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Very Long but GOOD reading. Did you know that it's been estimated that 75% of all overeating is due to our emotions? Emotional eating can sabotage even the BEST weight loss efforts. It can hold you captive to guilt, shame, body-hatred, low self-esteem and a host of other problems. It can hold you back from achieving the body of your dreams. BUT If you DO learn the secrets to stop emotional eating, losing weight becomes simple, clear and easy. Why? First of all, because you'll be cutting out approximately 75% of those extra calories due to overeating! Secondly, because extra weight is often not really about the food at all! It's about how we handle food that makes the difference. And if we don't learn how to handle our emotions and consequently our eating properly, we will STILL carry extra weight, even if we're eating all the 'right' foods and exercising ourselves silly! Talk about spinning your wheels and going nowhere! Nobody wants that! So what's the answer? How do we STOP emotional eating for good and let go of extra weight? First let's discover how emotional eating gets started and why it's such a growing problem: Most of us have an emotional connection to food. This connection is normal and completely natural. But in a society that is both FOOD and WEIGHT LOSS obsessed, it's very easy for this delicate emotional connection to get thrown out of balance. Advertisers and restaurants tell us to 'supersize it', 'get your money's worth', 'all-you-can eat', 'buy the combo to get your full value'. In the next moment we see messages everywhere that tell us we must be a size 0 and run around in bikinis & halter tops! -------------------------- Are you aware of · The quality of your relationship with food? · What prompts you to eat or not to eat? · Whether your emotions rule your eating? · Whether your eating rules your emotions? · Whether there is a compulsive, choiceless quality about your eating, a sense of being powerless to make changes? Food and feelings are frequently bound together. When people use food and eating to produce certain feelings or to cover up certain feelings, they may be engaging in emotional eating. Eating is tied to emotions. Emotional eating can create a "food fog" that anesthetizes feelings. No one is emotionally neutral about eating all the time. It is important to become aware, however, of whether you might be a person whose eating is primarily and consistently stimulated by your emotional state and needs. When eating, not eating, or restricting food is primarily triggered by how we feel or wish to feel, it can become unhealthy eating and lead to obesityor eating disorders. Once you learn to identify your patterns of emotional eating and become aware of the feelings of cir****tances that trigger it, you will become able to separate unwanted eating episodes from their triggers and learn to experience your feelings without having to turn to food. This provides greater options for solving problems at their source. Vulnerable emotional states include depression, anxiety, boredom and loneliness, anger and jealousy. Emotions may be categorized into four main groups: Mad, Sad, Glad, and Scared. "Fat" has become the new feeling of the decade. "Fat" has become a code word to camouflage real feelings. When a person adds "fat " to the list of feelings, ("I feel fat.") emotional eating may cross the line into dysfunctional eating. If "fat" becomes a feeling, look deeper. This form of emotional eating can create further negative feelings, leading to more deeply disordered eating. Am I an Emotional Eater? · I always eat when I am happy. · I always eat when I feel sad. · I always eat when I feel anxious or nervous. · I always eat when I feel angry. · I always eat when I feel frustrated. · I always eat when I am bored. · I always eat when I don't want to do other things that I have been putting off, like homework. · I always eat when I feel frightened. · I don't eat when I feel frightened about becoming fat. · When I am feeling badly, sometimes I "feel fat" even though I know that "fat" is not a feeling. · I am afraid that I will not be popular if I gain any weight. · I believe that I will be more popular if I weigh less. · Dieting gives me a sense of purpose and of being in control. · I feel good about skipping meals. There is no exact science about eating "right," and we are all a bit idiosyncratic or quirky about what and how we eat. That is natural. What is significant to note in the above exercise is the all-or-nothing, compulsive quality that you may discover about what or how you may be eating. There are better ways to respond to feelings without racking up calories, without doing damage to oneself. 1. Recognize your real feelings. Match up what you need with more appropriate responses. 2. Keep a "feeling" journal. In this journal, make note of: a. What triggers your eating behaviors? b. What kinds of things you would you like to change about your eating? c. How easily you are able to make changes in your eating? d. What helps you the most in attaining your eating goals? 3. Name your feelings. This gives you power. You can't solve a problem without first defining it. 4. Discover the feelings that act as eating triggers for you. 5. Find a friend who you can confide in or go to parents to talk out what is bothering you. 6. Take a bike ride or shoot baskets instead of eating. Take your dog for a walk. 7. Keep in mind what healthy eating is really about. 8. Never skip a meal. By eating enough of the right kinds of foods at each meal, you will regulate your hunger. By eating healthfully and exercising regularly, you will insure your fitness. By doing both, you will learn to trust your body, will feel more content with your life and in control of food, eating, yourself and your own happiness. ----------------------------------------------------------- http://www.prevention.com/topic/0,5768,s1-4-64-129-0-0,00.html Good Website on Emotional Eating ----------------------------------------------------------------------- Interesting Reading on Head Hunger For the first time in my life, I know that I can trust the information transmitted by my stomach to prompt, stop or otherwise regulate my consumption of food and calories. And between my use of high-yield protein shakes and to provide the nutrition I need, but can't fit or handle, from fruit and vegetables), I always know that if my body tells me I'm full, I have already have consumed enough protein and nutrition to sustain my body functioning in a healthy fashion. And yet... Sometimes, even knowing that my body has all the nourishment it needs, I "feel" hungry. Or, more precisely, I experience what seem to be real hunger pangs, even when I know they're artificial. This is what I call "head hunger". My belief is that unless Emotional Eating is recognized, acknowledged and dealt with, it can and will sabotage the extreme measures I and we have taken to live longer, healthier lives. I thought about this recently when I spent a long night alone in a motel room during a business trip. When I travel, I prepare conscientiously to assure that no matter the situations or unanticipated cir****tances that may present themselves, I will have what I need to take good care of my body. That translates into getting a room with a small refrigerator; bringing some yogurt for breakfast; my protein powder and portable wand blender; a bag of graham crackers; and my water bottle, which has become like a beloved Teddy Bear to me. In my former life (before WLS), when I found myself alone in a motel room, on the road (sometimes bathed in an accompanying self-pity), I used to stock the shelves with lots of sugar and other crap as comfort food to help me make it through the night. (After all, calories don't count when you're alone in a motel room, right?) Today, six months post-op and down 110 pounds, I've stopped buying those "treats" that used to assault my health and sabotage my eating plan. But this night, I found myself preparing to repeat the pattern. I knew, with certainty, that I had consumed enough to meet my body's needs. And yet I felt an unmistakable "hunger" that sure felt authentic and demanding and deserving of a response. So I reverted and took two half-crackers out of the baggie. In less time than it took to take that first bite, I realized what I was doing and PUT BOTH PIECES BACK INTO THE BAG. Because I became very, very clear, in that defining moment, that any apparent hunger messages I get when I know that I'm full are instead fraudulent, destructive, self-sabotaging Head Hunger messages from my past, my habits, my patterns, my childhood, my unconsciousness about my body, my past irresponsibility and unaccountability about my health. I can binge on anything - even two half crackers - if I eat when I know I'm full. Putting something back uneaten. Amazing! My life is really changing; my awareness is deepening; and I'm living, moment by moment, day by day, my commitment to using WLS to live healthy and long. I knew how far I have come, and how much self-work I have yet to do, when I drove by the new Jack-in-the-Box in my town. This fast food chain used to be my preferred source of comfort junk food, especially when traveling for business. Yet it was the one fast food joint that hadn't yet made a home in my community. Now it's here. Just the sight of the familiar sign was enough to generate a false message of hunger as I drove by. Fortunately, my trust in the information transmitted by my appetite regulator sustained me through the episode. For me, Head Hunger is a message that either I haven't yet done my requisite personal growth work to deal with and resolve all of the emotional reasons I used to compulsively overeat, or that I presently have some more work to do. I invested years of my pre-WLS life on a searching and fearless journey of self-examination, therapy and other personal growth work to figure out why I ate like I did and what I needed to learn, understand or apply in order to change. And still, like every time I pass Jack's Box, or any time I get too angry, lonely or tired, I have more work to do to remember, to be aware, and to use and choose what I know to take good care of myself. --------------------------------------------- When you're angry or depressed, food becomes a good source of comfort. Maybe you start with a light snack which later turns into a 3000 calorie binge. You begin to question your will power and self doubt creeps in. Your best plan for eating healthy goes out the door assuming you have a plan. Anger, depression and anxiety can play havoc with our eating habits because life revolves around food. Eating healthy can be difficult because we love to eat candy and desserts from childhood. We celebrate by eating fatty foods at birthdays, weddings and other special events. We subconsciously use food as a reward or to subdue the pains of life. We naturally turn to food as comfort when things go wrong. That's why we must always be aware of our daily emotions to prevent emotional eating. Examine your feelings everyday. Are you feeling anxious, depressed or angry? Eating healthy becomes easier when you ask these questions. Don't give up if you blow your diet for the day. Tomorrow is a new day for eating healthy foods. The worst thing you can do is beat yourself up with guilt after overeating or bingeing, and you're most vulnerable when anxious or depressed. Plan the time, portion and content of your meals each day and stick to it. Many people eat to fill a void in their lives. Examine your life and keep records of your eating habits. If you eat when you're not hungry, you may be trying to obtain comfort from food. Learn to eat when you're hungry and plan to eat four to six times a day. Cut down on portion but eat more often. Once you establish a habit of eating healthy by consuming smaller portions through the day, you will not be as vulnerable to overeating. Never eat spontaneously. Spontaneous eating in the absent of hunger is a sure sign of emotional problems, lack of discipline or lack of nutritional education. Help prevent emotional eating by identifying issues that will cause you to overeat. Find supportive friends to talk with when you feel the urge to overeat. Weigh****chers is a good support and accountability organization for weight management. Regular exercise and good friendship help fight depression and anxiety. Here are tips to help you fight the battle of emotional eating: Determine your mood especially before eating Develop interesting hobbies that take your mind off food Plan your meals each day Walk regularly through the week Strive to develop closer friendships Develop better spiritual health Monitor your emotions. Be prepared for the urge to overeat when emotionally upset. Drink 8 cups of water per day Replace junk food with fruits or low fat treats When you blow your diet.....Don't beat yourself up. Tomorrow is another new day. ------------------------------------------------ How does the pouch make you feel full? The nerves tell the brain the pouch is distended and that cuts off hunger with a feeling of fullness. What is the fate of the pouch? Does it enlarge? If it does, is it because the operation was bad, or the patient is overstuffing themselves, or does the pouch actually re-grow in a healing attempt to get back to normal? For ten years, I had patients eat until full with cottage cheese every three months, and report the amount of cottage cheese they were able to eat before feeling full. This gave me an idea of the size of their pouch at three month intervals. I found there was a regular growth in the amount of intake of every single pouch. The average date the pouch stopped growing was two years. After the second year, all pouches stopped growing. Most pouches ended at 6 oz., with some as large at 9-10 ozs. We then compared the weight loss of people with the known pouch size of each person, to see if the pouch size made a difference. In comparing the large pouches to the small pouches, THERE WAS NO DIFFERENCE IN PERCENTAGE OF WEIGHT LOSS AMONG THE PATIENTS. This important fact essentially shows that it is NOT the size of the pouch but how it is used that makes weight loss maintenance possible. OBSERVATIONAL BASED MEDICINE: The information here is taken from surgeon's "observations" as opposed to "blind" or "double blind" studies, but it IS based on 33 years of physician observation. Due to lack of insurance coverage for WLS, what originally seemed like a serious lack of patients to observe, turned into an advantage as I was able to follow my patients closely. The following are what I found to effect how the pouch works: 1. Getting a sense of fullness is the basis of successful WLS. 2. Success requires that a small pouch is created with a small outlet. 3. Regular meals larger than 1 ½ cups will result in eventual weight gain. 4. Using the thick, hard to stretch part of the stomach in making the pouch is important. 5. By lightly stretching the pouch with each meal, the pouch send signals to the brain that you need no more food. 6. Maintaining that feeling of fullness requires keeping the pouch stretched for awhile. 7. Almost all patients always feel full 24/7 for the first months, then that feeling disappears. 8. Incredible hunger will develop if there is no food or drink for eight hours. 9. After 1 year, heavier food makes the feeling of fullness last longer. 10. By drinking water as much as possible as fast as possible ("water loading"), the patient will get a feeling of fullness that lasts 15-25 minutes. 11. By eating "soft foods" patients will get hungry too soon and be hungry before their next meal, which can cause snacking, thus poor weight loss or weight gain. 12. The patients that follow "the rules of the pouch" lose their extra weight and keep it off. 13. The patients that lose too much weight can maintain their weight by doing the reverse of the "rules of the pouch." POUCH SIZE: By following the "rules of the pouch", it doesn't matter what size the pouch ends up. The feeling of fullness with 1 ½ cups of food can be achieved. OUTLET SIZE: Regardless of the outlet size, liquidy foods empty faster than solid foods. High calorie liquids will create weight gain. EARLY PROFOUND SATIETY: Before six months, patients much sip water constantly to get in enough water each day, which causes them to always feel full. After six months, about 2/3 of the pouch has grown larger due to the natural healing process. At this time, the patient can drink 1 cup of water at a time. IDEAL MEAL PROCESS (rules of the pouch): 1. The patient must time meals five hours apart or the patient will get too hungry in between. 2. The patient needs to eat finely cut meat and raw or slightly cooked veggies with each meal. 3. The patient must eat the entire meal in 5-15 minutes. A 30-45 minute meal will cause failure. 4. No liquids for 1 ½ hours to 2 hours after each meal. (I GO WITH 30 BEFORE AND 30 AFTER) 5. After 1 ½ to 2 hours, begin sipping water and over the next three hours slowly increase water intake. 6. 3 hours after last meal, begin drinking LOTS of water/fluids. 7. 15 minutes before the next meal, drink as much as possible as fast as possible. This is called "water loading." IF YOU HAVEN'T BEEN DRINKING OVER THE LAST FEW HOURS, THIS 'WATER LOADING' WILL NOT WORK. 8. You can water load at any time 2-3 hours before your next meal if you get hungry, which will cause a strong feeling of fullness. THE MANAGEMENT OF PATIENT TEACHING AND TRAINING: You must provide information to the patient pre-operatively regarding the fact that the pouch is only a tool: a tool is something that is used to perform a task but is useless if left on a shelf unused. Practice working with a tool makes the tool more effective. NECESSITY FOR LONG TERM FOLLOW-UP: Trying to practice the "rules of the pouch" before six to 12 months is a waste. Learning how to delay hunger if the patient is never hungry just doesn't work. The real work of learning the "rules of the pouch" begins after healing has caused hunger to return. PREVENTION OF VOMITING Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until the patient learns the size of his/her pouch to avoid being sick. It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient's mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth. In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting. Vomiting will occur only after eating of solid foods begins. Rice, pasta, granola, etc. will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when "comfortably satisfied," until the patient learns the size of his/her pouch. SIX WEEKS After six weeks, the patient can move from soft foods to heavy solids. At this time, they should use three or more different types of foods at each sitting. Each bite should be no larger than the size of a pinkie fingernail bed. The patient should choose a different food with each bite to prevent the same solids from lumping together. No liquids 15 minutes before or 1 ½ hours after meals. REASSURANCE OF ADEQUATE NUTRITION By taking vitamins everyday, the patient has no reason to worry about getting enough nutrition. Focus should be on proteins and vegetables at each meal. MEAL SKIPPING Regardless of lack of hunger, patient should eat three meals a day. In the beginning, one half or more of each meal should be protein, until the patient can eat at least two oz of protein at each meal. ARTIFICIAL SWEETENERS In our study, we noticed some patients had intense hunger cravings which stopped when they eliminated artificial sweeteners from their diets. AVOIDING ABSOLUTES Rules are made to be broken. No biggie if the patient drinks with one meal - as long as the patient knows he/she is breaking a rule and will get hungry early. Also if the patient pigs out at a party - that's OK because before surgery, the patient would have pigged on 3000 to 5000 calories and with the pouch, the patient can only pig on 600-1000 calories max. The patient needs to just get back to the rules and not beat him/herself up. THREE MONTHS At three months, the patient needs to become aware of the calories per gram of different foods to be aware of "the cost" of each gram. (cheddar cheese is 16 cal/gram; peanut butter is 24 cals/gram). As soon as hunger returns between three to six months, begin water loading procedures. THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY 1. Fill pouch full quickly at each meal. 2. Stay full by slowing the emptying of the pouch. (Eat solids. No liquids 15 minutes before and none until 1 ½ hours after the meal). A scientific test showed that a meal of egg/toast/milk had almost all emptied out of the pouch after 45 minutes. Without milk, just egg and toast, more than ½ of the meal still remained in the pouch after 1 ½ hours. 3. Protein, protein, protein. Three meals a day. No high calorie liquids. FLUID LOADING Fluid loading is drinking water/liquids as quickly as possible to fill the pouch which provides the feeling of fullness for about 15 to 25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15 to 30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 oz. Fluid loading works because the roux limb of the intestine swells up, contracting and backing up any future food to come into the pouch. The pouch is very sensitive to this and the feeling of fullness will last much longer than the reality of how long the pouch was actually full. Fluid load before each meal to prevent thirst after the meal as well as to create that feeling of fullness whenever suddenly hungry before meal time. POST PRANDIAL THIRST It is important that the patient be filled with water before his/her next meal as the meal will come with salt and will cause thirst afterwards. Being too thirsty, just like being too hungry will make a patient nauseous. While the pouch is still real small, it won't make sense to the patient to do this because salt intake will be low, but it is a good habit to get into because it will make all the difference once the pouch begins to regrow. URGENCY The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the regrowth of the pouch will have been done. That means that each present day, after surgery you will be satisfied with less calories than you will the very next day. Another way to put it is that every day that you are healing, you will be able to eat more. So exercise as much as you can during that first six months as you will never be able to lose weight as fast as you can during this time. SIX MONTHS Around this time, our patients begin to get hungry between meals. THEY NEED TO BATTLE THE EXTRA SALT INTAKE WITH DRINKING LOTS OF FLUIDS IN THE TWO TO THREE HOURS BEFORE THEIR NEXT MEAL. Their pouch needs to be well watered before they do the last gulping of water as fast as possible to fill the pouch 15 minutes before they eat. HONEYMOON SYNDROME The lack of hunger and quick weight loss patients have in the first six months sometimes leads them to think they don't need to exercise as much and can eat treats and extra calories as they still lose weight anyway. We call this the "honeymoon syndrome" and they need to be counseled that this is the only time they will lose this much weight this fast and this easy and not to waste it by losing less than they actually could. If the patient's weight loss slows in the first six months, remind them of the rules of water intake and encourage them to increase their exercise and drink more water. You can compare their weight loss to a graph showing the average drop of weight if it will help them to get back on track. EXERCISE In addition to exercise helping to increase the weight loss, it is important for the patient to understand that exercise is a natural antidepressant and will help them from falling into a depression cycle. In addition, exercise jacks up their metabolic rate during a time when their metabolism after the shock of surgery tends to want to slow down. THE IDEAL MEAL FOR WEIGHT LOSS The ideal meal is one that is made up of the following: ½ of your meal to be low fat protein, ¼ of your meal low starch vegetables and ¼ of your meal solid fruits. This type of meal will stay in your pouch a long time and is good for your health. VOLUME VS. CALORIES The gastric bypass patient needs to be aware of the length of time it takes to digest different foods and to focus on those that take up the most space and take time to digest so as to stay in the pouch the longest, don't worry about calories. This is the easiest way to "count your calories." For example, a regular stomach person could gag down two whole sticks of butter at one sitting and be starved all day long, although they more than have enough calories for the day. But you take the same amount of calories in vegetables, and that same person simply would not be able to eat that much food at three sittings - it would stuff them way too much. ISSUES FOR LONG TERM WEIGHT MAINTENANCE Although everything stated in this report deals with the first year after surgery, it should be a lifestyle that will benefit the gastric bypass patient for years to come, and help keep the extra weight off. COUNTER-INTUITIVENESS OF FLUID MANAGEMENT I admit that avoiding fluids at meal time and then pushing hard to drink fluids between meals is against everything normal in nature and not a natural thing to be doing. Regardless of that fact, it is the best way to stay full the longest between meals and not accidentally create a "soup" in the stomach that is easily digested. SUPPORT GROUPS It is natural for quite a few people to use the rules of the pouch and then to tire of it and stop going by the rules. Others "get it" and adhere to the rules as a way of life to avoid ever regaining extra weight. Having a support group makes all the difference to help those that go astray to be reminded of the importance of the rules of the pouch and to get back on track and keep that extra weight off. Support groups create a "peer pressure" to stick to the rules that the staff at the physician's office simply can't create. TEETER TOTTER EFFECT Think of a teeter totter suspended in mid air in front of you. Now on the left end is exercise that you do and the right end is the foods that you eat. The more exercise you do on the left, the less you need to worry about the amount of foods you eat on the right. In exact reverse, the more you worry about the foods you eat and keep it healthy on the right, the less exercise you need on the left. Now if you don't concern yourself with either side, the higher the teeter totter goes, which is your weight. The more you focus on one side or the other, or even both sides of the teeter totter, the lower it goes, and the less you weigh. TOO MUCH WEIGHT LOSS I have found that about 15% of the patients which exercise well and had between 100 to 150 lbs to lose, begin to lose way too much weight. I encourage them to keep up the exercise (which is great for their health) and to essentially "break the rules" of the pouch. Drink with meals so they can eat snacks between without feeling full and increase their fat content as well take a longer time to eat at meals, thus taking in more calories. A small but significant amount of gastric bypass patients actually go underweight because they have experienced (as all of our patients have experienced) the ravenous hunger after being on a diet with an out of control appetite once the diet is broken. They are afraid of eating again. They don't "get" that this situation is literally, physically different and that they can control their appetite this time by using the rules of the pouch to eliminate hunger. BARIATRIC MEDICINE A much more common problem is patients who after a year or two plateau at a level above their goal weight and don't lose as much weight as they want. Be careful that they are not given the "regular" advice given to any average overweight individual. Several small meals or skipping a meal with a liquid protein substitute is not the way to go for gastric bypass patients. They must follow the rules, fill themselves quickly with hard to digest foods, water load between, increase their exercise and the weight should come off much easier than with regular people diets. SUMMARY 1. The patient needs to understand how the new pouch physically works. 2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes. 3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch. EVALUATION FOR WEIGHT LOSS FAILURE The first thing that needs to be ruled out in patients *****gain their weight is how the pouch is set up. 1) the staple line needs to be intact; 2) same with the outlet and; 3) the pouch is reasonably small. 1) Use thick barium to confirm the staple line is intact. If it isn't, then the food will go into the large stomach, from there into the intestines and the patient will be hungry all the time. Check for a little ulcer at the staple line. A tiny ulcer may occur with no real opening at the line, which can be dealt with as you would any ulcer. Sometimes, though, the ulcer is there because of a break in the staple line. This will cause pain for the patient after the patient has eaten because the food rubs the little opening of the ulcer. If there is a tiny opening at the staple line, then a reoperation must be done to actually separate the pouch and the stomach completely and seal each shut. 2) If the outlet is smaller than 7-8 mill, the patient will have problems eating solid foods and will little by little begin eating only easy-to-digest foods, which we call "soft calorie syndrome." This causes frequent hunger and grazing, which leads to weight regain. 3) To assess pouch volume, an upper GI doesn't work as it is a liquid. The cottage cheese test is useful - eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn't be able to hold more than 1 ½ cups in 5 - 15 minutes of quick eating. If everything is intact then there are four problems that it may be: 1) The patient has never been taught the rules; 2) The patient is depressed; 3) The patient has a loss of peer support and eventual forgetting of rules, or 4) The patient simply refuses to follow the rules. 1) LACK OF TEACHING An excellent example is a female patient who is 62 years old. She had the operation when she was 47 years old. She had a total regain of her weight. She stated that she had not seen her surgeon after the six week follow up 15 years ago. She never knew of the rules of the pouch. She had initially lost 50 lbs and then with a commercial weight program lost another 40 lbs. After that, she yo-yoed up and down, each time gaining a little more back. She then developed a disease (with no connection to bariatric surgery) which weakened her muscles, at which time she gained all of her weight back. At the time she came to me, she was treated for her disease, which helped her to begin walking one mile per day. I checked her pouch with barium and the cottage cheese test which showed the pouch to be a small size and that there was no leakage. She was then given the rules of the pouch. She has begun an impressive and continuing weight loss, and is not focused on food as she was, and feeling the best she has felt since the first months after her operation 15 years ago. 2) DEPRESSION Depression is a strong force for stopping weight loss or causing weight gain. A small number of patients, who do well at the beginning, disappear for awhile only to return having gained a lot of weight. It seems that they almost on purpose do exactly opposite of everything they have learned about their pouch: they graze during the day, drink high calorie beverages, drink with meals and stop exercising, even though they know exercise helps stop depression. If your patient begins weight gain due to depression, get him/her into counseling quickly. Encourage your patient to refocus on the pouch rules and try to add a little exercise every day. Reassure your patient that he/she did not ruin the pouch, that it is still there, waiting to be used to help with weight control. When they are ready the pouch can be used once again to lose weight without being hungry. 3) EROSION OF THE USE OF PRINCIPLES: Some patients who are compliant, who are not depressed and have intact pouches, will begin to gain weight. These patients are struggling with their weight, have usually stopped connecting with their support groups, and have begun living their "new" life surrounded by those who have not had bariatric surgery. Everything around them encourages them to live life "normal" like their new peers: they begin taking little sips with their meals, and eating quick and easy-to-eat foods. The patient will not usually call their physician's office because they KNOW what they are doing is wrong and KNOW that they just need to get back on track. Even if you offer "refresher courses" for your patients on a yearly basis, they may not attend because they KNOW what the course is going to say, they know the rules and how they are breaking them. You need to identify these patients and somehow get them back into your office or back to interacting with their support group again. Once these patients return to their support group, and keep in contact with their WLS peers, it makes it much easier to return to the rules of the pouch and get their weight under control once again. 4) TRUE NON-COMPLIANCE: The most difficult problem is a patient who is truly non-compliant. This patient usually leaves your care, complains that there is no 'connection' between your staff and themselves and that they were not given the time and attention they needed. Most of the time, it is depression underlying the non-compliance that causes this attitude. A truly non-compliant patient will usually end up with revisions and/or reversal of the surgery due to weight gain or complications. This patient is usually quite resistant to counseling. There is not a whole lot that can be done for these patients as they will find a reason to be unhappy with their situation. It is easier to identify these patients BEFORE surgery than to help them afterwards, although I really haven't figured out how to do that yet... Besides having a psychological exam done before surgery, there is no real way to find them before surgery and I usually tend toward the side of offering patients the surgery with education in hopes they can live a good and healthy life. ******************************************************* What is Bulimia? Bulimia, also called bulimia nervosa, is a psychological eating disorder. Bulimia is characterized by episodes of binge-eating followed by inappropriate methods of weight control (purging). Inappropriate methods of weight control include vomiting, fasting, enemas, excessive use of laxatives and diuretics, or compulsive exercising. Excessive shape and weight concerns are also characteristics of bulimia. A binge is an episode where an individual eats a much larger amount of food than most people would in a similar situation. Binge eating is not a response to intense hunger. It is usually a response to depression, stress, or self esteem issues. During the binge episode, the individual experiences a loss of control. However, the sense of a loss of control is also followed by a short-lived calmness. The calmness is often followed by self-loathing. The cycle of overeating and purging usually becomes an obsession and is repeated often. Bulimia was only diagnosed as its own eating disorder in the 1980s. People with bulimia can look perfectly normal. Most of them are of normal weight, and some may be overweight. Women with bulimia tend to be high achievers. It is often difficult to determine whether a person is suffering from Bulimia. This occurs because binging and purging is often done in secret. Also, individuals suffering from Bulimia often deny their condition. Sufferers consume huge quantities of food. Sometimes up to 20,000 calories at a time. The foods on which they binge tend to be foods labeled as "comfort foods" -- sweet foods, high in calories, or smooth, soft foods like ice cream, cake, and pastry. An individual may binge anywhere from twice a day to several times daily. ------------------------------------------------------------ People who attend support group meetings are 80% likely to succeed. People who do not attend support group meetings are only 60% likely to succeed. -------------------------------------------------------------- After WLS you have added 15 years onto your life. -------------------------------------------------------------- You malabsorb 1/3 of your food for the first year to 2 years after surgery. The benefits to help you train your new eating lifestyle are that your pouch is smaller and full quicker, The Ghrelin Hormone which makes you hungry is bypassed, You will have dumping syndrome from sugars, You will have ANAL leakage from eating too much fats or severe diarrhea. After 1.5 - 2 years these go away. You will be on your own and hope that you have retrained yourself. ------------------------------------------------------- Eating too soon after surgery can irritate your new pouch and cause it to never fully heal. After several months it may still not be healed which can cause a colicky pouch and you will have a hard time eating meals without pain. ------------------------------------------------ Processed Foods (CARBS) spike insulin levels and then drop them dramatically and make the patient hungrier and want more food. They will make you full but of only empty non nutritious calories. PROTEIN first is best. Eat more whole foods and colorful veggies. --------------------------------------------------------------- WLS 10 COMMANDMENTS 1) Thou SHALT NOT drink with thy meals. This means NEVER. This is cheating..... Cheating yourself. It washes the food out of your pouch and allows you to eat more. This will slow and eventually stop your loss. 2) Thou SHALT eat slowly, very slowly. This is not a rule for the first few months post-op. This rule is for the rest of your life. If you eat too quickly, you will surely stretch your pouch. Eat too quickly and you will learn the hard way...the nausea is stifling, the pain is unforgettable and the vomiting is no fun either. 3) Thou SHALT take they vitamins. This surgery is a great tool for weight loss. But, as with all benefits, there are costs.....and malnutrition is one of the costs of this surgery. Take a multivitamin, Iron & B12, and Calcium supplement every day for the rest of your life. 4) Thou SHALT eat adequate protein. What is adequate? For women about 80g a day and men need about 100g a day. 5) Thou SHALT exercise... JUST DO IT!!!! 6) Thou SHALT drink a minimum of 64oz of water a day--EVERYDAY!!! Use a water bottle and carry it with you, EVERYWHERE!!! Sip, Sip, Sip... 7) Thou SHALT eat well-balanced meals. PROTEIN first, veggies and fruit after. 8) Thou SHALT NOT eat sugar in any form-no candy.... 9) Thou SHALT NOT modify these commandments to suit they needs. It will not work. You will only defeat yourself. 10) Thou SHALT love thyself and be happy with the body God gave thee. God did not intend for all of us to be supermodels, and this surgery will not make you one. Happiness comes from within. Be happy with who and what you are. ---------------------------------------------------------------------- Dumping Syndrome is caused after gastric bypass by intake of simple carbohydrates (sugar, or some starches) or when undigested food from the stomach fills the lower end of the small intestine (jejunum) too quickly. Early dumping: Caused by the high osmolarity of simple carbohydrates in the bowel. The various types of sugar all have small molecules, so that a gram of (for example) sucrose has MANY more molecules than a gram of protein, creating a higher concentration (number of molecules per cc) from simple sugars than from other foods. This matters because, inside the body, fluid shifts will generally go toward the higher concentration of molecules. So, if a patient consumes a bite of milk chocolate (lots of sugar), when it gets to the Roux limb it will quickly "suck" a significant amount of fluid into the bowel. This rapid filling of the small bowel causes it to be stretched (which causes cramping pain). This also causes the activation of hormonal and nerve responses that cause the heart to race (palpitations) and cause the individual to become clammy and sweaty. Vomiting or diarrhea may follow as the intestine tries to quickly rid itself of this "irritant." (So for the naysayers, Vomiting CAN BE PART OF DUMPING! but it is not typical) Late dumping: Has to do with the blood sugar level. The small bowel is very effective in absorbing sugar, so that the rapid absorption of a relatively small amount of sugar can cause the glucose level in the blood to "spike" upward. The pancreas responds to this glucose challenge by "cranking up" its output of insulin. Unfortunately, the sugar that started the whole cycle was such a small amount that it does not sustain the increase in blood glucose, which tends to fall back down at about the time the insulin surge really gets going. These factors combine to produce hypoglycemia (low blood sugar) which causes the individual to feel weak, sleepy, and profoundly fatigued. Late dumping is the mechanism by which sugar intake can create low blood sugar, and it is also a way for gastric bypass patients to get into a vicious cycle of eating. If the patient takes in sugar or a food that is closely related to sugar (simple carbohydrates like rice, pasta, potatoes) they will experience some degree of hypoglycemia in the hour or two after eating. The hypoglycemia stimulates appetite, and it's easy to see where that is going.... The reason that sugar does not cause dumping in non-operated people is that the stomach, pancreas, and liver work together to prepare nutrients (or sugar) before they reach the small intestine for absorption. The stomach serves as a reservoir that releases food downstream only at a controlled rate, avoiding sudden large influxes of sugar that can occur after a Roux-en-Y. The released food is also mixed with stomach acid, bile, and pancreatic juice to control the chemical makeup of the stuff that goes downstream and avoid all the effects outlined above. Note: Not everyone dumps the same or on the same stuff. Some people tolerate fats, some people can't. Some people tolerate sugar, some people can't. Some people dump on Sugar alcohols, but not regular sugar. It's a hit and miss thing. Only 30% of RNY's dump. But we should ALL go into the surgery thinking that "WE DO DUMP". That means avoiding High Sugar and High Fat. These are the things that can hinder our weightloss and make us fail. A Good Vitamin Supplement Could Be Just What the Doctor Ordered Ever wish that treating depression were as simple as taking a vitamin? Well, for some of you it may be just that simple. There are a variety of vitamin deficiencies that can lead to depression symptoms. The B-Complex Vitamins The B-complex vitamins are essential to mental and emotional well-being. They cannot be stored in our bodies, so we depend entirely on our daily diet to supply them. B vitamins are destroyed by alcohol, refined sugars, nicotine, and caffeine so it is no surprise that many people may be deficient in these. Here's a rundown of recent finding about the relationship of B-complex vitamins to depression: · Vitamin B1 (thiamine): The brain uses this vitamin to help convert glucose, or blood sugar, into fuel, and without it the brain rapidly runs out of energy. This can lead to fatigue, depression, irritability, anxiety, and even thoughts of suicide. Deficiencies can also cause memory problems, loss of appetite, insomnia, and gastrointestinal disorders. The consumption of refined carbohydrates, such as simple sugars, drains the body's B1 supply. · Vitamin B3 (niacin): Pellagra-which produces psychosis and dementia, among other symptoms-was eventually found to be caused by niacin deficiency. Many commercial food products now contain niacin, and pellagra has virtually disappeared. However, subclinical deficiencies of vitamin B3 can produce agitation and anxiety, as well as mental and physical slowness. · Vitamin B5 (pantothenic acid): Symptoms of deficiency are fatigue, chronic stress, and depression. Vitamin B5 is needed for hormone formation and the uptake of amino acids and the brain chemical acetylcholine, which combine to prevent certain types of depression. · Vitamin B6 (pyridoxine): This vitamin aids in the processing of amino acids, which are the building blocks of all proteins and some hormones. It is needed in the manufacture of serotonin, melatonin and dopamine. Vitamin B6 deficiencies, although very rare, cause impaired immunity, skin lesions, and mental confusion. A marginal deficiency sometimes occurs in alcoholics, patients with kidney failure, and women using oral contraceptives. MAOIs, ironically, may also lead to a shortage of this vitamin. Many nutritionally oriented doctors believe that most diets do not provide optimal amounts of this vitamin. · Vitamin B12: Because vitamin B12 is important to red blood cell formation, deficiency leads to an oxygen-transport problem known as pernicious anemia. This disorder can cause mood swings, paranoia, irritability, confusion, dementia, hallucinations, or mania, eventually followed by appetite loss, dizziness, weakness, shortage of breath, heart palpitations, diarrhea, and tingling sensations in the extremities. Deficiencies take a long time to develop, since the body stores a three- to five-year supply in the liver. When shortages do occur, they are often due to a lack of intrinsic factor, an enzyme that allows vitamin B12 to be absorbed in the intestinal tract. Since intrinsic factor diminishes with age, older people are more prone to B12 deficiencies. · Folic acid: This B vitamin is needed for DNA synthesis. It is also necessary for the production of SAM (S-adenosyl methionine). Poor dietary habits contribute to folic acid deficiencies, as do illness, alcoholism, and various drugs, including aspirin, birth control pills, barbiturates, and anticonvulsants. It is usually administered along with vitamin B12, since a B12 deficiency can mask a folic acid deficiency. Pregnant women are often advised to take this vitamin to prevent neural tube defects in the developing fetus. Vitamin C Subclinical deficiencies can produce depression, which requires the use of supplements. Supplementation is particularly important if you have had surgery or an inflammatory disease. Stress, pregnancy, and lactation also increase the body's need for vitamin C, while aspirin, tetracycline, and birth control pills can deplete the body's supply. Minerals Deficiencies in a number of minerals can also cause depression. · Magnesium: Deficiency can result in depressive symptoms, along with confusion, agitation, anxiety, and hallucinations, as well as a variety of physical problems. Most diets do not include enough magnesium, and stress also contributes to magnesium depletion · Calcium: Depletion affects the central nervous system. Low levels of calcium cause nervousness, apprehension, irritability, and numbness. · Zinc: Inadequacies result in apathy, lack of appetite, and lethargy. When zinc is low, copper in the body can increase to toxic levels, resulting in paranoia and fearfulness. · Iron: Depression is often a symptom of chronic iron deficiency. Other symptoms include general weakness, listlessness, exhaustion, lack of appetite, and headaches. · Manganese: This metal is needed for proper use of the B-complex vitamins and vitamin C. Since it also plays a role in amino-acid formation, a deficiency may contribute to depression stemming from low levels of the neurotransmitters serotonin and norepinephrine. Manganese also helps stabilize blood sugar and prevent hypoglycemic mood swings. · Potassium: Depletion is frequently associated with depression, tearfulness, weakness, and fatigue. Vitamin A Secondary vitamin A deficiency may be due to inadequate conversion of carotene to vitamin A or to interference with absorption, storage, or transport of vitamin A. Interference with absorption or storage is likely in celiac disease, sprue, cystic fibrosis, pancreatic disease, duodenal bypass, (gastric bypass bypasses the duodenum) congenital partial obstruction of the jejunum, obstruction of the bile ducts, giardiasis, and cirrhosis. Vitamin A deficiency is common in protein-energy malnutrition (marasmus or kwashiorkor), principally because the diet is deficient but also because vitamin A storage and transport are defective. Inadequate intake or utilization of vitamin A can cause impaired dark adaptation and night blindness; xerosis of the conjunctiva and cornea; xerophthalmia and keratomalacia; keratinization of lung, GI tract, and urinary tract epithelia; increased susceptibility to infections; and sometimes death. Follicular hyperkeratosis of the skin is common. The main function of vitamin D hormone is to increase calcium absorption from the intestine and promote normal bone formation and mineralization. Calcium Calcium in the body must be tightly controlled because it is necessary to cell function for such things as blood clotting, muscle contraction, enzyme reactions, cellular communication and skin differentiation. It also gives bones and teeth their strength. In fact, the hardest substance in the human body, tooth enamel, is 95% calcium. The calcium deficiencies in gastric bypass patients, is caused by the bypassing of the first part of the small bowel, called the duodenum. In adults, demineralization (osteomalacia****urs, particularly in the spine, pelvis, and lower extremities; the fibrous lamellae become visible on x-rays, and incomplete ribbonlike areas of demineralization (pseudofractures, Looser's lines, Milkman's syndrome) appear in the cortex. As the bones soften, weight may cause bowing of the long bones, vertical shortening of the vertebrae, and flattening of the pelvic bones, which narrows the pelvic outlet. Abetalipoproteinemia (Bassen-Kornzweig syndrome), due to the genetic absence of apolipoprotein B, causes serious fat malabsorption and steatorrhea, with progressive neuropathy and retinopathy in the first two decades of life (see Abetalipoproteinemia in Ch. 16). Plasma vitamin E levels are usually undetectable. Symptoms and signs are caused by hypoprothrombinemia and related depression of other vitamin K-dependent coagulation factors. Bleeding is the major manifestation whether the cause is inadequate dietary intake or antagonism of vitamin K by drugs. Easy bruisability and mucosal bleeding (especially epistaxis, GI hemorrhage, menorrhagia, and hematuria****ur in vitamin K deficiency. Oozing of blood from puncture sites or incisions may occur after trauma, and life-threatening intracranial hemorrhage can occur in infants. In obstructive jaundice, hemorrhage--if it occurs--usually begins after the 4th to 5th day. It may begin as a slow ooze from a surgical wound, the gums, the nose, or GI mucosa, or it may be massive into the GI tract. http://www.merck.com/pubs/mmanual/section1/chapter3 Vitamin B12 (gastric bypass patients should take shots at least once a week or better yet, daily) · Mechanisms of B12 deficiency o Reduced intrinsic factor production 2° parietal cell loss o Antibodies to B12 binding site on intrinsic factor: Prevent formation of complex that is normally carried to terminal ileum & absorbed · Associated immune disorders: Thyroiditis; Diabetes; Addison's; Ovarian failure; 1° hypoparathyroidism; Graves; Vitiligo; Myasthenia gravis; Lambert-Eaton syndrome; Common variable immunodeficiency with low Ig or IgA (younger patients) Vitamin E deficiency · Vitamin E o Mixture of tocopherols o a-tocopherol most potent o Antioxidant § Prevents peroxidation of polyunsaturated membrane fatty acids § ? Relationship with vitamin E o Recommended daily allowance: Males 10 mg; Females 8 mg o Absorbed & incorporated into chylomicrons in small intestine · Causes of deficiency o Transfer protein disorders § A-b-lipoproteinemia § Vitamin E transporter deficiency o Malabsorption § Chronic cholestasis § Cystic fibrosis § Chronic bowel disease: Celiac; Whipple's; Inflammatory; Tropical sprue; Chronic pancreatitis § Surgical: Post gastrectomy; Short bowel syndromes (i.e. gastric bypass) § Chylomicron retention disease o Reduced intake § Malnutrition § Total parenteral nutrition: May be associated with selenium deficiency · Clinical o Polyneuropathy § Sensory loss o Large fiber modalities o Sensory ataxia § Tendon reflexes: Absent § Electrodiagnostic o Sensory potentials: Usually small; May be normal o Abnormal somatosensory evoked potentials o Myopathy: 1 patient § Related to high dose cholestyramine treatment § Weakness: Generalized § Serum CK: High § Muscle pathology: Small ovoid inclusions (H&E purple; GT pink; Acid phos +) o CNS § Ophthalmoplegia § Spinal o Posterior column snesory loss o Extensor plantar responses o Systemic: A-b-lipoproteinemia § Retinitis pigmentosa § Acanthocytosis · Pathology o Dorsal root neurons: Early loss of distal region of central projection o Spinal cord: Loss of fibers in posterior & Clarke column o Axonal dystrophy (swellings) in cuneate & gracile nuclei · Diagnosis o Vitamin E levels: Undetectable or very low levels in serum o Other: Fat malabsorption ® Fatty stools; Low serum carotene · Treatment: Vitamin E supplementation o A-b-lipoproteinemia: 100 to 200 mg/kg/day in childhood ? + vitamins A & K o Malabsorption: 1 to 4 g/day Vitamin D deficiency · Function o Steroid hormone o Active form: 1,25-dihydroxy vitamin D3 (Calcitriol) o Action via intracellular receptor o Regulates Ca++ & Phosphorus homeostasis · Clinical: Similar to 1° hyperparathyroidism o Epidemiology: Dietary deficiency more common in § Northern Europe & US § Elderly patients § Immigrant populations § Infants: Vitamin D deficiency rickets o Myopathy (50%) § Weakness: Proximal; Symmetric § Muscle wasting § Myalgia § Muscle physiology o Reduced Force generation o Delayed relaxation § Tendon reflexes: Normal o Osteomalacia: See spinal disorders o Treatment § Ergocalciferol: Oral (50,000 U 1x/week x6) or IM § Improvement in strength & reduced pain over weeks · Laboratory o 25-Hydroxyvitamin D reduced o Parathyroid hormone increased o Alkaline phosphatase: Often increased o Serum CK: Often normal o Muscle biopsy: Normal or Non-specific changes · Vitamin D malabsorption: Causes o Dietary deficiency o Reduced Sun exposure o Malabsorption: Post-surgical; Bowel disease (i.e. gastric bypass) o Renal: Tubular acidosis; Chronic failure o Anticonvulsants Postgastroplasty syndrome: Polyneuropathy + · Epidemiology o Surgery: For morbid obesity o Frequency of neuropathy: 5% of Gastric bypass surgeries · Associated with o Surgical procedures § Gastrojejunectomy (BPD) § Gastric stapling (gastric bypass) § Gastroplasty § Gastrectomy o Vomiting § Severe protracted § May be chronic after gastrectomy (68%) o Weight loss § Degree: Mean 28%; Range 11% to 48% § Rapid · Polyneuropathy o Onset § Acute or Subacute § Numbness & paresthesias: Distal then proximal in legs o Sensory loss § Distal ± Proximal § Modalities o Large fiber: Joint position & Vibration o Small fiber § May simulate myelopathic pattern o Pain: Less prominent than in nutritional (Cuban) neuropathy o Weakness § Distal or Proximal § Legs > Arms o Hyporeflexia (66%) o Autonomic: Uncommon § Hyoptension: Syncope o Progression: May develop quadriparesis · CNS o Wernicke-Korsakoff like disorder § Confusion § Memory loss § Eye movement disorders o Affective disorders o D-lactate disorder: Bacterial overgrowth · Electrophysiology o EMG: Denervation o Nerve conduction studies § Axonal loss § Sensory + Motor involvement · Muscle biopsy o Type 2 muscle fiber atrophy o Denervation: Angular muscle fibers · Treatment o Parenteral nutrition o Vitamins: Thiamine + · Prognosis o Death 8% o Good resolution of signs 35% Selenium Deficiency3,4 (it is unknown whether gastric bypass patients can digest and absorb the micronutrients like selenium, chromium etc) · Selenium o Trace essential element o Sources: Meat; Fish; Cereals o Component of selenoproteins: Glutathione peroxidases; Iodothyronine 5'-deiodinases o Deficiency produces § Glutathione peroxidase activity: Reduced § Oxidative damage · Deficiency syndromes o Myopathy: Long term parenteral nutrition; Chronic bowel disease; Other dietary deficiency o Epidemic cardiomyopathy § 2° Reduced dietary selenium in pregnant women & children in Keshan, China o Animal disorders § "White muscle" or "Yellow fat" disease in horses & cattle § Probably related to concurrent selenium & vitamin E deficiency · Myopathy o Clinical § Muscle pain: Proximal § Weakness: Proximal, Symmetric § Treatment: Normal oral diet o Laboratory § Serum CK: High § Serum selenium: Low § Vitamin E levels: Commonly low § Muscle biopsy o Muscle fiber atrophy o Vacuoles o Thinned myofibrils o Mitochondria: Enlargement; Reduced Number · Cardiac disease: Arrhythmia; Cardiac failure Thiamin (vitamin B1 deficiency) Early deficiency produces fatigue, irritation, poor memory, sleep disturbances, precordial pain, anorexia, abdominal discomfort, and constipation. The syndrome of peripheral neurologic changes due to thiamine deficiency is called dry beriberi. These changes are bilateral and symmetric, involving predominantly the lower extremities, and begin with paresthesias of the toes, burning of the feet (particularly severe at night), muscle cramps in the calves, and pains in the legs. Calf muscle tenderness, difficulty in rising from a squatting position, a decrease in the vibratory sensation in the toes, and plantar dysesthesia are early signs. A diagnosis of mild peripheral neuropathy can be made when ankle jerks are absent. Continued deficiency causes loss of knee jerk, loss of vibratory and position sensation in the toes, atrophy of the calf and thigh muscles, and finally footdrop and toedrop. The arms may be affected after leg signs are well established. Cerebral beriberi (Wernicke-Korsakoff syndrome) results from severe acute deficiency superimposed on chronic deficiency (see Amnesias in Ch. 169). Mental confusion, aphonia, and confabulation constitute the early stage, called Korsakoff's syndrome. Cerebral blood flow is markedly reduced and vascular resistance increased. Wernicke's encephalopathy consists of nystagmus, total ophthalmoplegia, coma, and, if untreated, death. Cardiovascular (wet) beriberi (Shoshin beriberi****urs in thiamine deficiency when myocardial disease is prominent. This causes a high cardiac output with vasodilation and warm extremities. Before heart failure occurs, tachycardia, a wide pulse pressure, sweating, warm skin, and lactic acidosis develop. With heart failure, orthopnea and pulmonary and peripheral edema occur; vasodilation continues, sometimes resulting in shock. http://www.merck.com/pubs/mmanual/section1/chapter3/3j.htm Starvation Structural and functional changes due to the total lack of intake of energy and essential nutrients. Starvation is the most severe form of malnutrition. It may result from fasting, famine, anorexia nervosa, catastrophic disease of the GI tract, stroke, or coma. The basic metabolic response to starvation is conservation of energy and body tissues. However, the body will mobilize its own tissues as a source of energy, which results in the destruction of visceral organs and muscle and in extreme shrinkage of adipose tissue. Total starvation is fatal in 8 to 12 wk. Symptoms and Signs In adult volunteers who fasted for 30 to 40 days, weight loss was marked (25% of initial weight), metabolic rate decreased, and the rate and amount of tissue protein breakdown decreased by about 30%. In more prolonged starvation, weight loss may reach 50% in adults and possibly more in children. Loss of organ weight is greatest in the liver and intestine, moderate in the heart and kidneys, and least in the nervous system. Emaciation is most obvious in areas where prominent fat depots normally exist. Muscle mass shrinks and bones protrude. The skin becomes thin, dry, inelastic, pale, and cold. The hair is dry and sparse and falls out easily. Most body systems are affected. Achlorhydria and diarrhea are common. Heart size and cardiac output are reduced; the pulse slows and blood pressure falls. Respiratory rate and vital capacity decrease. The main endocrine disturbance is gonadal atrophy with loss of libido in men and women and amenorrhea in women. Intellect remains clear, but apathy and irritability are common. The patient feels weak. Work capacity is diminished because of muscle destruction and, eventually, is worsened by cardiorespiratory failure. The anemia is usually mild, normochromic, and normocytic. Reduction

Christine. That was very educational hun thanks alot. Now I have only one thing to say. I think you have to much time on your ahnds at work. lol jk. Had to say it and thanks again. Barry -97 lbs 03-14-05