is assumed that the illnesses influence each other and other factors also play a role.

In the obese population, the frequency of mental disorders varies greatly. Over 70% of obese patients seeking bariatric surgery have at least one mental disorder. Women with a high BMI are particularly susceptible. If conservative therapy (diet, exercise) is used to treat obesity, the frequency of mental disorders is significantly lower.

Stigmata - greedy, lazy and weak-willed

Stigmatizing attitudes towards obese people are widespread in society. Obese people are blamed for their obesity. They are often described as greedy, lazy and weak-willed and their overweight is regarded as a consequence of individual misconduct. Apart from negative or aggressive comments, obese people are often disadvantaged in educational institutions, in the workplace and in the health care system. People with stigmatisation develop a negative body image, experience a loss of self-esteem, become socially isolated and are exposed to an increased risk of depression and anxiety disorders. Against this background, the health-related quality of life of obese people is generally worse than in the general population.

Depression and anxiety disorders

Studies have shown the link between obesity and depression. Obesity is 55% more likely to develop depression than the general population. Here too, the greater the desire to lose weight, the more likely it is that those affected develop depression. Conversely, the likelihood of developing obesity is increased by 58%.

Anxiety disorders are among the most common mental disorders in developed countries, affecting around 25% of the population at least once in their lives. These include generalised anxiety disorders that are not fixed to a particular object or situation, panic disorders and phobias. For obese people, the risk of a co-existing anxiety disorder is increased by 40% and rises with increasing BMI.

Abuse and post-traumatic stress disorder (PTSD)

There is a clear link between physical and sexual abuse in childhood and the development of obesity. Studies show a 36% increase in the risk of developing obesity after childhood abuse.

Typical PTSD reactions are psychological reactions that occur against the background of a stressful event with an extraordinary threat, e.g. as flashbacks, nightmares, hyperexcitability or avoidance behaviour. 50% of all people with PTSD have visceral obesity. The likelihood of developing obesity as a result of PTSD is particularly high in women.

Bilbiography sources:

Brandheim S, Rantakeisu U, Starrin B (2013) BMI and psychological distress in 68,000 Swedish adults: a weak association when controlling for an age-gender combination. BMC Public Health 13: 68

Dallman MF (2010) Stress-induced obesity and the emotional nervous system. Trends Endocrinol Metab 21: 159–165 Danese A, Tan M (2014) Childhood maltreatment and obesity: systematic review and meta-analysis. Mol Psychiatry 19: 544–554

Danese A, Tan M (2014) Childhood maltreatment and obesity: systematic review and meta-analysis. Mol Psychiatry 19: 544–554

de Zwaan M, Enderle J, Wagner S, et al. (2011) Anxiety and depression in bariatric surgery patients: a prospective, follow-up study using structured clinical interviews. J Affect Disord 133: 61–68

Gariepy G, Nitka D, Schmitz N (2010) The association between obesity and anxiety disorders in the population: a systematic review and meta-analysis. Int J Obes 34: 407–419

Gerlach G, Herpertz S, Loeber S (2015) Personality traits and obesity: a systematic review. Obes Rev 16: 32–63

Herpertz S, Burgmer R, Stang A, et al. (2006) Prevalence of mental disorders in normal-weight and obese individuals with and without weight loss treatment in a German urban population. J Psychosom Res 61: 95–103

Luppino FS, de Wit LM, Bouvy PF, et al. (2010) Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry 67: 220–229

Malik S, Mitchell JE, Engel S, Crosby R, Wonderlich S (2014) Psychopathology in bariatric surgery candidates: a review of studies using structured diagnostic interviews. Compr Psychiatry 55: 248–259

Moore CJ, Cunningham SA (2012) Social position, psychological stress, and obesity: a systematic review. J Acad Nutr Diet 112: 518–526

Mühlhans B, Horbach T, de Zwaan M (2009) Psychiatric disorders in bariatric surgery candidates: a review of the literature and results of a German prebariatric surgery sample. Gen Hosp Psychiatry 31: 414–421

Pagoto SL, Schneider KL, Bodenlos JS (2012) Association of post-traumatic stress disorder and obesity in a nationally representative sample. Obesity 20: 200–205

Puhl RM, King KM (2013) Weight discrimination and bullying. Best Pract Res Clin Endocrinol Metab 27: 117–127

Rosenbaum S, Stubbs B, Ward PB, Steel Z, Lederman O, Vancampfort D (2015) The Prevalence and Risk of Metabolic Syndrome and its Components Among People with Posttraumatic Stress Disorder: A Systematic Review and Meta-analysis. Metabolism 64: 926–933

Eating Disorders

noreply@blogger.com (Unknown) — Sat, 01 Sep 2018 16:58:00 +0000

Eating disorders closely related to obesity are binge-eating disorder and bulimia nervosa.

Typical of binge-eating disorder is uncontrolled, fast eating of large amounts of food without feeling hungry. Diagnosis requires at least one eating attack per week over 3 months. Eating attacks are also typical of bulimia nervosa, which, unlike binge-eating disorders, includes subsequent vomiting, the consumption of laxatives or arbitrary periods of hunger.

The binge eating disorder occurs in the general population with a frequency of 1 - 3 %, but in the obese collective with up to 50 %. In contrast to anorexia and bulimia, binge eating disorder occurs in about 30% of men. Studies have shown that 33% of all patients with bulimia and 42% of all patients with binge-eating disorders are obese at the same time.

Other eating disorders that are related to the development of obesity:

night-eating syndrome, where large amounts of food are consumed in the evening or at night,
sweet-eating syndrome, which is characterised by the consumption of predominantly sweet foods,
grazing with frequent consumption of small amounts of food between main meals.

Bilbiography sources:

Gerlach G, Herpertz S, Loeber S (2015) Personality traits and obesity: a systematic review. Obes Rev 16: 32–63

Kessler RC, Berglund PA, Chiu, WT, et al. (2013) The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatry 73: 904–914

Moore CJ, Cunningham SA (2012) Social position, psychological stress, and obesity: a systematic review. J Acad Nutr Diet 112: 518–526

Indications and Therapeutic Goals of Obesity Treatment

noreply@blogger.com (Unknown) — Fri, 31 Aug 2018 17:01:00 +0000

Depending on the BMI, the body fat distribution, existing secondary diseases of overweight, risk factors and patient wishes, the indication can be provided for treatment.

The current German guideline "Prevention and therapy of obesity" recommends this treatment:

BMI from 30 kg/m² or
BMI between 25 and < 30 kg/m² and simultaneous presence of

obesity-related health disorders (e.g. high blood pressure, diabetes mellitus type 2) or
visceral obesity or
diseases aggravated by obesity or
a high level of psychological strain

Therapy goals

The aim of the therapy is a sustainable weight reduction as well as the prevention or improvement of already existing secondary diseases of obesity. Since obesity is usually due to over-nutrition and lack of exercise, the basic therapy of obesity is based on diet, exercise and behavioural therapy.

In the first phase of treatment, the focus is on weight loss, in the second phase on long-term weight stabilization. For a BMI of 25-35 kg/m², a weight reduction of > 5 % of the initial weight should be targeted within one year, for a BMI > 35 kg/m² by > 10 %.

Bilbiography sources:

Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counselling for weight loss. Ann Intern Med 2007;147(1):41-50.

Deutsche Adipositas-Gesellschaft, Deutsche Diabetes Gesellschaft, Deutsche Gesellschaft für Ernährung, Deutsche Gesellschaft für Ernährungsmedizin (2014) Interdisziplinäre Leitlinie der Qualität S3 zur „Prävention und Therapie der Adipositas“. AWMF-Register Nr. 050/001.

Holzapfel C, Hauner H. Weight maintenance after weight loss - how the body defends its weight. Dtsch Med Wochenschr 2011;136(3):89-94.

Kuk JL, Ardern CI, Church TS, Sharma AM, Padwal R, Sui X, Blair SN. Edmonton Obesity Staging System: association with weight history and mortality risk. Appl Physiol Nutr Metab 2011;36(4):570-6.

Leermakers EA, Perri MG, Shigaki CL, Fuller PR. Effects of exercise-focused versus weight-focused maintenance programs on the management of obesity. Addict Behav 1999;24(2):219-27.

Södlerlund A, Fischer A, Johansson T. Physical activity, diet and behaviour modification in the treatment of overweight and obese adults: a systematic review. Perspect Public Health 2009;129(3):132-42.

van Baak MA, van ME, Astrup AV, Finer N, Van Gaal LF, Hilsted J, Kopelman PG, Rossner S, James WP, Saris WH. Leisure-time activity is an important determinant of long-term weight maintenance after weight loss in the Sibutramine Trial on Obesity Reduction and Maintenance (STORM trial). Am J Clin Nutr 2003;78(2):209-14.

Witham MD, Avenell A. Interventions to achieve long-term weight loss in obese older people: a systematic review and meta-analysis. Age Ageing 2010;39(2):176-84

Wu T, Gao X, Chen M, van Dam RM. Long-term effectiveness of diet-plus-exercise interventions vs. diet-only interventions for weight loss: a meta-analysis. Obes Rev 2009;10(3):313-23.

Diet Therapy

noreply@blogger.com (Unknown) — Thu, 30 Aug 2018 17:06:00 +0000

The main focus of nutrition therapy is the reduction of daily calorie intake, which should take place over several steps.

1st step

In the first phase, energy intake is reduced by decreasing fat and/or carbohydrate intake. The avoidance of sugary foods is recommended.

2nd step

In the next phase, daily calorie intake should be 500 - 1000 kcal below the usual calorie intake. This calorie restriction should allow a weekly weight loss of 0.5 kg. In this phase an energy-reduced mixed diet is recommended, which is high in fibre and protein as well as low in fat: 50-55 % carbohydrates, 30 % fat and 15-20 % protein. A high level of fruit and vegetables should be taken into account when selecting food.

3rd step

In this phase individual or all meals can be replaced by formula products. This refers to ready-to-drink products or nutrient powders to be mixed with liquid, which contain protein, fat and carbohydrates in a balanced ratio, usually also vitamins and minerals. The nutritional value consumed in the diet by Formula products alone is a maximum of 1200 kcal per day, which should lead to a rapid loss of weight in the case of obesity.

Adherence to therapy requires that the change in diet can be permanently integrated into the individual everyday life of the patient. Preferences and lifestyle habits must, therefore, be taken into account when planning therapy.

Bilbiography sources:

Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ (2005) Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for weight loss and heart disease risk reduction: a randomized trial. JAMA 293: 43–53

Deutsche Gesellschaft für Ernährung (DGE) (2009) DGE BeratungsStandards. graphoprint Verlag Ruth Schlotter, Koblenz

Deutsche Gesellschaft für Ernährung (DGE), Österreichische Gesellschaft für Ernährung (ÖGE), Schweizerische Gesellschaft für Ernährungsforschung (SGE), Schweizerische Vereinigung für Ernährung (2008) Referenzwerte für die Nährstoffzufuhr. Neuer Umschau Buchverlag, Neustadt/Weinstraße

Physical-exercise Therapy

noreply@blogger.com (Unknown) — Wed, 29 Aug 2018 17:09:00 +0000

Exercise therapy increases energy consumption and plays a decisive role in weight loss in addition to the dietary changes. Exercise therapy alone only has a minor influence on weight loss. Only in combination with a reduced amount of calories is weight reduction achieved.

The following recommendations apply to exercise therapy:

An effective weight reduction is only achieved if an energy consumption of 1200-1800 kcal/week is achieved with 150 minutes of physical activity per week.
Strength training alone is not suitable for weight reduction.
In the case of obesity grade II and III, consideration must be given to the musculoskeletal system, which may not be able to cope with an excessively intensive strain in the context of movement therapy.
Increasing normal daily activities also helps to reduce body weight.
Physical activity not only supports weight loss, but it also has other health benefits (e.g. cardiovascular system).

Movement therapy primarily helps to stabilize the achieved body weight after successful obesity reduction. It is important to discuss realistic ways of increasing movement. Increased leisure activities and active commuting by avoidance of comfortable transport possibilities (on foot instead of a bus, train, car) help to increase physical activity. Pedometers and the documentation of the daily number of steps can be motivating.

Bilbiography sources:

Andersen RE, Wadden TA, Bartlett SJ, Zemel B, Verde TJ, Franckowiak SC. Effects of lifestyle activity vs structured aerobic exercise in obese women: a randomized trial. JAMA 1999;281(4):335-40.

Christiansen T, Paulsen SK, Bruun JM, Overgaard K, Ringgaard S, Pedersen SB, Positano V, Richelsen B. Comparable reduction of the visceral adipose tissue depot after a diet-induced weight loss with or without aerobic exercise in obese subjects: a 12-week randomized intervention study. Eur J Endocrinol 2009;160(5):759-67.

Church TS, Blair SN, Cocreham S, Johannsen N, Johnson W, Kramer K, Mikus CR, Myers V, Nauta M, Rodarte RQ, Sparks L, Thompson A, Earnest CP. Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA 2010;304(20):2253-62.

Franz MJ, van Wormer JJ, Crain AL, et al. (2007) Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc 107: 1755–1767

National Institute for Health and Clinical Excellence (NICE). Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. 2006

Scottish Intercollegiate Guidelines Network (SIGN). Management of Obesity. A national clinical guideline. Edinburgh: SIGN; 2010.

Slentz CA, Bateman LA, Willis LH, Shields AT, Tanner CJ, Piner LW, Hawk VH, Muehlbauer MJ, Samsa GP, Nelson RC, Huffman KM, Bales CW, Houmard JA, Kraus WE. Effects of aerobic vs. resistance training on visceral and liver fat stores, liver enzymes, and insulin resistance by HOMA in overweight adults from STRRIDE AT/RT. Am J Physiol Endocrinol Metab 2011;301(5): E1033-E9.

Thomas JG, Bond DS, Phelan S, Hill JO, Wing RR (2014) Weight-loss maintenance for 10 Years in the National Weight Control Registry. Am J Prev Med 46: 17–23

Wing RR, Hill JO (2001) Successful weight loss maintenance. Annu Rev Nutr 21: 323–341

Wu T, Gao X, Chen M, van Dam RM. Long-term effectiveness of diet-plus-exercise interventions vs. diet-only interventions for weight loss: a meta-analysis. Obes Rev 2009;10(3):313-23.

Behavioral Therapy

noreply@blogger.com (Unknown) — Tue, 28 Aug 2018 17:14:00 +0000

Behavioural therapy for the treatment of obesity aims to systematically change the behaviour that contributes to the development and maintenance of obesity. A distinction is made between so-called lifestyle interventions and behavioural therapeutic treatment methods. The effectiveness of behavioural interventions alone, but in particular in combination with nutrition and physical activity, has been systematically investigated and well documented. It seems that more intensive behavioural programs also lead to a higher weight loss. Whether group or individual behavioural therapies are effective should be decided individually.

The spectrum of suitable interventions and methods may include the following elements, among others:

self-observation of behaviour and progress (amount of food, body weight, exercise)
stimulus control
target agreements
training in conflict resolution
assertiveness training
prevention of relapses
social support

Individual areas should also be discussed in the context of behavioural therapy:

history: weight development, failed weight loss attempts, self-esteem, stigmatization
motivation situation
social environment: family, partners, work, leisure, friends
importance of food intake: relaxation, reward, frustration

Psychotherapy of any mental disorders such as anxiety disorders, depression or eating disorders that are often present in obese patients who wish to be treated should take place as part of behavioural therapy. Good evidence is also available for the psychotherapeutic treatment of binge-eating disorders.

Bilbiography sources:

Acharya SD, Elci OU, Sereika SM, Styn MA, Burke LE. Using a personal digital assistant for self monitoring influences diet quality in comparison to a standard paper record among overweight/obese adults. J Am Diet Assoc 2011;111(4):583-8.

Anderson JW, Reynolds LR, Bush HM, Rinsky JL, Washnock C. Effect of a behavioral/nutritional intervention program on weight loss in obese adults: a randomized controlled trial. Postgrad Med 2011;123(5):205-13.

Avenell A, Broom J, Brown TJ, Poobalan A, Aucott L, Stearns SC, Smith WC, Jung RT, Campbell MK, Grant AM. Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technol Assess 2004;8(21):iii-182.

Burke LE, Conroy MB, Sereika SM, Elci OU, Styn MA, Acharya SD, Sevick MA, Ewing LJ, Glanz K. The effect of electronic self-monitoring on weight loss and dietary intake: a randomized behavioral weight loss trial. Obesity (Silver Spring) 2011;19(2):338-44.

McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, Lohr KN. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003;139(11):933-49.

National Institute for Health and Clinical Excellence (NICE). Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. 2006

Rodriguez-Hernandez H, Morales-Amaya UA, Rosales-Valdez R, Rivera-Hinojosa F, Rodriguez-Moran M, Guerrero-Romero F. Adding cognitive behavioural treatment to either low-carbohydrate or low fat diets: differential short-term effects. Br J Nutr 2009;102(12):1847-53.

Scottish Intercollegiate Guidelines Network (SIGN). Management of Obesity. A national clinical guideline. Edinburgh: SIGN; 2010.

Shaw K, O'Rourke P, Del MC, Kenardy J. Psychological interventions for overweight or obesity. Cochrane Database Syst Rev 2005(2): CD003818.

Smith SR, Weissman NJ, Anderson CM, Sanchez M, Chuang E, Stubbe S, Bays H, Shanahan WR. Multicenter, placebo-controlled trial of lorcaserin for weight management. N Engl J Med 2010;363(3):245-56.

Teufel M, Becker S, Rieber N, Stephan K, Zipfel S. [Psychotherapy and obesity: strategies, challenges and possibilities]. Nervenarzt 2011;82(9):1133-9

Pharmacological Therapy

noreply@blogger.com (Unknown) — Mon, 27 Aug 2018 17:18:00 +0000

Drug therapy is not a primary form of treatment for overweight and obesity, as only a change in diet and exercise can permanently reduce body weight. Drugs are only used if no or insufficient weight loss is achieved through lifestyle changes. A drug therapy should always be carried out in combination with a basic program consisting of nutrition, exercise and behavioural therapy.

For patients with a BMI ≥ 28 kg/m² and additional risk factors or already existing secondary diseases of obesity or a BMI ≥ 30 kg/m² a drug therapy can be considered under the following conditions:

weight loss of < 5% of initial weight within six months under basic therapy
weight gain of > 5 % of the initial weight within six months after a phase of weight reduction

Continuation of the drug treatment should only be continued if weight loss of at least 2 kg has been achieved within the first four weeks.

The current guideline "Prevention and Therapy of Obesity" of the German Obesity Society (as of 2014) only recommends the drug "Orlistat" for the drug treatment of obesity.

Orlistat

Orlistat is approved from a BMI ≥ 28 kg/m² for the supportive treatment of obesity. It inhibits lipases (fat-splitting enzymes) in the gastrointestinal tract and thereby reduces fat absorption. The maximum dosage of orlistat is 120 mg 3x daily with the main meals.

Because of insufficient digestion of fat in the gastrointestinal tract, orlistat can lead to abdominal cramps, flatulence, increased stool urge and diarrhoea. The absorption of fat-soluble vitamins by the preparation is also reduced.

The weight-reducing effect of orlistat should not be overestimated. In a study conducted over 4 years, the weight loss with simultaneous lifestyle intervention was 10.6 kg after 1 year and 5.8 kg after 4 years.

Bilbiography sources:

Davidson MH, Hauptman J, DiGirolamo M, Foreyt JP, Halsted CH, Heber D, Heimburger DC, Lucas CP, Robbins DC, Chung J, Heymsfield SB. Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat: a randomized controlled trial. JAMA 1999;281(3):235-42.

Hauptman J, Lucas C, Boldrin MN, Collins H, Segal KR. Orlistat in the long-term treatment of obesity in primary care settings. Arch Fam Med 2000;9(2):160-7

Hollander PA, Elbein SC, Hirsch IB, Kelley D, McGill J, Taylor T, Weiss SR, Crockett SE, Kaplan RA, Comstock J, Lucas CP, Lodewick PA, Canovatchel W, Chung J, Hauptman J. Role of orlistat in the treatment of obese patients with type 2 diabetes. A 1-year randomized double-blind study. Diabetes Care 1998;21(8):1288-94.

Kelley DE, Bray GA, Pi-Sunyer FX, Klein S, Hill J, Miles J, Hollander P. Clinical efficacy of orlistat therapy in overweight and obese patients with insulin-treated type 2 diabetes: A 1-year randomized controlled trial. Diabetes Care 2002;25(6):1033-41.

Rossner S, Sjostrom L, Noack R, Meinders AE, Noseda G. Weight loss, weight maintenance, and improved cardiovascular risk factors after 2 years treatment with orlistat for obesity. European Orlistat Obesity Study Group. Obes Res 2000;8(1):49-61.

Rucker D, Padwal R, Li SK, Curioni C, Lau DC. Long term pharmacotherapy for obesity and overweight: updated meta-analysis. BMJ 2007;335(7631):1194-9

Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. Xenical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients. Diabetes Care 2004;27(1):155-61.

Bariatric surgery

noreply@blogger.com (Unknown) — Sun, 26 Aug 2018 17:21:00 +0000

The conservative treatment of obesity, consisting of dietary, exercise and behavioural therapy and possibly drug therapy, often does not show sufficient and lasting effects. Surgical therapy for obesity, on the other hand, has proven to be very effective and sustainable, is safe and cost-effective. It not only leads to a considerable weight reduction, but also to a significant improvement in obesity-related diseases such as diabetes mellitus type 2, high blood pressure and sleep apnoea syndrome. In type 2 diabetes mellitus, the improvement in blood sugar levels already occurs immediately after surgery, irrespective of weight reduction. With increasing weight reduction, quality of life and life expectancy increase.

Bariatric surgery

Bariatric surgery is a branch of surgery that deals with procedures designed to facilitate a reduction in body weight. Most bariatric procedures are performed endoscopically via small incisions inside the abdomen. The most common weight loss procedures performed in Germany are the gastric sleeve and gastric bypass surgery.

Obesity surgery

Obesity surgery is a bariatric procedure whose primary goal is weight reduction. Through a sustainable weight reduction, an improvement in obesity-related concomitant diseases or their prevention and an improvement in the quality of life can be achieved.

Metabolic surgery

Metabolic surgery is understood as bariatric surgery as above, but here the indication is primarily for improving the metabolic situation in a pre-existing diabetes mellitus type 2. Weight loss is a welcome side effect but is not the primary goal of the procedure. For other diseases associated with obesity or metabolic syndrome, such as high blood pressure, there is currently insufficient data to provide the indication for metabolic intervention primarily because of these diseases.

Quality management (Germany)

Obesity surgery should only be performed in clinics that are certified as a centre for obesity surgery or are seeking certification. Centres for obesity surgery should be limited to the following procedures:

patient age between ≥ 18 and < 65 years
patients without severe concomitant diseases (ASA* ≤)
patients with BMI < 60 kg/m²
standard obesity surgery procedures: gastric sleeve, gastric banding, proximal Roux-en-Y gastric bypass and omega-loop gastric bypass.

Patients outside these criteria, more demanding operations and primary metabolic interventions for the treatment of type 2 diabetes mellitus will be performed at a centre for obesity and metabolic surgery with special expertise:

any patient age, especially <18 or ≥ 65 years (cf. obesity centre)
risk patients with severe concomitant diseases (ASA* >3)
patients with BMI ≥ 60 kg/m²
in addition to standard obesity surgery, difficult bypass operations, conversion operations and redo operations
primary metabolic interventions (for BMI < 40kg/m² in cooperation with a physician experienced in diabetology)

In addition, the responsible surgeon should have the expertise of at least 300 obesity or metabolic surgery procedures, which also include difficult correction or transformation procedures.

If obesity surgery or metabolic procedures are planned for children or adolescents, these should only be carried out in cooperation with a paediatric clinic with experience in the treatment of obesity, suitably qualified specialist staff and an intensive care unit suitable for children and adolescents.

Bilbiography sources:

Deutsche Adipositas-Gesellschaft, Deutsche Diabetes Gesellschaft, Deutsche Gesellschaft für Ernährung, deutsche Gesellschaft für Ernährungsmedizin (2014) Interdisziplinäre Leitlinie der Qualität S3 zur „Prävention und Therapie der Adipositas“. AWMF-Register Nr. 050/001. Klasse: S3. Version 2.0

Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, Chirurgische Arbeitsgemeinschaft für Adipositastherapie (CAADIP), Deutsche Adipositas-Gesellschaft (DAG), Deutsche Gesellschaft für Psychosomatische Medizin und Psychotherapie, Deutsche Gesellschaft für Ernährungsmedizin (2010) S3-Leitlinie: Chirurgie der Adipositas.

Fried M, Yumuk V, Oppert JM, et al. (2013) Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery. Obes Facts 6: 449–468

Hüttl TP, Stauch P, Wood H, Fruhmann J (2015) Bariatrische Chirurgie. Aktuelle Ernährungsmed 40: 256–274

Mingrone G, Panunzi S, De Gaetano A, et al. (2012). Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 366: 1577–1585

Runkel N, Colombo-Benkmann M, Hüttl TP, et al. (2011) Bariatric Surgery. Dtsch Arztebl Int 108: 341–346

Weiner RA (2015) Adipositas – Wann ist der Chirurg gefragt? Dtsch Med Wochenschr 140: 29–33

Frequency of Bariatric Surgery Procedures

noreply@blogger.com (Unknown) — Sat, 25 Aug 2018 17:34:00 +0000

The long-term weight reduction and improvement of obesity-related concomitant diseases through bariatric surgery have been well documented in numerous studies. Obesity and metabolic surgery have therefore become firmly established in the treatment concept of obese patients.

More than 300,000 bariatric procedures are performed worldwide every year, most of them in terms of population in Sweden (90 procedures/100,000 inhabitants), Belgium (77/100,000) and the USA (69/100,000). With around 11 interventions per 100,000 inhabitants, bariatric interventions are comparatively rare in Germany. This means that not even 1% of patients with severe obesity in Germany receive bariatric surgery, although they are eligible for it according to the recommendations of medical associations.

The main reason for the low number of bariatric operations in Germany is the complicated approval practice of the health insurance companies, which drive affected persons forward with a lengthy and bureaucratic application procedure. Often the application procedures lead to a delay of the operation with considerable health consequences for the affected persons. Recommendations and reasons for rejection by the Medical Service of Health Insurance Funds (MDK) are often incomprehensible.

However, taking into account the sharp increase in the number of severely obese people and the very good effectiveness of bariatric surgery, an increase in bariatric interventions can also be expected in Germany. Experts estimate that 20,000 to 30,000 operations will be performed per year in the future.

Bilbiography sources:

Carlsson LM, Peltonen M, Ahlin S, et al. (2012) Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med 367: 695–704

Fried M, Yumuk V, Oppert JM, et al. (2013) Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery. Obes Facts 6: 449–468

Hüttl TP, Stauch P, Wood H, Fruhmann J (2015) Bariatrische Chirurgie. Aktuelle Ernährungsmed 40: 256–274

Lo Menzo E, Szomstein S, Rosenthal RJ (2015) Changing Trends in Bariatric Surgery. Scand J Surg 104: 18–23

Indications for Obesity Surgery

noreply@blogger.com (Unknown) — Fri, 24 Aug 2018 17:37:00 +0000

The indication for obesity surgery is given if the goal of the procedure is a sustained reduction in weight. Type 2 diabetes mellitus may occur by chance but is not absolutely necessary for the indication of the procedure.

According to the current guideline "Surgery of Obesity and Metabolic Diseases" of the German Society for General and Visceral Surgery (status 2010), the indication is given under the following conditions:

BMI ≥ 40 kg/m² without accompanying diseases - after exhaustion of the conservative treatment of obesity
BMI ≥ 35 kg/m² with one or more obesity-related concomitant diseases such as diabetes mellitus type 2, coronary heart disease, cardiac insufficiency, lipometabolic disorders, high blood pressure, sleep apnoea syndrome, liver metabolic disorders, reflux disease, asthma, leg vein diseases, urinary bladder weakness, joint diseases, infertility - after exhaustion of the conservative treatment of obesity
The indication can also be given without a previous conservative treatment attempt:

BMI ≥ 50 kg/m²
patients for whom a conservative therapy attempt was classified as unpromising or hopeless
patients with particular severity of concomitant diseases that do not allow a delay in surgery

When is the conservative treatment of obesity considered to have failed?

According to the above guideline, conservative treatment measures are failed

after at least 6 months of comprehensive lifestyle intervention in the last two years, a reduction of the initial weight of > 15% with a BMI of 35-39.9 kg/m² and > 20% with a BMI above 40 kg/m² has not been achieved.
the above weight reduction could be achieved by conservative measures, but persisting obesity-related diseases can be further improved by the intervention
after a successful weight reduction within one year a weight gain of > 10% takes place again

Bilbiography sources:

Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292(14):1724-37.

Christou NV, Sampalis JS, Liberman M, Look D, Auger S, McLean AP, MacLean LD. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240(3):416-23.

Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev 2009(2): CD003641.

Dixon JB, Zimmet P, Alberti KG, Rubino F. Bariatric surgery: an IDF statement for obese Type 2 diabetes. Diabet Med 2011;28(6):628-42.

Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugerman HJ, Livingston EH, Nguyen NT, Li Z, Mojica WA, Hilton L, Rhodes S, Morton SC, Shekelle PG. Metaanalysis: surgical treatment of obesity. Ann Intern Med 2005;142(7):547-59.

Runkel N, Colombo-Benkmann M, Huttl TP, Tigges H, Mann O, Flade-Kuthe R, Shang E, Susewind M, Wolff S, Wunder R, Wirth A, Winckler K, Weimann A, de ZM, Sauerland S. Evidence-based German guidelines for surgery for obesity. Int J Colorectal Dis 2011;26(4):397-404.

Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, Thomas S, Abood B, Nissen SE, Bhatt DL. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366(17):1567-76.

Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjostrom CD, Sullivan M, Wedel H. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351(26):2683-93.

Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lonroth H, Naslund I, Olbers T, Stenlof K, Torgerson J, Agren G, Carlsson LM. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357(8):741-52.

Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B, Dolan K, Fielding GA. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg 2004;8(1):48-55.

Indications for Metabolic Surgery

noreply@blogger.com (Unknown) — Thu, 23 Aug 2018 17:43:00 +0000

The indication for a metabolic surgery procedure is given if the aim is to improve blood sugar levels in diabetes mellitus type 2. Since weight reduction also begins at the same time, the patient benefits not only from an improvement in the diabetic metabolism but also from an improvement in the quality of life through weight reduction.

Metabolic surgery is indicated only for pre-existing type 2 diabetes mellitus and not for type 1, which is an autoimmune disease that does not respond to metabolic surgery!

Patients who are eligible for metabolic surgery should first undergo diabetes training and nutritional advice in preparation for the procedure. The indications for the intervention in pre-existing diabetes mellitus type 2 are:

BMI ≥ 40 kg/m²
BMI ≥ 35 kg/m² and < 40 kg/m² if conservative treatment fails to improve blood sugar levels
BMI ≥ 30 kg/m² and < 35 kg/m² if conservative treatment fails to improve blood sugar levels -> intervention may be considered
BMI < 30 kg/m² -> only in the context of scientific studies

Metabolic surgery procedures should only be performed in a centre with special experience. For the indication of a BMI < 40 kg/m², it is recommended to consult a diabetologist.

As before every surgery procedure, alternative treatment methods must also be discussed when discussing a metabolic surgery with the patient, i.e. the conservative possibilities of weight reduction and methods for diabetes control.

Bilbiography sources:

Blüher M (2014) Insulin oder Chirurgie? Die Sicht des Diabetologen. Chirurg 85: 957–962

Brethauer SA, Aminian A, Romero-Talamas H, et al. (2013) Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Ann Surg 258: 628–636

Buchwald H, Avidor Y, Braunwald E, et al. (2009) Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 122: 248–256

Carlsson LM, Peltonen M, Ahlin S, et al. (2012) Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med 367: 695–704

Hüttl TP, Kramer KM, Wood H (2010) Bariatrische Chirurgie – Adipositaschirurgische Verfahren und ihre Besonderheiten. Diabetologe 8: 637–646

Mingrone G, Panunzi S, De Gaetano A, et al. (2012). Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 366: 1577–1585

Pories WJ, Swanson MS, MacDonald kg, et al. (1995) Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 222: 339–350

Schauer PR, Bhatt DL, Kirwan JP, et al. (2014) Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 3 Year Outcomes. N Engl J Med 370: 2002–2013

Contraindications for Bariatric Surgery

noreply@blogger.com (Unknown) — Wed, 22 Aug 2018 17:46:00 +0000

There are certain contraindications for bariatric procedures, i.e. in these cases, it is recommended not to perform the procedures. These include among others:

untreated eating disorders such as bulimia
substance addictions (alcohol, drugs, medication)
threatening underlying diseases
malign diseases
untreated diseases of hormone-producing organs
pregnancy or soon planned pregnancy

In principle, there is no contraindication to perform bariatric surgery on patients at an advanced age (> 65 years). Older patients also benefit from the positive effects of obesity or metabolic surgery, although the extent of weight loss at this stage of life may be less than at a younger age. The positive effects regarding diabetes mellitus type 2, high blood pressure, sleep apnoea syndrome and lipometabolic disorders are comparable with the results of younger patients. Patients of older age also benefit from an improved quality of life, mobility and a delay in the need for long-term care.

In the case of exhausted or hopeless conservative therapy, obesity or metabolic surgery can be considered at an advanced age from a BMI > 40 kg/m² or > 35 kg/m² with significant obesity-related concomitant diseases. In these cases, however, the indication for surgery is an individual decision on a case-by-case basis. The rate of intra- and postoperative complications in older patients undergoing bariatric surgery is only slightly higher than in younger patients.

Bilbiography sources:

Almerie MQ, Rao VSR, Peter MB, Sedman P, Jain P. The Impact of Laparoscopic Gastric Bypass on Comorbidities and Quality of Life in the Older Obese Patients (Age > 60): Our UK Experience. Obes Surg. 2018 Jul 28.

Bianco P, Rizzuto A, Velotti N, Bocchetti A, Manzolillo D, Maietta P, Milone M, Amato M, Conzo G, Buonomo O, Petrella G, Musella M. Results following laparoscopic sleeve gastrectomy in elderly obese patients: a single center experience with follow up at three years. Minerva Chir. 2018 Jun 29.

Chouillard E, Alsabah S, Chahine E, Saikaly E, Debs T, Kassir R. Changing the quality of life in old age bariatric patients. Cross-sectional study for 79 old age patients. Int J Surg. 2018 Jun;54(Pt A):236-241.

Giordano, S.; Victorzon, M. (2015): Bariatric surgery in elderly patients: A systematic review 10, S. 1627–1635.

Hassinger TE, Mehaffey JH, Johnston LE, Hawkins RB, Schirmer BD, Hallowell PT. Roux-en-Y gastric bypass is safe in elderly patients: a propensity-score matched analysis. Surg Obes Relat Dis. 2018 Apr 17. pii: S1550-7289(18)30172-2

Janik MR, Mustafa RR, Rogula TG, Alhaj Saleh A, Abbas M, Khaitan L. Safety of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in elderly patients - analysis of the MBSAQIP. Surg Obes Relat Dis. 2018 Apr 23. pii: S1550-7289(18)30214-4

Kaplan U, Penner S, Farrokhyar F, Andruszkiewicz N, Breau R, Gmora S, Hong D, Anvari M. Bariatric Surgery in the Elderly Is Associated with Similar Surgical Risks and Significant Long-Term Health Benefits. Obes Surg. 2018 Aug;28(8):2165-2170

Lynch, J.; Belgaumkar, A. (2012): Bariatric surgery is effective and safe in patients over 55: A systematic review and meta-analysis. In: Obesity surgery 22, S. 1507–1516.

Mohun SH, Spitznagel MB, Gunstad J, Rochette A, Heinberg LJ. Performance on the Montreal Cognitive Assessment (MoCA) in Older Adults Presenting for Bariatric Surgery. Obes Surg. 2018 Jun 5.

O'Brien R, Johnson E, Haneuse S, Coleman KJ, O'Connor PJ, Fisher DP, Sidney S, Bogart A, Theis MK, Anau J, Schroeder EB, Arterburn D. Microvascular Outcomes in Patients With Diabetes After Bariatric Surgery Versus Usual Care: A Matched Cohort Study. Ann Intern Med. 2018 Aug 7.

Bariatric Surgery in Children and Adolescents

noreply@blogger.com (Unknown) — Tue, 21 Aug 2018 17:49:00 +0000

Overweight and obesity in children and adolescents have increased worldwide in recent years. Depending on the definition, for example, 10-20% of all schoolchildren and adolescents in Germany are overweight, making increased body weight the most frequent nutrition-related health disorder in these age groups.

The health risks of obesity in adulthood are scientifically well documented and have already been presented here. The development of obesity in childhood has an additional negative impact on health. Obessive children and adolescents are often stigmatised, which has a problematic effect on psychosocial development and can lead to the development of eating disorders.

In obese children and adolescents, the risk of dying from a disease caused by overweight increases by 6-7% every 2 years. The treatment of childhood obesity must therefore be as early and effective as possible. Although the conservative treatment of obesity in children and adolescents leads to good short-term results, the long-term results are often disappointing, as they are in adults. The aim of bariatric interventions in childhood and adolescence is to improve quality of life, health and life expectancy through the expected weight reduction or control of further weight gain.

Surgical procedures in childhood are still controversially discussed. The "International Pediatric Endosurgery Group" (IPEG) recommends that bariatric surgery should be considered for adolescents with a BMI >40 kg/m² or a BMI >35 kg/m² with severe secondary diseases, if the patients are almost fully grown and conservative therapy methods are exhausted.

The indication for a bariatric intervention in childhood and adolescence must always be given individually and as a team with the family. The treatment team should have appropriate experience in the treatment of obesity in young patients and should consist of a paediatrician, an internist, a nutritionist, a paediatrician/youth psychiatrist, a social worker, a psychologist and a surgeon with several years of experience in bariatric surgery. Counselling and surgery should only be carried out in a centre with special experience in bariatric surgery. In addition, an age-appropriate environment is required in the clinic: pediatric anaesthesia, intensive care unit for children and adolescents, etc. Close follow-up care must also be guaranteed.

Bilbiography sources:

Alqahtani AR, Antonisamy B, Alamri H, et al. (2012) Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg 256: 266–273.

Al-Qahtani AR. (2007) Laparoscopic adjustable gastric banding in adolescent: safety and efficacy. J Pediatr Surg 42: 894–897.

Fatima J, Houghton SG (2006) Bariatric Surgery at the Extremes of Age. J Gastrointest Surg 10: 1392–1396.

Givan F. Paulus, et al. (2015) Bariatric Surgery in Morbidly Obese Adolescents: a Systematic Review and Metaanalysis. Obes Surg 25: 860–878.

International Pediatric Endosurgery G (2009) IPEG guidelines for surgical treatment of extremely obese adolescents. J Laparoendosc Adv Surg Tech A 19: (Suppl 1)

Oude Luttikhuis H, Baur L, Jansen H, et al. (2009) Interventions for treating obesity in children. Cochrane Database Syst Rev (online) (1): CD001872.

Treadwell JR, Sun F, Schoelles K (2008) Systematic review and metaanalysis of bariatric surgery for pediatric obesity. Ann Surg 248: 763–776.

Presurgical Evaluation of the Patient

noreply@blogger.com (Unknown) — Mon, 20 Aug 2018 17:51:00 +0000

Patients with obesity who wish to undergo bariatric surgery require an extensive interdisciplinary examination. This should already take place at a certified obesity centre with corresponding departments.

Surgical evaluation serves primarily to clarify surgical risk factors and possible contraindications for bariatric surgery.

The internal evaluation is primarily about clarifying whether the patient may be suffering from a hormonal disease leading to obesity. Furthermore, the typically associated diseases of obesity should be recorded and, if necessary, treated with medication (e.g. improvement of blood pressure values). If necessary, further examinations are carried out, e.g. heart-lung diagnostics.

Psychosomatic evaluation is about uncovering possible psychosocial problems, addictions and eating disorders. Nutritional aspects must also be discussed carefully.

Surgical Evaluation

noreply@blogger.com (Unknown) — Sun, 19 Aug 2018 17:55:00 +0000

The surgical evaluation includes a detailed examination of the patient's medical history and a physical check-up. The following points must be clarified:

Is there a pathological overweight?
Are there co-existing diseases?
Have conservative interventions for weight reduction already been carried out?
What is the risk of bariatric surgery?
What goals are to be achieved with the operation?
Which surgical procedure is suitable for this?
Is regular aftercare guaranteed?

Any contraindications for bariatric surgery must also be clarified:

no or insufficient conservative therapy attempts
malign diseases
acute psychiatric diseases
chronic substance addiction (alcohol, drugs, medication)
advanced cirrhosis of the liver
lack of cooperativeness of the patient
existing pregnancy

Of course, the current BMI is also determined during the initial examination. However, this is not the only decisive factor for the therapy decision; obesity-associated diseases such as diabetes mellitus type 2, high blood pressure, heart disease, depression and psychosocial abnormalities (e.g. eating disorders) must also be taken into account in the therapy decision. For this reason, the Edmonton Obesity Staging System (EOSS) is used to assess the so-called disease burden of obesity in addition to the BMI. The EOSS consists of five steps:

Step 0

There is obesity, but there are no obesity-related risk factors, no physical symptoms, restrictions or impairments of well-being.

Step 1

There is at least one obesity-related risk factor of low clinical severity (e.g. abnormal fasting blood sugar level), mild physical symptoms (e.g. shortness of breath after climbing stairs) or mild impairment of well-being.

Step 2

At least one manifest obesity-related disease is present, e.g. diabetes mellitus type 2, high blood pressure or anxiety disorder.

Step 3

The patient has already suffered complications due to obesity: Heart attack, cardiac insufficiency, complications due to diabetes mellitus type 2 (e.g. kidney problems) as well as considerable impairment of well-being.

Step 4

The patient suffers from the severe consequential damage of obesity, severe psychosocial disorders and serious impairment of well-being.

Overall, surgical evaluation is a relatively time-consuming affair, which usually requires several outpatient appointments in a centre for obesity surgery.

Bilbiography sources:

Hüttl TP, Stauch P, Wood H, Fruhmann J (2015) Bariatrische Chirurgie. Aktuelle Ernährungsmed 40: 256–274

Sharma AM, Kushner RF (2009) A proposed clinical staging system for obesity. Int J Obes 33: 289–295

Internal Evaluation

noreply@blogger.com (Unknown) — Sat, 18 Aug 2018 18:00:00 +0000

The internal evaluation is to identify diseases that could have led to obesity, even if these are very rare in terms of numbers. These include diseases of the thyroid gland and adrenal glands.

Diseases associated with underactive thyroid glands can cause obesity. However, mild subfunctions of the thyroid gland, which many people suffer from, are clearly overestimated in their importance for the development of overweight and obesity.

The situation is different with Cushing's syndrome, a disease of the adrenal gland that is associated with increased cortisol production. Although it is rather rare, it regularly leads to so-called trunk adiposity, in which the trunk has considerable fat deposits but the extremities are very thin. Typical are also over 1 cm wide reddish stretch marks of the skin. After all, around 1% of all obese people who present themselves in a centre for obesity surgery suffer from this adrenal disease. If obesity has developed rapidly within a short period of time, a tumour of the pituitary gland must also be considered.

Another focus of the internal evaluation is the identification of typical secondary diseases of obesity such as diabetes mellitus type 2, high blood pressure and cardiovascular diseases. Existing complications such as cardiac insufficiency, myocardial infarction, strokes, etc. are surveyed. Screening for sleep-related respiratory disorders makes sense.

The nutritional status should also be examined with regard to an adequate supply of micro- and macronutrients and a screening for deficiencies should be carried out (e.g. vitamin D, B12 and iron status). In many centres examinations for ulcers using gastrointestinal and duodenal endoscopy are also performed, as ultrasound examinations of the abdominal cavity (gallstones? liver size?). For women, bone density measurement is also recommended.

The evaluation of eating behaviour should be carried out by a nutritionist:

the frequency of daily meals
ingredients of meals
the amount of food consumed during and, if necessary, between meals.
feeling hungry and satiated
eating circumstances (alone, in company, at home, eat outside)
experiences with diets

Bilbiography sources:

Farooqi S, O’Rahilly S (2014) 20 YEARS OF LEPTIN: Human disorders of leptin action. J Endocrinology 223: T63–T70

Flier JS, Maratos-Flier E Elbelt U, Scholze JE (2012) Adipositas. In: Longo DL, Fauci AS, Kaspar DL, et al. (Hrsg) Harrisons Innere Medizin, 18. Aufl. ABW Wissenschaftsverlag, Berlin, S 665–672

Fierabracci P, Pinchera A, Martinelli S, et al. (2011) Prevalence of endocrine diseases in morbidly obese patients scheduled for bariatric surgery: beyond diabetes. Obes Surg 21: 54–60

Freedhoff Y, Sharma AM Hellbardt M, Schilling-Maßmann B, Haberl PM (2012) Best Weight. Ein Leitfaden für das Adipositas-Management. Pabst Science Publishers, Lengerich

Fried M, Yumuk V, Oppert J-M, et al. (2013) Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes Facts 6: 449–468

Kushner RF Elbelt U, Scholze JE (2012) Diagnostik und Management der Adipositas. In: Longo DL, Fauci AS, Kaspar DL, et al. (Hrsg) Harrisons Innere Medizin, 18. Aufl. ABW Wissenschaftsverlag, Berlin, S 673–681

Mechanik JI, Youdim A, Jones DB, et al. (2013) Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 Update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity 21: S1–27

Singh A, Tipton K (2013) Preoperative Evaluation of the obese patient. Bariat Surg Pract Pat Care 8: 127–133

Wiegand S, Krude H (2015) Monogene und syndromale Krankheitsbilder bei morbider Adipositas. Internist 56: 111–120

Psychosomatic Evaluation

noreply@blogger.com (Unknown) — Fri, 17 Aug 2018 18:06:00 +0000

Against the background that up to 70% of all obesity patients were affected by a mental illness at some point in their lives, the guidelines for obesity surgery recommend a psychosomatic evaluation.

Psychosomatic evaluation does not have the function of consistently sorting out obesity patients with mental abnormalities or denying them access to bariatric surgery. Instead, mental illnesses should be recognised and treated in advance in order to optimise the outcome of the surgical intervention and to prepare the patients for the psychosocial changes after the operation. Only in the case of serious psychopathological conditions such as psychoses, suicidal tendencies, substance dependencies and untreated bulimia does the bariatric intervention have to be postponed for the time being.

The evaluation is carried out through personal interviews and questionnaires. These include eating disorders, unsuccessful conservative weight loss attempts, but also substance abuse, depression, suicidal thoughts and attempts. Patients' expectations of the bariatric operation should also be discussed, as these are often unrealistic with regard to weight loss and the expected aesthetics of the physical changes. Sometimes the surgical treatment of obesity is regarded as a quick and comprehensive solution to problems which, from the point of view of the person concerned, are attributed exclusively to obesity. Further topics of the psychosomatic evaluation are the willingness of the patient to sustainably change previous living and eating habits and to guarantee reliable lifelong medical aftercare.

Bilbiography sources:

Müller A, Herpertz S, de Zwaan M (2012) Psychosomatische Aspekte der Adipositaschirurgie. Psychother Psychosom Med Psychol 62: 473–479

Wimmelmann CL, Dela F, Mortensen EL (2014) Psychological predictors of mental health and health-related quality of life after bariatric surgery: a review of the recent research. Obes Res Clin Pract 8: e314–324

Wimmelmann CL, Dela F, Mortensen EL (2014) Psychological predictors of weight loss after bariatric surgery: a review of the recent research. Obes Res Clin Pract 8: e299–313

Which surgical procedure to choose?

noreply@blogger.com (Unknown) — Thu, 16 Aug 2018 18:09:00 +0000

Which surgical procedure is used for an obesity patient is always an individual decision. The decision-making process depends on numerous factors such as weight, age, accompanying diseases, psychosocial stress and social environment.

In order for the patient to be included in the decision, the advantages and disadvantages of the various surgical options must be discussed with him. The following points are important for the choice of procedure:

the height of the initial weight
patient's expectations of the procedure
the previous eating behaviour of the patient
the risk profile of the patient
expected weight loss due to bariatric surgery
influence of the procedure on the obesity-related diseases of the patient, in particular, diabetes mellitus type 2
the willingness of the patient to consistently carry out the necessary lifelong aftercare

The patient's willingness to cooperate can be assessed on the basis of previous diets and exercise programmes. Age, occupation, regular medication and social environment also play a role in the decision opting for a particular surgical technique. The choice of procedure depends not only on the patient's eating habits but also on obesity-related concomitant diseases. This is because not only weight reduction is in the focus, but also the improvement of accompanying and secondary illnesses, which are not equally good in all surgical procedures.

Patients with extreme obesity may also need to undergo several procedures. A two-stage concept could, for example, be that the patient first receives a gastric balloon. Balloon therapy leads to a short-term reduction in weight, which leads to an improvement in accompanying illnesses, which in turn reduces the risk of complications that can occur during the actual bariatric operation.

The surgeon, internist, psychosomatist, nutritional therapist and of course the patient should be involved in deciding which surgical procedure is most suitable.

Bilbiography sources:

Hüttl TP (2014) Adipositaschirurgie – Indikation, Operationsverfahren und Erfolgsaussichten. Klinikarzt 43: 198–204

Runkel N, Colombo-Benkmann M, Hüttl TP, et al. (2011) Bariatric Surgery. Dtsch Arztebl Int 108: 341–346

Bariatric Surgery - how does it work?

noreply@blogger.com (Unknown) — Wed, 15 Aug 2018 18:12:00 +0000

Bariatric surgery was originally developed with the aim of reducing the patient's intake of food and energy, thereby achieving sustainable weight reduction. Restriction and malabsorption were regarded as mechanisms of action.

Restrictive procedures are interventions in which the amount of food intake is limited. Typical examples are gastric banding and gastric sleeve procedure. Malabsorptive procedures are interventions that limit the intake of food components and lead to consciously induced deficiency digestion. This includes biliopancreatic diversion (BPD) according to Scorpino. Combined procedures are interventions in which restrictive and malabsorptive mechanisms of action occur together. The gastric bypass technique, for example, is a restrictive procedure in which slight malabsorptive effects also occur. Biliopancreatic diversion with duodenal switch is also a classic combination procedure.

The presumed mechanisms of restriction and malabsorption are increasingly being questioned since physiological effects of bariatric interventions explain the favourable results on body weight and obesity-related secondary diseases much more plausible. These include the effect of bariatric interventions on hormones produced in the gastrointestinal tract, changes in the intestinal flora and changes in the concentration of bile acids in the blood.

Further information on the various mechanisms of action of bariatric surgery:

Bilbiography sources:

Baraboi ED, Li W, Labbé SM, Roy MC, Samson P, Hould FS, Lebel S, Marceau S, Biertho L, Richard D. Metabolic changes induced by the biliopancreatic diversion in diet-induced obesity in male rats: the contributions of sleeve gastrectomy and duodenal switch. Endocrinology. 2015 Apr;156(4):1316-29.

Browning MG, Franco RL, Cyrus JC, Celi F, Evans RK. Changes in Resting Energy Expenditure in Relation to Body Weight and Composition Following Gastric Restriction: A Systematic Review. Obes Surg. 2016 Jul;26(7):1607-15.

Bueter M, Seyfried F, Germer CT. Why patients lose weight after bariatric operations. Zentralbl Chir. 2010 Feb;135(1):28-33.

Chakravartty S, Tassinari D, Salerno A, Giorgakis E, Rubino F. What is the Mechanism Behind Weight Loss Maintenance with Gastric Bypass? Curr Obes Rep. 2015 Jun;4(2):262-8.

Corteville C, Fassnacht M, Bueter M. [Surgery as pluripotent instrument for metabolic disease. What are the mechanisms?]. Chirurg. 2014 Nov;85(11):963-8.

Dixon JB, Lambert EA, Lambert GW. Neuroendocrine adaptations to bariatric surgery. Mol Cell Endocrinol. 2015 Dec 15;418 Pt 2:143-52.

Farias G, Netto BDM, Bettini SC, Dâmaso AR, de Freitas ACT. Neuroendocrine regulation of energy balance: Implications on the development and surgical treatment of obesity. Nutr Health. 2017 Sep;23(3):131-146.

Garruti G, Di Ciaula A, Wang HH, Wang DQ, Portincasa P. Cross-Talk Between Bile Acids and Gastro-Intestinal and Thermogenic Hormones: Clues from Bariatric Surgery. Ann Hepatol. 2017 Nov;16(Suppl. 1: s3-105.):s68-s82.

Harvey EJ, Arroyo K, Korner J, Inabnet WB. Hormone changes affecting energy homeostasis after metabolic surgery. Mt Sinai J Med. 2010 Sep-Oct;77(5):446-65.

Ionut V, Burch M, Youdim A, Bergman RN. Gastrointestinal hormones and bariatric surgery-induced weight loss. Obesity (Silver Spring). 2013 Jun;21(6):1093-103. Review.

Lin C, Våge V, Mjøs SA, Kvalheim OM. Changes in Serum Fatty Acid Levels During the First Year After Bariatric Surgery. Obes Surg. 2016 Aug;26(8):1735-42.

Liu H, Hu C, Zhang X, Jia W. Role of gut microbiota, bile acids and their cross-talk in the effects of bariatric surgery on obesity and type 2 diabetes. J Diabetes Investig. 2018 Jan;9(1):13-20.

Lutz TA, Bueter M. The physiology underlying Roux-en-Y gastric bypass: a status report. Am J Physiol Regul Integr Comp Physiol. 2014 Dec 1;307(11): R1275-91.

Lutz TA, Bueter M. Physiological mechanisms behind Roux-en-Y gastric bypass surgery. Dig Surg. 2014;31(1):13-24. Review.

Miras AD, le Roux CW. Mechanisms underlying weight loss after bariatric surgery. Nat Rev Gastroenterol Hepatol. 2013 Oct;10(10):575-84.

Nimeri A. Making sense of gastric/intestinal bypass surgeries: forget the name and remember the degree of restriction and malabsorption the surgeries provide. Surg Obes Relat Dis. 2017 Apr;13(4):716-719.

Peat CM, Kleiman SC, Bulik CM, Carroll IM. The Intestinal Microbiome in Bariatric Surgery Patients. Eur Eat Disord Rev. 2015 Nov;23(6):496-503.

Sandoval D. Bariatric surgeries: beyond restriction and malabsorption. Int J Obes (Lond). 2011 Sep;35 Suppl 3: S45-9.

Restriction and Malabsorption

noreply@blogger.com (Unknown) — Tue, 14 Aug 2018 18:16:00 +0000

Bariatric surgery was originally developed under the assumption that restriction and malabsorption lead to the desired weight reduction. In the meantime, these explanatory approaches have become obsolete, as changes in hormonal regulation, intestinal flora and bile acids have a strong influence on the feeling of hunger and satiety during weight reduction.

Restriction

The restriction means that the capacity of the stomach is reduced and a narrowing of the passage to the rest of the digestive tract is created. The principle of sole restriction is given in gastric banding. Gastric banding gives the stomach a "waist" that separates a small part of the stomach from the remaining stomach. The constriction can be easily passed by liquid food. Solid food, on the other hand, lingers longer in the small part of the stomach, resulting in a longer lasting feeling of satiety, which already occurs with small food amounts. Effects in the sense of malabsorption do not occur with gastric banding.

https://magenverkleinerung.tips/, Gastric banding Icon, CC BY-SA 4.0

Another restrictive procedure is gastric sleeve procedure, in which part of the stomach is permanently removed. This procedure can achieve a considerable reduction in weight. However, this is not exclusively due to a restrictive effect, but also to a change in the formation of gastrointestinal hormones. According to scientific studies, pure restriction for weight reduction even seems to be of secondary importance in the case of gastric sleeve procedure.

Malabsorption

The principle of malabsorption is based on a delayed combination of food and digestive juices, primarily pancreatic and bile secretions, which reduce the absorption of fat-bearing food. A classic example of a malabsorptive procedure is biliopancreatic diversion according to Scopinaro.

The biliopancreatic diversion leads to the strongest weight reduction in comparison with all other bariatric surgical techniques due to the significant lack of digestion. This may be useful for extreme obesity, but it has its price. Malabsorption leads to a severe loss of nutrients and can result in massive diarrhoea. A consistent supplementation of micro- and macronutrients is necessary as well as a lifelong aftercare with regular laboratory controls.

Bilbiography sources:

Bueter M, Seyfried F, Germer CT. Why patients lose weight after bariatric operations. Zentralbl Chir. 2010 Feb;135(1):28-33.

Chakravartty S, Tassinari D, Salerno A, Giorgakis E, Rubino F. What is the Mechanism Behind Weight Loss Maintenance with Gastric Bypass? Curr Obes Rep. 2015 Jun;4(2):262-8.

Corteville C, Fassnacht M, Bueter M. [Surgery as pluripotent instrument for metabolic disease. What are the mechanisms?]. Chirurg. 2014 Nov;85(11):963-8.

Dixon JB, Lambert EA, Lambert GW. Neuroendocrine adaptations to bariatric surgery. Mol Cell Endocrinol. 2015 Dec 15;418 Pt 2:143-52.

Harvey EJ, Arroyo K, Korner J, Inabnet WB. Hormone changes affecting energy homeostasis after metabolic surgery. Mt Sinai J Med. 2010 Sep-Oct;77(5):446-65.

Ionut V, Burch M, Youdim A, Bergman RN. Gastrointestinal hormones and bariatric surgery-induced weight loss. Obesity (Silver Spring). 2013 Jun;21(6):1093-103. doi: 10.1002/oby.20364. Review.

Lin C, Våge V, Mjøs SA, Kvalheim OM. Changes in Serum Fatty Acid Levels During the First Year After Bariatric Surgery. Obes Surg. 2016 Aug;26(8):1735-42.

Liu H, Hu C, Zhang X, Jia W. Role of gut microbiota, bile acids and their cross-talk in the effects of bariatric surgery on obesity and type 2 diabetes. J Diabetes Investig. 2018 Jan;9(1):13-20.

Lutz TA, Bueter M. The physiology underlying Roux-en-Y gastric bypass: a status report. Am J Physiol Regul Integr Comp Physiol. 2014 Dec 1;307(11):R1275-91.

Lutz TA, Bueter M. Physiological mechanisms behind Roux-en-Y gastric bypass surgery. Dig Surg. 2014;31(1):13-24.

Miras AD, le Roux CW. Mechanisms underlying weight loss after bariatric surgery. Nat Rev Gastroenterol Hepatol. 2013 Oct;10(10):575-84.

Peat CM, Kleiman SC, Bulik CM, Carroll IM. The Intestinal Microbiome in Bariatric Surgery Patients. Eur Eat Disord Rev. 2015 Nov;23(6):496-503.

Sandoval D. Bariatric surgeries: beyond restriction and malabsorption. Int J Obes (Lond). 2011 Sep;35 Suppl 3:S45-9.