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What to Eat After Weight Loss Surgery - FAQ on Macros & Calories. As part of your post-operative care, you will be given special dietary guidelines that you will need to follow closely during the first 6 weeks from surgery to prevent complications and for proper healing of your new stomach pouch.

Weight Loss Surgery 0 - 3 Months Post-op

 As part of your post-operative care, you will be given special dietary guidelines that you will need to follow closely during the first 6 weeks from surgery to prevent complications and for proper healing of your new stomach pouch.

After 6 weeks, when able to eat solid foods, you will be on the bariatric nutritional plan meant to heal your body from the inside out, prevent nutrient deficiencies and be ready for massive weight loss!

What to expect while on weight loss surgery recovery?

The amount of food that you can have immediately after surgery will be limited. This restriction will change over the first months, letting you eat a little bit more at each time. The pouch will change from being rather stiff -due to inflammation from surgery- to recovering its plasticity at about nine months after surgery. This is normal and expected. If you notice that you have less restriction as time passes by it doesn’t mean that you have stretched the pouch, it only means that swelling is subsiding. Stretching of the pouch is doubtful to have happened during the first year unless you are forcing the food or combining solids with liquids; this stretching is noticeable from vomiting frequently, “foaming” (P’Bing) or feeling pain immediately after eating. These symptoms can be prevented from slowing down while eating, sitting down to have your “meal”, chewing thoroughly, avoid drinking while eating and paying attention to feeling satisfied rather than full (the difference between feeling satisfied or full may be a teaspoon size bite!).

During the first 6 weeks, as you move from liquids to solid foods, you do not need to establish mealtimes, count calories or try to figure out a dietary plan; inflammation will only allow a few bites of food or sips of liquids. During this period, since eating and drinking is limited, your main objectives are to meet protein intake, fluid intake and to establish a regimen for supplementation. Protein intake thru either liquids or foods should be accounted for and calculated in as many “meals” as necessary until the minimum of 60 grams of protein per day is met. Eat as often as necessary, this may mean eating every 2 hours, up to 8 times in a day. Once protein intake is at 60g/day, you will need to include vegetables and fruit as long as either one has the specific texture described in each of the diet stages – “pass thru straw”, “baby food”, or “moist”-.  Including produce is necessary to boost fiber, micronutrient and phytochemical intake which will promote bowel movements, improve digestion and absorption of nutrients, and fuel fat-burning metabolism! Intake of vegetables and fruit should be alternated at each meal and compromise half the volume of food that you can eat.

How should I eat after recovery?

During the first three months, the new stomach (“the pouch”) can hold as much as a baby could. Thus, eating often to prevent hunger and meet nutrient needs, is expected. Some patients can have 2 tablespoons of food at one time, others may have up to ¾ cup. The difference on how much food can be eaten depends on healing and inflammation, this is different to each patient and this will determine how often you will need to eat. It is important to be aware that carbs from grains and flours slip thru the pouch a lot faster than other foods and will allow you to eat more than expected.

Early postoperative (0-3 months) patients increase average calorie intake from 400 kcal/day to about 850 kcal/day per day. But, we highly recommend paying close attention to the quality of food and tracking protein intake instead of choosing food depending on its caloric content. Energy balance is not about “calories-in or calories-out” but about IF your body can burn them or not. This equation -plain and simple- has proven not to work. A low toxic load, a functional digestive tract and retaining muscle while losing a massive amount of weight will allow your body to burn the calories from food.

To put the caloric intake debate to rest, consider this:

  • For each kilogram of fat-free mass lost (mainly constituted by muscle mass), metabolic rate drops by about 18 kcal per day. Therefore, retaining more fat-free mass (muscle) relative to the amount of weight lost, will enable you to have a more sustainable caloric intake without the risk of weight regain.
  • Certain bacteria help reduce the number of calories you absorb from food. They also affect hormones related to appetite and fat storage and help reduce inflammation, a known cause of obesity. These are good reasons why we recommend supplementing with specific probiotics*

Thus, not all calories are created equal and not all calories are burned as efficiently. The same number of calories from different foods have very different biological effects: processed foods will have a detrimental effect on organ function and quality foods will optimize cellular function, boosting metabolism and weight loss.

Once in solid foods -after 6 weeks from surgery-, it is important to differentiate between nutrition and food. The first is eaten with the intention to heal -homemade food, meal prepping- and optimize cellular function, speeding up weight loss. The second, comes in usually in the form of “tasty and convenient” products, eaten when hungry, and readily available as pre-made or pre-packaged items; these are pouch fillers which lack nutrition and may even contain anti-nutrients (toxicants or pesticides such as glyphosate that block or overuse nutrients, resulting in malnutrition). Generally, if a person can consume a normal amount of food, he or she doesn’t have to worry about antinutrients. But, for those at risk of malnutrition from having a limited capacity of food intake, antinutrients can increase toxic load and the risk of malnutrition far worse. The key with antinutrients is reducing their consumption from choosing quality food and supplements.

Wholesome organic produce, grass-fed animal sources and pharmaceutical graded supplements, which avoid additives and pesticides, are the best sources to get the nutrients that will facilitate the liver’s work of detoxification processes and fat burning. Thus, nutrient-void foods such as processed food, cheap proteins, and grains and flours should be avoided to prevent weight loss stalls or even weight regain at a later time. The most common factor leading to weight gain after a year from weight loss surgery is relying on the surgery instead of using its restriction to facilitate changes related to exercise, eating habits and food choices. Unfortunately, to some patients, making these changes is considered unnecessary as during this time the scale is moving down regardless of food choices, taking supplements, or whether exercising or not. This mindset, along with the expected expanding of the pouch at nine months from surgery, can lead to weight stalls or even weight regain.

The early months from surgery are the best window of opportunity to establish a new lifestyle, a supplement regimen and choose healthier foods. The OCC program uses highly specialized bariatric supplements* to fill the nutritional gap from the restrictive amount of food that you can eat, these supplement kits surpass current nutritional recommendations and guidelines for bariatric patients. This emphasis on minimally processed and nutrient dense foods and supplements aligns with our philosophy of using the surgery to facilitate detoxification processes, get back to health from the inside out and accelerate fat burning, not just weight loss.

To meet your DAILY nutrient needs, your nutritional plan consists of the following foods:

Protein intake.

(FOR LIFE! -  MONTHLY KIT )

Our bodies do not have a storage for protein, this nutrient must come from our diet on a daily basis. Protein is the main component of hair, muscle and blood plasma -including proteins that help make up your immune system. Protein supports your body in building healthy tissues, including healing of the stomach after surgery. It also boosts metabolism and fat-burning. You will need to have at least 60g of protein PER DAY to heal adequately, prevent hair loss, anemia, muscle breakdown and risk of infections. During the early stages post-op meeting protein intake will be a challenge, start early in the day and do not skip meals. Once you can have the minimum amount of 60 grams per day, aim to meet your personal need -as set on surgery day. By nine months after surgery you should be getting closer to meeting this personal protein goal. Build it up slowly and choose quality sources.

  • Eat protein first and track its intake.
  • Protein should be at least half of the volume of the food that you can eat.
  • Calculate mealtimes depending on how much protein you can have per meal. For example, if you can only have 10 grams of protein in one meal, you will need to eat at least 6 times in a day.
  • Cheap protein shakes, are usually either incomplete or diluted and will not help you meet protein intake. The first signs of not meeting protein needs are hair loss, slow wound healing, weakness, feeling anxious and moody, menstrual cycle becoming irregular, low immunity, and trouble losing weight.
  • Collagen has great benefits for hair, nails, skin, and joints and to repair the digestive tract but it is not a complete protein. Do not rely on collagen to meet your protein needs.

Carbs

Fruit and vegetables are the only type of carbs your body needs. They provide fiber, vitamins, minerals and antioxidants; compounds that nourish and repair the damage from “chronic inflammation” caused by being overweight or obese.

Any nutrient-void carb sources such as those from grains and flours are limited to 2 tablespoons of complex carbs such as quinoa, wild rice, brown rice, sweet potatoes, potatoes, yam, whole wheat spaghetti, whole oatmeal, or ½ whole wheat bread or tortilla but ONLY AFTER meeting your daily nutrient needs coming from protein, fruit, vegetables and healthy oil intake, and preferably before or immediately after exercising.

  • Include two pieces of fruit per day, eaten at different times; fresh or frozen. You may blend one serving into your protein shake. Have a wide variety of colors to get many different phytochemicals -beneficial biologically active compounds produced by plants.

  • Have as many vegetables as possible, at least 3 cups daily; cooked vegetables occupy less space in the pouch allowing you to eat more. You may also blend some vegetables into your protein shake.

Healthy oils or fats

Include 5 to 7 servings daily; at least one serving at each meal.

Do not avoid these! You need fat to burn fat.

Fat is essential as it constitutes part of each of our cell membranes maintaining its function; lack of function means the early death of the cell, progressing into aging and disease. The human brain is nearly 60% fat. Glucose, on the other hand, is toxic to the brain, recent research suggests glucose buildup in the blood stream from insulin deficiency or insulin resistance as the culprit of Alzheimer and referred to it as Type 3 Diabetes.

There are many other reasons why fat is essential:

  • It produces hormones, we have more than 100 hormones, not just reproductive hormones, but hormones that have the purpose of keeping the body alive!
  • Fat is an energy source better than glucose! as it can be maintained over longer periods of time, improving performance and clarity of mind, without suffering sugar crushes.
  • Fat triggers satiety hormones and reduces the speed at which your stomach empties, therefore, keeps hunger at bay.
  • Fat is a carrier of vitamins and antioxidants which are disease-fighting compounds.

Most people are afraid of including fat into their diets and choose food-industry nutrition stripped foods labeled as “low-fat”. This is the result of bad science from more than 50 years ago. That science changed the dietary guidelines leading to disease and confusion. Although fat and oils are essential, fats should be chosen carefully as some animals are not fed properly and toxins and antibiotics can also be stored in fat tissue or pesticides can concentrate in vegetable oils such as canola or soy oil. I want to encourage you to include wholesome full-fat foods as long as these are quality sourced.  

Quality fats include fatty meat or fish, pasture-raised or grass-fed butter and ghee, lard, duck fat and some vegetable sourced oils such as avocado oil, olive oil, olives, avocado and nuts and seeds.

Another important consideration to have with fats is that there must be an adequate ratio of Omega 3 and Omega 6. Omega 3 is anti-inflammatory and Omega-6 is pro-inflammatory (inflammatory to the cell membrane, inducing premature death). An adequate ratio between Omega-3 and Omega-6 is 1:1 to a maximum of 1:5. Nowadays, the ratio is 1:40 thanks to that bad science of 50 years ago when the dietary guidelines recommended avoiding fats and increasing the consumption of carbohydrates ---but not in the form of veggies and fruit but from bread, flours, baked product, etc.

How can you get the proper ratio between Omega-3 and Omega-6?
  • Reduce the consumption of Omega 6 found in almost every processed food -including some premade shakes- and any type of baked product (bread, "healthy" protein bars and cookies),
  • Increase intake of Omega 3 from fish, grass-fed butter or ghee, nuts, seeds (flaxseed, chia, hemp, saccha inchi)
  • Take an Omega 3 supplement*---make sure this supplement doesn't have Omega-6! and that it has been tested for dioxins, PCB, heavy metals, pesticides and rancidity values.

To lose weight, have better hormonal balance, protect your brain, reduce the risk of diabetes, reduce cravings, increase fertility, and many other benefits, you need to reduce carbohydrate intake from grains, pastries, and flour and increase consumption of fats and oils.

  • Each serving of fat consists of your choice of 1 teaspoon of healthy oils or fats, 1/8 avocado or 1 oz of nuts or seeds.

  • Healthy oils and fats include organic coconut, MCT, olive, avocado or hemp oil; or, grass fed butter, ghee, or lard.

Other recommendations.

In addition to the macronutrient recommendations, you may include as many herbs or spices as you want as these are high in phytochemicals and enhance the flavor of food. You can also use a small amount of either stevia, monk fruit or erythritol for added sweetness; although it is best to avoid all types of sugary and sweet products as doing so will change your taste buds into appreciating food as it is and help reduce sugar cravings.

In summary

Leave the pouch’s room for quality food, establish a regimen for supplementation, eat protein and produce along with healthy fats at each meal, and determine the amount of meal times you need to have depending on protein intake.  

*Specialty supplements for weight loss patients available at VITALEPH

Daily approximate macros Protein Carbs Fats
0 - 6 weeks(post-op) 60 - 80g/day 2 cups of veggies and 2 pieces of fruit (~30g) 3 - 5 servings (~30g)
6 weeks – 6 months 60 - 80g/day 2 cups of veggies and 2 pieces of fruit (~30g) 5 servings (~30g)
6 months – 1 year Personal goal(Women ~60 - 80 g; Men ~80 - 110 g)5 -7 servings (~60g) 2 - 3 cups of veggies and 2 pieces of fruit (~60g) 5 -7 servings (~60g)
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The ketogenic diet is is a very high-fat, moderate-protein, very low- carbohydrate meal plan in which you get 70-75 percent of your calories from fat, 15-20 percent from protein, and 5-10 percent from carbohydrates.

The good and bad about keto diet The ketogenic diet is is a very high-fat, moderate-protein, very low-carbohydrate meal plan in which you get 70-75 percent of your calories from fat, 15-20 percent from protein, and 5-10 percent from carbohydrates.

The purpose of this diet is to get your body into ketosis, the state in which your body shifts its primary fuel source from glucose to fatty acids and ketone bodies. Once on ketosis, you should experience outstanding weight loss and a positive effect on your blood cholesterol and triglyceride levels. 3

The ketogenic diet is used in children with drug-resistant epilepsy. A randomized, controlled trial showed that the number of seizures fell by more than 50% in approximately half of children after 1 year on the diet (class II evidence). 1

The diet seems to be effective for all seizure types. The major problem is adherence to the restrictive (and unpleasant) dietary regimen.
Therefore, a modified Atkins diet is under evaluation as a potential alternative in adults and for environments in which strict supervision is
unavailable (class IV evidence). 2

1: Neal EG, Chaffe H, Schwartz RH, et al. The ketogenic diet for the
treatment of childhood epilepsy: a randomised con- trolled trial. Lancet
Neurol 2008;7:500-6.

2: Kossoff EH, Dorward JL. The modified Atkins diet. Epilepsia
2008;49:Suppl 8: 37-41.

3: Brehm, B. J., Seeley, R. J., Daniels, S. R., & D’alessio, D. A. (2003).
The Journal of Clinical Endocrinology & Metabolism, 88(4), 1617-1623.

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Cholesterol is simply a fatty substance found in every single cell in your body, both in the cell membranes and within organelles inside the cell. Cholesterol is a vital substance, necessary for numerous functions

What is Cholesterol? Cholesterol is simply a fatty substance found in every single cell in your body, both in the cell membranes and within organelles inside the cell. Cholesterol is a vital substance, necessary for numerous functions, including:
  • Maintaining cell membrane integrity and fluidity within the cell
  • Assisting with cell signaling
  • Integral for hormone production, especially reproductive hormones
  • Vitamin D production
  • Used in bile acids production, necessary for digestion
  • Brain and neurological function (the brain generally holds about 25% of the body’s cholesterol)

Cholesterol is so vital to the body’s functions that your liver can make all that it needs to survive. It’s not reliant upon you to eat cholesterol to provide the necessary amount, though some of the cholesterol that you eat may make its way into the bloodstream. Looking at the importance of cholesterol, it’s difficult to imagine how modern medicine has come to vilify it. The answer to that involves a look at the plaque inside of hardened arteries (atherosclerosis).

We know that heart disease arises from hardened arteries, called atherosclerosis. In those with atherosclerosis, plaque builds up along arterial walls, diminishing both the elasticity of the artery and the space available for blood to flow through it. When doctors analyzed the plaque itself, they found that it was made up of several components, including calcium and, you guessed it, cholesterol. This led to cholesterol eventually being declared dangerous at high levels in the blood, and the development of drugs to lower cholesterol, like statins. When looking at cholesterol levels, doctors further subdivide it into LDL (low density lipoproteins), HDL (high density lipoproteins), and triglycerides (not actually a cholesterol, but another kind of blood fat, involved in energy storage). A lipid panel is the usual test for
establishing blood cholesterol levels, and measures total cholesterol in the blood. The results are compared against a range of norms for each type. Depending on where you fall compared to these “normal” ranges, your doctor could advise the use of statins and/or a “heart healthy” low fat diet.

Cholesterol can’t travel alone through the blood, because it’s water insoluble. Once it’s manufactured in the liver, cholesterol is combined with other compounds like sulfur or protein to transit through the bloodstream. The protein in a lipoprotein surrounds the cholesterol kind of like passengers in a car, hence the word lipoprotein. LDL (low density lipoprotein) is considered the bad cholesterol, the most involved in damage to the inner walls of blood vessels. In actuality, LDL isn’t necessarily a bad thing. It’s sent out from the liver to perform the many functions that cholesterol performs, as noted. HDL (high density lipoprotein) is in many ways LDL’s balance. HDL’s are on their way back to the liver, and are involved in healing damage to vessel walls (plaque removal) and latching on to spent or oxidized LDL particles in order to return them to the liver for reprocessing. This is why HDL is considered the good cholesterol. HDL levels are what doctors are looking for when they test total cholesterol. Statins come in when doctors want to lower LDL levels in the blood.

How Do Statins Work?

Statins are basically enzyme blockers. They target a reductase enzyme, specifically HMG-CoA reductase (abbreviated to HMGCR), which sends the trigger to the liver to produce cholesterol. Normally this process happens naturally in the body, and is balanced by other triggers, which induce the liver to break down LDL particles. Statins inhibit HMGCR production, which reduces the amount of cholesterol that the liver can produce, often resulting in lowered total blood cholesterol.

Sounds good, right? Here’s the catch...
Mainstream doctors will tell you that high cholesterol will increase your risk of heart attack or stroke, and so, therefore, taking a lipid lowering drug like a statin will reduce that risk. Then they use the standard lipid panel to determine cholesterol levels, and a whole lot of people end up on statin drugs. But did you know that many people who have heart attacks don’t have high cholesterol levels? A very large study using data from the WHO established that only about half of the people who suffered from a heart attack had elevated LDL levels at the time. About 20% of those in the study were taking lipid lowering meds and still had a heart attack. This calls the effectiveness of statin drugs into question.

Now let’s look at the side effects of statins. We learned earlier that cholesterol is vital to the proper functioning of our cells and numerous systems of the body. Inhibiting the production of cholesterol can have some very negative effects, and we see this borne out in the listed side effects of statin drugs which include:

  • Myalgia (muscle pain or weakness) and muscle damage, potentially severe
  • Insomnia
  • Headaches
  • Rashes
  • Digestion problems
  • High blood pressure
  • Type 2 diabetes (increased risk)
  • Neurological problems, including memory loss, brain fog, mental confusion, cognition problems
  • A Better Solution to High Cholesterol

Remember, just because you have high cholesterol doesn’t mean you are at risk for a heart attack, just as having low cholesterol doesn’t mean you aren’t at risk. Fix the cell, get well. I can’t tell you get off statins, only your doctor can do so. I can suggest you educate yourself
about statins, cholesterol’s true function, inflammation, and root causes of disease. Story at-a-glance primary cause of heart disease is not high cholesterol but insulin and leptin resistance, which increase LDL particle number via a couple of different mechanisms. Poor thyroid function can also directly increase LDL particle number, and should be checked if your LDL particle number is high Insulin and leptin resistance is caused by factors inherent in our modern lifestyle, including a diet high in processed and refined carbohydrates, sugars/fructose, refined flours, and industrial seed oils; insufficient physical activity; chronic sleep deprivation; environmental toxins; and poor gut health.

The incorrect idea that high cholesterol causes heart disease has led to the demonization of entire categories of extremely healthful foods (like eggs and saturated fats), and cholesterol has been falsely blamed for just about every case of heart disease in the last 20 years.
Fat and cholesterol are commonly believed to be the worst foods you can consume. Please understand that these myths are actually harming your health. Not only is cholesterol most likely not going to destroy your health (as you have been led to
believe), but it is also not the cause of heart disease.

The Problem with the Conventional Approach

For the past 50 years, you've been told that eating saturated fat and high-cholesterol foods will raise cholesterol serum levels. However, research published over the past 10 or 15 years suggests that neither of those statements are true. One of the main problems there is the massive conflicts of interest in the medical profession. We have a situation where two-thirds of medical research is sponsored by pharmaceutical companies.

Conventional Tests Are Not Accurate Predictors of Heart Disease
If you've had your cholesterol levels checked, your doctor most likely tested your total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. But we now know those are not accurate predictors for cardiovascular disease risk.

Which Fats Are Healthy?
  • Sources of healthful fats (and in some cases cholesterol) include:
  • Olives and Olive oil,Coconuts and coconut oil
  • Butter made from raw grass-fed organic milk, Raw nuts, such as almonds or pecans
  • Organic pastured egg yolks,Avocados
  • Grass-fed meat, Unheated organic nut oil
  • Another healthful fat you want to be mindful of is animal-based omega-3. Deficiency in this essential fat can cause or contribute to very serious health problems, both mental and physical, and may be a significant underlying factor of up to 96,000 premature deaths each year.
High Cholesterol Is NOT the Cause of Heart Disease

The first thing to understand is you don't have a cholesterol level in your blood, actually. Cholesterol is fat-soluble, and blood is mostly water. For it to be transported around the blood, cholesterol needs to be carried by a protein, specifically by a lipoprotein. These lipoproteins are classified by density. So, you have very low-density lipoprotein or VLDL, low-density lipoprotein or LDL, and high-density lipoprotein or HDL, which are the main ones. I mentioned before the analogy that our bloodstream is like a river. Remember that the
lipoproteins are like boats that carry the cholesterol and fats around the body. The cholesterol and fats are like cargo in the boats.

What Raises Your LDL Particle Number?

If the primary cause of heart disease is not high cholesterol, then what is? Part of the reason why statins are ineffective for heart disease prevention (besides the fact that the drug causes heart disease as a side effect) is that drugs cannot address the real cause of heart disease, which is insulin and leptin resistance, which in turn increase LDL particle number via a couple of different mechanisms. While some genetic predisposition can play a role, insulin and leptin resistance is primarily caused by a combination of factors that are epidemic in our modern lifestyle:

  • A diet high in processed and refined carbohydrates, sugars/fructose, refined flours, and industrial seed oils
  • Insufficient everyday physical activity. Leading a sedentary lifestyle causes biochemical changes that predispose you to insulin and leptin resistance
  • Chronic sleep deprivation. Studies have shown that even one night of disturbed sleep can decrease your insulin sensitivity the next day and cause cravings and overeating
  • Environmental toxins. Exposure to BPA, for example, can disrupt your brain's regulation of weight
  • Poor gut health. Studies indicate that imbalances in your gut flora (the bacteria that live in our gut) can predispose you to obesity and insulin and leptin resistance. According to Kresser, gut inflammation can even affect your cholesterol more directly.

"There are some studies that show that lipopolysaccharide, which is an endotoxin that can be found in some types of bacteria in the gut... If the intestinal barrier is permeable, which shouldn't be, of course, some of that lipopolysaccharide can get into your bloodstream. LDL
particles actually have an antimicrobial effect. So, LDL particles will increase if there is some endotoxin going into the bloodstream... causing a direct increase of LDL particles." The culmination of the synergistic effect of these factors will put pressure on your liver to increase production of lipoproteins, more specifically: low-density lipoproteins (LDL), (i.e. more "boats in the river"), which increases your heart disease risk.

Besides insulin and leptin resistance, another common cause of elevated LDL particle number is poor thyroid function. T3 hormone (which is the most active form of thyroid hormone) is required to activate the LDL receptor, which is what takes LDL out of the circulation. If you have poor thyroid function or low T3 levels, then your LDL receptor activity will be poor, and you'll have a higher number of LDL particles. The good news is, if this is the cause for your elevated LDL particle number, then addressing your thyroid problem will reduce it. "Insulin resistance and leptin resistance are widespread problems... and that's one of the main driving forces in elevated LDL particle number. The reason for that is that LDL particles carry not only cholesterol, but also triglycerides, fat-soluble vitamins, and antioxidants... If you have high triglycerides, which you often will when you have insulin or leptin resistance, then that means a given LDL particle can carry less cholesterol, because it's stuffed full of triglycerides. Your liver will then have to make more LDL particles to carry that same given amount of cholesterol around the tissues and cells in your body.

Intermittent fasting is one of many ways to improve insulin sensitivity and leptin sensitivity, because there are certain processes in the body that engage after you haven't eaten for a period of time. They're all evolutionary mechanisms that are designed to help us survive in
periods of food scarcity. You have an upregulation in metabolism basically, and... your insulin and leptin sensitivity improves.
It's a really good way for people to lose weight, which again will improve insulin and leptin sensitivity, because obesity is both a cause and an effect of leptin resistance. I think it's a really great strategy for most people; The only kind of caution might be in people who have pretty severe fatigue, or are suffering from some kind of chronic illness, and need to eat more often.
But for most people, I think it's great."

Coconut oil is most beneficial during the transition period from burning sugar to burning fat, as it will not upset insulin and leptin resistance. It's neutral, yet it is rapidly metabolized and provides a good source of energy. Fatigue can be a real challenge, so if you want to try intermittent fasting but worry about flagging energy levels, coconut oil can be a useful tool. You can even have some coconut oil during your fasting period as it will not interrupt the beneficial processes that are happening while you're fasting. It's mainly protein and carbohydrate that will interrupt those processes. So having a little coconut oil in the morning might help you make it through until you break your fast for your first meal.

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Having a quality protein powder is essential to weight loss and to help your body restore health. Getting enough protein after a weight loss surgery is a major concern to patients; this is justified as many weight loss surgical patients have issues related to malnutrition that include hair loss, muscle break-down, being prone to infections, general weakness; hit a weight loss stall; or even worse…face the dreadful weight regain.

Protein for extreme weight loss Having a quality protein powder is essential to weight loss and to help your body restore health. Getting enough protein after a weight loss surgery is a major concern to patients; this is justified as many weight loss surgical patients have issues related to malnutrition that include hair loss, muscle break-down, being prone to infections, general weakness; hit a weight loss stall; or even worse…face the dreadful weight regain.

One of the most popular protein supplements today is whey as it is the most easily absorbed and tolerated protein source. But, whey can be used with different purposes and not all protein powders are created equally. There are whey products that are mass gainers that include carbs and fats which contribute to excess calorie; not for bariatric patients. Some, especially those that are pre-made, tend to contain chemicals that interfere with fat burning at the liver; not for bariatric patients. Others, are suspect of protein spiking; definitely, not for bariatric patients!

How to choose? Next, you can find my answers to this very most common question.
First, we need to deep dive into its quality and its cost.

COST

Protein in general is an expensive nutrient and generally the macronutrient that defines the cost of food. Any type of food. If it doesn’t have much protein, it will not cost much. Say for example that you want cheap ham; well, processed ham has modified starch and “ham” flavorings and colorings -may taste as ham but it will have very little protein or no protein at all. If you decide to choose this, you are actually paying for very expensive starch, chemicals and almost no protein. It may feel as you are being smart about it and getting a real bargain. But in reality, you are not bringing any nutrients at cellular level to work with, rather you would be increasing the toxic load to your liver, sabotaging its efforts to lose fat. Not really the smartest choice.

Protein is expensive. And, extracting protein and bringing it into a concentrated form… doesn’t come cheap.

PROTEIN EXTRACTION AND THE USE OF OTHER INGREDIENTS

Whey in particular can be one of the most expensive protein sources, but you are getting what you are paying for! To preserve essential nutrients, it processing requires the use of filters and low temperature to maintain its highly bioavailable undernatured proteins.

High quality protein powders usually do not contain artificial flavorings, colorings or additives as doing so counteracts the purpose of getting the purest form of protein. The ingredient list should have whey as the first ingredient and pretty much, it should be the only ingredient. This gives you variety and flexibility to use it in any way you want and create your own flavor, preferably from using organic (frozen or fresh) fruit and/or vegetables, extracts or spices such as cinnamon, cardamom, chai, masala… the sky is the limit. Please see the chart below for ideas on add-ins to your protein shake.

MAKING IT CHEAP

A “diluted whey” is easily identifiable as it would be one of many ingredients of a “Proprietary Blend” as opposed to being the main or only ingredient. In labels, listing ingredients in descending order of predominance by weight means that the ingredient that weighs the most is listed first, and the ingredient that weighs the least is listed last. A “proprietary blend” allows to hide a formula from the amount used out of any ingredients to the content of toxic ingredients. Bariatric patients need to be aware of this as protein shakes become a staple food and the use of what I call “chemical cocktails” bioaccumulates toxins in such a way that it will greatly impact their health, from gut function to brain health.

Since everyone has a different tolerance to toxic load, the impact could be immediate from having a diarrhea episode to lack of energy or, overtime, generalized conditions such as joint pain, muscle pains, skin rashes, brain fog, mood swings, or weight regain.

Protein powders that have higher amounts of 20g of protein on the label are suspect of using diluted whey as more than 20 grams of whey produces osmotic diarrhea -something the manufacturing companies like to avoid. Of course, any protein powder that contains milk as an ingredient is just a very high-priced dried milk powder, no matter how cheap it sales for.

In the following example, you can see that whey concentrate is the least of the ingredients of the proprietary blend, being milk protein concentrate the first and whey the last -without disclosure of the amounts used for each.

Take a look at the following disclosure of ingredients (Premier Protein):

On the other hand, you need to know about “protein spiking”. The current method used to measure the amount of protein in a protein powder involves measuring the nitrogen content. Nitrogen is used because protein is made up of amino acids that contain nitrogen, so measuring nitrogen content of a protein powder indicates the amount of protein it “has”, assuming that the protein powder contains complete proteins, such as whey, casein and/or egg protein. Unfortunately, many protein powders have "extra" amino acids added to them, which may lead you into thinking that this is good, the problem is that the amino acids added do not provide any benefit, they are added for their nitrogen content.
Amino acids such as taurine and glycine are cheaper than whey. So, doubt of any protein powder that has more than 20g per serving.

ORIGIN

Another consideration is to choose whey that comes from cows that do not contain the synthetic Bovine Growth Hormone (rBGH). Being overweight implies a disrupted endocrine system, the food you eat, including whey, should aid in recuperating hormonal balance, not make it worse.

OTHER INGREDIENTS

And, last but not least, it is best if your bariatric protein powder is fortified with L-Glutamine. Research has shown that L-Glutamine can minimize muscle breakdown and improve protein metabolism, which in turn helps to metabolize fat. L-Glutamine is also an important nutrient to boost immune system and it is the primary energy source for intestinal health. This is very important as it is well known that people who have excess of weight have disruption of the ecological equilibrium in the gut, L-Glutamine and a comprehensive nutritional plan that includes probiotics help reshape the gut microbial balance and improving nutrient absorption, a relevant matter after bariatric surgery.

CONCLUSION

Think of whey as a pure ingredient. Just like eggs can be turned into eggs benedict, frittata, deviled or scrambled eggs… whey can be turned into dessert, gelatin, pudding or a delicious smoothie! Choose a high-quality protein powder and make it yours with high quality ingredients. Don’t fall into commercial “tasty and convenient” traps as you’d end up paying more from missing the most important ingredient and including unwanted ingredients.

You can find tasty and nutritious recipes here: https://www.vitaleph.com/kitchen-recipes/
Add-ins to your shake will boost its texture, taste, and nutrition content. Have fun and enjoy! (choose organic when possible):

To a long, healthy, productive, and happy life,
Lucía Chavez 

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EVA records the abnormal temperatures in the breasts with the presence of cysts, calcifications, and malignant tumors to detect breast cancer.

Winning the competition

The eighteen-year-old Mexican, Julián Ríos, has won $ 20,000 for getting first place in the Global Student Entrepreneurs' Awards with his project. With the collaboration of Higia a Mexican biosensor company that detects breast cancer which sponsored him, Ríos and his team were able to design «EVA», a bra that detects breast cancer through a device that records thermal data.  

The Global Student Entrepreneur competition is for excellent students who have a for-profit business or a social enterprise. This year it was attended by 1,700 competitors from more than 50 countries. The countries that reached the final in Germany in addition to Mexico were El Salvador, Guatemala, Malaysia, and Pakistan. This was Mexico's seventh time participating in this contest and thanks to Rios they got the first place in this edition.

Getting the tech right

In 2015, Ríos decided to invent a method that would help detect breast cancer by overcoming the limitations of conventional methods, said the Tecnológico de Monterrey high school student last March. Rios started looking on the internet "What is cancer?" And shortly afterward managed to design, along with three colleagues, a device that detects breast cancer thanks to biosensors. This device can be easily used by placing it inside the bra making a very practical option.

Jose Antonio Torres, co-founder and technology director of the company, explained last March how the device works, which records the abnormal temperatures in the breasts with the presence of cysts, calcifications, and malignant tumors."EVA" is used one hour a week for a month to store user data, which can be monitored with an application on the mobile: "The more data we have from the woman, the better the algorithm is made to predict cancer", explains Torres. The algorithm has a diagnostic efficiency of 93 %, "which is quite high compared to other elements such as scanning and ultrasound, ranging from 20 % to 50 %".

EVA will come back soon

In an optimal scenario, "EVA" would go on sale by the end of 2018, but they still have to get the corresponding authorizations from the Federal Commission for Protection against Health Risks (Cofepris), which could delay the process. 

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8 out of 10 adults experience gingivitis, this serious disease can be prevented and treated in a very easy way.

Gingivitis is the most frequent periodontal disease, affecting almost 100% of the population at some point in its life.Periodontal diseases affect 8 out of 10 adults. Among them, gingivitis is especially common, but it can be identified, prevented and treated in a very simple way.

It´s a group of disorders that affect the periodontium, that is, the tissues that support the teeth. They are produced mainly by the action of bacteria that accumulate on the teeth, gums, restorations ..., forming a thin layer known as dental plaque or dental biofilm. In the case that the infection produced by these bacteria affects only the gingiva, they cause a "reversible" inflammatory process called gingivitis. But if the infection stays long and/or is associated with other risk factors, it may progress (in those most predisposed) to periodontitis.

Periodontitis is a deeper infection in which there is destruction of the bone that is attached to the tooth, an irreversible process that can also increase the risk of onset and influence the evolution of other systemic diseases (affecting other parts of the body located outside of the oral cavity).That is why it is essential to prevent gingivitis or, if not, to detect and treat it as soon as possible.

Gingivitis is the most frequent periodontal disease, affecting practically 100% of the population at some point in its life. That is why, usually not given too much importance, in addition to the fact that does not usually cause discomfort or pain.

A sign of alarm that can warn about the presence of this disorder is the bleeding of the gums. And is that, a healthy gingiva should not bleed and, if it does, it´s because something is not right.

Most patients attribute bleeding to brushing with a certain type of brush (harder) or the technique used (stronger), without knowing that the cause of bleeding is a disease of their gums and that it should be treated.

If we have gingivitis, the gingiva will look red (not pink), swollen, shiny (losing the orange-pear-shaped dotting that characterizes the healthy gingiva) and bleeds when brushing, biting certain foods or even spontaneously (At night, while we sleep as it mixes with the saliva to stain the pillow of the bed). These changes occur as a result of increased vascularization in the area, although they do not always occur in all patients.

In this regard, special emphasis should be placed on the fact that, if you are a smoker, these signs are not so obvious, since gingivitis is camouflaged by tobacco, which makes it difficult to detect them early. Thus, since this harmful habit triples the risk of periodontal disease, if you are a smoker you think that a simple visit to the dentist will be enough to detect the presence of inadequate levels of bacterial plaque and gingival inflammation.

Groups of greater risk

Gingivitis, in its different degrees of severity, is practically universal in children (reaches 70% in children aged 7 years) and adolescents (it rises to 90% at 10 years). Although these gum disorders in children do not usually acquire a serious profile, it is considered essential to diagnose them at an early age to begin instilling good hygiene habits from infancy and avoiding a possible progression of gum disease over time.

Although gingivitis also affects a large number of adults, in the case of women it has particular consequences. The female sex is especially susceptible to this gum disease due to the hormonal changes it undergoes throughout its life (puberty, pregnancy, taking of contraceptives as well as in the menopause); these hormonal changes favor an exaggerated inflammatory response to the action of bacteria. This is especially significant because of the possible repercussions of a periodontal infection in pregnancy.

Can gingivitis be prevented?

Yes, very simply. The basis of prevention is the realization of an adequate daily dental hygiene, ideally under an appropriate advice and following specific recommendations for each person. Once the disease has appeared, specific treatments may be necessary in the dental office in order to eliminate the bacteria that are deposited in the oral cavity, as well as create the right conditions so that these do not accumulate in excess and so that the Gum disease can be maintained in the long term.

Basic care

As basic care to be taken to prevent gum disease and to maintain optimal oral health, it is advisable to apply the so-called "Rule of 2".To achieve adequate oral hygiene, teeth and gums should be brushed for at least 2 minutes at least 2 times a day and periodic visits to the dental clinic at least twice a year.

7 tips to take care of our oral health
  1. - Brush teeth and tongue at least twice a day, being the most important brushing at night, before bed.
  2. - Only brushing is unable to eliminate all plaque, being essential in all cases the use of some method of hygiene between teeth (such as dental wire / dental tape or interdental brushes).
  3. - The use of a mouthwash can be in some cases an adequate complement of hygiene, always following the recommendation of your dentist.
  4. - The prevention of periodontal diseases is a lifelong commitment; the mechanical removal of plaque should be daily and should be accompanied by other measures aimed at avoiding additional risks for oral health.
  5. - Go to the dentist or periodontist at least once a year to check the condition of the gums and teeth; this will allow to prevent possible dental pathologies, periodontal and the maintenance of good general health.
  6. - A healthy way of life should be followed, avoiding factors harmful to oral health, such as the consumption of foods with a high content of sugars, alcohol, tobacco, and stress.
  7. - Avoid self-medication with oral health products in the absence of a correct diagnosis and professional advice.
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Eko, the company that’s responsible for the Eko CORE has now released a new device.

Eko, the company that’s responsible for the Eko CORE digital stethoscope we highly praised, is now releasing an interesting new device that provides ECG and auscultation capabilities in a mobile package. The Eko DUO looks a bit like a cell phone from the 1990’s, but with only three buttons on its body. When held against the chest, it provides both a 1-lead ECG and auscultation comparable to a standard stethoscope.

The device can be used by clinicians or by patients themselves. As a clinical tool, it can work just like a typical stethoscope, featuring a 3.5 mm audio jack on the bottom that can accept headphones, external speakers, or a traditional stethoscope earpiece that comes along in the product box.

If used remotely by the patients, the heart and lung sounds, as well as the ECG chart, can be easily shared with their doctors via the accompanying Eko app. The sounds and ECG readings are recorded simultaneously, and are shown synchronized together within the HIPAA compliant app. The data can also be transferred into a hospitals electronic medical records (EMR) to keep on file in case further review is necessary.

The DUO features wireless charging, as it’s simply placed on top of an accompanying charging pad whenever the batteries start to run low. Of note, a single charge is sufficient for about nine hours of continuous vitals recording and to help increase that, the DUO automatically shuts down after five minutes of not being used.

The digital stethoscope amplifies sounds up to sixty times and comes with built-in noise reduction, as well as four digital audio filters (diaphragm, bellmode, midrange, and extended). The ECG works at 500 Hz sampling resolution, the signals passing through a .01 Hz high pass filter and through a selectable 50 or 60 Hz mains filter.

This is certainly an interesting product, and having been impressed by the Eko CORE stethoscope.

At Cardiac Care and OCC Health we are using the Eko CORE technology with all our patients to detect any heart or cardiopulmonary problems.

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One medical center is fighting this epidemic by limiting the opioids prescriptions, but while still providing outstanding pain control.

Six out of ten overdose deaths in the US involve an opioid drug. Between 2000 and 2015, more than 500,000 people died from drug overdoses. And every day, 91 Americans die from an opioid overdose.
This epidemic has been called the worst drug epidemic in the history of the United States. According to the US Centers for Disease Control, the amount of prescription opioids sold in the U.S. nearly quadrupled since 1999, yet there has not been an overall change in the amount of pain that Americans report. Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 1999.


We now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths. The increase in heroin addiction and overdose deaths followed shortly thereafter, when patients who had become hooked on opioid painkillers were unable to obtain further prescriptions for opiates.

One Medical Center Moves to Reduce the Opioid Epidemic

At St. Joseph’s Health Care System in Patterson, New Jersey, Dr. Alexis LaPietra, Medical Director of Pain Management experienced a dissonance that is likely familiar to emergency physicians around the country.
“I was in one room, resuscitating a patient who had overdosed on heroin or another opiate, and a few beds down, you’re prescribing opiates for patients in pain,” says Dr. LaPietra, who realized that heroin overdoses often started with a prescription for opioid painkillers in the ER.

While the federal government has been slow to respond to the epidemic, individual hospitals and medical centers have launched their own initiatives to begin addressing the serious health crisis. Realizing that prescription opiates are fueling the addiction epidemic, St. Joseph’s made the bold decision to drastically reduce the number of opioid prescriptions originating from their own ED while maintaining outstanding pain control for their patients.

Non-opioid Methods to Combat Pain in the ED and Beyond
St. Joseph’s has the second-busiest Emergency Department in the United States, seeing 175,000 patients in 2016. St. Joseph’s Emergency Department launched the ALTOSM (ALTernatives to Opioids) Program in January 2016.
The program uses targeted non-opioid medications, trigger point injections, nitrous oxide, ultrasound-guided nerve blocks, and even meditation, to help ease pain in patients with acute injuries like broken bones, and ongoing issues like migraine headaches.
Dr. LaPietra describes a patient who received a nerve block with ultrasound guidance when the ALTOSM program first launched, an 89 year-old woman with a hip fracture.

“Hip fracture pain is exquisite,” says Dr. LaPietra, “They are in a lot of discomfort. They cannot move; they cannot breathe well. And within 5-10 minutes of the [ultrasound-guided] nerve block, she had complete pain relief.”
But why use ultrasound for nerve blocks?
“It’s very important to be precise, and the ultrasound equipment helps us be precise,” explains says Judy Padula, Vice President of Patient Care Services and Chief Nursing Officer at St. Joseph’s Healthcare System.
Regional nerve blocks are usually the purvey of anesthesiologists, but increasingly, emergency physicians are adopting the practice to provide relief to patients suffering from acute pain.

Every Patient Matters

“We have had people who are in recovery who have come to our Emergency Department [for pain treatment], because they don’t want to have opioids again,” says Dr. Mark Rosenberg, Chairman of Emergency Medicine at St. Joseph’s Population Health Initiative. “It… decreased the cost of care while improving and giving better care to the individual.”
At OCC we also believe to avoid as much as possible the use of narcotics for pain in our patients after surgery, recommended to walk more time, other pharmacological ways

Jose A Jimenez MD

Cardiac and Health Care OCC

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Superbugs are able to resist antibiotics making it harder to treat people, but Pseudouridimycine might be the answer to this problem.

Antibiotic-resistant bacteria, popularly known as 'superbugs', are one of the major threats to global public health. These microorganisms have once evolved to counteract the efficacy of antibiotics - usually by abusive or improper use of these drugs, in the case of their use in the treatment of diseases, such as influenza, caused by Virus and not a bacterium - little more can be done than committing to the patient's immune system's ability to fight infection.

In addition, the number of ongoing studies to develop new antibiotics is negligible, so the future does not seem to be too hopeful.
So what can you do? For example, look at Nature to see if, as happened in the discovery - accidental - of penicillin, there is a new compound capable of dealing with these resistant bacteria. One possibility that, as a study led by researchers at Rutgers University in New Brunswick, USA, can show some remarkable results.

Specifically, the study, published in the journal "Cell", describes an antibiotic that is naturally produced by a bacterium and dubbed "pseudouridimycina", has a novel mechanism of action capable of destroying a broad spectrum of both sensitive and resistant bacteria. The antibiotics available and to cure bacterial infections in animal models - mice.

As explained by Stefano Donadio, co-director of the research, "among other results, our work highlights the importance of natural products to provide new antibiotics. And it's that microbes have been billions of years developing 'chemical weapons' to kill other microbes."

The antibiotic pseudouridimycine acts by inhibiting bacterial RNA polymerase, that is, the enzyme responsible for synthesizing the RNA of the bacteria. However, to date there is another available antibiotic which, called 'rifampicin', also acts by inhibiting this bacterial enzyme.

So, should bacteria resistant to rifampicin be expected to be resistant to pseudouridimycine? Well, no, since both its mechanisms and enzyme binding sites are different. This is so when they are administered in combination they add their antibiotic effects.

It's more, the rate of spontaneous resistance of pseudouridimycine is only one tenth of that of rifampicin; in other words, the probability that a bacterium develops resistance to pseudouridimycine as a result of a spontaneous mutation is 10 times lower than that observed with rifampicin.

Specifically, pseudouridimycine acts as an analogous nucleoside inhibitor in bacterial RNA polymerase. That is, it mimics chemical compounds which, like building blocks, are used by the enzyme to synthesize bacterial RNA. Thus, what the antibiotic does is bind to RNA polymerase in the place where the building blocks - a molecule called 'nucleoside triphosphate' (NTP) - would do. And since the NTP can no longer be bound, the enzyme does not have the raw material to construct the RNA.

And does not this new antibiotic, as it does with the bacterial enzyme, also inhibit human RNA polymerase? Well, no. Pseudouridimycine is the first nucleoside analogue to selectively inhibit bacterial RNA polymerase but not human RNA polymerases.

As Richard H. Ebright, co-director of research, indicates, "since the point of attachment of NTP to bacterial RNA polymerase has exactly the same structure and sequence as the point of attachment of NTP to human RNA polymerase, most of the researchers believed it impossible that an analogous nucleoside inhibitor could inhibit bacterial RNA polymerase without doing the same with human. However, the pseudouridimycine contains a side chain that remains outside the point of attachment of the NTP and touches an adjacent point present in bacterial but not human RNA polymerase. The result is that the antibiotic binds much more strongly to the bacterial enzyme than to the human enzyme.

It's more; as the authors point out, the fact that pseudouridimycine acts as an analogous nucleoside inhibitor explains the low rate of spontaneous antibiotic resistance.

As Richard H. Ebright reports, "the new antibiotic interacts with essential residues at the point of attachment of NTP that can not be altered without losing the activity of RNA polymerase and thus the viability of the bacterium. The alterations at the point of attachment of the NTP that prevent the new antibiotic from joining also make bacterial activity impossible, so that the bacterium eventually dies before it develops resistance.

In definitive, pseudouridimycine appears as a very promising drug to combat the increasingly pressing problem of bacterial resistance.

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Researchers are creating a better alternative for wearable fitness devices by making ultra-thin electronic tattoos that are less intrusive and provide valuable real-time information.

 

Wearable fitness devices can track pulse rates and physical activity over time in order to achieve long-term health goals; however, more advanced technology is being developed to monitor what’s happening inside the body in real time.

Researchers are now creating wearable devices that analyze the effects of activity on biochemical markers usually obtained from blood samples.  By interfacing a device directly with the skin, sweat can be collected to determine its volume and levels of biochemical markers such as chloride.

Knowing how much fluid one is losing through sweat and how that’s affecting their fluid-electrolyte balance and acid-base balance during exercise, may help one know when to increase or decrease fluid and/or electrolytes.Abnormal hydration status can be fatal or lead to an increased risk for kidney failure, infections, altered mental status, or decreased physical performance.

Researchers at Northwestern University have created a soft flexible epidermal microfluidic patch that can detect sweat volume and rate, along with markers of health status found in sweat.A new process that can make ultra-thin electronic tattoos using a household printer has been developed by another group of researchers.While smart tattoos that can monitor a person's health have been developed before, this new method could allow people to print them cheaply in their own homes.The elastic nanosheets could be used for applications such as drug delivery or for monitoring a person's health, or the amount they have drunk.The researchers used an inkjet printer to print black lines that can conduct electricity onto a nanosheet.

The whole procedure can be done on a home inkjet printer at room temperature without the need for a sterile room, so the tattoo can be produced fairly easily and cheaply.The ultra-thin film, developed by the researchers at Waseda University in Japan, has elasticity and flexibility 50 times better than other polymer nanosheets and sits comfortably on the skin.

The film is only 750 nanometers thick - 120 times thinner than a human hair - and could change what wearable electronics look like, from things such as wristwatches to other items less noticeable than a band-aid.The research team also developed a method of joining electronic components without the need for soldering, enabling the elastomer film to be thinner and more flexible.

The electrically conductive black lines are connected to components such as chips and LEDs by sandwiching them in between two nanosheets - without the need for special conductive adhesives.The film sticks onto the skin without the need for glue, tapes or chemical bonding, and it can stretch over the skin without easily breaking the circuits.

The researchers tested the tattoo on an artificial skin model and found that it worked for several days.The technology is expected to have applications including human-machine interfaces and sensors in the form of electronic tattoos for the fields of medicine, healthcare and sports training.

One of the most recent tech tattoo efforts we heard about comes from the University of California, San Diego. It's designed to measure blood alcohol levels in a quick, inexpensive and non-invasive way and replace the oft-used techniques of pricking someone's finger or using breathalyzers which can be gamed.

There are different projects all over the globe: Microsoft Research, MIT Media Lab, Duo Skin, Tech Tats; you named it, tech is always there to rock and roll!!!

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