text:
June 2015 Issue
CPE Monthly: Bariatric Surgery In Diabetes Management
By Nina Crowley, PhD, RDN, LD
Vol. 17 No. 6 P. 48
Suggested CDR Learning Codes: 4140, 5125, 5190
Suggested CDR Performance Indicators: 8.1.5, 8.3.1, 8.3.6
CPE Level 2
The latest National Health and Nutrition Examination Survey data indicate that between 2009 and 2010, roughly 35% of adults (78 million) and 16.9% of children and adolescents (12.5 million) were obese.1 Excess weight is associated with an increased prevalence of type 2 diabetes, and both diabetes and obesity are associated with an increased risk of mortality and higher health care costs.2 Since obesity is considered a modifiable risk factor for diabetes, preventing it is ideal, but treatment for those who are currently obese is critical.
Diet, exercise, and medications are the cornerstones of therapy for type 2 diabetes, but outcomes remain disappointing.3 Fewer than 50% of people with moderate to severe diabetes achieve and maintain therapeutic thresholds for glycemic control. Diet, exercise, and behavioral therapy are first-line treatment modalities for obesity, but results also are inadequate.4 In addition, many diabetes medications (eg, insulin, sulfonylureas, thiazolidinediones) promote weight gain, further exacerbating obesity among people with diabetes.5
This continuing education course reviews the research on bariatric surgery as a treatment option for type 2 diabetes. The course reviews the types of interventions, remission rates, and the mechanisms for diabetes resolution and outlines practical applications for dietitians.
Types of Bariatric Surgery
The choice of surgery type for a particular patient often is discussed with diabetes resolution in mind. Because diabetes is one of the primary reasons patients elect to have bariatric surgery, surgeons typically help patients weigh the pros and cons of each type of procedure as they relate both to weight loss and the resolution of comorbid health conditions.
As of 2013, the vertical sleeve gastrectomy (VSG) is the most common bariatric procedure (42.1% of new cases), followed by the Roux-en-Y gastric bypass (RYGBP) (34.2%).6 The adjustable gastric band (AGB) now represents only 14% of total surgeries, due to inadequate weight loss or band removal in as many as 40% to 50%, and reoperation or conversion to another surgery in about 20% to 30% of patients.7 Some surgeons perform the biliopancreatic diversion (BPD) with or without a duodenal switch (BPD/DS), but it's less accepted because it can cause macronutrient malabsorption and serious micronutrient deficiencies; in 2013, BPD/DS represented only 1% of the 179,000 surgeries performed in the United States.6
The RYGBP involves the creation of a small pouch (volume of fewer than 30 mL) divided from the gastric remnant, or excluded stomach, which is joined to the jejunum through a narrow gastro-jejunal anastomosis. The biliopancreatic limb and alimentary limb are reconnected 75 to 100 cm distal to that connection. Ingested food bypasses 95% of the stomach, the entire duodenum, and a portion of the jejunum.8
VSG surgically restricts the stomach to a long tubular shape with a reduced volume of 150 to 200 mL while preserving the pylorus. In addition to reduced capacity, appetite hormones and gastric acid are reduced.9 The excluded stomach, representing about 85% of the original capacity, is removed.
The BPD procedure, a distal, horizontal gastrectomy, leaves behind a functional stomach (volume of 200 to 500 mL) that is anastomosed to the distal 250 cm of small intestine. The excluded small intestine carries bile and pancreatic secretions and connects with the alimentary channel 50 cm above the ileocecal valve, which leaves 50 cm of intestine in which digestive enzymes and nutrients mix.8
In the BPD/DS procedure, a sleeve gastrectomy is created, and the duodenum is closed distal to the pylorus. A duodeno-ileal anastomosis (switch) also is performed, leaving 100 cm of common channel where the food, digestive enzymes, and bile mix before entering the large intestine.8
In gastric banding, an AGB device filled with saline is implanted around the upper part of the stomach, distal to the gastroesophageal junction. Restriction is adjusted by injecting and withdrawing saline through a port implanted in the abdomen and accessed by a needle; no manipulation of the small intestine is involved in placing the band.
BPD/DS, despite being performed infrequently, results in the greatest weight loss and diabetes resolution, followed by RYGBP, VSG, and the AGB.10 Even when RYGBP and the AGB produce similar rates of weight loss, the former is more effective in the long term both at keeping weight off and resolving diabetes.11
While there are arguments for performing certain procedures over others both for weight-loss outcomes and diabetes resolution, these choices are dictated by insurance coverage, patient choice, surgeon preference, and options offered by various surgery centers. Insurance coverage historically has been available most for RYGBP and the AGB, although coverage for VSG is becoming more common. Few surgeons perform the BPD/DS due to issues with the more extreme malabsorption and complication rates.12
Earlier Intervention in Diabetes Patients With Lower BMI
Bariatric surgery generally is considered appropriate for those with a BMI greater than 35 and at least one weight-related comorbidity, such as type 2 diabetes, and for those with a BMI greater than 40 with and without comorbidities.13
The National Institutes of Health criteria for bariatric surgery haven't been revisited in more than 20 years but still are used to decide for which patients surgery is appropriate.14 Approximately 6.3% of the US population has a BMI higher than 40, and 15.5% have a BMI of 35 to 40, making up 21.8% of the US population's potential candidates for bariatric surgery.15 However, because of factors such as access to care and patient interest in pursuing surgery as a treatment option, only 1% to 2% of the morbidly obese meeting the criteria for surgery undergo the treatment.16
More research is becoming available to support the use of bariatric surgery in diabetes patients with a BMI below 35.8 The first evidence that the surgery benefited people with diabetes came with the observation that those who had gastric resections with proximal intestinal reconstruction (similar to gastric bypass) for ulcers or cancer achieved rapid postoperative hyperglycemia normalization.8 In one study, Cohen and colleagues showed significant reductions in fasting blood glucose levels in patients with diabetes with a BMI below 35 who underwent gastric bypass.14
In the first study to evaluate bariatric surgery as a treatment both for obesity and diabetes, Pories and colleagues established that gastric bypass is a safe and effective therapy for morbid obesity and associated comorbidities; no other therapy could produce durable and complete diabetes control.17 Surgical intervention has since become a more common treatment option for obese patients with type 2 diabetes.
Metabolic surgery describes procedures that modify a patient's physiology for the better vs simply correcting or removing an anatomic defect.18 In addition to treating primarily morbid obesity for those with a BMI of greater than 35 to 40, metabolic surgery has been proposed for people with co-occurring diabetes and a lower BMI range (BMI greater than 30,19 and even in those with a BMI as low as 27). 4
Reducing the BMI requirements for surgical candidates to 30 to 35 would include another 20% of the US population. A BMI of 30 to 35 and type 2 diabetes co-occur in about 4% of the US population, so revised recommendations would have a tremendous impact.20
A multinational, multicenter, randomized controlled study compared lifestyle and intensive medical management with gastric bypass in 120 obese patients with poorly controlled diabetes, a BMI of 30 to 40, and a glycated hemoglobin test (hemoglobin A1c [HbA1c]) greater than 8%. The patients had been diagnosed with diabetes at least six months previously.19
After one year, 49% of the gastric bypass patients and 19% of the lifestyle-medication management patients achieved the HbA1c goal of less than 7%, LDL cholesterol of less than 100 mg/dL, and systolic blood pressure of less than 130 mm Hg. Moreover, the gastric bypass patients lost 26% of their initial body weight compared with 8% in the lifestyle-medical management group. Ikramuddin noted that while there were 22 serious adverse events in the surgery group, even intensive medical management of type 2 diabetes can have complications (15 serious adverse events).19
In another important study, 66 people with longstanding diabetes and a BMI of 30 to 35 who had gastric bypass were followed for six years. Diabetes remission, based on criteria of HbA1c of less than 6.5% without diabetes medication, occurred in 88% of patients. Glycemic improvement without meeting full remission criteria occurred in another 11%.14
Diabetes Resolution and Remission After Surgery
To evaluate the differences between diet and behavioral interventions and surgery, it's important to understand how diabetes resolution and remission are defined. It's difficult to compare results of different studies since many subjectively use the terms "resolution" and "remission" and use HbA1c levels ranging from less than 6% to 7%.8
According to the American Diabetes Association criteria, partial remission of diabetes occurs when a patient's HbA1c is less than 6.5% and fasting glucose is 100 to 125 mg/dL, and no antidiabetic drugs have been used for the past 12 months. Complete remission occurs when HbA1c is less than 6% and fasting glucose is less than 100 mg/dL, and no antidiabetic drugs have been used for the past 12 months.21
Early and late diabetes remissions are different. Early remission occurs within the first two months after surgery and lasts for at least 12 more months, while late remission begins more than two months after surgery and lasts for at least 12 more months. Patients who achieve prolonged remission (complete remission lasting more than five years) are considered cured, although relapse may occur.21 Jimenez and colleagues defined the criteria for relapse as a fasting glucose of greater than 126 mg/dL and HbA1c greater than 6.5% after a patient has been in remission for at least 12 months following bariatric surgery.22
In a retrospective cohort study of 690 people with type 2 diabetes who underwent gastric bypass, 63% achieved partial or complete remission, of which 22% achieved partial remission and 78% achieved complete remission. Predictors of early and late remission were younger age, lower HbA1c, no use of insulin sensitizing agents, and high serum insulin concentrations. Seventy eight percent of those who hadn't been using insulin therapy before surgery achieved complete diabetes remission compared with 15% of insulin-dependent patients.23
Based on similar diabetes remission criteria, Buchwald and colleagues' meta-analysis found that roughly 78% of bariatric patients experienced complete hyperglycemia resolution, with variations by procedure.10 Remission occurred in 98.9% of those who underwent BPD, 83.7% who had RYGBP, and 47.9% who had the AGB; the sleeve wasn't included as a procedure in this analysis.10 Schauer and colleagues discovered that those with the shortest duration of diabetes (fewer than five years), the mildest form of type 2 diabetes, and the greatest weight loss after gastric bypass were most likely to have diabetes resolution.24
Medical Therapy vs Bariatric Surgery
A recent systematic review and meta-analysis of randomized controlled trials comparing surgical vs nonsurgical obesity treatment evaluated 11 studies and 796 individuals. Bariatric surgery (all types included) was found to be more effective than nonsurgical obesity treatment for up to two years of follow-up. Specifically, in those treated with bariatric surgery, there was greater weight loss, higher type 2 diabetes remission, greater improvements in quality of life, and greater reductions of antidiabetic, antihypertensive, and lipid-lowering drug use.25
Schauer and colleagues' randomized controlled trial (the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently—STAMPEDE) compared the efficacy of intensive medical therapy alone vs medical therapy plus gastric bypass or VSG in 150 obese individuals with uncontrolled diabetes who had an average HbA1c greater than 9% and average disease duration of more than eight years, and who were taking an average of three antidiabetes medications. Outcomes were evaluated using a goal of HbA1c of less than 6%. After one year, 12% of those who received medical therapy, 42% of those who had gastric bypass, and 37% of those who had VSG met the intended HbA1c goal.4 After three years, 5% of those who received medical therapy, 38% of those who had gastric bypass, and 24% of those who had VSG met the primary end point of HbA1c less than 6%.26 Eighty percent of medical therapy patients met the goal at one year but not at three years, whereas 24% of gastric bypass and 50% of VSG patients had reached the HbA1c of less than 6% at one year but not at three years.
Mingrone and colleagues' randomized controlled trial compared the efficacy of conventional medical therapy with gastric bypass or BPD in 60 severely obese people with diabetes (average HbA1c of greater than 7% and average disease duration of more than five years). Outcomes were evaluated using a goal of HbA1c of less than 6.5% and fasting glucose of less than 100 mg/dL after two years. None of those who received medical therapy, 75% of those who had gastric bypass, and 95% of those who had BPD met the remission criteria.27
Mechanisms of Action
There have been several suggested mechanisms of improved glycemic control in postbariatric surgery patients. While weight loss itself, regardless of the method, does affect glycemic control, most bariatric operations ameliorate type 2 diabetes through mechanisms beyond reduced calorie intake and weight loss.8
Pories first commented on the surprising speed of normalization of glucose metabolism that occurred in patients in the days to weeks following gastric bypass before they had achieved rapid weight loss.17 Schauer found that one-third of patients with type 2 diabetes who had gastric bypass were discharged from their average three-day hospital stays with normal blood sugars and no need for diabetes medications.24
However, not all surgeries produce these effects. In the large Swedish Obese Subjects study, Sjöström and colleagues didn't observe the rapid diabetes remission following the purely restrictive operations although improvements were seen with these procedures after weight loss was achieved.28 The adjustable gastric band and the no-longer-performed vertical banded gastroplasty are considered purely restrictive as they only create a smaller-volume stomach, whereas the gastric bypass, sleeve gastrectomy, and BPD/DS are thought of as combination procedures of varying amounts of restriction, malabsorption, and neurohormonal effects.
The hindgut theory (or lower intestine hypothesis) suggests that rerouting food through an altered gastrointestinal (GI) tract results in increased delivery of incompletely digested nutrients to the distal jejunum, which overstimulates L cells.29 Secretion of the hormone glucagonlike peptide-1 (GLP-1) from L cells slows gastric emptying and has appetite-suppressing effects.30
After gastric bypass and BPD/DS, by which food is rerouted through intestinal bypass, there's an increased secretion of GLP-1 after meal intake, resulting in stimulation of insulin release by pancreatic beta cells and normalized plasma glucose. This response occurs early after surgery, lasts months to years after surgery, and is independent of weight loss.22 GLP-1 also increases to a lesser extent with the sleeve gastrectomy, even though the intestine is left intact.31
In people with diabetes who were randomized to gastric bypass or diet, those in the surgery group, after losing an average of 20 lbs, had greater improvements in glucose tolerance, elevated GLP-1 levels, and an increased incretin effect than did those in the diet group after similar weight loss.32 Euglycemia, enhanced insulin sensitivity, and an exaggerated GLP-1 response were maintained in a sample of people with diabetes 10 years after gastric bypass, suggesting durability of the phenomenon.33
Jimenez and colleagues believe that enhanced GLP-1 response after eating isn't sufficient to maintain the normal glucose tolerance long term. They suggest that beta-cell function is an important factor in determining diabetes remission, and those with preserved beta-cell function are more likely than others to remain in remission long term.22
The foregut theory (or upper intestine hypothesis) suggests that surgically bypassing the duodenum and proximal jejunum from contact with nutrients inhibits the release of a signal responsible for insulin resistance and type 2 diabetes.34 Excluding the upper intestine reduces the secretion of both ghrelin from the stomach and duodenum and glucose-dependent insulinotropic polypeptide (GIP) from the duodenum.
Ghrelin, an enteric peptide hormone, is a known appetite stimulant produced by the stomach and duodenum; after gastric bypass and sleeve gastrectomy, ghrelin levels typically are suppressed. Depending on the surgeon's technique, the vagus nerve, which innervates the stomach and stimulates ghrelin production, may or may not be severed, and that variable is associated with the variation in ghrelin levels between studies.35
GIP is secreted by K cells in the duodenum and jejunum, is elevated in obesity and diabetes, and contributes to insulin resistance.30 Bypassing the duodenum and jejunum with gastric bypass and BPD/DS keeps the K cells from being exposed to nutrients and in most studies is shown to result in a beneficial decrease in GIP.
Better beta-cell function at the time of surgery is believed to maximize the effect of the surgery-altered secretion of gut peptides that enhance beta-cell insulin secretion.35 Still and colleagues suggest that an increased duration of diabetes negatively affects beta-cell function, which is an important factor in determining long-term diabetes remission after bariatric surgery.23 Presurgery beta-cell glucose sensitivity was a positive predictor of diabetes remission in bypass and sleeve patients.36 Cohen and colleagues suggest that gastric bypass can reverse the progressive beta-cell failure seen in patients with type 2 diabetes.14
The precise mechanisms that mediate diabetes remission after certain bariatric surgeries aren't well defined, but it's clear that rearranging the anatomy of the GI tract can exert antidiabetes effects beyond reduced caloric intake and weight loss.8 Karra and colleagues suggest that the key mechanism is increased hindgut stimulation due to enhanced nutrient delivery and exaggerated release of hindgut hormones (GLP-1 and peptide YY).29 Peterli and colleagues believe that neither the foregut nor the hindgut intestinal hypothesis can fully account for improvement in glucose homeostasis; rather, balance between hormones involved in the foregut (eg, ghrelin, GIP) and hindgut (eg, GLP-1, peptide YY) hypotheses are key to understanding the improved glucose homeostasis.37 In addition, while the sleeve gastrectomy isn't considered a malabsorptive procedure since there isn't a rerouting of small intestines, a recent systematic review and meta-analysis found no significant differences in type 2 diabetes with gastric bypass and sleeve gastrectomy.31
Reactive Hypoglycemia and Nutrition Intervention
While RDs may be involved in helping patients decide which surgery to undergo or understand how the surgery ameliorates diabetes, their most probable role is in postoperative care. RDs can help with the intervention of postoperative complications such as malnutrition, vitamin and mineral deficiencies, and eating behavior disturbances. Clinical practice guidelines endorsed by the American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery outline the postoperative nutrition guidelines including energy intake, macronutrient breakdown, and micronutrient supplementation for bariatric patients.38 Pertaining specifically to glucose control, however, dumping syndrome and reactive hypoglycemia are the most common postop complications requiring RD involvement. Moreover, if patients' weight regain promotes relapses to diabetes or poor glucose control, RDs play a crucial role in counseling them about eating behaviors to prevent or counteract weight regain.
If the pylorus is bypassed or gastric innervation is disrupted during surgery, rapid emptying of gastric contents into the small intestine leads to GI and vasomotor symptoms known as dumping syndrome. Dumping syndrome is characterized by adrenergic symptoms such as palpitations, sweats, tremors, anxiety, and neuroglycopenic symptoms, including extreme hunger, numbness, confusion, and fainting.39
Early dumping syndrome occurs about 15 minutes after eating and typically is caused by postmeal fluid shifts into the proximal small bowel in response to hyperosmolar loads (typically from eating or drinking added sugars) and associated with the release of the vasodilator serotonin.40
Late dumping syndrome occurs roughly 1.5 to 3 hours after eating and may be related to consuming high-glucose foods, leading to an excessive insulin response that causes transient hypoglycemia.40 This reactive hypoglycemia (also called postprandial hypoglycemia, hyperinsulinemic hypoglycemia, or noninsulinoma pancreatogenous hypoglycemia) is commonly thought to begin late after gastric bypass and late after food ingestion, but it also has been reported early after surgery and soon after eating.39
Dietary modification should focus on eliminating simple sugars, concentrated sweets, high-fat foods, alcohol, and possibly lactose.41 Helping patients plan low-volume, high-protein, carbohydrate-controlled mini meals to be spaced equally throughout the day and advising them to separate food and fluid intake by 30 to 60 minutes may help.42 Consuming soluble fiber from guar gum, glucomannan, and pectin may help delay gastric emptying and increase small intestine transit time, slowing glucose absorption.41 Alpha-glucosidase inhibitors such as the prescription medication acarbose also may slow carbohydrate digestion, which can decrease the postprandial glucose and insulin response.40
In more complicated or severe cases, other health care professionals should be involved in treating reactive hypoglycemia. Dietitians would be part of a multidisciplinary team involved in hypoglycemia management. Physicians might consider treatments such as somatostatin analogs (eg, octreotide), pancreatic resection, reversal of the gastric bypass, or feeding into the excluded remnant stomach, which have variable results.39 In these rare cases, patients likely will be evaluated for nesidioblastosis (acquired hyperinsulinism with beta-cell hyperplasia) and even may undergo subtotal pancreatectomy.40
While diabetes remission rates with bariatric surgery are impressive, in a subset of patients who experience remission after surgery, diabetes does recur. DiGiorgi and colleagues followed 42 gastric bypass patients for three years after surgery and found diabetes recurrence in 24% of patients, most often in those with a lower preoperative BMI (48 vs 53). Recurrence was considered if HbA1c was greater than 6% and fasting glucose was greater than 124 mg/dL or the person had resumed taking diabetes medication after a period of resolution.43
The authors suggested that individuals with diabetes with a lower BMI produce less insulin or become insulin resistant with only minimal weight gain. Those who experienced recurrence also regained more weight after surgery. Since weight regain is associated with increased caloric intake, the increased demand for insulin may have reduced insulin sensitivity. In general, the more severe the diabetes in terms of duration and insulin requirement, the less likely it is that full remission will occur after bariatric surgery.43
Chikunguwo and colleagues found that 89% of 177 people with both obesity and diabetes had complete remission of their diabetes at some point after gastric bypass surgery 5 to 16 years earlier; in 43% of these patients, the disease recurred, which correlated with some weight regain.44 Durability of diabetes remission correlates with the type of preoperative diabetes therapy, as those treated with diet or oral hypoglycemic agents were more likely to achieve remission, while those treated with insulin were more likely to relapse. The authors suggested that while the mechanism still is unclear, those who need insulin therapy may be those for whom weight loss is insufficient to compensate for the decreased insulin secretory capacity.44 In addition, the mechanism that results in early or short-term diabetes remission may be different from that which mediates long-term remission.
These findings underlie the importance of bariatric surgery for people with diabetes and suggest that it isn't always just the heaviest, sickest patients who should undergo these procedures. Even less obese patients who present with diet-controlled diabetes may be good surgical candidates. Dietitians who work with diabetes patients should keep abreast of the literature in this field so they can present patients with evidence to help them decide what their best options are for controlling diabetes and their weight.
Dietitians should work closely with patients who have had bariatric surgery to promote long-term weight maintenance and initiate early intervention if patients begin to regain weight. For people with diabetes who have achieved remission, weight maintenance takes on added importance as it may keep diabetes in remission.
The recently published American Association of Clinical Endocrinologists' Comprehensive Diabetes Management Algorithm and Consensus Statement45 is a practical, evidence-based guide for health care providers who manage diabetes patients. They focus on glycemic control to reduce microvascular complications and obesity as an underlying risk factor for diabetes and macrovascular complications. Weight loss is recommended for all overweight and obese patients with diabetes or prediabetes to lower glycemia, improve lipid profile, and reduce blood pressure.45
This complications-centric algorithm for caring for overweight or obese diabetes patients is designed to help clinicians evaluate and stage patients for insulin resistance or cardiometabolic disease or biomechanical complications of excess body weight. Clinicians can use it to help determine therapeutic goals and decide on the intensity of treatment needed to help patients meet weight-loss targets.
Counseling by physicians or RDs, Internet-based programs, and structured multidisciplinary programs to promote therapeutic lifestyle changes are appropriate for all patients. Interventions such as weight-loss medications (eg, phentermines, orlistat, lorcaserin, phentermine/topiramate extended release, and/or any of the newly available drugs) are advised for patients with BMIs greater than 27 and who have comorbidities. Surgical therapy (eg, AGB, VSG, and gastric bypass) is recommended for those with BMIs higher than 35 and who have comorbidities, especially when therapeutic goals haven't been reached using other methods. The guidelines recommend periodic target reassessment and modifications of the therapy modality or intensities to achieve greater weight loss.
Based on the most recent evidence, weight loss appears to be one of the most effective treatments both for type 2 diabetes and severe obesity. Schauer suggested that if weight loss is achieved early in the disease process, patients will have a better chance of diabetes resolution.24 At this time, bariatric surgery is the most effective treatment for sustaining weight loss in the morbidly obese, and bariatric surgery should be considered as a treatment option for morbidly obese patients with type 2 diabetes who are appropriate surgical candidates.
Recently, the specialty fields of bariatric surgery and diabetes management have begun converging. In addition to the integral role that dietitians play in helping all bariatric patients on their journey to a healthier lifestyle, working with diabetes patients who are considering bariatric surgery adds another level of complexity. Dietitians in both fields will be expected to play a critical role in helping patients decide the treatment course that's right for their diabetes and/or obesity, prepare for the lifestyle and dietary changes required to manage diabetes and their weight, and manage nutritional complications such as reactive hyperglycemia or diabetes relapse.
— Nina Crowley, PhD, RDN, LD, is a bariatric surgery dietitian at the Medical University of South Carolina in Charleston who recently received her PhD in health psychology.
After completing this continuing education course, nutrition professionals should be better able to:
1. Compare and contrast common types of bariatric surgical procedures and resulting diabetes remission rates.
2. Evaluate and compare the current research on dietary or medical interventions vs surgery for diabetes remission.
3. Provide nutrition interventions for patients experiencing reactive hypoglycemia, diabetes relapse, and/or weight regain.
4. Use clinical practice guidelines and evidence-based research to help patients make informed decisions about treatment options for diabetes and obesity.
1. Diabetes remission rates are highest in the following bariatric procedure types in order of greatest to least):
a. Biliopancreatic diversion/duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGBP), vertical sleeve gastrectomy (VSG), adjustable gastric band (AGB)
b. BPD/DS, VSG, RYGBP, AGB
c. RYGBP, BPD/DS, VSG, AGB
d. RYGBP, VSG, BPD/DS, AGB
2. Which bariatric procedure has the greatest rates of resolution of hyperglycemia?
3. The hindgut or lower intestine hypothesis suggests that rerouting food through the altered gastrointestinal tract results in increased delivery of incompletely digested nutrients to the distal jejunum. Which of the following slows gastric emptying and suppresses appetite?
b. Glucose-dependent insulinotropic polypeptide
c. Glucagonlike peptide-1
4. What dietary modifications in the diet can you suggest to someone who has had gastric bypass and is complaining of symptoms consistent with late dumping syndrome?
a. Eat higher volume meals less often.
b. Eat lower volume meals spaced equally throughout the day.
c. Eat more protein and no carbohydrates.
d. Eat more carbohydrates and no fat.
5. How can consuming soluble fiber from guar gum, glucomannan, or pectin help a patient with reactive hypoglycemia manage his or her blood sugar levels?
a. Soluble fiber increases carbohydrate digestion.
b. Soluble fiber increases postprandial glucose and insulin response.
c. Soluble fiber delays gastric emptying.
d. Soluble fiber decreases small intestine transit time.
6. Which of the following can you tell a patient who has diabetes and a BMI of 31 about bariatric surgery?
a. Bariatric surgery is being considered for people with a BMI between 30 and 35.
b. Bariatric surgery is being proposed for people with diabetes and a BMI of 30 to 35.
c. Bariatric surgery is only for those with the most severe form of diabetes.
d. Bariatric surgery is only for those with a BMI higher than 40.
7. Using the American Association of Clinical Endocrinologists diabetes management algorithm for a person with diabetes who also is overweight, at what BMI should bariatric surgery be considered?
8. A patient considering bariatric surgery visits you to discuss diabetes remission after surgery. What can you tell her about current treatment for diabetes and the likelihood of permanent diabetes remission and relapse?
a. Treatment with diet or oral hypoglycemic agents is more likely to result in remission.
b. Treatment with diet or oral hypoglycemic agents is more likely to result in relapse.
c. Treatment with insulin is more likely to result in remission.
d. Treatment with insulin is less likely to result in relapse.
9. What helpful advice can an RD give to a patient who's overweight and has diabetes?
a. I'm not a bariatric dietitian, so I don't know what to tell you about surgery and diabetes.
b. The sooner you can lose weight, the more likely your diabetes will resolve permanently.
c. Get your diabetes under control, then we can discuss bariatric surgery.
d. Don't worry about your diet. If you have bariatric surgery, your blood sugars automatically will be under control.
10. What can you tell your patient about the BPD procedure?
a. It involves removing the functional stomach.
b. It leaves 200 cm of small intestine for digestive enzymes and nutrients to mix.
c. All obese diabetes patients should undergo the procedure.
d. It has the highest percentage of diabetes remission.
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23. Still CD, Wood GC, Benotti P, et al. Preoperative prediction of type 2 diabetes remission after Roux-en-Y gastric bypass surgery: a retrospective cohort study. Lancet Diabetes Endocrinol. 2014;2(1):38-45.
24. Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238(4):467-485.
25. Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:1-16.
26. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes — 3-year outcomes. N Engl J Med. 2014; 370(21):2002-2013.
27. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366(17):1577-1585.
28. Sjöström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683-2693.
29. Karra E, Yousseif A, Batterham RL. Mechanisms facilitating weight loss and resolution of type 2 diabetes following bariatric surgery. Trends Endocrinol Metabol. 2010;21(6):337-344.
30. Rao RS, Kini S. GIP and bariatric surgery. Obes Surg. 2011;21(2):244-252.
31. Yip S, Plank LD, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: A systematic review and meta-analysis of outcomes. Obes Surg. 2013;23(12):1994-2003.
32. Laferrerre B, Heshka S, Wang K, et al. Incretin levels and effect are markedly enhanced 1 month after Roux-en-Y gastric bypass surgery in obese patients with type 2 diabetes. Diabetes Care. 2007;30(7):1709–16.
33. Dar MS, Chapman WH, Pender JR, et al. GLP-1 response to a mixed meal: what happens 10 years after Roux-en-Y gastric bypass (RYGB)? Obes Surg. 2012;22(7):1077-1083.
34. Rubino F, Forgione A, Cummings DE, et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg. 2006;244(5):741.
35. Vetter ML, Cardillo S, Rickels MR, Iqbal N. Narrative review: effect of bariatric surgery on type 2 diabetes mellitus. Ann Int Med. 2009;150(2):94-103.
36. Nannipieri M, Baldi S, Mari A, et al. Roux-en-Y gastric bypass and sleeve gastrectomy: mechanisms of diabetes remission and role of gut hormones. J Clin Endocr Metab. 2013;98(11):4391-4399.
37. Peterli R, Steinert RE, Woelnerhanssen B, et al. Metabolic and hormonal changes after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a randomized, prospective trial. Obes Surg. 2012;22(5):740-748.
38. Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, ... & Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: Cosponsored by american association of clinical endocrinologists, The obesity society, and american society for metabolic & bariatric surgery. Obesity. 2013;21(S1):S1-S27.
39. Magee C, Clare K. Hypoglycemia after gastric bypass: findings from the Reactive Hypoglycemia Examination of Symptom Statistics (RHeosSTat) Survey [published online August 19, 2013]. Surg Obes Relat Dis. doi: 10.1016/j.soard.2013.08.002
40. Deitel M. The change in the dumping syndrome concept. Obes Surg. 2008;18(12):1622-1624.
41. DeLegge M, Petitpain D, Crowley N. Bariatric surgery and post-bariatric surgery nutrition needs. In: Kohlstadt I, ed. Advancing Medicine With Food and Nutrients. 2nd ed. Boca Raton, FL: CRC Press; 2012:341-355.
42. Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surg Obes Relat Dis. 2008;4(5):S73-S108.
43. DiGiorgi M, Rosen DJ, Choi JJ, Milone L, et al. Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up. Surg Obes Relat Dis. 2010;6(3):249-253.
44. Chikunguwo SM, Wolfe LG, Dodson P, et al. Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;6(3):254-259.
45. Garber AJ, Abrahamson MJ, Barzilay JI, et al. American Association of Clinical Endocrinologists' Comprehensive Diabetes Management Algorithm 2013 Consensus Statement. Endocr Pract. 2013;19(3):536-557.


text:
Soon investigative reporter Jace Larson will be packing up Rocky, his Italian Greyhound, and moving to KPRC from Gannett's KUSA 9News in Denver. That makes Larson the fifth member of the Post-Newsweek Houston station's investigative unit.
Larson has been at KUSA since 2007.
"I am very excited and can't wait to bring what we've done in Denver and add it to KPRC's strong viewer-centered coverage," Larson told mikemcguff.com. "Plus, it's nice to be moving to a bigger market."
According to Larson's bio, he's won the Columbia duPont Award, four Emmy awards and an Edward R. Murrow award. He's been nominated for a national Emmy award too. Plus the Investigative Reporters and Editors (IRE) group recognized his "Failed to Death" series, which covered Colorado's child welfare system, as a finalist in the Freedom of Information category.
In addition to Denver, Larson has done television stints in Tulsa, Oklahoma and Quincy, Illinois. He attended Principia College near St. Louis.
Oh yeah, Larson says his weakness is, "good food and a dirty vodka martini." Plenty of that available in H-Town. So if any miscreants out there want to butter this new Houston investigative watchdog up, that could be their method, but based on all of the awards on Larson's wall, I wouldn't count on it!
Texas will make this new transplant feel right at home. Larson grew up on a cattle ranch in Washington State and enjoys country music.
Look for Larson to join the channel 2 investigative team in October - just in time for November sweeps.
In the meantime, you can watch examples of Larson's work on his website.

domain: news


text:
[Trending Now] 20 Million Poor Filipinos Will Receive A Mandatory Basic Check-Up For FREE By Christmas From DOH!
An early Christmas gift to some 20 million poor Filipinos will be given by the Department of Health. As part of the Duterte administra...
An early Christmas gift to some 20 million poor Filipinos will be given by the Department of Health.
As part of the Duterte administration’s universal healthcare program, 20 million poor Filipinos will get free mandatory basic check-up on December, Health Secretary Paulyn Jean Rosell-Ubial said yesterday.
She said at a press briefing this mandatory check-up will be launched today to achieve an end date of Dec. 25.
“The first 100 days is the check-up. That means our goal is to really look into who are listed in the National Household Targeting System of the DSWD (Department of Social Welfare and Development) and to get to all those individuals," Ubial said.
She added that maintenance medicine can be given at the checkup while additional procedure like surgeries will be schedule at a later date.
"Kung sino ho ang makitang may further need, diagnostic—kailangan ng CT Scan, MRI, kailangan operahan—yun po ay gagawin natin in the immediate future. But the drugs and medicine, these are now available. As soon as the patients are detected in our check-ups, they will be provided the maintenance medicine," Ubial said.
Today will also be the launch of Sen. Risa Hontiveros’ event called National Health summit where she hopes that it will give the importance of local government units in preventive response.
"We need to seriously study the possibility of building super barangay centers to strengthen our current barangay health system by modernizing it with adequate facilities, personnel, and expertise," she said.
Universal health care is part of the Duterte Health Agenda that will be launched at the summit. Its three main goals is to prevent premature deaths "from the scourges of stressful daily living and emerging public health threats like drug addiction and Zika"; to give poor Filipinos freedom from high cost of medical care; and to give all Filipinos satisfactory experiences when they access health services.
The summit will formally unveil the universal health care plan of Duterte Health Agenda.
Its three main goals are:
- Premature death from the scourges of stressful daily living and emerging public health threats like drug addiction and Zika
- to give poor Filipinos freedom from high cost of medical care
- to give all Filipinos satisfactory experiences when they access health services

domain: medical


text:
One of Arthur C. Clarke’s best novels Childhood’s End is getting a miniseries treatment (6 hours worth) via Syfy with a staff featuring a highly efficient producers Michael De Luca and Akiva Goldsman, and a writer (Matthew Graham) and director (Nick Hurran) who both cut their teeth on Doctor Who and other British Television series. […]
From American Horror Story writer James Wong and NBC comes a little baby called Rosemary’s Baby.
How does the Serial Killer Killer hold up to the Deadite Destroyer?
Sorry, this is one of those “NOT MASTER CHIEF” series that people whine about but elated fanboys clap their cheeto stained hands about.
A one year celebration of the longest-running science fiction show in the world has to start somewhere!
What fan of Teenage Mutant Ninja Turtles doesn’t want to know how the Foot Clan started and how the Shredder came into power?
You know, I’ve never read Peter Pan, nor have I ever seen the play based off of the book. I’m a charlatan I know! However, that doesn’t stop me from enjoying the mythos that both Walt Disney and Robin Williams turned me onto when I was just a lad.
I picked up the book, Wicked: The Life and Times of the Wicked Witch of the West, a couple of years ago when my wife and I had our first child, and it was one of those books that I could not put down. Little did I know there was a musical out for it […]

domain: artistic


text:
-This pack contains many interesting modifications, which will make th...
- by JPModding
- by HazelEyed28
- by Shadowfx02
- by GXP-10
- by Catalin21
Gta IV weapon anims for GTA San Andreas
Speeds up the strelel′bu on the AK-47, MP-5, TC-9, UZI, M4! But it does not work on the sump, which...
Niko Bellic mod in GTA San Andreas. Only works via: Skin Selector v 2.1 for GTA San Andreas....
Great Subaru Impreza 22B. Works well in a filter sump. All clear)) tested!
This modification adds to almost any tire replaced models and on all standard models of the famous...
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domain: game


Maputo — A massive flood surge down the Limpopo River hit the town of Chokwe, in the southern Mozambican province of Gaza, on Wednesday morning.
The waters of the Limpopo were rising sharply as from 20.00 on Tuesday evening, but according to the mayor of Chokwe, Jorge Macuacua, cited by the independent television station STV, the main flood wave hit Chokwe at about 11.00 on Wednesday morning. By midday the entire town was swamped. Some of the smaller houses were completely submerged.
In some Chokwe streets, the water was about two metres deep. All the roads were impassable, and movement through the town was only possible in boats operated by the country’s relief agency, the National Disaster Management Institute (INGC).
The whole town has shut down, with all banks and shops closed. Electricity supplies have been cut.
These are certainly the worse floods Chokwe has faced since the huge flood on the Limpopo in 2000. The authorities have tried to organise evacuation.
The INGC has set up a temporary accommodation centre at the village of Xihaquelane, 40 kilometres from Chokwe town, but this centre can only accommodate around 600 people in 50 tents. The number of people at risk in Chokwe town and district is put at 55,000.
So many people have preferred to move 60 kilometres to Macia, capital of the neighbouring district of Bilene. A long queue of vehicles could be seen on the road from Chokwe to Macia, carrying people to safety. The same road became a corridor for herds of cattle, goats and sheep, as farmers tried to move their livestock out of the path of the flood.
A Chokwe magistrate, Fernando Macamo, contacted by the independent newsheet “Mediafax” described the situation as one of “extreme emergency”,
“My residence has been engulfed by the waters, all my property has been submerged, and to escape from this situation I have taken refuge on the terrace of the Limpopo hotel”, said Macamo. The hotel was much in demand from Chokwe residents who had ignored recommendations to leave the town.
Macamo and Macuacua both said that many other people have climbed trees or are stranded on rooftops.
Speaking to reporters on Wednesday in Maputo, the INGC general director, Joao Ribeiro, regretted that, although most people in high risk zones had left their homes, many others had stubbornly ignored recommendations to leave flood prone areas in the river basins of southern and central Mozambique. The INGC was therefore forced to resort to coercive evacuations in order to save lives, he said.
“We have begun to remove people affected by force, and now we’re stepping this up, because there’s still resistance and the danger is real”, he stressed,
Over the last few days, Ribeiro said, the INGC has increased its communications with endangered communities, including the use of megaphones urging people to leave their homes. “It’s not for lack of communication that people have not left”, he added. “We have informed people to abandon areas at risk, and most of them have now done so”.
The flood surge that engulfed Chokwe is moving downstream, and by Friday it will strike the Gaza provincial capital, Xai-Xai, near the mouth of the Limpopo.
The National Water Board (DNA) has urged everyone living on the lower Limpopo to evacuate now.
“The situation is critical and so people should evacuate”, declared Rute Nhamucho, head of the DNA Water Resource Department. “Xai-Xai is on maximum alert, and the city could be evacuated at any moment”.
The Maputo daily “Noticias” reports that people and institutions (both public and private) are already leaving Xai-Xai, fearing a repeat of the catastrophic floods of 2000.


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Written by Teresa Ristow
In the best of circumstances, the road to homeownership can be complex, and the day the keys are finally handed over can be life changing. In more challenging circumstances, it’s hard to put into words what it means. “It’s night and day,” said Eryn Sisson, who moved into her new home on Bend’s west side in late July. “We feel safe and sound and secure and spoiled.” Sisson and her son Paxton are the proud new owners of a two-bedroom, two-bath home in northwest Bend, in a mini neighborhood full of other new homeowners. The single mother and her son are just some of the faces of the latest Bend-Redmond Habitat for Humanity development, an eleven-home neighborhood off Northwest Juniper Street. For Sisson, the opportunity to buy a home through Habitat for Humanity couldn’t have come at a better time.
ROAD TO HOME
Sisson and now 11-year-old Paxton learned in March 2020, just a couple of weeks before the pandemic set in, that their northeast Bend rental was under foreclosure. They’d paid the rent each month, but the owner hadn’t kept up with the mortgage, and the bank was ready to step in. While Sisson scrambled to find another rental, a friend reminded her of Habitat for Humanity. She’d applied in the past, but never had quite the right qualifications to move forward. In order to pursue homeownership with Habitat for Humanity, applicants must fall into a specific income range, making more than what would qualify them for any public assistance, but less than seventy-five percent of the area’s median income when applying. Applicants must also have a solid credit score, have a steady work history, agree to 150 hours of volunteer work and help pay closing costs. Once they move in, they’re expected to pay a mortgage that matches thirty-three percent of their income at the time they enter the program. “It’s a massive commitment,” Sisson said. “And meant for people who are living way below their means.” Sisson has spent the past seven years as a paralegal, and with a steady work history and just the right circumstances, this time she was approved.
The next eighteen months were kind of a blur. Sisson and her son spent time volunteering at the ReStore, Habitat for Humanity’s secondhand store for home goods and tools. When construction started on their future home, they also pitched in on Saturdays, helping to literally raise the walls of the residence. Sisson learned about homeownership and budgeting through online classes and Zoom meetings organized by Habitat. In the meantime, Sisson continued her full-time job and Paxton stayed busy with remote schooling while the two lived in a temporary rental.
Eventually, near the end of the process, Sisson and her son visited a park in Bend where they were introduced to many of their future neighbors. Many have shared stories of overcoming hardships, but together Sisson envisions they’ll become a tight-knit group of neighbors who support each other and recognize how significant the opportunity of homeownership is for them. “I can’t even explain it, we are so grateful,” she said. “And we deserve this, and I think every family in the neighborhood deserves this.”
In Central Oregon, Sisson and her son are one of many families struggling with the region’s lack of affordable housing, according to Robin Cooper Engle, vice president of resource development for Bend-Redmond Habitat for Humanity. The local organization, which is affiliated with the greater Habitat for Humanity but operated and funded independently, tries to plan a few years ahead on inventory of homes, but even with dozens of homes in the pipeline, the need is far greater, Cooper Engle said. “There are a lot more applicants than we can serve,” she said. Habitat works with local cities, foundations, businesses and private donors to raise money for land and construction, and generates money from the ReStore, but the organization is always seeking more funds to keep up with demand. In the case of the west Bend development, the undeveloped land was donated to the organization, and Habitat will own and lease the land to the new homeowners, with an agreement that if the homeowners wish to sell, they must sell back to Habitat to ensure the home ends up in the hands of another applicant. “It’s just really about serving people with housing,” Cooper Engle said.
Cooper Engle and her daughter Carly went through the Habitat program themselves eleven years ago, when Cooper Engle was a single mother and Carly was three years old. The experience gives Cooper Engle a unique perspective and deep appreciation for the organization she works for. “Giving people an opportunity for homeownership is so transformational,” she said.
Sisson and Paxton moved into their new two-story home in late July. It’s 1,200 square feet (including a garage) and is just the right amount of space for the duo. Paxton, a sixth-grader at Pacific Crest Middle School, settled into the downstairs bedroom, and his mom moved in upstairs, taking advantage of a small walk-in closet and her own upstairs bathroom with a tub. The home has white cabinetry, light finishes and neutral walls, allowing Sisson to customize the space and add her own pops of color, which she quickly started doing late this summer. Just before they moved in, the home was staged with furniture from the ReStore for showings as part of the Central Oregon Builders Association Tour of Homes. When the family of two began moving in, they were gifted a beautiful coral couch from the staging, and Sisson designed the rest of the living room around it. It’s a comfortable sitting piece that’s well enjoyed by the family’s two cats—one-year-old Watson, and Pua, who was adopted this summer.
While the family was still settling in this September, Sisson was quick to share what they’re enjoying about the home so far. “It’s bright, and it’s happy and it’s everything we ever wanted or needed,” she said. Together, she and Paxton love cooking—they’ve recently been making Asian dumplings—and Paxton is planning a tinkering space in the garage to work on projects. Paxton loves spending time outside the home, on his pogo stick, playing basketball or biking around. Sisson also just got a bike, a pink cruiser, which will be great for transportation around town. “I haven’t used my vehicle hardly at all since I’ve been here,” Sisson said. “We’ve just been walking everywhere.”
Finally moved in and able to reflect on their journey over the past year and a half, Sisson gets teary eyed thinking about how much has changed, and what their future looks like in their new home. “We’re going to build our life here—and we get to figure out what that looks like, inside these walls.”


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There have been a lot of people asking for more details on my meal plan. I am going to briefly touch on the main key points here, as I have something coming along that will go into much greater detail!
First I’ll talk about my particulars… I am somewhere between 18-22% body fat therefore I need to eat more fat to meet my energy needs and not take too big of a deficit. This is where calorie cycling comes in. There are a couple different ways to cycle. You could eat at say a straight 20% deficit for three weeks then on the fourth week eat at maintenance; this is a simple straight forward approach. I choose to use a three tier approach and cycle with my training. Cycling a low, medium and high calorie day paired with the intensity of my training. Low being rest days and high being my most intense workout.
I also incorporate circadian weighted meal timing. This optimizes meal timing and content of meals to coincide with our bodies’ natural rhythms which are regulated by day night cycles. There are three aspects to this.
- First is the general idea to eat when you are active, therefore during daylight hours and to have all your meals in before night fall.
- Second that body has different times when fat and muscle tissue is more or less insulin sensitive and this affects when we should be eating the carbohydrates contained in our diets.
- And thirdly, Breakfast should be the biggest meal and less for lunch and less for dinner, and partially over laps with the second point above.
I also implement a TKD (targeted keto diet) protocol. This is a method for consuming some quick absorbing carbs right before training to help fill muscle glycogen to support great effort.
Lastly I also aim to maximize MPS (muscle protein synthesis) so no snacking, all food is eaten with a meal, and these meals are spaced to allow the body to refill ATP and for plasma levels of leucine to fall back to baseline, and set up for the next time MPS is triggered. Also enough leucine is eaten at each meal to trigger MPS in the first place.
I really concentrate on getting enough leucine and therefore about 2/3 of my protein for the day comes from cheese like swiss, parmesan and cheddar. I find that as long as I keep the cheese to meals, and DO NOT snack on it, it does not negatively affect me at all! And since I have always loved cheese it makes my meals very enjoyable. The meats I generally eat are things like chicken breast, sirloin or ny strip steak, salmon, eggs (whole and whites) and ground beef of varying fat contents to meet my macros. I actually eat salmon every night for meal 3; this optimizes omega fatty acids as well. I include some veggies in my first two meals; such as broccoli, asparagus, spinach and green beans.
This is really the nuts and bolts of my meal plan. As you can see I aim to optimize a lot of different areas, and I feel that it is really paying off! I am eating 1650-2200 calories and losing 1-2 lbs a week. I am very close to goal, and generally losses like these are not realized with so little weight left to lose. I lift intensely in the gym and do very little cardio.
Please stay tuned I have some exciting things coming up in the near future! Hoping you all success in your weight loss / muscle gain efforts!
Meal Timing & When to Eat
Insulin sensitivity/Insulin Resistance (IR) & Muscle Protein Synthesis (Ketogenic Dieters Facebook Group Post)
Here are is some further reading on circadian rhythms.
Further reading on TKD
Videos and further reading on MPS
Dr. Layne Norton presents on Refractory Phenomenon
some further reason not to snack
Cheese Rocks for protein and leucine especially Swiss, Parmesan & Cheddar
List of some meats to reach leucine threshold for mps (Ketogenic Dieters Facebook Group Post)

domain: food


text:
As days become shorter and cooler, time out-of-doors slips away. Ten Thousand Villages Wildwood Jewelry Collection replicates the colors of fall and the shapes of summer, allowing you to adorn yourself with natural beauty.
Find a sampling of our earth-inspired jewelry collection below and browse the full collection online and in-store!
This set captures the vibrant colors of autumn. Created with sustainably harvested tagua nuts carved into irregular beads, the necklace and bracelet add the hues of fall to your ensemble in a simple, understated way.
Hand-embroidered flowers whisper of summertime memories in this stylish shoulder bag. Keep your closest possessions safe in this fall-inspired bag.
These silver-plated earrings depict the Banyan Tree, a symbol of life and power. Share your affinity with nature as you complete your outfit with these memorable earrings.
Chase cooler breezes away with a rust-colored light silk scarf from Laos. With a distinct linen-like appearance and texture, Lao silk sets the standard for natural beauty. Hand-woven and naturally dyed, the scarf bears the gentle strength of the Lao women who create it.
Forged from the deepest mountains of Peru, silver and stone collide in this beautiful cocktail ring, available in assorted colors and adjustable. At $16 each, you can afford to have one of each color.


text:
The business meeting of IPA will be held in Beijing from May 15-17, China. This meeting will be hosted by the Institute of Vertebrate Paleontology and Paleoanthropology (IVPP), Chinese Academy of Sciences.
The meeting includes about 20 participants, including the Executive Committee members of IPA, such as President, Vice president, secretary-general, Councilors-At-Large, Last President, Last Secretary-General, Representatives of Corporate Members, and members of specially invited.
The major topics of this business meeting till include, 1), to enhance connections of IPA with IUGS and IUBS in order to make IPA more active and visible among world geological and biological community; 2) discussion on the establishment of fellow of IPA and other honors or prizes of the organization. 3) discussion on how to improve the Paleoparks Projects, in order to have it play a bigger role in promoting the conservation of important fossil sites and raising the public awareness of the significance of the fossil conservations. 4), discussion on how to expand the number of the membership of the IPA. 5), discussion on issues of the next IPC in 2018.

domain: biology


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text:
Australian Machine Quilting Festival
AMQ Festival 2012 will be held at the Award Winning Adelaide Convention Centre, North Terrace, Adelaide. AMQ caters for all machine quilters that own either a Long arm, Mid arm AND/or domestic sewing machines.
Featuring the amazing world reknowned quilt artist, teacher, author, TV Show host & concert pianist Ricky Tims.
BERNINA Australia Ricky Tims Seminar
RICKY'S BEST KEPT SECRETS - all day seminar!
Friday 28th September 2012 at the Adelaide Convention Centre Hall C, North Tce, Adelaide
Join Ricky Tims as he shares some of his most sought after quilting secrets in a day-long event that will leave you amazed and wanting more. Enjoy entertaining and informative live lecture and video demonstrations as Ricky shares his favourite tips, techniques and a ton of fantastic quilting information.
For more information visit the AMQ Festival website http://www.amqfestival.com.au
The 4 day event also includes:
Vendor Mall with up to 50 booths
Quilt Show presented by the Australian Machine Quilting Association Inc
Classes for longarm machine quilting, domestic machine quilting, digitising for quilters AND machine embroiderers & more....
BERNINA Australia Gala Evening featuriing a banquet dinner, special concert by Ricky Tims and Alzheimer's Benefit Quilt Auction!


text:
Chennai, Oct 6 (PTI) Leader of Opposition and DMK chief M K Stalin on Tuesday urged Chief Minister K Palaniswami to convene the Assembly and pass resolutions against the Centre's farm laws and file a petition in the Supreme Court challenging the legislations.
These laws have triggered a wave of opposition among the farmers and people, Stalin said,adding only the state governments had powers under the Constitution to enact laws on agriculture and related aspects like land and land tenure as they fell under the state list.
Tamil Nadu cannot be a mere spectator or accept Centre 'entering' the field assigned to states by the Constitution on agriculture matters, the leader of opposition said in a letter to Palaniswami.
Pointing out that his party has already gone to the apex court against these Central laws, he wanted the Tamil Nadu government alsoto challenge it in the Supreme Court.
The DMK president urged the Chief Minister to recommend convening the Assembly immediately to debate and adopt resolutions against the farm legislations.
Such initiatives were 'necessary and urgent' so as to 'avoid blame' from farmers against the state government, he said.
DMK, an ally of the Congress, had both inside and outsideParliament vehemently opposed the legislations.
The party staged state-wide protests including a candle light march to Raj Bhavan led by party MP Kanimozhi on Monday. PTI VGN BN WELCOME WELCOME

domain: law


text:
Royal Canin Yorkshire Terrier Adult Wet Food Pouch
ROYAL CANIN® Yorkshire Terrier in Loaf contributes to maintaining the skin and long coat health of Yorkshire Terriers with an exclusive blend of optimal nutrients – to help keep their coat glossy, shiny and silky.
This food also helps support digestive health with a precise level of nutrition that has been formulated specifically for the Yorkshire Terrier breed. ROYAL CANIN® Yorkshire Terrier in Loaf is crafted to provide an adapted texture in order to increase levels of palatability to help stimulate your dog's appetite.
The scent and softness of this tasty loaf should help satisfy the appetite of even the fussiest Yorkshire Terrier!
To cater to each dog's individual preferences, ROYAL CANIN® Yorkshire Terrier in Loaf is also available as dry food, with crunchy and tasty kibble.If you're considering mixed feeding, simply follow our feeding guidelines to ensure your dog gets an accurate amount of both wet and dry food for optimal benefit.
- Coat health: Contributes to maintaining the health of the Yorkshire terrier’s skin and long coat with an exclusive blend of nutrients.
- Appetite stimulation: Help satisfy the Yorkshire Terrier’s appetite.
- Stool quality: Helps support digestive health.
Meat and animal derivatives, derivatives of vegetable origin, cereals, minerals, oils and fats, various sugars.
Additives (per kg):
Nutritional additives: Vitamin D3: 190 IU, E1 (Iron): 9 mg, E2 (Iodine): 0.3 mg, E4 (Copper): 2.2 mg, E5 (Manganese): 2.7 mg, E6 (Zinc): 27 mg - Technological additives: Clinoptilolite of sedimentary origin: 2.2 g.
Protein: 8.5% - Fat content: 6.0% - Crude ash: 2.2% - Crude fibres: 1.6% - Moisture: 78.0%.

domain: pet


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What is the U = U statement?
Scientific research is clear: people living with HIV who are adhering to an effective treatment plan and have an undetectable viral load cannot pass the virus to their sexual partners.
The Undetectable = Untransmittable (or U = U) consensus statement has been endorsed by more and more medical professionals and HIV service organizations. The U =U consensus statement states that the “risk of HIV transmission from a person living with HIV (PLHIV), who is on Antiretroviral Therapy (ART) and has achieved an undetectable viral load in their blood for at least 6 months is negligible to non-existent. While HIV is not always transmitted even with a detectable viral load, when the partner with HIV has an undetectable viral load this both protects their own health and prevents new HIV infections.”
We at Realize are proud to endorse the U= U consensus statement via this video. It is important to help clear the air about the transmissibility of HIV, about the stigma associated with living with HIV, in order to ensure people living with HIV can get access to the most effective treatment and live longer, healthier lives. We hope you will join us in sharing this message with your friends, family and colleagues.
For more information about the U=U statement, please visit: www.preventionaccess.org/consensus

domain: health


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I thought I would share what I wrote in my journal last night. So I can remember it in more place than one.
Life is a thousand sorrows.
I see them in my impatience with the dog, the hurried snap of displeasure. I see them at the stop sign when I just want the person ahead to be brave and go. I see it in the way I gloss over people who ask “how are you?” because internally they long to be asked. They long to be really seen. I see it in my anger toward coworkers and frustrations toward family. Sorrows roll with me out of my thankless bed into my thankless day as I awake from restless, dissatisfied slumber.
A thousand sorrows trail behind my selfishness, laziness, cruel words, careless attitudes, impatience, forgetfulness, worry… sorrows upon sorrows. Day upon day. Moment upon moment.
Paradoxically, look closely enough to see that life is also… a thousand gifts.
Thankfulness that rises to the sky with a bright sun every morning. I see these gifts in the peanut butter I spread on morning toast and coffee I drink with a faint smile. I see them in the stranger’s eyes that light up with kind words given. I see them in moments I stop to pet my puppy. When I choose love instead of impatience. When I trade frustrations for forgiveness, passiveness for hard work, hurried moments for tranquil time… I see blessings fall down with each sunset and rise with the lift of heavy weights. Gifts pour with sweat from exercise, because… I CAN. I see them in the car as tears flow to His Glory! I see them in the hands of small children who ask to pray, in innocent eyes that answer gnawing questions. Gifts shower me with shock as I read word upon word in exodus and weep for joy at the beauty of Israelite people being His, and Him being their God, worshiping day after day.
Every day. Every moment. A thousand gifts. Blessings. Smile. Love.

domain: literature


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Atelier Swarovski Kalix Ring Black
Named after a great European river, the Atelier Swarovski Kalix collection is inspired by the many qualities of water. This striking ring features sparkling crystals and blackened metal, capturing the icy, spiked, crystalline forms of the Nordic peninsula in winter. Each spike is gently rounded to avoid discomfort. An empowering and bold statement piece that adds instant glamour to any outfit.


text: This came across my desk the other day; though some of you might find it interesting. Some sections are technical, but you can get the major points. Very long migration routes for large catfish species, and the negative results of anthropogenic actions. Thank you chicxulub for assistance with the pictures. Hopefully I get them posted in the correct order.

domain: geography


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The level of commercial mortgage debt outstanding dropped 0.9% in the first quarter to $3.31 trillion, according to the Mortgage Bankers Association (MBA), which analyzed Federal Reserve Board data.
Declines in commercial mortgages held in commercial mortgage-backed securities (CMBS) drove the decrease, along with construction loans held by banks and thrifts, the association reported.
The debt outstanding recorded by the Federal Reserve in the first quarter represents $31 billion less than the amount outstanding in the fourth quarter of 2009. However, multifamily mortgage debt outstanding rose to $852 billion, an increase of $3 billion, or 0.4% more than in the fourth quarter of 2009.
“Low levels of commercial mortgage borrowing mean that property investors are paying off and paying down more in mortgages than they are taking out,” said Jamie Woodwell vice president of commercial real estate research at MBA.
“The balance of construction loans at banks, and commercial and multifamily mortgages held in CMBS and by life insurance companies, saw the largest declines. The balance of multifamily mortgages backed by Fannie Mae, Freddie Mac and FHA saw the largest increase,” added Woodwell.
The Federal Reserve’s flow of funds data summarizes the holding of loans or the form of a security, according to the MBA. Many life insurance companies invest both in whole loans for which they hold the mortgage note, and in CMBS, collateralized debt obligations (CDOs) and other asset-backed securities.
Commercial banks hold the lion’s share of commercial loans, including multifamily mortgages. The commercial banks hold $1.49 trillion, or 45% of the total.
Among the top 10 commercial real estate bank lenders, 48% of their aggregate balance of commercial real estate loans, excluding multifamily, were related to owner-occupied properties, according to MBA. The borrower's business income, rather than income derived from a property's rents and leases, drives the underwriting, pricing and performance of those loans.
CMBS, CDO and other asset-based issuers are the second largest holders of commercial mortgages, with $679 billion, or 21% of the total. Agency and government-sponsored enterprise portfolios and MBS hold $309 billion, or 9% of the total. Life insurance companies hold $302 billion, or 9%, and savings institutions, $184 billion, or 6% of the total.
The government-sponsored enterprises and Ginnie Mae hold or guarantee the largest share of multifamily mortgages, 36% of the debt outstanding for apartments, amounting to $309 billion.


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Big Eyes, Little Plates
Cherry picking at Piattini
By Gail Guengerich
Gail Guengerich checks out a new Italian restaurant that’s rigged for sharing.
A Drinkable Feast
Dark, Incurable and Violent
Celebrate Hunter S. Thompson’s birthday with local beer and food
By Hosho McCreesh
Drunken poet Hosho McCreesh celebrates the great gonzo’s b-day with local food and drink.
Tequila, Taco and Cerveza Fest
By Rini Grammer
A showcase of diverse Mexican alcohols, unique local taco recipes, live bands, water pong, Chihuahua racing and much more.
Fundraiser Night at Flying Star Café
Benefiting Companion Animal Rescue and Medical Assistance which is a non-profit organization that helps with the adoption and placement of rescue animals.
Tasty Wednesdays at the Farm Shop at Los Poblanos Historic Inn & Organic Farm
Cinco de Mayo Celebration at M’Tucci’s Cocina GrillMore Recommended Events ››


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Rakul Preet Singh is one of the prettiest actresses of Bollywood and while she is unstoppable with releases this year, she is charming her way into the hearts of the audiences in any and every role she takes up, looking only more gorgeous than ever. Every year, she is coming up with amazing performances and we can not get over how soothing to the eyes she is in every look and role.
With several films slated to release and many already released, Rakul has made a special place in our hearts with her magnificent aura and distinct charm. Here is looking at a glimpse of all her looks from films in 2022 alone:
With the first release of the year being, Attack, her performance as a scientist was widely talked about. She looked spectacular playing that role and her intelligence really added extra charm to her character.
The actress played the role of a Pilot in the film Runway 34 and she looked as gorgeous as bold in such a different character.
Her role in Cuttputlli was fierce and she made an impressive outing in it.
Rakul Preet and Ayushmann Khurrana starrer Doctor G is gearing up for release and in the trailer released, we couldn’t get over how gorgeous Rakul looked in the character of a medical student in the film.
Thank God is yet another film featuring Rakul Preet that is gearing up for release and the actress will be seen playing the role of a police officer. Without a doubt, she is the prettiest cop to be added to the massive cop universe of B-town.


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Educational trip to Chandigarh was organized on the 27th of November, 2022 by the Department of Horticulture
An educational trip to Chandigarh was organized on the 27th of November, 2022 by the Department of Horticulture, for IV-year B.Sc. students. The students learned about different varieties of roses like B P Pal, Queen Elizabeth, and Twice in bloom, and some introduced hybridized varieties like Kiss of Fire, Cristina, etc. Students learned about the cultivation of some varieties of wild #rose, fairy rose, icebergs, and their creepers. Students along with the faculty members namely Dr. Kanika Issar, Dr. Jagdish Purohit, and Ms.Himani Rawat also visited Rock #garden. The students got a very good practical exposure to gardens and museums, specifically the Dolls Museum in Rock garden.


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Celebrate Three Kings Day with this shining star design! Actual item and print may differ in color, as every monitor is made and calibrated differently.
- Print may appear slightly different in size, color, and location on item than in picture shown.
- Unique, TooLoud (trademark) copyrighted design.
- Authentic TooLoud brand, printed with pride in the USA.
- flat polyester on one side, and quilted heat-resistant fabric on the other.
- Original design.
Feliz Dia de Reyes - Estrellas Brillantes White Fabric Pot Holder Hot Pad by TooLoud 2


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Preparedness Advice Blog
- The Best Strategy for Homeschooling When Life Gets Hard
- Survival Shopping at Costco: A Quick and Easy Guide
- 6 Important Survival Lessons I Learned as a Scout
- The Food Storage Companies I Recommend and Why
- Simple Food Storage Meals for Tight Times: Stock up on three months worth, fast!
- 5 Common Sense Steps to Grow What You Eat
Tag Archives: funnel oven
Today I went to the Solar Oven Cook Off. Not a large crowd but a lot of good information. For today, I am going to post a spread of pictures of different ovens. Later in another post we will discuss some of them in detail.
Picture 1 Is a simple oven, the man who owns it cooks a high percentage of his meals with it on a regular basis.
Picture 2 A homemade oven that reached temperatures of over 300 degrees.
Picture 3 A Sun Brand oven, it worked well.
Picture 4 An oven made by the Solar Oven Society, it was the least favorite one at the cook off.…Read More...


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Kanye West Biography
Kanye West is an American rap artist, manufacturer, and stylist, born upon June 8, 1977, in Atlanta, Georgia. He is understood for his ingenious and also influential work in hip-hop music, along with his forthright individuality and also debatable public statements.
West matured in Chicago, Illinois, and also began making songs in his teens. He gained focus in the early 2000s for his work as a manufacturer, working together with musicians such as Jay-Z
, Alicia Keys
, and Ludacris.
In 2004, West launched his launching album, "The College Dropout", which was a vital and also industrial success, earning him numerous Grammy Awards. He took place to release a collection of highly well-known cds, including "Late Registration", "Graduation", and "My Beautiful Dark Twisted Fantasy", sealing his standing as one of one of the most significant and also cutting-edge numbers in hip-hop.
In addition to his songs profession, West has likewise worked as a fashion designer, teaming up with brand names such as Adidas as well as Louis Vuitton. He has been recognized for his strong as well as controversial style options, usually pressing the limits of typical gender standards as well as stereotypes.
West has additionally been recognized for his outspoken and questionable public statements, including his support for President Donald Trump
and his criticism of various other celebs and also somebodies. He has been the topic of conflict as well as criticism throughout his occupation yet has actually likewise been commended for his creative vision and his willingness to take risks.
Despite the conflicts surrounding him, West continues to be one of the most prominent and also celebrated figures in hip-hop and popular culture. He remains to press the borders of music, fashion, and art as well as to inspire and also challenge audiences around the world.
Our collection contains 23 quotes who is written / told by Kanye.
Related authors: Donald Trump (Businessman), Pharrell Williams (Musician), John Legend (Musician), Beanie Sigel (Musician), Lloyd Banks (Musician), Nick Cannon (Musician), Andre Benjamin (Musician), Kim Kardashian (Celebrity), Lawrence Taylor (Athlete), Rick Ross (Celebrity)
Source / external links:

domain: celebrity


The Function Editor is a visual programming language for building imagery and raster analysis workflows. An analysis workflow can be saved as a raster function template (RFT) that can be used to automate processes or for rendering. You create and modify RFTs in the Function Editor pane. The Function Editor represents a function chain as a diagram that chains together function sequences using the output of one or more functions as the input to another function.
You can use various techniques to model a process that results in an RFT. For example, you can open the Function Editor pane and insert a raster variable and any functions. In this mode, no input data is connected to the chain so certain capabilities, such as previewing the result of a section of the processing chain, are disabled. Once data is connected to the processing chain, you can preview the results. You can save the raster function chain (now the RFT) and share and run it with different input datasets.
You can apply a raster function on a raster layer in the map using the Raster Functions pane, which creates a temporary raster layer in the map. You can also apply additional raster functions on the output layer. When you are finished applying functions, right-click the final output and click Save Function Chain or Edit Function Chain. The layer with the final function applied to it contains all of the previous functions with their parameter settings. Saving a layer's function chain removes the original input data and inserts raster variables that can be made public so the template can be used again with different data.
The function or raster function chain must have a final and single output to be valid.
You can do the following using the Function Editor pane:
- Visualize a workflow sequence as a diagram.
- Build an RFT by adding raster functions, raster variables, scalars, raster layers, datasets, and other data types to the diagram and connecting them to perform an analysis. The analysis can be performed on the current display extent or in a distributed manner using raster analysis on Portal for ArcGIS.
- Iteratively check parameters on a function raster layer's function chain. To interact with the display and the settings in the function chain, right-click the function raster layer in the Contents pane and click Edit Function Chain. When you make changes to parameters, click the Apply button on the Function Editor toolbar to refresh the layer to reflect the changes.
- Save a function raster layer's function chain as an RFT.
- Make an RFT usable to others by renaming functions, raster variables, and function variables.
Tools in the Function Editor
The Function Editor provides a set of tools available on the toolbar at the top of the Function Editor window.
Tools in the Function Editor
Move around the diagram.
|Fixed Zoom In
Zoom in by a fixed factor.
|Fixed Zoom Out
Zoom out by a fixed factor.
Automatically arrange the elements in the diagram.
|Fit to Window
Fit the entire diagram within the visible view of the window.
|Insert Python Raster Function
Insert a Python raster function by importing a script file (.py).
Add an input raster dataset to the diagram.
Add an input constant value representing a constant raster.
|Add Raster Variable
Add a raster variable, which is a default value that can be changed.
Delete the selected elements in the diagram.
Save the raster function template to the Project category or Custom category section of the Raster Functions pane.
Save the raster function template with a new name and location.
Open the Raster Functions pane.
The RFT below demonstrates a methodology for describing burn severity and the health of vegetation recovery using prefire and postfire imagery.
This example RFT is composed of the following raster functions:
- Apparent Reflectance—Express the input imagery as albedo, which is the percentage of the available energy reflected by the planetary surface. It is commonly used by scientific users for complex modeling and technical remote sensing applications.
- Band Arithmetic—Perform a normalized burn ratio (NBR) index for prefire and postfire data from the output of albedo data.
- Minus—Create the change (or delta) in the NBR from the prefire NBR and postfire NBR.
- Remap—Define class break values for severity and vegetation health from the difference of the NBR.
- Attribute Table—Assign attributes and colors to the integer values created from each class defined in the Remap function.
Access the Function Editor
To build an RFT using the Function Editor, open a new editor window. Click the Function Editor button in the Analysis group on the Imagery tab. Then select and drag raster functions from the Raster Functions pane into the Function Editor pane.


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Perhaps the most significant trend is that a mighty 4 in 5 internet users aged 16-64 say they have interacted with a brand in at least one of the 20 different ways we monitor in the GWI survey. And this rises still higher among certain groups – hitting 85% for 16-24s and peaking at an impressive 95% in fast-growth markets such as Indonesia and Vietnam.
Brand websites remain crucial within this process; almost half of internet users say they have visited one in the last month. Somewhat fewer have “liked” a brand (28%) or visited a brand’s social network group/page (22%), but there’s a notable over-index for these behaviors among 25-34s – a group which remains particularly wedded to social media.
Branded videos are a major touchpoint too: 1 in 5 have watched one within the last month and – globally – more people are now visiting YouTube than Facebook each month.

domain: sociology


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You can free download Novel The King’s Captive by K. M. Shea in Epub & PDF format on fictiondose.com.
- Novel: The King’s Captive
- Writer(s): K. M. Shea
- Format: Epub & PDF
I can turn into a housecat.
It’s a fun magic, except in a world filled with vampires and werewolves, it doesn’t exactly make me a powerhouse. Instead, the supernatural community has classified me as an outcast, which means one thing: picking on me is open season all day, every day.
The local fae are the worst of all, and it’s during one of their regular “capture the cat-girl” sessions that I shift into my cat form and meet HIM for the first time.
Noctus is so powerful his magic radiates off him like a sun, and my fae captors can barely look in his general direction. And then my life gets even more terrifying when Noctus decides to take me with him. As a pet.
Why did he pick today to “adopt don’t shop” a cat?
It gets worse when I realize he’s an elf, a ruling race of supernaturals that was supposedly killed off centuries ago.


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OTTAWA • It seems obvious that promoting trade between provinces would be easier if truckers didn’t need to change tire sizes just to transport their goods to market.
But that is just one example of the roadblocks that still exist in Canada’s regulatory landscape.
There are other hurdles of red tape that businesses must clear before they can operate or invest across borders; labour mobility has been another stumbling block.
There are too many impediments here
Industry Minister Christian Paradis likens these internal trade barriers to “an invisible monster” that is eating away at tens of billions of dollars in economic productivity each year.
“There are too many impediments here. We cannot do business among each other,” said Mr. Paradis, who is this year’s chairman of the Committee on Internal Trade (CIT), an offshoot of a 1995 agreement between federal, provincial and territorial governments to harmonize barriers to trade, investment and mobility.
Slaying that “invisible monster” remains a work in progress.
“It has to become visible, and we need to all be aware of it to ensure we combat it, and make sure we have open markets everywhere in Canada,” the minister said in an interview Thursday, after speaking at a symposium on trade barriers in Ottawa.
“It’s easier for us to go into China or Romania than to go into Quebec. It doesn’t make sense.”
The 100 or so who gathered in Ottawa — government and business representatives, as well as public policy experts and academics — were asked to access the track record of the 1995 Agreement on Internal Trade and make recommendations at CIT’s annual meeting, set for the fall and likely to be held in Ottawa.
The federal government says CIT has made progress in areas such as labour mobility for regulated occupations, and freer trade in agricultural products.
Some provinces have already moved ahead with harmonization. For instance, the New West Partnership Trade Agreement — initiated in 2010 — integrates cross-border regulations between British Columbia, Alberta and Saskatchewan.
In his speech Thursday, Mr. Paradis said “we need to build off agreements such as the New West Partnership.”
“These provinces have become an economic powerhouse with a combined GDP of $500-billion and a market of nine million Canadians. That translates into money in the pockets of our entrepreneurs.”
It might seem silly, but this is the state of the matter here
The tire-size example speaks volumes for the harmonization problems still facing the country.
“If you are a trucking company, you have to change your tires on your van depending on which province you are in,” Mr. Paradis told the Financial Post.
This only adds to the costs for businesses and cuts into the country’s overall economic growth, he said. “It might seem silly, but this is the state of the matter here.”
Martin Lavoie, director of policy at Canadian Manufacturers & Exporters, says is if a truck is carrying a large load — such as an aircraft fuselage — to Toronto from Halifax, for example, “all provinces will have different rules with respect to when you can go on certain types of highways and roads.”
“If you need to cross three or four provinces to get your fuselage to Ontario you might face less regulations if you bring it to the port of New York and put it on a truck directly to Toronto.”
Some estimates put the cost to the economy of undue red tape at as much as $50-billion a year.
“It’s hard to put a number on it, but we know there is a problem,” Mr. Paradis said.
As CIT chair, the minister hopes to raise public awareness of the problem, along with political awareness. His goal with other levels of government is to reform rules so they are fully harmonized, such is the case with the New West Partnership.
He also wants simplified business registrations and reporting methods, along with more consistency between international and internal trade rules, and the removal of barriers created unilaterally by federal regulators.
“These will be the four pillars that I think we can achieve.”
Mr. Paradis acknowledged that Ottawa is not without overlapping jurisdictions among its own departments.
“I want to make sure the Feds are seen as not just talking the talk but walking the walk. We want to lead by example. We are seriously committed to make sure we clean our own shop.”

domain: economics


Best Selling Suv In America 2020
A global bestseller sets another new record: in spring 2020, the Volkswagen Tiguan broke the production barrier of six million units. A total of 910,926 units of the SUV were manufactured in 2019 . A global bestseller sets another new record: in spring 2020, the Volkswagen Tiguan broke the production barrier of six million units. A total of 910,926 units of the SUV were manufactured in 2019 .
Tiguan is now best-selling model in the Volkswagen Group, and one of the top three best-selling SUVs Production has increased from 120,000 a year in 2007 to just shy of 911,000 units in 2019 . In spring 2020, the Volkswagen Tiguan broke the production barrier of six million units, with 910,926 units manufactured in 2019 alone. This makes the Tiguan the best-selling car in the Volkswagen .
Ford Mustang celebrates 56th birthday as the world’s best-selling sports car. Alvin Reyes – Apr 17, 2020, This makes the Ford Mustang the best-selling sports car in America for the last 50 years. . Volkswagen will unveil a refreshed Tiguan SUV later in 2020, featuring new front and rear styling, a redesigned interior and new powertrains, including a plug-in hybrid version for the European market .
Review 2020 Jaguar F-PACE SVR: Since going on sale in 2016, it has been firmly entrenched as the British marque’s bestselling car in North America, a trend that continues to this day. the .
Best Selling Suv In America 2020 : The 25 most popular vehicles in the U.S. through March 2020. … The post Best-Selling Cars of 2020 . . . So Far appeared first on autoNXT.net. . The recall includes 2020 Ford Ranger and 2020 F-150 vehicles with 10-speed automatic transmissions and 2020 Expedition vehicles with the police package and 10-speed automatic transmissions, according .
March brought the end of the first sales quarter of 2020, and with it we With more than 144,000 units sold in Q1, the Silverado has once again overtaken the Ram as the second-best-selling pickup . .