The American College of Sports Medicine (ACSM), the American Heart Association (AHA), and the US Department of Health and Human services released guidelines for physical activity/exercise in 2008. Before the guidelines are discussed the difference between physical activity and exercise must be clearly defined.
• Physical activity: any bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above a basal (rest) level. This includes personal grooming/hygiene, feeding oneself, standing, walking from parking lot to entrance of building, family care, household chores, occupational requirements, gardening, and so on.
• Exercise: is structured physical activity specifically designed to improve one’s cardiovascular fitness, muscular strength/endurance, flexibility, and body composition (lean mass/fat mass).
• All exercise is physical activity but not all physical activity is exercise.
Cardiovascular Recommendations:
Most if not all days of the week (3-5 days/week) for at least thirty minutes per day. Moderate intensity level: Working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation (talk test).
METs: A metabolic equivalent or MET is a unit useful for describing the energy expenditure for a specific activity. A MET is the ratio of the rate of energy expended during an activity to the rate of energy expended at rest. Example: 1 MET is the rate of energy expenditure at rest, expressed as 3.5 ml/kg/min or 1 kcal/kg/h or 4.184 kj/kg/h. A 4 MET activity expends four times the energy used by the body at rest.
Two methods of assessing aerobic intensity:
1. Absolute Intensity (Overall guide)
Light: are defined as 1.1 to 2.9 METS
Moderate: are defined as 3.0 to 5.9 METS. Walking at 3.0 mph requires 3.3 METS of energy expenditure
Vigorous: are defined as > 6.0 METS. Running at 10 minute/mile pace is a 10 MET activity
2. Relative Intensity (Specific to individual): Intensity expressed in terms of percent of maximal heart rate, heart rate reserve or aerobic capacity reserve.
Moderate: 40-59% of aerobic capacity reserve (0% resting and 100% maximal) or a 5-6 on a scale of 0-10 (0=sitting, 10=maximal effort)
Vigorous: 60-84 % of aerobic reserve capacity or a 7-8 on a scale of 0-10
Four classifications of cardiovascular exercise:
Inactive: no activity beyond baseline activities of daily living.
Low Activity: <150 minutes (2.5 hours) of moderate intensity exercise or 75 minutes (1.25 hours) of vigorous intensity exercise per week.
Medium Activity: 150-300 minutes (2.5-5 hours) of moderate intensity activity or 75-150 minutes (1.25-2.5 hours) of vigorous intensity exercise per week.
High Activity: > 300 minutes (> 5 hours/week) of moderate intensity exercise.
A good rule of thumb is that vigorous intensity exercise requires only 50% of the weekly duration (time) of moderate intensity exercise to obtain the same health benefits.
The greater the amount of regular exercise (moderate or vigorous) performed on a weekly basis the greater the health benefits. Examples below:
Lower risk for premature death (17-28 years)
Lower risk for coronary heart disease (CHD)
Lower risk of stroke
Lower risk for hypertension (High blood pressure)
Lower risk for dyslipidemia (High cholesterol)
Lower risk for Type 2 diabetes mellitus
Reduced depression
Improvement in cognitive function
Reduction in the number of falls
Cardiovascular Activity
Any activity where the body’s large muscles move in a rhythmic manner for a sustained period of time (i.e. brisk walking, running, cycling, jumping rope, swimming, and hiking).
Three components to consider when selecting an activity (FIT Principle):
Frequency: how often on a weekly basis is the exercise performed.
Intensity: how hard to work during the activity. Moderate = brisk walking, vigorous = jogging/running.
Time: how long (duration) each session should last (i.e. 10-60 minutes).
Since its introduction in 1992, the Food Guide Pyramid has been criticized for being too difficult to read and too hard to understand. The 2005 revision, MyPyramid, didn’t give much clarity. Foods were removed from the image, making it harder to teach especially to young children. In an effort to capture attention and increase public knowledge of healthy eating, the USDA retired the well-recognized Food Guide Pyramid and replaced it with MyPlate.
MyPlate is a dinner plate that consists of the following parts: Half of the circle is filled with fruits and vegetables, with another portion featuring grains, and the rest consists of proteins. To the side of this plate is a glass of milk to represent the amount of dairy products that one should be having daily. It’s crisp, clear and colorful. Families shouldn’t have trouble identifying what goes where. The main goal of the new look is to emphasize that fruits and vegetables should consist of half of the food that is consumed and portions should be smaller.
Regarding the “fine print,” the USDA will be promoting three simple rules:
Balancing Calories
• Enjoy your food, but eat less.
• Avoid oversized portions.
Foods to Increase
• Make half your plate fruits and vegetables.
• Make at least half your grains whole grains.
• Switch to fat-free or low-fat (1%) milk.
Foods to Reduce
• Compare sodium in foods like soup, bread, and frozen meals ― and choose the foods with lower numbers.
• Drink water instead of sugary drinks.
According to the USDA, “The new food icon will be part of a comprehensive nutrition communication initiative that provides consumers with easy-to-understand recommendations, a new website with expanded information, and other tools and resources.”
It is a well accepted idea that iron absorption and anemia can be altered by malabsoptive surgeries such as Roux En Y Gastric Bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD-DS). There are multiple variables involved that have both negative and positive effects on iron absorption but the overall incidence of anemia increase from an average of 12% before surgery to about 23% afterward. To understand this you must have a basic understanding of how iron is absorbed.
Iron is absorbed best in the first part of the intestine (doedenum jejunum). This part of the intestine is usually bypassed by RYGB and BPD giving a negative effect on absorption. Also, iron is better absorbed in an acid environment, which is also reduced by RYGB and BPD. Iron is easier to absorb in the form of “heme” which is found in meats and thus tends to be negative effect as meat consumption decreases after surgery. These negative effects are counter-balanced by, and even overcome by, a reduction in systemic inflammation that occurs as a result of the dramatic weight loss. This reduction of systematic inflammation appears to have multiple beneficial effects. It is such a powerful effect that after 24-48 months most patients will actually see increase in serum iron levels!
So, why then do we have to take all this damn iron? Despite the actual improvement in serum iron there is still an overall increase in the incidence of anemia, some of which appears to be iron related. The anemias that develop after weight loss may not be secondary to actual absorption of iron as much as a product of the altered metabolism or processing of iron once it is in your body. Unfortunately, the metabolism of iron and effects of weight loss surgery on iron storage and metabolism are poorly understood at this time. It is known that premenopausal women are the most likely population to develop anemia after weight loss surgery.
Dr. K. Robert Williams Jr.
New Life for Bariatric Surgery
Posted on March 22, 2011 at 9:19 AM in Uncategorized
How many times have you been driving home after work, exhausted, fretting about what you are going to cook for your family? The thought alone is enough to amplify the feeling of exhaustion! This often opens the door for temptation to take the easy road – ie, pull into the local fast food restaurant, place an order, and head for home. The problem with doing this is that it can lead to weight gain and other health problems.
So, what’s the solution? Make a meal plan! I know what you are thinking – it takes too much time. Meal planning doesn’t have to be complicated, it does take time upfront but it will pay off in the long run. Setting aside one hour on the weekend to plan the next week’s meals will really pay off. Allow me to show you how meal planning can save you time, save you money, and improve your nutrition. Sound alluring now?
Start Small
Most people have the intention of making a meal plan, but sit down with a recipe book and start to feel overwhelmed. Just focus on one week at a time. You don’t have to plan your meals until the year 2012. Five to seven meals – it’s not that many!
Two Choices: Handwritten or Electronic
You can either use a paper calendar to make your meal plan or an electronic calendar. With either method, always record the recipe book and the page number of the recipe along with the name of the recipe. This eliminates the frustrating game of ‘Where’s the recipe” when it comes time to cook.
If you are technologically inclined, I highly recommend using the electronic version. Download a calendar into a word processor (ie, Microsoft word). You can find many templates online. Then, search for recipes online or in recipe books. If you use a recipe book, remember to record the name of the book and page number. You can either print the recipe out so that it’s ready when you need it or, if you have a laptop or iPad, insert the hyperlink into the document so all you have to do is open up the webpage and cook.
Search for Ingredients
The best part about meal planning is that you can use ingredients that you already have on hand. Prior to meal planning, I would walk through the aisles, grab things, and go. I would often end up with 10 cans of black beans and nothing to go with them. Use a website like KraftFoods.com which allows you to enter up to 3 ingredients and search for recipes based on those ingredients. You can also use a search engine to enter ingredients. Simply type in Ingredient A + Ingredient B + Ingredient C. You will have thousands of recipes at your demand. This really comes in handy if you see an item on sale in the weekly sales ad.
Grocery Lists
As you compile your recipes, make a grocery list as you go. Write all ingredients, whether you have them or not, on your list (explanation in ‘recycle meal plans’ below). My best advice is to take a little time and make an isle by isle map of your grocery store. Next time you are there, make a note of the large signs hanging above each aisle. This allows you to make your list based on location in the store and zip right through. Many stores have a store layout, so check with their customer service desk. If you do not wish to organize it by aisle, make a master list of categories (breakfast foods, breads, dairy, baking, etc). The worst idea is to make a running list of ingredients without categorizing it. You will find yourself darting back and forth over the entire store.
Recycle Meal Plans
Coordinate your meal plans and shopping lists. Make a few weeks worth of menus and start over – no thinking required! The reason for writing down all ingredients, whether you need them or not, is so that you’ll have the list ready if you use the meal plan again.
Ready, Set, Go!
Don’t give up – the first time I sat down to plan my meals, it took 2 hours. Now, it generally takes about 45 minutes for 1 week. Prior to meal planning, I would spend at least that long standing in front of the refrigerator trying to figure out what ingredients I had. My husband is very grateful now that I’m meal planning. It eliminated the monotony of having the same 4-5 meals over and over. If you are still not convinced that you can do it on your own, visit meal planning websites. MealTimeMakover.com is a great site that bases meal plans on grocery store sale cycles. It provides you with a menu, recipes, shopping list broken down by category, and includes the price of the item for each grocery store. There is a charge for subscribing to the site ($5 per month), but my friends/family that use it say it is well worth it.
Posted on February 16, 2011 at 1:47 PM in Uncategorized
We all have a tendency to become creatures of habit in most areas of our lives, especially when it comes to what we eat and what we do for exercise. Usually, routine is good; we know what to expect, how to prepare for our day, and with exercise, being in a good routine is necessary in order to reap the benefits that exercise has in store for us. However, developing a good habit of exercise does not mean you always have to do the same mode of exercise, like always walking, using the same DVD to exercise at home, or using the same machines when we go to the gym.
How do you know if it is time to change it up? One of the first signs that it is time to vary our routine is that we become bored or complacent regarding our exercise. Perhaps we even experience a “lack of change” that use to be taking place with our body. Being bored with exercise leads us to become complacent, and once complacency sets in, it is hard to overcome it. After eight to ten weeks of a structured routine, our bodies have made the changes necessary to meet the demands placed on our body by that routine. In order to continue to experience the benefits, we need to change it up! I know, I know, it is easier said than done, but I am going to make a few suggestions for how you can change things up without feeling like you have to do a major overhaul on your workout routine. Remember, variety is the spice of life!
•If using DVDs at home, consider purchasing different ones or checking with a DVD rental company (Blockbuster, Netflix, etc.) to see if they have exercise DVDs available for rent. If the current DVD you are using has a harder level or the instructor on the video gives harder modifications for the exercises, try doing those instead of what you have always done.
•If you primarily walk outside for exercise, consider taking a different route or just doing your current route in reverse! That way, those hills you always do first will come at the end of your walk and will be more challenging. Consider driving to a park or greenway to walk instead of walking in your neighborhood or at the local school track.
•When using a piece of cardiovascular equipment (i.e. treadmill, bike, elliptical, or stair climber), whether at home or at the gym, choose a program that is different from the one you always do. For example, if walking on the treadmill, instead of doing the manual program where you choose the speed and incline, choose one of the many programs that vary both the speed and incline over the course of the exercise time. You can always override the speed and incline if you feel the exercise is too difficult for you. If you are using an elliptical, stair climber, or bicycle, choosing the “Random” or “Interval” workout is a great option for variability instead of using the “Fat Burning” or “Manual” program.
•Rather than performing all 30 minutes on one piece of cardiovascular equipment, choose two different machines to use for 15 minutes each, or split your 30 minutes up between three different machines, doing 10 minutes on each.
•Instead of always doing your 30 minutes of cardio first and then doing weight training, reverse the order.
•For resistance training, if you have always used machines for your weight training, consider using dumbbells for some or all of the exercises you have been doing with a machine. Dumbbells require more body control while performing the exercise so they have a different effect on your muscles. If you work out at a gym, any staff member could show you a dumbbell exercise that correlates to the machine exercise you have been doing.
•Consider changing the order in which you do your weight training exercises; instead of doing your chest exercise first, start with back or shoulder exercises, then finish with chest.
•For more variability, intersperse intervals of cardiovascular exercise into your resistance training time. Below is an example using chest press and seated row exercises and the use of a treadmill:
Warm up of 3-5 minutes on the treadmill
Set #1 of Chest Press
Set #1 of Seated Row
Set #2 of Chest Press
Set #2 of Seated Row
Set #3 of Chest Press
Set #3 of Seated Row
Perform 1-3 minutes of high intensity exercise on the treadmill
Set #1 of first exercise in the next pair
Set #1 of second exercise in the next pair
oUse this model for all exercises you normally perform, keeping in mind that you do not have to have cardiovascular equipment available to you to do this. If you are at home doing weight training and without a treadmill, bike, elliptical, etc., consider jumping rope (or pretending to), doing jumping jacks, or jogging in place for the cardio portion.
•If you belong to a gym, consider taking a group fitness class for your cardio and/or weight training. Most gyms post class descriptions of the classes offered and most classes are a combination of cardio and weight training. Group fitness classes are a great way to get both cardio and weight training during a 45-60 minute time slot.
Of course, involving other people into your exercise time (family, friends, and co-workers) will help you stay motivated and accountable to doing your exercise. Now, get out there and exercise!!
I have often been asked by patients how much protein is adequate for bariatric surgery. Our post-op resource guide details our recommendations, but I am often faced with the question, “How much protein do I need?” and “What protein shake should I drink?” The answer is you don’t have to drink any, but you will likely feel and progress better if you manage to take in a certain amount of protein.
How much protein do I need? The amount depends on the type of weight loss surgery that you have had. Our restructure patients (lap bands and sleeve gastrectomy) require a little less protein around 6 grams daily. They will absorb protein better and therefore require a little less. Our Gastric Bypass patients will generally need 60 to 80 grams daily because there is a malabsorptive component to this mixed procedure. Our Billary Pancreatic Diversion patients (BPD) will generally need 80 to 100 grams daily because this procedure involves a higher degree of malabsorption.
What protein shakes should I get? There are many protein shakes that would be adequate for our post bariatric patients; there are so many brands that it is impossible to list them all in this context. In general, it is important to look at the nutrition label, make sure that aren’t too many calories, carbohydrates, or fat grams per serving. It usually recommends less than 120 calories, less than 5grams of fat, and less than 8 grams of carbohydrates, also to be affective it should have at least 12 grams of protein. In Summary, shakes are not absolutely necessary, but they do facilitate healthy weight loss in both bariatricand non-bariatric patients. Protein is vital for all body functions; including maintenance of muscle mass. In my early years of bariatric surgery 2004-2005, I worked in a bariatric program that forbade all protein shakes. Now our program activity encourages protein shakes, I can honestly say, the patients feel and progress better.
If you are just getting started with your journey after weight loss surgery, follow the recommendations that you have been given.
Early on in the journey motivation is high, compliance is great and weight loss is at its peak. Later on, as weight loss slows (naturally), daily routine takes priority, old habits can gradually creep back in at times and exercise may even dwindle somewhat. If this seems to be happening with you, think back to what motivated you to have surgery and write down the goals that you had at that time. See how many of them you have accomplished and see which ones are yet to be realized. Maybe even set new goals.
Your number one goal was probably to get healthy. The second one was probably to lose weight, or maybe it was a combination of the two; to get healthier and lose weight. If your goal was to get healthy, realize that the only way to get healthy is to eat healthy foods most of the time (a great majority of the time) and to exercise regularly, get quality sleep, manage stress, and do things that make you happy. Make sure that you set yourself up to be successful at eating the right amount of foods and the right types of foods that have been recommended to you. In addition, make sure that you are making time to exercise five or more days per week.
Sometimes things happen that interfere with your routine, but do not let this interference become a long term hindrance to exercise. You have to figure out for yourself how you can make your circumstances allow for regular exercise and healthy eating. Use an exercise record sheet to stay on track and a food journal for your diet as needed. For example, if your work schedule changes and you have to work overtime and this is cutting into your exercise time, don’t quit, modify your exercise routine and do what you can as often as you can until your schedule permits returning to your old routine. Remember 10 minutes of vigorous exercise is better than none and you can always divide your total exercise time between two different sessions throughout the day. For example, if your goal is to exercise for 30 minutes each day, but there are several days where you do not have 30 minutes at once to exercise, complete two 15-minute sessions with appropriate intensity and you will have 30 minutes of exercise for the day. When you are sick you need to rest, but during that time continue to use your record sheet and document that you are sick. Return to more exercise as tolerated.
Gastric Bypass surgery has evolved over the past forty years and the technique used today is better than ever before. Unfortunately, previous versions of the bypass made it possible for the patient to develop an enlarged pouch or a dilated gastrojejunal anastomosis (connection of the small bowel to the gastric pouch). A dilated pouch allows the patient to eat too much and a dilated stoma removes the restrictive component of the operation also allowing excessive food intake. Both of these conditions lead to weight re-gain after successful gastric bypass surgery. Weight re-gain is terribly demoralizing for the gastric bypass patient and previously available options for treatment of weight re-gain have been invasive and only marginally effective.
I am proud to announce that there is now a non invasive option to repair the dilated gastric pouch and dilated anastomosis. The ROSE procedure is an incision-less endoscopic (through the mouth) option that allows the surgeon to plicate the pouch and or the stoma to aid the patient with losing the re-gained weight. ROSE stands for Revision Obesity Surgery Endoscopic. I was selected to be trained on this new procedure along with a small number of surgeons in the United States. I believe that it provides options not previously present for properly selected patients to help them lose weight.
Weight re-gain can occur for a variety of reasons. Sometimes the patients behavior is the cause. If a patient stops exercising and begins snacking weight re-gain will occur. Food choices and using the tool correctly (not drinking while you eat) are also important. Other causes include overeating causing pouch dilation, formation of a gastro-gastric fistula, and technical errors by the surgeon such as making the pouch too big or the Roux limb too short to begin with. Above are examples of why patients must be properly evaluated before undergoing any form of revision surgery whether it is endoscopic, laparoscopic or open. Evaluation includes:
Evaluation of Diet
Evaluation of Exercise Habits
Upper GI X-ray (can be done in office at the New Life Center)
Upper Endoscopy
For the properly selected patient, the operation is performed as an outpatient procedure. After undergoing general anesthesia, a transport tube is place through the patients mouth into the gastric pouch. The transport has channels through which an endoscope, graspers, and suturing instruments may be passed. In this way permanent suture anchors are placed to plicate or shrink down the pouch and stoma.
Post operatively, patients return home and can usually return to work the next day. Many patients experience a sore throat that quickly goes away.
Other options for treating weight re-gain exist as well. I routinely perform revision operations on patients from other practices and I know that a thorough evaluation of the patient is necessary in order to tailor the treatment to their needs. Having said that, I am also very excited to have this cutting edge technology available for the properly selected patient!
