Obesity, Addiction, Alcohol and Bariatric Surgery Part I

We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors.  We are also learning increasingly that there are many areas of neurophysiologic, psychological and behavioural overlap in the realms of obesity and addiction.  A recent review draws on our knowledge of alcohol use after bariatric surgery to help us understand these connections.

After gastric bypass surgery:

• 9.4% of patients who have had gastric bypass surgery report a period of excessive alcohol intake at some point after surgery
• 7% of patients with no preoperative history of excessive alcohol intake develop a problem after surgery
• middle aged females seem to be at higher risk
• post bariatric surgery addiction problems seem to be fairly specific to alcohol (though addictions to other substances, or activities such as gambling are also seen - see 'addiction transference' below)
• when a person who has had gastric bypass surgery drinks alcohol, there is a faster rise, higher peak, and longer duration of blood alcohol levels 

Interestingly, some people who were frequent alcohol consumers before surgery actually have a decreased enjoyment of alcohol after surgery, which may be mediated by an increase in the gut hormone GLP-1, and a decrease in the hunger hormone ghrelin.

Psychological and social factors can also have a big influence on alcohol consumption after surgery.  As blogged previously, food addiction seeking a new outlet (called 'addiction transference') may be a factor for some people.  A need for a coping mechanism as a person watches their body change after surgery may be involved.   Some may reach for alcohol as a way to manage the complex psychological issues that can arise after surgery. 

Stay tuned for the next blog post, where I'll discuss some of the parallels between obesity and addiction discussed in this review. 

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www.drsue.ca © 2017

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Eating for Two? Risks of Too Much - or Too Little - Weight Gain In Pregnancy

Many studies have suggested that too much, or too little, weight gain in pregnancy can be harmful to both baby and mother.  A recent review brings together data from over 1.3 million women, to help us understands what the health risk are of inappropriate weight gain in pregnancy.

First, let's review the recommendations for weight gain in pregnancy.  The recommended amount is based on Body Mass Index pre pregnancy, which is calculated by your weight in kg, divided by your height in metres squared (kg/m2). Note that these numbers apply to single pregnancies only (recommendations are higher for twin, triplets etc).

• BMI less than18.5:  28-40 lbs (about 13-18 kg)
• BMI 18.5-24.9:       25-35 lbs (about 11-16 kg)
• BMI 25-29.9:          15-25 lbs (about 7-11 kg)
• BMI 30 or more:     11-20 lbs (about 5-9 kg)

The review, published in the Journal of the American Medical Association, found that gestational weight gain fell below these guidelines in 23% of pregnancies, and above these guidelines in 47% of the pregnancies studied.

For women not gaining enough weight in pregnancy, there was a 53% higher risk of having a small for gestational age baby, and a 70% increase in the risk of preterm birth.

For women gaining excessive weight in pregnancy, there was an 85% higher risk of having a large for gestational age baby, and a 30% increased risk of needing a C section.

Not only do we know that it is important to manage weight during pregnancy, but optimizing weight prior to pregnancy is important too, as underweight or overweight pre-pregnancy is also associated with adverse outcomes.

If you are pregnant or thinking about becoming pregnant, be sure to speak with your doctor about optimizing weight both before and during pregnancy.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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Could Antacid Medications Affect Blood Sugar Control in Diabetes?

Proton pump inhibitors (PPIs) are medications commonly prescribed to treat heartburn and peptic ulcer disease [eg omeprazole (Losec), pantoprazole (Pantoloc), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Pariet)].    Since PPIs work by blocking acid secretion in the stomach, and since a higher acid content of food lowers its glycemic index, I was asked whether PPIs could increase the effective glycemic index of a meal and thus have a negative impact on diabetes control.

It turns out that PPIs have a very interesting relationship with pancreatic function and blood sugars.

Firstly, as PPIs work by blocking acid secretion in the stomach,  PPIs do increase the pH in the stomach and very high up in the small intestine (proximal duodenum).  However, there is little to no effect on pH in the majority of the small intestine, where carbohydrates are absorbed.

PPIs raise serum levels of a hormone called gastrin, which is responsible for stimulating acid secretion in the stomach.  This is because the gastrin secreting cells in the stomach sense that acid production is low, so more gastrin gets cranked out in an attempt to increase acid secretion.

Interestingly, gastrin stimulates glucose-induced insulin secretion from the beta cells of the pancreas.  There is also some experimental evidence that gastrin may stimulate the production of new beta cells.   Further, PPIs slow emptying of the stomach, because less acid in the stomach means that it takes longer for solid food to be broken down and be ready to pass into the small intestine.

So, based on these mechanisms, it seems that PPIs could possibly have a benefit to blood sugar levels.  While the studies on this are still quite limited, the available evidence suggests that PPIs could lower A1C (a marker of diabetes control) by 0.5% to as much as 1% - possibly as much as a diabetes medication!

PPIs are medications that have benefits but also potential risks, including increased risk of gastrointestinal infections, malabsorption of important micronutrients like calcium, magnesium, vitamin B12, and iron, increased risk of fracture, changes in gut bacteria, and others (note this list is not exhaustive), and they should not be prescribed for the purpose of blood sugar control.

That being said, I will be watching blood sugar control with extra interest the next time one of my patients with diabetes is started on a PPI for their gastrointestinal issues.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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