Mystery of 4th of July BBQ Solved


BBQ Mystery

Case History

Jack had a gastric sleeve surgery and is able to sustain his 75 lb weight-loss for over 4 years His BMI went from 38 to 27 and he no longer had diabetes, or hypertension, had no evidence of disease and was an excellent example of a successful and healthy WLS patient. He was compliant with post-surgery dietary guidelines, and followed a keto styled diet. Being a Southerner he attributed much of his success to his love for BBQ (rib eye steak, baby back ribs, pork belly, pork chops etc).

Symptoms Begin

Several hours after one of his Sunday BBQs he developed a headache. had stomach cramps , became dizzy, nauseous and itchy  He had a sleepless night and just attributed to have eaten something that was spoiled. During that week he started recognizing similar symptoms in the early afternoon and more severe symptoms that would wake him at night. He reported this to his internist who thought it might be related to his gastric sleeve surgery. He made and appointment with his surgeon who then referred him to a GI doctor that performed an upper endoscopy and found nothing that could explain Jacks symptoms and referred him to an allergist. Continue reading



Science has historically been riddled with the nature vs nurture conundrum as it relates to human development. Perhaps this riddle has been solved with the emergence of the field of epigenetics. Epigenetics suggests that it is not nature vs nurture but rather nature via nurture that shapes human development.

Epigenetics recognizes that we all are born with a heritable genetic “blue print” that predisposes our development. Like father, like son; like mother, like daughter.  Developmental conditions like height and weight are more heritable then almost any other human condition studied. However, some of these inherited genes (nature) are malleable by outside influences (nurture) that can shape or reshape these predisposition potentials and affect our development.

Having tall parentage would likely predispose for tallness. But that predisposition potential cannot be realized unless weight baring activity and optimal nutrition (calcium, protein, Vitamin D etc.) is available. Continue reading

Best Practices: Biopsychosocial Implications of Metabolism Testing

Bariatric science, is an emerging science that has progressed and developed diagnostic tools that can accurately determine an individual’s energy (calorie) needs as well as quantify their metabolic efficiency. The Resting Metabolic Rate test (RMR), and our ability to interpret the results, allows weight management to be an empirical science. This noninvasive 10 min. breathing test, accurately measures an individual’s energy needs and their specific rate of metabolism referred to as metabolic factor (MF).

These are physical metrics that bariatric health specialists can use to determine individual weight-loss and weight stabilization dietary plans. It provides an opportunity to predict an individual’s energy needs at the weight they choose as their goal; which may or may not realistic based on their MF. It also offers an opportunity to explain variability in losses and gains and surgeons can use these metrics when choosing an appropriate surgical procedure.

When a patient that has continually been plagued with “the slings and arrows” of lifelong obesity, discovers that they have a very low metabolic factor (hypo-metabolic) and likely the primary cause of their obesity….this test can begin to relieve a good deal of the shame and self-blame that has riddled their lives. Metabolic science can be shared with patients and even used as part of cognitive behavioral programs.

Seemingly a “numbers game” and only a physiological metric. Hopefully by watching the video tutorial (below) you will recognize the plethora of biopsychosocial implications. For bariatric professionals, not using RMR/MF testing would be like treating hypertension without measuring blood pressure or diabetes without measuring glucose.

 Tutorial: Interpreting Metabolism (RMR/MF)

AABC Research Fellows Identify “The Missing Link”. A New And Important Metric, In Understanding Why Some People Are Thin And Others Thick Despite Similar Caloric Intake.

The American Association of Bariatric Counselors is pleased to announce that two of their research fellows have completed an important bariatric science research project that identifies a primary cause of a most prevalent category of obesity.   The researchers, Dr. Brandon Davis from Grinnell Iowa and Dr. Joseph Indelicato from Queens, NY have recently been informed that their manuscript entitled "Stability of Metabolic Factor Before and After Bariatric Surgery" will be published in Obesity Surgery, the official journal of the International Federation for the Surgery of Obesity and Metabolic Disorders and is currently available online at:  
Dr. Brandon Davis Metabolic Factor

Dr. Brandon Davis

Lead researcher, Dr. Davis, a psychologist and Board Certified Bariatric Counselor commented, “Our research has identified a new metric that we call the Metabolic Factor, which can be thought of as the missing link in understanding why some folks are thin and others thick despite similar caloric intake. It can also explain why many dieters and bariatric surgery patients relapse and regain weight lost. Obese individuals with a low metabolic factor (hypo-metabolic) lend support to a genetic predisposition to a very prevalent category of obesity. The tools and the methodology we developed to diagnose and quantify an individual’s Metabolic Factor are currently available. This study's findings indicate that Metabolic Factor seems to be a stable characteristic within a person despite significant weight loss. We expect this discovery to be a game changer in the understanding of obesities and helping patients and bariatric health professionals make informed choices regarding care and treatment.”  
Dr. Joseph Indelicato

Dr. Joseph Indelicato

Dr. Indelicato, a professor at Touro College/University System and AABC Research Director noted, “For Bariatric Surgeons treating based on an individual’s Metabolic Factor, it is an essential metric for selecting an appropriate surgical procedure for each patient and thereby improving long-term, post-surgical weight loss and surgical procedure efficacy.”   Both researchers agree that perhaps a most important contribution of this discovery is the potential to reduce societal stigma and shame associated with obesities. Board Certified Bariatric Professionals are already licensed/certified health and education professionals. They include medical doctors, educators, psychologists, nurses, nutritionists and other disciplines that engage in research, diagnosis, treatment and prevention of obesities and related disorders. Click to view video
Female research partners; one a biochemist who weighed 250lbs (Lifelong obesity) and the other an endocrinologist who has always weighed 135lbs (since her teens). We performed their RMR tests; The endocrinologist’s RMR was 1485 Kcal per day. The biochemist RMR was 1500 Kcal per day. Both expend almost identical Kcal per day (1485/1500) and if they replace their expended calories with food they would remain at the same weight.   Despite one being thin and the other thick, they consume the same amount of calories. However, if you divide their individual RMRs by their weights: Endocrinologist: 1485/135lbs = 11 (MF) Biochemist: 1500/250lbs = 6 (MF)   The endocrinologist has a MF of 11 (which is in typical range) and likely predisposed her to be thin (135lbs). The biochemist has a MF of 6 which is very low (hypometabolic) and likely predisposed her to obesity (250lbs).You could say one has 6 cylinders and the other 11 cylinders. Needless to say, you use more gasoline (energy) if you have 11 cylinders.   We reviewed the test results with these friends and colleagues. The thin endocrinologist’s guilt fully addressed her friend; "I always privately believed you did not care about yourself, you were lazy and responsible for your own girth." She then told her how terribly sorry she was for her unfounded beliefs. You might say that this test helped both overcome irrational belief systems.   This is a shining example of how a numeric physiological test had profound psychosocial implications. It is up to us to use “best practices” in bariatric science (mind and body) and not get caught up in the science of public consensus.  

American Association of Bariatric Counselors

Admission and Application Process for Domestic and International Certification

What Bariatric Professionals Need To Know

As Bariatric Professionals, I think we can all agree that health and happiness is more than a number on scale.

Bariatric ProfessionalsHaving a sense of inner peace, pride and self-worth, being loved, prized, earning the respect and approval of others, these are some of the basic human conditions inherent in happiness.

But by being “fat” in a hostile weightism culture, by default, you are not entitled to these inherent human conditions of happiness.  Our cultural distain for obesity simply does not allow obese people to be happy.

This is the unspoken tormenting psychological burden that many/most patients endure and a very powerful motive for wanting to escape obesity.

Is our job merely to help them attain their aesthetic ideals so they could finally win the approval of the very same culture that created the social injustice of weightism?  Isn’t it also our job to right the wrong of this injustice?  If we are to be the professional and caring agents of change our focus requires attention to their happiness and wellbeing and not just their weight.

Obesity is a chronic condition and many patients (surgical or non-surgical), will not be able to permanently lose weight under our care.  But by prizing patients at every size, what we can help them lose is the tormenting psychological burden of the injustice of weightism. Health and happiness in not a number on a scale.

Excerpts from:  The Weight Of The Nation: Stigma- The Human Cost of Obesity

Avoidance Syndrome and  Dysregulated Eating Behaviors 


Bariatric clinicians at The American Association of Bariatric Counselors have identified a frequently undiagnosed shame based dysfunctional psychological disorder that is pervasive amongst many obese patients that can help explain relapses: AVOIDANT PERSONALITY DISORDER DSM-5 30

As the diagnosis suggests, the main coping mechanism of those with avoidant personality disorder is avoidance. This chronic disorder is so deeply rooted, that shame riddled obese patients will avoid the pain of confronting anything that conjures up their obesity shame.

Feelings of shame triggers avoidant behaviors; interruption of self-monitoring, scale use, exercise, mindful eating, weight gain and especially not keeping appointments at your office/clinic This can explain how a minor weight gain can become a full blown relapse.

How Avoidant Personality Disorder Leads To Avoidance Syndrome and  Dysregulated Eating Behaviors

The best way we can explain how the Avoidance Syndrome leads to dysregulated eating behaviors and weight gain is by telling by a real story. There are many ways that this story can begin but this is the version that most patients identify with and how the story was told to me by a patient.


This completes part three our three part best practices series:

Subscribe to the Best Practices Blog below.

Part 1: Why Would Somebody Lose All The Weight and Then Gain It Back?

Part 2: Treating the Shame of Weight Gain

Best Practices: Treating the Shame of Weight Gain

Most folks that go on diets lose weight and most of the time gain it back. And often gain back more than they lost. Even bariatric surgery is wrought with substantial regains.

 Bariatric practitioners have identified a most prevalent shame based diagnosis:

Avoidant Personality Disorder, that is common to many that have weight relapses/collapses.  As the diagnosis suggests, the main coping mechanism of those with avoidant personality disorder is avoidance. They will avoid most things that elicits their deep feelings of personal shame, like weight gain.  As a result they are most vulnerable to relapse/collapse stages.

Anecdote: Julie was introduced to a group of patients seeking surgery, as a successful patient that lost and keeps off 60 pounds for over five years. Julie interrupted and said, “That’s not true”.  I gain back about 60 pounds every couple of years but instead of completely relapsing, I gain and lose 2-3 pounds about 20 times every couple of years”.

Prudent bariatric counseling had taught Julie that weight gain is a typical expectancy following weight loss and no longer avoided that expectancy and viewed her lapses as part of her recovery and not worthy of shame or guilt.

Reducing Shame Narrative for Rational Cognitive Therapy:

Most intuitive, naturally thin people, without weighing themselves, or consciously censoring their food choices stay within a weight range… they do go up and down the scale, but stay within a tight range. Using them as our index we realize that weight gain is a natural occurrence. But here lies the difference, most diet veterans or surgical patients that have intentionally lost weight eventually start regaining weight. But they do not have that compensatory intuitive mechanism that allows them to stay within a tight range of their desired lower weight. If we know in advance that weight gain is simply a typical expectancy following weight loss, why view that as a failing? Why feed into that irrational belief system of weight gain and failure? It is that very belief that can elicit shame and avoidance behaviors and that is how a manageable lapse becomes a relapse/collapse.

Learning How to Gain Weight Without Shame:

Learning how to shamelessly accept and not avoid the expectancy of weight gain is an important stage for long-term obesity recovery. When a patient does reach their desired weight goal or during the weight-loss process, asking them to surplus calories and gain a pound or two (lapse) and then reverse it, is prudent relapse prevention counseling. That is a lifelong behavioral skill they will need, long after they have left our care. When we praise patients for confronting a lapse and then reversing that lapse, they reduce both weight and shame importantly they learn to master a skill they will likely need forever. Ironically, realistic patient preparation to prevent relapse/collapse is teaching patients how to gain weight with both their and your approval.

Dr. Brené Brown: “Shame Is Lethal” | SuperSoul Sunday | Oprah Winfrey Network

The price of shame | Monica Lewinsky