Alcohol and poor compliance as factors in Wernicke's encephalopathy diagnosed 13 years after gastric bypass.

A severely obese man achieved rapid and significant weight loss after Roux-en-Y gastric bypass. Thirteen years later Wernicke's encephalopathy developed as a result of the patient's alcoholism, poor compliance with his micronutrient intake, poor oral intake and the decreased absorptive ability of the small bowel. In selecting any operation to treat morbid obesity the possibility of metabolic problems must be considered as well as the potential for substantial weight loss.

Similarity in gallstone formation from 900 kcal/day diets containing 16 g vs 30 g of daily fat: evidence that fat restriction is not the main culprit of cholelithiasis during rapid weight reduction.

Diets containing essentially no fat, 1-2 g fat per day, have resulted in cholesterol gallstones. Greater fat may result in less gallbladder stasis. Do gallstones form with greater fat content? We studied 272 moderately obese subjects who had normal gallbladder ultrasonograms. The 900 kcal/day liquid diets contained either 16 g fat (N = 94) or 30 g fat (N = 178) each day for 13 weeks. A second gallbladder ultrasound was performed. Sixteen of 94 (17.0%) of the 16-g fat group developed stones with a weight loss of 18 (+/- 7) kg and a body mass index (BMI) decrease of 6 (+/- 2) kg/m2. Twenty of 178 (11.2%) of the 30-g fat group developed stones (P = 0.18, no difference in stone formation) with similar weight loss of 20 (+/- 7) kg (P = 0.08) and BMI decrease of 7 (+/- 2) kg/m2 (P = 0.04). Substantial fat for rapid weight-reducing diets resulted in gallstone formation. Since experiments have shown that our higher fat diet, containing 10 g fat per meal, results in maximal gallbladder emptying, cholelithiasis from rapid weight loss may not be solely attributable to gallbladder stasis.

Selenium and zinc levels in surgical patients receiving total parenteral nutrition.

The zinc and selenium levels of 40 surgical patients were monitored pre- and post-TPN. The initial selenium level was low normal, and the initial zinc level was also low. Both selenium and zinc are potent antioxidants involved in cellular defense against free radicals. Surgical patients are at risk for selenium and zinc deficiencies secondary to both increased needs and losses. TPN blood work protocols should include monitoring of selenium and zinc with supplementation of the nutrient solutions, as required.

A comparison of fat intake of normal weight, moderately obese and severely obese subjects.

BACKGROUND: Excess dietary fat has been implicated in the etiology of obesity. METHODS: This study examined the fat intake of three weight groups, normal (20.0 < or = BMI < or = 27.0), moderately obese (27.1 < or = BMI < or = 39.9) and severely obese (BMI > or = 40.0). Each group contained 50 subjects. Detailed 3-day food records were used to gather the nutritional data. Anthropometric and sociodemographic information was also collected. RESULTS: Overall fat intake was 89 +/- 42 g/day or 37 +/- 10% of total energy. Total fat (g/1000 kcalories) intake was found to be significantly higher in the obese groups (p < 0.05). Subjects in the moderately and severely obese groups consumed significantly more fat and cholesterol and less carbohydrate than did normal weight subjects. Compared to the normal weight subjects, obese subjects also had higher intakes of saturated, monounsaturated and polyunsaturated fat (as a percentage of dietary energy). There was no difference in energy or protein intake, and P/S ratio among the three groups. BMI was strongly positively correlated with total fat, saturated, monounsaturated, polyunsaturated fat, cholesterol, and protein intake (as g/day only), and negatively correlated with carbohydrate intake and the CHO/FAT ratio. Energy intake was not significantly associated with BMI. CONCLUSION: A high fat diet may promote obesity, independently of its calorie contribution.

Can elevated chromium induce somatopsychic responses?

The possible somatopsychological effects of chromium (Cr) was investigated in a population of patients, from a surgical ward of our hospital, who required total parenteral nutrition (TPN) solutions, and who became exposed to various amounts of this metal from this treatment. The study involved a questionnaire as well as biochemical tests which included serum Cr and other selected trace metals. The renal status for all eligible patients was within normal parameters. The patient population varied in age, pathology, surgical treatment, and duration on TPN. The results showed that every patient who received TPN had an increased serum Cr level; some increases were up to 50-fold above the normal reference level for serum Cr. Although statistical analysis failed to show any significant statistical relationship between an increased serum Cr and the investigated somatopsychological disturbances, this effect cannot be ruled out since one case did show all the dream disturbances. Considering these cases, the action of sedative medications that may suppress the effects of Cr, cannot be ruled out. As Cr(III) may be potentially genotoxic at high concentrations, infusion of this metal over long time periods should be avoided. Supplementation of Cr in TPN solutions appears to be unnecessary for short-term TPN because this metal is a known contaminant of these solutions. Efforts are required to find TPN nutrients with low or no Cr contamination.

Fiber intake of normal weight, moderately obese and severely obese subjects.

The lack of dietary fiber may be a contributing factor in obesity. This study examined the fiber intake of three weight groups: normal (20.0 < or = BMI < or = 27.0), moderately obese (27.1 < or = BMI < or = 39.9) and severely obese (BMI > or = 40.0). Each group contained 50 subjects. Detailed 3-day food records were used to gather the nutritional data. Fiber intake in the normal weight group was 18.8 +/- 9.3 grams, the moderately obese consumed 13.3 +/- 5.8 grams of fiber and the severely obese 13.7 +/- 5.7 grams. Total fiber intake in grams was found to be significantly higher in the lean group (p < 0.05) and was positively associated with sex and education level with men and more highly educated individuals consuming more fiber. Using regression analysis total fiber in grams and fiber in g/1000 kcalories was inversely associated with BMI after adjusting for sex, age, education level and income (p < 0.01). A high fiber diet may help to promote a negative energy balance by causing early satiety secondary to gastric distention. Dietitians and physicians need to emphasize the importance of a high fiber diet to their obese patients.

Determinants of perceived consistency: the relationship between group entitativity and the meaningfulness of categories.

The concept of entitativity was developed by Campbell (1958) to refer to the extent to which a group is perceived as a coherent whole or entity. This concept is relevant to research in both social perception (e.g. the categorization effects approach to the study of social stereotyping) and social influence (e.g. the consistency attributed to minority groups in theories of minority influence). On the basis of previous research, four variables were expected to play a role in group entitativity judgements. These were intra-group variability, group size, diversity (or variety) and extremity. In two empirical studies it was found that entitativity decreased as variability and diversity increased and that it increased with group size. These effects and interactions between group size and extremity, size and diversity, and variability and extremity are consistent with the idea that entitativity is a function of how meaningful a stimulus pattern is. This is in turn (in part) a function of how unlikely the pattern is.

Abnormal trace elements in a patient on total parenteral nutrition with normal renal function.

OBJECTIVE: To describe trace metal changes in a 74-year-old male patient with mesenteric fibrosis and a small bowel fistula who was maintained on total parenteral nutrition in the hospital and at home. METHODS: Trace elements which included chromium and selenium were monitored over a 14-month period as part of his nutrient follow-up. RESULTS: Serum chromium reached levels > 21-fold the upper reference range, and serum selenium, in contrast, was < 0.5 the lower reference range. Plasma aluminum was also measured, and found to be nearly twice the upper reference range, although the patient had normal renal function. We measured the aluminum content of the parenteral nutrients and additives, and found that replacement of calcium gluconate by calcium chloride helped to reduce the aluminum content in the final parenteral solution by 34%. Aluminum and chromium contaminants found in parenteral solutions need to be reduced or removed to avoid toxic accumulation. CONCLUSION: This study illustrates the importance of adequately adjusting essential trace elements, and monitoring contaminants in parenteral fluids in an individual on total parenteral nutrition.

Gastric restriction procedures for treating severe obesity.

Gastric restriction procedures are operations to decrease gastric volume. They are the most common, simple, and safe operations for the treatment of severe obesity. The original horizontal gastroplasties were unsuccessful but modern operations such as vertical banded gastroplasty, silastic ring gastroplasty, and gastric banding produce good weight loss with improvement in health. Although late weight gain does occur, satisfactory 5-y results are available and are presented. Patient selection, complications, mechanism of action, and future studies are also discussed. Long-term data with complete patient follow-up and randomized trials comparing modern operations with nonoperative treatment are still needed.

A longitudinal study of smoking status and weight loss following gastroplasty in a group of morbidly obese patients.

A study of morbidly obese patients was carried out to determine the frequency of preoperative smoking, the effect of smoking status on weight loss after vertical banded gastroplasty, and the effect of gastroplasty on postoperative smoking. There were 93 of 104 eligible patients (89.4 percent) available for study, 86 percent female and 14 percent male. All had a gastroplasty more than one year before with a mean follow-up of 22.9 +/- 7.8 months. Preoperative and postoperative weights were 124.4 +/- 19.5 kg and 89.4 +/- 17.9 kg for females and 156.5 +/- 22.3 kg and 102 +/- 17.4 kg for males. Preoperatively 38 percent smoked (females 36.7 percent, males 46.2 percent) and 57 percent were heavy smokers (greater than 25 cigarettes per day). Ten smokers quit postoperatively but seven nonsmokers started smoking. Those who smoked before operation lost more weight (43.26 kg) than nonsmokers (34.97 kg) and ex-smokers (32.41 kg); P less than 0.05. Those who smoked postoperatively lost more weight (44.47 kg) than nonsmokers (35.06 kg) and ex-smokers (33.07 kg); P less than 0.05. Because of the health risks of smoking, cessation is encouraged in spite of the advantage in weight loss for smokers after gastroplasty. More effective methods of controlling smoking and severe obesity are needed.

Increased volume and decreased emptying of the gallbladder in large (morbidly obese, tall normal, and muscular normal) people.

Impaired gallbladder emptying has been suggested as a possible factor in the pathogenesis of gallstones. Obese people have an increased incidence of gallstones, but there is no evidence of this in nonobese large people. This study was undertaken to determine if abnormal gallbladder motility is present in obese people. Fasting gallbladder volumes were determined using real-time ultrasound in 18 morbidly obese subjects whose weights were in a steady state [45 kg (100 lb) over ideal weight or twice expected weight for age and height; 9 males, 9 females], 18 age- and sex-matched volunteers of average size, and 18 nonobese large normal males (9 tall, 9 muscular). Gallbladder emptying studies with 99mtechnetium-diisopropyliminodiacetic acid were performed using 200 ml of 10% cream as a stimulus. The small-volume liquid fatty meal contained 113indium-diethylenetriaminepentaacetic acid to control for differences in gastric emptying in obesity. The gallbladder emptying rate in large people, both obese and nonobese, was less than that in normals of average size (p = 0.05). Fasting gallbladder volumes in large people were: obese, 41 ml (37-66 ml) (median; 95% confidence limits); nonobese large normal, 40 ml (27-43 ml). These values were greater than in normals of average size [17 ml (14-21 ml) (p = 0.03)]. Postprandial gallbladder volumes were also greater in large people: obese, 15 ml (8-23 ml); nonobese large normal, 20 ml (13-23 ml) compared with 2 ml (1-5 ml) in normals of average size (p less than 0.05). There were no differences between obese and nonobese large people. There were no differences in gastric emptying rates or in cholecystokinin, gastrin, motilin, and secretin release between obese and normal subjects. Gallbladder volume is crudely proportional to body size. Although fasting and postprandial volumes are greater in obesity, this is also present in nonobese, relatively size-matched controls. These data do not support a role for impaired gallbladder emptying in gallstone formation in obese patients whose weights are in a steady state.

Pathological gamblers are neither impulsive nor sensation-seekers.

Ten pathological gamblers, ten alcoholics, ten heroin addicts and twenty five non-patients were compared using Zuckerman's Sensation Seeking Scale (SSS) and Barratt's Impulsivity Scale (BIS). The pathological gamblers did not differ from the non-patient group on either measure. Drug addicts scored significantly higher and alcoholics significantly lower than the pathological gamblers and the non-patient group on the SSS, while drug addicts scored significantly higher than the other groups on the BIS. The difficulties in defining impulsivity are discussed. It is suggested that the classification of pathological gambling as a disorder of impulse control should be reconsidered.

Patient selection for obesity surgery.

Patients selected for gastroplasty should be at least 45 kg above ideal weight, between the ages of 18 and 50, and operated on in a center with good results, where team assessment and long-term follow-up is emphasized. Referral by a family doctor who provides local care and support is important. Medical complications need not be present because the idea is to prevent them, but problems such as sleep apnea, adult onset diabetes mellitus, hypertension, osteoarthritis, and infertility, which may be corrected by weight loss, increase the indication for gastroplasty. Patients should have social support and be intelligent enough to understand the postoperative diet and the need for regular follow-up. Those with a history of psychiatric admission require careful preoperative assessment by psychiatrist or psychologist and close follow-up and support. Patients should have made a good supervised attempt at dieting, have had stable weight for 3 to 5 years preoperatively, and have stopped smoking at least 6 weeks prior to operation. Tests to assess personality factors, eating habits, and motivation are developing, but more precise methods of selecting patients for gastroplasty and predicting successful and uncomplicated weight loss are still needed.

Smoking habits of the morbidly obese prior to gastroplasty.

Smokers weigh less on average than nonsmokers, but there is little data on the smoking habits of the severely obese. Cigarette smoking increases the risk of cardiovascular disease and may add to the existing risk among obese individuals. The purpose of this article is to report on smoking habits of a group of morbidly obese individuals being considered for surgery, to compare these smoking levels to those in the general population, and to assess the relationship between smoking and hypertension in this group. In Canada as in other countries, smoking prevalence has decreased in recent years, but it remains a major health problem.