Illustration: Roy Scott

6 Life-Changing Effects of Bariatric Surgery

Written by FitRx on . Posted in Blog, Etc, weight loss

After the Surgery: Nutrition Rules

(Featured illustration: Roy Scott)

Bariatric surgery has been getting a good bit of media attention lately. The thought of waking up with a smaller stomach or a smaller appetite may seem like miraculous relief to someone whose struggle with food has gone on so long it’s impacting their health. In a select few cases, these surgeries do provide miraculous relief.

But they also come with extreme, long-term commitments. So the decision to seek bariatric surgery should be made with the whole picture in mind. For example, one area that is not always fully considered in pre-op conversations about bariatric surgery is the area of nutrition. Individuals seeking surgery should understand the range of nutritional consequences that surgery will set in motion.

So what are the important nutritional implications of bariatric surgery?

#1 Less Nutrient Absorption

Surgical Weight LossFirst, when the stomach is surgically altered it cannot return to its original state. The stomach is responsible for all breakdown of food and nutrients so that they can later travel to the small and large intestine for absorption. When the stomach is bypassed or made smaller, the food loses the ability to be broken down for absorption resulting in lifelong nutrient deficiencies.

 #2 Vitamins Forever

The stomach also releases intrinsic factor which is necessary for the absorption of B12. Because this process is impaired by bariatric surgery, the individual who has bariatric surgery is recommended to take bariatric vitamins and minerals for the remainder of the lifespan. If supplements are not taken, it can result in hair loss; brittle bones, fingernails, and teeth; and perhaps more importantly, serious or chronic health issues.

#3 Diet: Eat Nutrient Rich Foods

Focusing on nutrient dense foods such as fruits, vegetables, healthy fats, lean proteins and complex carbohydrates becomes more important than ever due to the stomach’s very small intake capacity and limited ability to break intake down for absorption.

#4 Small Portions, Many Meals

The small stomach capacity will also require the individual to eat very small meals several times throughout the day. Individuals considering bariatric surgery should ask themselves if they could realistically sustain this eating pattern for the rest of their lives.

If supplements are not taken, it can result in hair loss; brittle bones, fingernails, and teeth; and perhaps more importantly, serious or chronic health issues.

#5 Eat Slowly, Chew Well

The mechanics of eating are forever changed as well. One with bariatric surgery must eat very slowly and chew food very well. If this is not practiced, the individual can become quite ill.

#6 Dumping Syndrome – Avoiding It Is an Individual Art

Dumping syndrome is another complication associated with the mechanics of eating and digestion. It is generally experienced after a simple carbohydrate or sugar meal is ingested and leads to intense vomiting or diarrhea. However, it is hard to predict with certainty how this complication will play out in each individual because different foods affect different people in different ways. So the prospect of dumping can make eating somewhat of a gamble across a whole range of palatable foods.

Surgery, Last Resort

Lap Band bariatric deviceIt is interesting to point out that FitRx works with clients to instill some of these same support systems.

  • Our clients practice “attuned eating,” which includes eating slowly and chewing food thoroughly.
  • We teach clients how to recognize, shop for, cook, and enjoy nutrient dense foods.
  • We also help clients to balance their food groups to make sure they obtain the full range of dietary nutrition

These practices will yield improved health, weight, and fitness. Though the dramatic results may take a lot longer without surgery, surgery itself is far from a simple weight loss toggle switch.

Many individuals can be successful with bariatric surgery, but it requires lifelong support from behavioral health therapists, dietitians, exercise professionals, medical professionals and support groups. Individuals choosing bariatric surgery must realize they are committing to long-term engagement with the whole support community. Typically, when the post-surgery patient disconnects from any of these support sources, relapse occurs. At FitRx, we have provided this much-needed support for post-op bariatric patients, but we highly recommend that surgery always be viewed as a last option.


Long-Term Weight Maintenance: Science is Kinder than You Think

Written by Dr. Ralph E. Carson on . Posted in Blog, Etc, Exercise, From the Desk of Dr. Carson

In order to maintain our size we need to MOVE. (Hill ’13)

The moment we stop moving, increased deposition of fat can commence! With inactivity the metabolism slows and the appetite goes haywire. We talk about the desirability of having a “flexible metabolism,” but flexible metabolism is not about metabolic boosting so as to burn more calories while sitting. Flexible metabolism refers to the body’s ability to switch rapidly between the types of fuel we are feeding it (protein, carbohydrate, and fat). Flexible metabolism is about allowing your body to be more efficient at burning the types of food you eat.

Dr. James Hill heads up the National Weight Control Registry with a data base of more than 10,000 people who have dropped at least 30 pounds and maintained that loss for at least a year.  Dr. Hill recommends 70 minutes per day of moderate to intense exercise, six days per week.  The friendly word, here, is “moderate.” The entire 70 minutes can be carried out in a structured plan, but as we have eluded to previously, better to have a flexible plan combining structure with increased movement opportunities scattered through your daily life. Why is this?

Hill J, Aschwanden C, and Wyatt H State of Slim Rodale Books (2013). 

Exercise is best served in small doses, comfortable speed, and reasonable distances (Cool ’12; O’Keefe ’12)

fitrx5Developing a flexible metabolism doesn’t require endurance training or marathon running. In fact, the latter activities can push your heart to its limits causing acute problems such as arrhythmias, irregular heartbeats, diastolic dysfunction and lasting damage (calcification and scarring; larger artery wall stiffening). For older athletes (>35), the pleasure of intense physical exercise for long periods may take its toll on the body, causing it to age more quickly (musculoskeletal body trauma and cardiovascular stress).

Flexible metabolism is not about metabolic boosting so as to burn more calories while sitting…

Temperatures increase causing sweating, fluid and electrolyte loss, dehydration, muscle weakness and disorientation. Spikes in inflammation are a key concern in this type of exercise because they can cause permanent scarring of the ventricles. Sudden cardiac death occurs in 1 out of 15,000 joggers and 1 in 50,000 runners (Mohlenkamp ’00). More than 90% of sudden cardiac deaths occur during recreational sports (Marion ’11). The runners who were better trained over a longer period were less likely to experience heart damage, inflammation, swelling, and decreased heart perfusion.


Facing Fears – Starve a Fear; Nourish a Soul

Written by FitRx on . Posted in Blog, Etc

For you Fit Rx alumni, here is a refresher; for you newbies I hope this helps. We are all facing fear in various forms, and in case you’ve forgotten, here are some tips on how to move forward in spite of them. Let’s all agree that we have been slaves of fear far too long!

Fear is a distressing emotion aroused by impending danger, evil, pain, etc., whether the threat is real or imagined; it’s the feeling or condition of being afraid. Synonyms: foreboding, apprehension, consternation, dismay, dread, terror, fright, panic, horror, trepidation.

“Too many of us are not living our dreams because we are living our fears.”

-Les Brown

Strategies to Face and Move through Fear

  1. Find out what the fear behind the fear is! For example, the root of most performance fears, the fear behind the fear, is often “I’m not good enough” or “They won’t like me.”  Identifying the true fear creates awareness, the first step in creating change.
  1. Ask “what is really true?” F.E.A.R. = “False Expectations Appearing Real.” It’s a great reminder that our minds think the threat is real.  If I ask myself what is really true, then, as with public speaking, I can admit that I am good enough, know enough – maybe more than my audience.  The truth is I am capable of speaking in front of anyone when I’m in my most confident state.
  1. Play the “what if” game. What is the worst that could happen?”  To play the game, ask yourself “What if my fear happens, then what? And what if THAT happens, then what?”  By the time you follow this path a few times, the possible outcomes start to seem preposterous and the real risk is put into a new, less threatening perspective.  You also start to calmly prepare for reasonable unexpected events.

(Note - be mindful that “worst case scenario” thinking usually cripples us and doesn’t benefit us. Despair expects horrible things around the corner. Hope expects good things around the corner.)

  “Fear makes the wolf bigger than he is.”

-German Proverb

  1. Make sure you are spiritually and emotionally grounded. I use deep breathing, prayer, inspiring quotes, YouTube videos, movie scenes, and positive present-tense affirmations to get myself centered and calm.  I return to my confident state of mind by reviewing my successes and my belief in myself no matter WHAT happens.
  1. Ask for help. Turn to someone you trust, with whom you feel safe, who you know cares about you and ask them to go with you, help you, hold you accountable to facing your fear. Verbalize your fear and commit to facing it. When we verbalize our fears it can help to disempower them.

Bite into a Healthy Lifestyle with Asparagus Salad

Written by FitRx on . Posted in Blog, Recipe

March is National Nutrition Month® ! This year’s theme is “Bite into a Healthy Lifestyle,” which encourages everyone to adopt eating and physical activity plans that are focused on pairing nutrient dense foods with daily body movement. In general, this one-two combination is a powerful way to reduce the risk of chronic disease. Hopefully, this bite into a healthy lifestyle can inspire you adopt sustainable practices for overall health and wellness. Don’t forget to thank your dietitian on March 11, which is National Registered Dietitian Nutritionist Day!

 Tip: look for the freshest, most tender asparagus spears you can find and slice them into very thin rounds.

Green Salad with Asparagus and Peas

Eating Well

Photo: cherie at

Choose tender asparagus. (Photo: cherie at

Makes: 8 servings

Start to Finish: 35 minutes


2 teaspoons freshly grated lemon zest

¼ cup lemon juice

¼ cup canola oil, or extra-virgin olive oil

1 teaspoon sugar

½ teaspoon salt

¼ teaspoon freshly ground pepper

2 heads Boston or Bibb lettuce, torn into bite-size pieces

2 cups very thinly sliced fresh asparagus, (about 1 bunch)

2 cups shelled fresh peas, (about 3 pounds unshelled)

1 pint grape or cherry tomatoes, halved

2 tablespoons minced fresh chives, or scallion greens


  1. Combine lemon zest and juice, oil, sugar, salt, and pepper in a large salad bowl.
  2. Add lettuce, asparagus, peas, tomatoes, and chives (or scallion greens).
  3. Toss to coat.

Nutrition Information:

Per serving: 113 cal, 7 g total fat, 152 mg sodium, 10 g carb, 3 g fiber, 3 g protein

This salad combines two stars of the spring garden, asparagus and peas, which provide a healthy dose of Vitamin A and C and folate. Tip: look for the freshest, most tender asparagus spears you can find and slice them into very thin rounds. Bite into this recipe and into a healthy lifestyle!


More Troubles with Sitting – and What Won’t Help

Written by Dr. Ralph E. Carson on . Posted in Blog, Exercise, From the Desk of Dr. Carson

In his first of two articles, Dr. Carson presented evidence showing that sitting for long, uninterrupted periods has serious health risks. And he followed that with some techniques for mitigating or avoiding those risks. Here is a brief addendum to underscore both the risks and the ways to counteract too much sitting.

 Troubles with Sitting – Orthopedic Health Problems attributed to too much sitting

(Mathews ’12; Ford ’12; Berkowitz; Hamilton ’07; George ‘13)

Muscle degeneration (Back problems)too-much-sitting-back-pain

  • Slumped muscles go unused — tight back and weak abdominal muscles combined to cause serious back pain due to extreme lower curvature (lordosis)
  • Sore back: inflexible spine movement causes soft disc dehydrated and brittle. This can lead to a herniated disc. Typically the disc between vertebrae expand and contract like a sponge soaking up fresh blood and nutrients with activity.
  • Collagen hardens around supporting tendons and ligaments with extended inactivity

Tight hips: decreased hip mobility due to tight hip flexors (short and tight) limit range of motion and produce falls

Limp gluts (buttocks): hurt stability and stride

Strained neck: Craning neck forward over key board or tilting head to cradle phone

Sore Shoulders

Soft bones: Weight bearing exercises cause bone to grow thicker and lack thereof causes osteoporosis


Sitting can reduce life expectancy

Standing could increase your life span. The more time on your feet strengthens the bits of DNA called telomeres (Sjogren ’14). Telomeres protect the ends of chromosomes (like the tips that keep shoelaces from fraying). Telomeres tend to get shorter and shorter until they can shorten anymore and cause cell death.

Women who spend too much time sitting around (>11 hours/d) had a 12% risk of premature death (13% more cardiovascular disease; 21% more cancer; 27% more coronary artery disease) than those who were inactive for <4 hours (Sequin ’14).


Can scheduled exercise sessions offset the negative effects of sitting?

Adults spend 50% – 70% of their waking hours sitting or approximately 8 hours per day. Sitting for extended periods of time can harm even those that exercise (Craft ’12; Wilmot ’12). The increased risk of sitting is not offset by moderate to vigorous exercise or meeting the recommended physical guidelines. Regular exercise does not reduce the risk of an otherwise sedentary life style as one remains susceptible to just as great a risk of diabetes, cardiovascular disease, obesity and premature death. Short but frequent walks or alternative activity sparks (short term episodes of movement lasting 5 – 10 minutes) can counteract the harm caused by sitting long periods.



Craft LL et al Evidence that women meeting physical activity guidelines do not sit less: An observational inclinometry study Int J Behav Nutr Phys Act (2012) 9: 122.

Ford ES and Caspersen CJ Sedentary behaviour and cardiovascular disease: a review of prospective studies Int J Epidemiol (2012) 41: 1338 – 1353.

George ES et al Chronic disease and sitting time in middle-aged Australian males: findings from the 45 and Up Study Int J Behav Nutr Phys Act (2013) 10:20.

Hamilton MT et al Role of Low Energy Expenditure and Sitting in Obesity, Metabolic Syndrome, Type 2 Diabetes, and Cardiovascular Disease Diabetes (2007) 56: 2655 – 2667.

Matthews CE et al Amount of time spent in sedentary behaviors and cause-specific mortality in US adults AJCN (2012) 95: 437 – 445.

Sjogren P et al Stand up for health–avoiding sedentary behaviour might lengthen your telomeres: secondary outcomes from a physical activity RCT in older people Br J Sports Med (2014) 48: 1407 – 1409.

Wilmot EG et al Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis Dibaetologia (2012) 55: 2895 – 2905.


15 Tricks to Avoid Sitting Risks

Written by Dr. Ralph E. Carson on . Posted in Blog, Exercise, From the Desk of Dr. Carson

Don’t just sit theretry these

(Ekblom-Bak ’12; Loprinzi ’13; Yancy ’10; Healy ’08)

Last week, we learned of many possible health risks caused by habitual, uninterrupted sitting over long periods. Since it’s not how much but how often you exercise that matters, you can counteract the harmful effects of sitting with small lifestyle adjustments. The following activities may do just as much good as formal exercise to reduce chronic disease such as heart attacks, stroke, cancer, and diabetes (Ekblom-Bak ‘13).

An active lifestyle is an effective way to provide health benefits such as preventing high blood pressure, high cholesterol, and metabolic syndrome. Despite not exercising according to the recommendations, as many as 40% of adults may be achieving the exercise guidelines by making movement part of their life (Loprinzi ’13).

If your lifestyle requires a lot of sitting, try breaking up the stasis with some of these healthy movement activities:

  1. Standing with computer on top of the filing cabinet
  2. Sitting on exercise (stability) ball instead of desk chair
  3. Dance about, wiggle around, take a few steps back and forth, fidget
  4. Standing during meetings
  5. Standing talking on the telephone
  6. Walking during lunch breaks
  7. Gardening and lawn care
  8. Housework (vacuuming and mopping floors)
  9. Stand folding laundry or ironing
  10. Do-it-yourself projects
  11. Marching in place during TV commercials
  12. Getting up from your desk and doing jumping jacks, knee lifts and bends
  13. Purchase an activity monitor
  14. Set a timer for to go off once per hour
  15. Move printer farther away
  16. Sit up straight
  17. Take water breaks
Photocredit: Cat York, from "Get up and Stretch"

Photocredit: Cat York, from “Get up and Stretch”


Ekblom-Bak E et al The importance of non-exercise physical activity for cardiovascular health and longevity Br J Sports Med (2013) 092038.

Healy GN et al Breaks in sedentary time: beneficial associations with metabolic risk Diabetes Care (2008) 31: 661 – 666.

Loprinzi PD and Cardinal BJ Association between biologic outcomes and objectively measured physical activity accumulated in ≥ 10-minute bouts and <10-minute bouts Am J Health Promotion (2013) 27: 143 – 151.


Love at Three G’s

Written by Marianne Messina on . Posted in Blog, Etc

Three Tips to the Lovelorn from FitRx Therapist Jonathan Rios

“Envy is the art of counting the other fellow’s blessings instead of your own.” – Harold Coffin

For many, the month around Valentine’s Day is a reminder of lost loves, longing for love, or even love not yet experienced. We can all agree, ours is a culture obsessed with fairy tale lovers and happily ever afters.

When these expectations aren’t met, our hearts are easily wounded. Those of us who don’t have a current love often turn to thoughts of our “lack” and become intensely critical of love itself. In fact, we may even find ourselves bitter towards those around us who seem to have found that “true love.” Does this sound like you?

Photo Credit:

Photo Credit:

How about any of these:

  • Are you unable to be happy for the love others have found?
  • Is it hard to congratulate others on their relationships?
  • Do you secretly rejoice when others experience heartbreak?

If you found yourself answering even the tiniest “yes,” let these three g’s help you avoid the trap of becoming embittered:

Gratitude – Write down all the romantic and platonic relationships (past and current) that have been a blessing in your life. (What lessons did you learn about yourself?). Instead of meditating on all the “misfires” and “heartache,” flip your focus to that of thanksgiving.

Generosity – Realize there’s someone in your immediate community who is “heartbroken” this year and could use a dose of love themselves. (Get the focus off of you and onto others.) Bring them a gift. Offer to babysit. Write them a note. Take them out for dinner. Actually verbalize how important they are to you.

Grace – Give yourself an unmerited treat. See a movie that inspires you. Spend time with people who care about you. Watch YouTube clips of your favorite comedian.  Visit your favorite museum. Go hiking. Go on a road trip. Call out sick. Declare a “self-enrichment day.”

It’s virtually impossible to be both jealous and grateful at the same time. Our internal world is one of constant tensions and we must do the hard work of choosing which thoughts and emotions will steer the ship.

This month of Valentine’s, I implore you to choose love in the truest sense by loving yourself and giving yourself away to the people around you. Someone nearby needs what you have to offer.


The Trouble with Sitting

Written by Dr. Ralph E. Carson on . Posted in Blog, Exercise, From the Desk of Dr. Carson

Are you doing too much sitting?
Metabolic Health problems attributed to “too much sitting”

 The last few years have seen a good bit of research showing health risks associated with “too much sitting,” where “too much” suggests periods of more than an hour at a time. For better or worse, here’s a list of the bodily systems found to be compromised by “too much sitting.”

Heart Disease:

  • Blood pools in legs because muscles are not contracting and pumping blood effectively
    • Impairment of endothelia function (inability of arteries to expand). Endothelia function is reduced by over 50% with just one hour of sitting (Thosar ’14).
    • Men who walked 5 minutes per hour had no reduction in function of arteries during a 3-hour period
  • Blood flows more sluggishly during a long period of sitting allowing fatty acids to more easily clog the heart
  • Linked to high blood pressure
  • Linked to high cholesterol
  • Twice as likely to have cardiovascular disease
  • Older men who spend a great deal of time sitting are more than twice as likely to face heart failure even for those who exercise regularly (Young ’14)
  • Men reporting 24 hours per week of sedentary activity have a 64% greater risk of dying from heart disease than those who were inactive < 11 hours per week (Blair ’11)

Metabolic Syndrome (Bey ’03)

  • Decrease in lipoprotein lipase (LPL) in skeletal muscle explains poor lipid metabolism and metabolic syndrome
  • Riding in cars and watching TV are significant predictors of metabolic syndrome (High BP, high triglycerides, High cholesterol, high blood sugar and excess belly fat) (Warren ’10)

Diabetes (Over productive pancreas)



  • Most consistent association of sitting and diabetes (Wilmot ’12)
  • Three (15 minute) bouts of moderate post meal (30 minutes after meal) walking significantly improved 24 hour blood sugar control in older people at risk of impaired glucose tolerance (DiPietro ’13)
  • Interrupting sitting time by walking lowers post prandial (after meal) glucose and insulin levels in overweight and obese (Dunstan ’12)
  • Cells in sedentary muscles do not respond readily to insulin – pancreas as a result has to produce more insulin
  • Decreases in insulin response were seen just one day of prolonged sitting (Stephens ’11)

Cancer (Schmid ‘14b; Zhang ’14)

  • Colon cancer (Schmid ‘14a)
  • Breast cancer
  • Endometrial cancer
  • Excess insulin encourages cell growth
  • Movement boosts natural anti-oxidants that scavenge and destroy cell damaging free radicals

Poor circulation in legs

  • Fluid pools, swollen ankles, varicose veins, and deep vein thrombosis (DVT)

Larger waistline

  • Burn 6x fewer calories
  • Risk of inflammation (due to visceral abdominal fat) which can result in heart disease, diabetes and metabolic syndrome
  • Each hour of daily sitting was associated with 2.39 cm of pericardial fat (fat collecting around the heart) and explains the high incidence of coronary heart disease. This pericardial fat stayed in place even when undertaking exercise (Larsen ’14)

Foggy brain

  • Circulation triggers release of cognitive and mood enhancing chemicals

Next: 15 Ways to Counteract Too Much Sitting


Bey L and Hamilton MT Suppression of skeletal muscle lipoprotein lipase activity during physical inactivity: a molecular reason to maintain daily low-intensity activity J Physiology (2003) 551: 673 – 682.

Blair S Sitting All Day Is Worse For You Than You Might Think: NPR (April 25, 2011).

DiPietro L et al Three 15-min bouts of moderate post-meal walking significantly improves 24-h glycemic control in older people at risk for impaired glucose tolerance Diabetes Care (2013) 36: 3262 – 3268.

Dunstan DW et al Breaking up prolonged sitting reduces postprandial glucose and insulin responses Diabetes Care (2012) 35: 976 – 983.

Ford ES and Caspersen CJ Sedentary behaviour and cardiovascular disease: a review of prospective studies Int J Epidemiol (2012) 41: 1338 – 1353.

George ES et al Chronic disease and sitting time in middle-aged Australian males: findings from the 45 and Up Study Int J Behav Nutr Phys Act (2013) 10:20.

Hamilton MT et al Role of Low Energy Expenditure and Sitting in Obesity, Metabolic Syndrome, Type 2 Diabetes, and Cardiovascular Disease Diabetes (2007) 56: 2655 – 2667.

Hamilton MT et al Too Little Exercise and Too Much Sitting: Inactivity Physiology and the Need for New Recommendations on Sedentary Behavior Curr Cardiovasc Risk Rep (2008) 2: 292 – 298.

Larsen BA et al Associations of Physical Activity and Sedentary Behavior with Regional Fat Deposition Med Sc Sports Exerc (2014) 46: 520 – 528.

Matthews CE et al Amount of time spent in sedentary behaviors and cause-specific mortality in US adults AJCN (2012) 95: 437 – 445.

Schmid D and Colditz G Sedentary behavior increases the risk of certain cancers J Natl Cancer Inst (2014b) 106 (7): dju206.

Stephens BR et al Effects of 1 day of inactivity on insulin action in healthy men and women: interaction with energy intake Metabolism (2011) 60: 941 – 949.

Thosar SS et al Effect of Prolonged Sitting and Breaks in Sitting Time on Endothelial Function Med Sci Sports Exerc (2014, Aug 18).

Warren TY et al Sedentary behavior increase risk of cardiovascular disease mortality in men Med Sci Sports Exerc (2010) 42: 879 – 885.

Wilmot EG et al Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis Dibaetologia (2012) 55: 2895 – 2905.

Young DR et al Effects of physical activity and sedentary time on the risk of heart failure Circulation: Heart Failure (2014) 7: 21 – 27.

Orbital frontal cortex (OFC)

FDA-approved “Gastric Pacemaker” – What do the studies say?

Written by Dr. Ralph E. Carson on . Posted in Blog, From the Desk of Dr. Carson

For many years, gastric electrical stimulation (GES) has been under investigation as a treatment for obesity and overeating, but until last week, it has only been experimental. After 12 years, the FDA finally approved EnteroMedics device for treatment of obesity, making it the first “gastric pacemaker” to be approved for obesity treatment.

About the size of a pacemaker and implanted into the person’s abdomen, the EnteroMedics’ Maestro™ device is intended to offer potential weight loss for those struggling with obesity. Called VBLOC™ for vagal blocking therapy, its electrode touches the vagus nerve at a point between the esophagus and the stomach, and it works by intermittently down-regulating or blocking input from the stomach’s vagal nerve to part of the brain linked to appetite in people who have issues with obesity and metabolism.

Historically, the independent research of such devices has not been earth shattering. Both SBU (’04) and Buchwald (’02) felt that the results were not conclusive and that EGS did not provide satisfactory results. This discouraged them from carrying on with the study (Salvi ’09).

In a 2009 study, Shikora et al compared implantable gastric stimulation therapy to a standard diet and therapy regimen. Within their group of obese subjects, the team evaluated differences in weight loss and found that the control group lost 11.7% and the IGS group also lost 17.6% of excess body weight. The difference in results between the two groups was less than a high recommendation of the treatment.

In a more recent study, after 12 months with the EnteroMedics device, those with the device fitted lost an average of 24 per cent of their excess weight, while those in the control group without the device fitted lost only 16 per cent. The device produced an overall difference in total body weight of only 3% over the sham device, which did nothing (Ikamuddin’14). Therefore, though there was certainly clinically significant weight loss with this device, the procedure fell short of being as effective as the researchers had hoped.

Repeated evidenced-based failures to support the “stomach fullness theory” suggest seeking alternative signals to relay cessation of eating. This adds credibility to the idea that the primary feedback may be dictated by satisfaction rather than fullness. This suggests placing more emphasis on hedonic (pleasure) messages in research and potential therapy.

While this FDA approval may show some promise, who will it work for, what will it work with?

There are still several important under-researched questions to consider coming out of the trials to date:

  • How useful is it to rely solely on stomach hunger and fullness to create eating cessation? (Ikamuddin’14)
  • How will gastric stimulation stack up in more comprehensive comparisons to other treatments – such as diet, behavioral therapy, exercise? (Ikamuddin ’14; Dixon ’11).
  • We should be looking at response systems other than fullness, such as hedonic (pleasure) messages, for which treatment would be entirely different, less invasive, and possibly more long-lasting.
  • Cross-study between the medical mechanisms of obesity and the psychological/behavioral components is needed for optimum diagnoses – that is, which patients will benefit from which treatments – surgical, pharmaceutical, psychotherapeutic, and implant – or treatment combinations.


Buchwald H and Buchwald JN Evolution of operative procedures for the management of morbid obesity 1950-2000 Obes Surg (2002) 12: 705 – 717.

Salvi PF et al Gastric pacing to treat morbid obesity: Two years’ experience in four patients Ann Ital Chir (2009) 80: 25 – 28.

Shikora SA et al Implantable gastric stimulation for the treatment of clinically severe obesity: Results of the SHAPE trial Surg Obes Relat Dis (2009) 5: 31 – 37.

Swedish Council on Technology Assessment in Healthcare (SBU)n Gastric pacing (gastric electrical stimulation) for the treatment of obesity — early assessment briefs (Alert) Stockholm, Sweden: SBU (2004).

Yao S et al Retrograde gastric pacing reduces food intake and delays gastric emptying in humans: A potential therapy for obesity? Dig Dis Sci (2005) 50: 1569 – 1575.

Dixon JB et al Surgical approaches to the treatment of obesity Nature Reviews Gastroenterology and Hepatology (2011) : 429 – 437.

Ikamuddin S et al Effect of reversible intermittent intra-abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial JAMA (2014) 312: 915 – 922 [VBLOC-DM2 ENABLE Trial].


Why stress can make you fatter around the middle

Written by Dr. Ralph E. Carson on . Posted in Blog, Etc, From the Desk of Dr. Carson

As we have been seeing, those struggling with obesity are beset by many vicious cycles of fat begets fat. This self-fueling problem explains why only a slow, steady approach, accompanied by lifestyle changes that carry through the long haul, is the best solution. Another way that fat begets fat occurs in the area of belly fat. Studies paint an interesting picture on the nature of belly fat – its composition, and how it responds to stress, alcohol, fried foods, and processed foods, and how it increases. These studies shed light on why certain behaviors add to belly fat.

There are two different types of fat stores, the fat that forms a layer beneath the skin (called subcutaneous adipose tissue – SCAT), and fat that forms an apron around the belly, visceral belly fat. Within the body, and as a response to what you do on the outside (eat, exercise, undergo stress), these two types of fats act in very different ways. Subcutaneous fat can be exercised away much more easily than belly fat. This visceral belly fat receives more blood flow and is more responsive to cortisol than the subcutaneous fat deposited around the waist (beneath the skin).

The abdominal fat cell environment contains more nerves, more inflammatory and immune cells, has more testosterone (androgen) receptors, and produces a greater percentage of large fat cells (as opposed to greater numbers). It’s a lively, responsive cauldron of activity. As a consequence, intra-abdominal fat cells are more metabolically active, absorb and store more dietary fatty acids from circulation, and are less inclined to release fat during dieting (Ibrahim ’10).

The absorptive nature of belly fat is quite significant because these absorptive properties make belly fat more responsive to cortisol – the stress hormone. Stress increases the enzyme (11beta-HSD-1) that regulates cortisol in the belly.

What this means to the dieter, the average person watching his or her waist, is that when you add stress to excess belly fat, you get a chain reaction in which the 11beta-HSD-1 enzyme speeds up the conversion of inactive cortisone to active cortisol. And enough studies have shown that the over-expression of 11beta-HSD-1 in belly fat tissue results in a host of problems, not the least of which is more fat. The problems include an amazing fourfold cortisol receptor increase (greater sensitivity to cortisol), insulin resistance (glucose intolerance or the inability to utilize sugar appropriately) and central obesity (Kannisto ’04; Anderson ’02; Morris ’05).

Since the enzyme activity is higher in belly fat than subcutaneous fat, it explains how stress significantly increases girth (Tomlinson ’02).

It’s important to know what behaviors tend towards the creation of belly fat. And not just from the perspective of a waist watcher. We’ve also seen studies that connect belly fat to learning, memory, and decision-making.

For more (graphic view):


Andrews RC et al Abnormal cortisol metabolism and tissue sensitivity to cortisol in patients with glucose intolerance The Journal of Clinical Endocrinology (2002) 87: 5587 – 5593.

Ibrahim MM Subcutaneous and visceral adipose tissue: Structural and functional differences Obesity Reviews (2010) 11: 11 – 18.

Johnstone AM et al Influence of short-term dietary weight loss on cortisol secretion and metabolism in obese men Eur J Endocrinol (2004) 150: 185 – 194.

Kannisto K et al Overexpression of 11 beta-hydroxysteroid dehydrogenase-1 in adipose tissue is associated with acquired obesity and features of insulin resistance: studies in young adult monozygotic twins J Clin Encocrinol Metab (2004) 89: 4414 – 1421.

Morris KL and MB Zemel ,25-dihydroxyvitamin D3 modulation of adipocyte glucocorticoid function Obesity Research (2005) 13: 670 – 677.

Tomlinson JW and PM Stewart The functional consequences of 11-beta hydroxysteroid dehydrogenase expression in adipose tissue Hormone and Metabolism Research (2002) 34: 746 – 751.

White PC et al 11 beta hydroxysteroid dehydrogenase and its role in syndrome of apparent mineralcocoricoid excess Pediatri Res (1997) 41: 25 – 29.