Monthly Archives: March 2014

Depression After Gastric Bypass Surgery

For those whose weight has climbed steadily after years of failing on traditional diets, gastric surgery to reduce the size of the stomach seems almost inevitable. If the stomach pouch is made so small that it holds about the same amount of food that would feed a gnat, weight loss is inevitable. So little food can be eaten at a time that patients are told not to drink water at mealtime because doing so leaves no room for food. Pounds seem to melt off, leaving the post-operative patients optimistic about improved health, energy, and a lifestyle no longer limited by excessive weight.

But for some, as the pounds disappear, the problems begin. Nutritional deficiencies due to changes in absorption of food into the body are well characterized but handled by monitoring of food intake and vitamin-mineral supplements. Eating too much causes severe nausea and pain, another unpleasant but avoidable side effect if the temptation to take one too many bites is overcome.

However, some problems don’t disappear as quickly as the weight, and for some, may persist for years. Anxiety, depression and insomnia may be so severe and resistant to medication that some patients consider having the operation reversed. Anxiety about the operation is understandable. Who among us awaiting any operation has not awakened at 3AM with a pounding heart and in a cold sweat thinking about the procedure about to be done? And anxiety after the stomach reduction is also understandable. There is no rehearsal time to prepare for an entirely new way of eating and a newly emerging body. Clinical depression and insomnia are not so easily explained.

One could surmise that depression might follow the realization that certain foods are never again going to be eaten. Presumably waking up after surgery and knowing you would never eat chocolate again might put you into a permanent funk. But the depressions reported both in the scientific literature, and in the hundreds of personal anecdotes on gastric surgery blog sites, suggests otherwise. Some have associated depression with the very low-calorie diet followed for several months following the surgery. Studies carried out during and post-World War II on volunteers given a semi-starvation diet similar to those in prisoner of war camps showed significant depression that disappeared when the subjects were given enough food. For some, however, a clinical depression lasts well beyond the first months of very restricted feeding and is resistant toantidepressant therapy.

Could the cause be the lack of a specific nutrient in the diet, i.e. carbohydrates? The absence of carbohydrate in the diet invariably alters serotonin levels and that neurotransmitter activity. It is the insulin release after carbohydrates are eaten that indirectly allows more serotonin in thebrain to be made. Insulin changes the levels of amino acids in the blood and this enables one amino acid, tryptophan, to enter the brain. Serotonin is made from tryptophan, and thus is dependent on its brain availability.

Dietary regimens before and after bariatric surgery often create the perfect storm for serotonin depletion. High-protein/very low-carbohydrate diets are imposed on pre-surgical patients so they will lose some weight before surgery. Post-operatively, patients eat only protein and supplements to prevent muscle, vitamin and mineral loss. Even though tryptophan is one of the amino acids making up protein, studies done over several decades at MIT showed that when protein is eaten, little or no tryptophan enters the brain.

Low and/or inactive serotonin is associated with depressed mood and anxious mood, anger, irritability and fatigue. Women normally have less serotonin in their brains and are more likely to be depressed than men. Might their depression after bariatric surgery be related to their serotonin depleting diet?

How to increase serotonin production during the protein feeding phase is a difficult problem. The stomach is so small, there is not room for both carbohydrate and protein and the latter must be eaten. Would giving tryptophan as a supplement help? Should studies be done to see if increasing the synthesis of serotonin prevents or decreases depression?

Insomnia is also an unexpected side effect of the surgery. Other than patient reports, not much is known about the cause or how to handle it. “I was awake until 2AM, fell asleep, and then woke up at 4 AM. The only way I can sleep is by taking prescription sleep medication,” is not an uncommon description of persistent wakefulness of many post-surgical patients. According to some of their reports, the insomnia lasts for months and even years. Some people reported taking melatonin but in such large doses (the correct dose is 0.3 mg) that it shut off their body’s own production of this hormone and stopped working. Others would attempt to limit the use of prescription drugs for fear of addiction, but eventually give in after several sleepless nights.

Would eating more carbohydrates help? Might more serotonin help calm and soothe the mind so it stops racing around like a gerbil on a running wheel and allow sleep to come?

No one disputes the life-saving consequence of bariatric surgery as it removes or decreases the many health problems of excessive weight. But unless depressed, insomniac individuals find some way to feel and sleep better, they are a risk for regaining weight and losing their health. Call it an unexpected blindside of a surgery meant to make life easier to begin with.

A New Diet Each Day May Make The Pounds Go Away

There is something enticing and optimistic about a brand new diet. Like buying a cream to eliminate wrinkles or a set of language tapes to finally learn French, we hope that this time THIS diet will work. This new diet will detoxify the liver, decrease the acidity of our stomach, remove those inflammation-causing glutens from our blood stream, burn the fat, increase muscle mass, and eradicate any desire we have for food… permanently. Just the past month, magazines and newspapers have touted the advantages of a 10-day detox diet, an alkaline diet (no foods can be eaten that lower the pH in the stomach) and the life-affirming effects of avoiding any food that is white (cottage cheese, chicken, and yogurt excepted).

Novel ways of eating in the interests of losing weight have been put forth for decades. Liquid diets have come and gone and will come again. Eating certain foods on specific days (does anyone remember the Beverly Hills diet?), fasting, the Atkins fat and protein regimen, diets based on blood type, personality, and presumably on whether one uses a Mac or PC, keep popping up in both respectable and sketchy magazines. Indeed, I am seriously contemplating inventing the Patriotic Diet in time for the 4th of July. This novel diet insists that the dieter eat only red, white, or blue foods on specific days of the week during July. In addition to honoring our flag, the diet could promote weight loss or at least make the dieter dislike red, white and blue foods based upon an aversion through restriction model.

My diet is not real, but alas others with little more great authority and scientific basis are. They are marketed so the dieter believes that they will really work. And for a while, they do.

They work because they are examples of the effect of a placebo on changing behavior. A placebo is defined as an inert, inactive substance or intervention or device without any function. For decades clinicians have found that placebo treatments, e.g., the sugar pill or colored water or sham acupuncture needle, really do work to reduce pain, depression, and a large variety of other ills that seem impervious to medical treatment. [1] The explanation is that if one believes something is going to work, in many cases, it does. So if a new diet comes along that claims to detoxify my intestinal tract, rejuvenate my liver and make me energetic and happy, I may reap these benefits because I truly expect that these things will happen.

Another reason is a logistical one. Diet plans that target certain foods for consumption or avoidance must by necessity eliminate large numbers of foods that are fattening. Do away with bread, and presto! One therefore also eliminates butter, cream cheese, peanut butter, mayonnaise, cheese spread, and Nutella. Tell people that dairy products will do dreadful things to their gut and they right away stop eating not only fat-free yogurt and skim milk, but ice cream as well. Having a newly-discovered gluten sensitivity used to be a reliable way of losing weight because so few foods could be eaten. Now, alas, so many manufacturers are making gluten-free foods which resemble the old foods we used to eat problem-free, that it is hard to eliminate much from our diet.

Alas, there is no placebo for smaller portions, lower-calorie foods, substitution of vegetables and fruits for chips and cookies, and none for exercise. New diets become old very quickly as the weight returns and the diet plan is shoved under a stack of others that are no longer interesting.

The weight-loss plans that work are boring, predictable, slow acting, and do not make for interesting conversation. Very few people who exercise consistently rarely consider their workouts sufficiently unique to chat about them with others. (Golfers are an exception.) Who wants to know how many minutes your neighbor spent on an exercycle or doing a yoga pose? People who always eat salads, fish, low-fat dairy and steamed rice rarely mention these foods as the newest diet fad in the tabloids. Who wants to know how many servings of vegetables you ate this week or cups of cottage cheese you managed to swallow? Alas, a boring, slow weight loss, sensible diet will not make celebrity headlines or you, the follower, the center of attention at a party.

A new diet-a-day will not make the weight go away. What will make it go away is finding and following an eating and exercise plan that works for you, day after day, year after year. Eventually having a fit, thinner, healthy body will no longer be a novelty. It will simply be a way of life.



If Kids Played More, Would They Be Less Fat?

As someone who was called “butterball” by my second-grade classmates, I was aware of the social stigma of being one of the fattest (my mother preferred chubby) in my class. Fortunately, the pounds came off a few years after the braces and, unlike current predictions of how fat kids become fat adults, I managed to go through my adult life at a normal weight. The good and the bad news is that today, being chubby, a.k.a. fat, would no longer make me an outlier on the playground but one of the gang.

National concern is growing over the rapidly increasing number of obese in our youth population and interventions have begun, such as changing the menus of school lunches and contents of school vending machines. Unfortunately, these nutritional improvements do not extend to fast-food chains or convenience stores, so kids who have the money and mobility can buy the fattening meals, snacks, or drinks they no longer can get in school. Indeed, I’ve seen a convenience store near the subway stop for an urban high school doing a brisk business in Doritos and Cokes, the preferred breakf

Excessive calorie intake seems to be the most obvious reason behind the weight gain of the young population. I certainly can point to an endless stream of homemade sour cream coffee cakes, blueberry pies, and peanut butter cookies as the reason I waddled around when I was 7. But a steady decline in physical activity over the past couple of decades may also be a potent reason for the increase in weight we are now seeing among school children. Walking to school, running around the playground during recess, riding a bike, jumping rope, skating, sledding, and kicking or hitting a ball in your friend’s backyard may be as old-fashioned as a black-and-white movie. Where did we lose our sense of play in the great outdoors?

Today’s kids are more likely to let their thumbs run around a touch screen. Kids are bused or driven to school and are either so laden with homework, afterschool activities or jobs, that playtime seems as quaint as a landline. Even something as commonplace as after-school team sports like Little League or its newer alternative, soccer, is losing members. A recent Wall Street Journal article reported an across the board decrease in participation of team sports such as football, soccer, basketball, and baseball, and the decline was seen among both elementary school and older students.1 The reasons for this shift were not known and may be related more to the inability of schools to pay for the support staff for such activities and /or parents to spend the time and money on equipment, uniforms, and getting the kids to practice. But the effect is a drop in physical activity that is not compensated for with kids running around the neighborhood.

No one wants to go back to a time when children were sent out to work at age 8 or 9 and were thin because they spent hours at hard labor and never were fed enough. Indeed, one of the historical errors of the very popular TV show Downton Abbey is the robust health of the young servants who seem to live in the kitchen. Young girls who went into service at 13 or 14 worked 16-18 hours days doing what we would consider today to be hard manual labor and were underfed and undernourished.

When are we going to take seriously the effects of very limited opportunities for daily physical activity on the health and longevity of our young population? If, as now seems to be the case, obesity in childhood predisposes an individual to obesity throughout adulthood, can we continue to ignore the problem? Making time for daily physical activity is an obvious solution, but one whose implementation seems dubious. Where and when are kids going to be able to really exercise? Where is the child who goes to school in the inner city going to be able to play ball or where, in the sidewalk-less, heavily trafficked, no shoulder roads, can a suburban child ride a bike? Kids have to leave school when the buses come; they can’t hang around and play in the schoolyard. And the necessity to fill every hour of the school day with teaching leaves little time for leisurely recesses.

And yet, what will have the most lasting effect on our kids? Remembering the periodic table or the capitals of all of our states, or being of a healthy weight and good nutritional status? This is not to suggest that kids stop going to school so they can play soccer or go sledding. But we can’t wring our hands over the overweight status of our children and moan over the implication for their future health but then provide them with no financial support or time to keep them physically active.