Thursday, December 20, 2007

Big Medicine revisited

People may remember a blog I wrote in June 2007 in which I accused the TV show "BIG MEDICINE" of being an infomercial for weight loss surgery.

In retrospect, now that I have watched the first season of this Discovery channel show twice, I will say that if you watch it carefully, it actually shows some instances which give a clue about how risky this surgery (gastric bypass) IS.

For example, the one large lady in the last or second to the last episode who was rejected for WLS, was told by Dr Garth (the young WLS surgeon) that he did not feel it safe to operate on her because she lived too far away and did not have any family to support her (she had moved from one of the Southern states to Houston in hopes of getting the surgery). He went on to say something about how he had to bring one of his recently post op gastric bypass patients back to the hospital four times and pointed out to her that if that was her, living an hour away from the hospital, she could die.

In another show, Dr Davis senior remarks that the gastric bypass is basically creating a situation of malnutrition in a patient and that SOME patients would be better off remaining fat. Big admission.

And finally, each episode has one patient who has HAD a gastric bypass and ended up with very little muscle tissue (the body in starvation in the quick weight loss period eats its own muscle to obtain the protein it needs on a daily basis - if it did not do this the patient would die). These 1-4 year post ops especially the larger weight losers were shown sans clothing and looked like melted candles with a very unusual shape. Some needed several plastic surgery procedures and STILL after all of that pain and work (and risk) felt the need to cover up their bodies.

I have heard this from countless patients... those going in with a looks expectation especially, that they say they looked worse AFTER surgery than before.

A sad thing especially as some of the muscle which has been wasted in the starvation/quick weight loss period does not seem to be able to be rebuilt (perhaps because even when the weight loss stops, there are still hundreds of nutrients which gastric bypass patients cannot digest and cannot supplement through injection or sublingually).

So the bottom line is that I think the show has the potential of informing prospective patients about things they might not think about or read about before but unfortunately many will see only the end story which is the usual gushy "I'm so happy now, I can buy clothing off the shelves, I can ride on carnival rides" which one hears from some of the new post ops.... these stories tend to make people forget all the darker possibilities in their desperate hope that this surgery will magically heal them of obesity.

I did receive a letter responding to this blog which I'd like to share with you. It's obviously from a gastric bypass new op and reads:

Wow - This is some great research. To site articles from 15 years ago. Hate to tell you, but surgery has advanced since then. Also doctors such as Drs Davis will not do surgery on patients just because the want it. The patient has to meet certain criteria. You make it sound as though a person who is 20lbs overweight will get this surgery, then die. I'm certainly glad you have no weight issue yourself. Otherwise you might know what it feels like to be sick and in pain all the time. Oh and by the way-My surgery was a success, and I plan on keeping it that way. I did my research so I know how to make that happen.
I would like to respond here. I quoted three studies - one dated 2002 and one dated 2003 and true, the Hebrew University Study in 1992, however, studies published later such as the Swedish Obesity study published in the NEJM Dec. 23, 2004 issue showed similar results as to weight loss (or lack thereof). At the 10 year point, the 541 patients who were available for followup, had only kept off an average of 16 percent of their original weight. (BTW, that same report stated that only 35 percent of the diabetic patients were still - at the 10 year post op point - "disease free").

SOURCE: New England Journal of Medicine: Volume 351:2683-2693 December 23, 2004 Number 26
Lifestyle, Diabetes, and Cardiovascular Risk Factors 10 Years after Bariatric Surgery
Lars Sjostrom, M.D., Ph.D et al

And earlier in 2007, the ASBS, (the weight loss surgeons professional organization) in endorsing a new revision procedure called "STOMAPHYX", admitted that 30 percent of gastric bypass patients gain all or most of the weight back (thus the ASBS felt there was a need for this procedure which is less invasive than other types of revision).

It should be noted that the inventor of the gastric bypass, Edward Mason, who after his initial follow up has recommended people have RESTRICTIVE ONLY surgery (like the gastric band) because of the inherent vitamin deficiencies of the gastric bypass, has written several articles with that recommendation, one of the most recent ones being in 2003 for the U of I healthletter, reminding that we know a lot more now, about the digestive tract than we did in 1965 when he adapted the gastric bypass from the 1880's billroth II surgery - this article included the following:

Bypassing the first part of the intestine interferes with normal absorption of critical nutrients and causes complications related to vitamin and mineral deficiencies such as anemia (iron deficiency) and metabolic bone disease (calcium and vitamin D deficiency).

These side effects led Mason to develop a simpler procedure known as vertical banded gastroplasty, which he began performing in 1980. Vertical banded gastroplasty reduces the region of the stomach that can initially receive food, but does not alter the rest of the digestive process.

" The future of weight loss surgery rests in greater use of simple stomach restriction procedures like vertical banded gastroplasty, which preserve the normal weight-maintenance mechanisms of the body," Mason said. "If simple restriction procedures did not produce sufficient weight loss, it was always my inclination to work with the patient to solve other problems affecting weight loss rather than going to a more radical procedure."

The writer of the letter assumes I have no weight problem myself. This is only partially true. I am, according to BMI standards, 120 lbs overweight but this is NOT a problem for me. Overweight does not automatically mean "sick" just as much as slim does not automatically mean "healthy". The writer apparently managed to miss the many studies including one published recently which point out that fitness determines lifespan and NOT fatness (or thinness). This study which hit the news on Dec 4, 2007 (even discoveryhealth news - home of the National body challenge DIET and Dr Oz of "You on a diet" fame) clearly suggested (AGAIN) that a fat person who exercised regularly was expected to live MUCH LONGER than a slim person who did NOT exercise and that the amount of exercise a person does predicts lifespan REGARDLESS OF WEIGHT.

So have I fought the battle of weight all 63 years of my life - the answer is yes but because I have also exercised for the last 14 years without stop, my weight is NOT a problem. See - weight but not a "weight problem".

I must say however, that the so called "risks" of obesity even in a person who does NOT exercise seem basically unproven. That is, although there are a bunch of epidemiological studies suggesting a fat person is under greater risk of illness etc there are an EQUAL amount of epidemiological studies which suggest that being under risk more involves things like being HUMAN and/or what we eat and/or how much we exercise rather than whether we are fat or not.

Finally the writer of the letter assures me that SHE will NOT fail with her gastric bypass because SHE did the research before and knows how to do the aftercare.

Surely if she remains faithful to all the rules suggested for post op gastric bypass patients including regular exercise, protein drinks and B12 / B6 injections at least once a week, and she gets a measure of luck mixed in, she has a better chance of avoiding serious repercussions at least for the first several years or so.

However, that being said, I also know gastric bypass patients who did all of the above but just by the luck of the draw, ended up fighting rather difficult health issues like post gastric bypass hypoglycemia (that's where you can "dump" i.e. feel faint and ill - after every meal) and bowel obstruction. I also know gastric bypass patients several years post op who have faithfully exercised and strictly watched what they ate and STILL regained a significant amount of weight.

How the body will react in the long run to such a drastic "re-plumbing" of the digestive system is unknown before the surgery which is why the American Medical association warned physicians to alert patients about the "unknowns" of the surgery to avoid lawsuits and the "ethical haze":

"The ethical haze surrounding bariatric procedures is not unknown in surgery", said Laurence B. McCullough, PhD, a professor of medicine and medical ethics at Baylor College of Medicine in Houston, Texas.

"This is the classic problem in surgery-innovation without the research to guide it. So all this should be brought under experimental protocols," McCullough said. "That's how you handle the conflict of interest make sure you tell the patient, 'The procedure is investigational; we don't know if it will help you."'

1762 JAMA, April 9, 2003-VoL 289, No. 14
In that same issue of the Journal of the American Medical association (JAMA), they commented that although the early results are impressive, the repercussions and even whether the weight stays off are unknown:

" Short-term outcomes are impressive-patients undergoing bariatric surgery maintain more weight loss compared with diet and exercise. Comorbidities such as type 2 diabetes can be reversed. But long-term consequences remain uncertain. Issues such as whether weight loss is maintained and the long-term effects of altering nutrient absorption remain unresolved."

1762-JAMA, April 9, 2003-VoL 289, No. 14
I thank this gastric bypass patient for reading my blog and for writing to me and wish her the best of luck with her surgery.