Friday, June 27, 2008

Bariatric surgery slashes cancer risk?

Latest news - front page for several days - has been that having a gastric bypass can cut cancer risks.

Bariatric surgeons at McGill University compared the records of 1000 patients mostly gastric bypass to 5700 people matched by age, weight and sex who did not have the surgery.

In the surgical group, 2 percent developed cancer and in the non surgical group, 8.5 percent developed cancer.

Although the study is yet unpublished, these bariatric surgeons presented their preliminary findings at the latest meeting of bariatric surgeons of the ASBMS recently. (talk about preaching to the choir).

And isn't it amazing that an unpublished study has made such headlines for several days now?

What is even more amazing is that while Dr Glenn Gaesser found in his metastudy that obese people were 40 percent less likely to develop cancer, how these surgeons found the opposite. Of course 6 percent more cancer isn't really that great although you can express it to sound amazing as MSNBC did .... saying 80 percent greater chance of cancer in the non surgical group.

One of the objections to this study was actually brought up by another bariatric surgeon. Edward Phillips, a bariatric surgeon at Cedars-Sinai Medical Center told the LA Times that patients who have weight loss surgery, are often screened for cancer before surgery. "We may be selecting patients who don't have cancer for surgery, thus biasing the study", he said.

It's hard to judge without seeing the study. For example, a lot of very obese people are yo yo dieters and that weight cycling raises all health risks. Also I am wondering why they had to pick so many obese people to compare. Why not select 1000 fat people to match up with the 1000 WLS patients? Because I bet in 1000 fat people you might not get any cancer at all and that wasn't what they wanted to prove with their study.

The study only ran for 5 years and critics of the study have pointed out that it often takes a cancer many more years to develop than that and that had the study been taken out longer, the results might have been different.

Breast cancer was one of the cancers which they saw less of in the bariatric patients. Could it be that after a gastric bypass, patients were unable to take birth control medication (a major risk factor for breast cancer - that is medications work differently in gastric bypass patients because of the malabsorption issues)? Or that the gastric bypass patients were unable to eat or digest foods with transfat in them (another cancer activator). Also most weight loss surgery surgeons require their patients to quit smoking whereas the fat controls were not necessarily non smokers. Another thing is that most gastric bypass patients can no longer drink alcohol especially the newer ops as they would have been looking at, if the study only ran 5 years - alcohol can be another risk factor for cancer.

There are just too many other factors which could be operational in all of this to assume that it was the surgery and weight loss which explained the 6 percent less cancer in the surgical group.

For example, most gastric bypass patients are told to exercise often in order to help keep off the weight. Exercising can knock the risk of cancer (in anyone of any size) down, 40 percent. Most of the obese controls were probably not exercising regularly.

Ideally the fat controls should have also been matched for exercise, not smoking and dietary modifiations (like the elimination of trans fat in the diet) if the scientists wanted to really see if it was the surgery or the weight loss which explained the less cancer in the surgical group.

A non randomized study always raises red flags. The fat people could have been picked for their cancer risk (i.e. cancer in the family etc).

I guess the thing which rather annoys me about this whole deal (besides the news media making it a headline for the last week or more) is that all the research I've done comes out the opposite...

  • Cancer is seen 40 percent less in fat people than in slim people - it has been considered a disease of the slim and yet now they are trying to link it like everything else to obesity.
  • Two oncologists have told me that fat people if they get cancer, are much more likely to survive than slimmer people.

So unlike the media is trying to tell us, the "link between obesity and cancer" has not been well proven at all. On the contrary. The American Cancer society has stated that lifestyle (not girth) is a factor in 85 percent of cancers.

Even the release form for gastric bypass used by many surgeons and usually attributed to Kaiser Permanante warns:

Keep In Mind: Slender individuals have adult diabetes. Slender individuals have heart attacks. Slender individuals develop arthritis and have joint problems. Slender individuals have strokes and develop cancer. If obese individuals have these problems more commonly than the slender, it is because the same bad health habits just don't happen to cause obesity in some individuals "fortunate" enough to be slender no matter what they eat. They may be slender but they could very likely die just as early in life as someone who is overweight.****

And obviously those who wrote this release form do believe in bariatric surgery.

Additionally, I have seen many get cancer who were very slim. Some of them were very fit like a 53 year old family member. She ran marathons and I'm sure the last time she visited her doctor before she came down with the cancer which was to kill her 3 years later, her doctor proclaimed her totally healthy, at her perfect weight with low risk numbers.

So much for the risk numbers and perfect weight predicting protection against cancer!

I would not take this one to the bank. Many gastric bypass patients can develop a condition called "leaky bowel" wherein bacteria, not killed in stomach acid, enter the small gut and are absorbed along with the food. With this condition causing in many, auto immune disorder like RA and lupus, it is suspected that the immune system of a gastric bypass patient might been impaired by the surgery and not strengthened as these McGill bariatric surgeons would like us to believe.

Monday, June 16, 2008

Brooke Bates revisited

If you remember Brooke Bates, she's the 12 year old who had a lap band put in after having 35 lbs of fat removed by liposuction and dieting (since the age of 3 years old) did not produce the desired results. I, at the time, followed the attitude of the media, which blamed the parents. Frankly my blog was horribly judgmental as I re-read it.

Recently Brooke Bates' mother wrote a feedback to one of my blogs and I feel that it's important enough for her to have a voice in all of this that I decided to reprint her feedback letter here:

This of course, argues that the media (and myself) were way too harsh on Brooke's parents for as Cindy pointed out, she loves her daughter deeply and wants the best for her.

First I would like to formally apologize to Mr and Mrs Bates for my judgmental attitudes toward them. Cindy is right... she just had the best in mind for her daughter and was likely, following her medical provider's advice or at least, acting with her medical provider's blessings.

But secondly, I think we all perhaps missed the point and that is that Brooke's parents were as much a victim of an out-of-control diet industry as Brooke herself. And that is sad.

I'm sure that neither Brooke NOR her parents were told that 34 percent of even the more invasive gastric bypass patients regain all or most of the weight loss according to a 2006 study.
(Annals of Surgery. 244(5):734-740, November 2006.
Christou, Nicolas V. MD, PhD; Look, Didier MD; MacLean, Lloyd D. MD, PhD)

I'm sure they were not told that in years to come, the lap band can grow into the stomach, causing the necessity for a partial gastrectomy or removal of a part of Brooke's stomach. Even in the most non invasive form (and the lap band is a wonderful improvement over the other WLS procedures available), ANY gastric surgery can upset mother nature in a way that can have repercussions later on.

And doubly sure the Bates family was NOT given the only long term statistics we have on the lap band (and gastric bypass) i.e. the Swedish Obesity study in which it was found at the 10 year post op point, the average amount of weight kept off was only 16 percent of the original weight.
(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)

Brooke's high weight was 220 so that means at 10 years post op, if she is average, she will have kept off 35 pounds after having her band in for 10 years and this she could have done with Weight Watchers or something non invasive.

Recently I read on one of the groups, a new WLS patient who lamented "I cannot eat normally now!" WLS patients must observe rules some of which I also observe because I have a stricture of the esophagus from GERD and a medical procedure which was a bad idea. Some of those rules include 'eat bites the size of a pea', "take time between each bite and chew each bite until it's liquid". But unwritten rules say "no pizza or steak", and "if you want to not get around the surgery, you must find things which are soft but not caloric and that takes a lot of creativity." I frankly find the stricture even at the age of 63, quite a hit on the quality of life and I cannot imagine a 12 year old having to worry about these things and never being able to "have a party in her mouth" as Dr Phil has put it.

Additionally, I know most folks do not know (and many medical providers do not tell us either) that kids who diet, tend to really mess up their metabolisms and that comes back to bite later on. I know - I WAS one of those kids and I kept slim in High School (well normal sized) by severe calorie restriction. But most of my adult life I have weighed well over 200 lbs and if I don't calorie restrict now I keep on gaining (which I did very nicely after my last dieting attempt at the age of 60). Working out daily which I have done for 14 years does in NO WAY prevent me from gaining weight.

I am deeply sorry for any hurt I might have caused Mr and Mrs Bates and Brooke.

However, I do hope that people reading this will realize that in this confusing, complex world, more than good intentions are needed. We need to become informed ourselves as we may not hear the best advice from the news media (which is an advertising platform), or even from our medical providers when it comes to weight control and healthy lifestyle. For example, if an overweight person goes to the medical provider, they invariably hear "lose weight" but if they smoke cigarettes, they might hear "well you should give up smoking" ** wink wink ** but that's it. Strange considering they have a ton of studies out there suggesting smoking not only is a major cause of heart disease but also, hastens the onset of diabetes and many other ailments, whereas obesity alone has never yet been proven deadly.

Obesity is not a killer. In the release form used by many WLS surgeons and usually attributed to the insurance company, "Kaiser Permanante", they say up front that obesity is NOT a killer but rather, it is bad health habits which can raise the risks for both fat and slim folks. This being said, it should be noted that the increased risk of even fat couch potatoes is minimal according to several studies including those of the Cooper Institute and the bottom line is, heart attacks, strokes and diabetes happen in individuals of all weights:

****Keep In Mind: Slender individuals have adult diabetes. Slender individuals have heart attacks. Slender individuals develop arthritis and have joint problems. Slender individuals have strokes and develop cancer. If obese individuals have these problems more commonly than the slender, it is because the same bad health habits just don't happen to cause obesity in some individuals "fortunate" enough to be slender no matter what they eat. They may be slender but they could very likely die just as early in life as someone who is overweight.****

(Kaiser Permanante Release form for WLS)

*** If you believe this surgery will restore you to complete and normal health you are mistaken. You are trading one nutrition problem for another problem. Obesity alone, does not necessarily kill you...Do not think you know better because you had a friend who had the surgery and did well despite eating whatever they wanted. This is an exception. Given enough time, they will probably put most of the weight back on.

Kaiser permanante release form for gastric bypass/duodenal switch
I plan to delete my earlier blog about Brooke Bates because it is overly judgmental and I did not mean to do that and I absolutely did put the blame in the wrong place. Brooke Bates is healthy today and we applaud her for her hard work for as a WLS surgeon put it, "success with WLS is 10 percent the surgery and 90 percent the patient!" Brooke obviously has put in the work and deserves the credit, however, we cannot help but observe that with better medical advice, she could have avoided disturbing her digestive system and her quality of life.

Friday, June 06, 2008

V-Bloc - new hope or old spin?

Several years ago, they did a study on a device developed, I believe, in Switzerland called the "gastric pacer". Several US Weight loss surgery surgeons jumped on the bandwagon. What this device (implanted in the back - and similar in function to a heart pacemaker) did was send electrical impulses to the vagus nerve of the stomach. No intestines were rearranged, the stomach was not otherwise disturbed and it seemed a really great idea. One surgeon wrote to a listserve "I am testing a device now which will outdate all weight loss surgery in five years!"

I followed the studies on gastric pacing and even interviewed some patients. Unfortunately the results, weightloss-wise, were extremely poor. One patient out of the three studies in one area, lost 70 lbs. One patient lost 100 lbs but became very ill from several things including cancer, partially from the side effects of the device and had to have it removed. The rest in the three studies, either lost very little weight or no weight at all. All of the patients except the two previously mentioned, ended up getting other procedures, either gastric bypass or lap band which they all, down to the man, found not only far more effective with weight loss but also, far more comfortable than the gastric pacer.

But worse yet, this "totally non invasive device" (as it was _heavily_ advertised) had a set of co morbidities of its own, some of which I understand are also true of the heart pacemaker but to a lesser degree.

First, it could travel around in the body causing problems getting where it didn't belong (like heavily inflaming surrounding tissue). The one patient who had to have it removed in an emergency situation, had it travel halfway down her back.

Secondly, the amount of current required to block the vagus nerve turned out to be about 10 times the amount of current required in a heart pacemaker. When the device was working, many patients complained of tingling uncomfortable feelings in their arms.

Third, patients were told it stopped the appetite. But the way it stopped the appetite was to keep the stomach from emptying into the small intestine, a condition well known to GERD patients. What they didn't tell the patients was that if the food just sits in the stomach, it starts to rot and can cause a horrendous case of upset stomach (and burping up, rotten food - I know because I have GERD myself). It can also cause too much stomach acid which splashes into the esophagus and can cause not only heartburn but also a condition of ulcers and sores in the esophagus called "Barrett's Esophagus" which can lead to esophageal cancer - a rather distressing type of cancer.

Fourth, patients were told the battery on the gastric pacer would require changing every 2-9 years which are the statistics on heart pacemakers. But what patients found out was that, because the amount of electrical current required for blocking the vagus nerve, was about 10 times what a heart requires, gastric pacer batteries generally had to be changed every 9 months to a year and that required a small surgery.

And finally, for many patients, disturbing the emptying of the stomach did not cause a great deal of weight loss just like the discomfort (and even stricture) associated with GERD doesn't necessarily cause weight loss either. (Again I can attest to that one - I easily managed a BMI of 44 for years until I found Weight Watchers, even with GERD, and a stricture of the esophagus).

Needless to say, the gastric pacing listserve was closed, the studies of this "utterly hopeful" device having been ended but not without a few lawsuits from sick or upset patients.

But ........

As they say in "infomercials"... but wait! Because the gastric pacer came back in 2005, with a new name, new studies and more heavy advertising! That's right.

In 2005, a small company named EnteroMedics in Minnesota announced that they were working on a type of gastric pacer. The press release included the following:

The company says cutting off the nerve supply may slow down digestion because the stomach doesn't register the food and start the digestive process.
Well, apparently they had begun trials of this device in several cities and like the gastric pacer, they claimed it's totally non invasive. Interestingly enough, the TV blurb on it used a gastric bypass patient to show how great losing weight is and claimed the new gastric pacer (the V-Bloc) "may" work just as well as the gastric bypass.  (Which they soon found out to be not as true - in some studies the weight loss in the controls equaled or exceeded that of the people using the v-Bloc.

So you'd think the second time around, they would have gotten the message.  But apparently they didn't because in Jan 2015, guess what's back!

None other but the V-bloc dolled up with a new name but it's the same old, same old.  They opened a new website for it at:

Look quickly because after two or three go-arounds with this device, I suspect the website will be as long lived as the last websites were.  But not until they've sold patients with huge promises of its success.  People cannot remember as far back as 2005, I guess they are reasoning (or hoping?)

The following is from my research in 2005 - I'm quite certain this device has the same issues despite the new name! :)

It was difficult to research the V-bloc. Both the EnteroMedics website and the research study website were very vague about how the device works.

So I called a phone number which stated: "For more information about VBLOC Therapy and the EMPOWER clinical research study, please call the nurse-staffed information line at ......"

I spoke to 2 nurses, one of whom got short with me when I was apparently asking too many questions. She said "really this phone number is merely to identify and qualify patients for the study". To which I answered "well that's NOT what you stated on the website" and I quoted the above. Then I reminded her that as soon as they have advertised the device on TV, then the public has a right to know the details. By the time I spoke to the second nurse (a different lady from the first nurse so they apparently are paying no small fee for having nurses to answer phones!), I had a specific question and was prepared with an answer when she told me the line was just to qualify patients.

I did find out that the chest belt part of V-bloc is the battery pack so apparently one improvement V-Bloc has over the gastric pacer is that to change the battery you don't need the small surgery.

But something else on the EnteroMedics website about what the V-Bloc really does (and this website is not given on the Empower study website either - I had to google it) is a bit unsettling. They admitted that they don't really know how the Vagus nerve interfaces with the appetite but listed the functions of the vagus nerve and it's more than just stopping the peristalsis (the muscular action of the stomach to digest the food and send it to the small bowel). Here is the list of vagus nerve functions which the V-Bloc supposedly stops (from their website) :

The mechanisms responsible for obesity and the role played by the vagal nerves are not yet fully understood. Vagus nerve function appears to play a significant role in enabling multiple mechanisms including:
  • Expansion of the stomach as food enters.
  • Stomach contractions that break food into smaller particles.
  • Release of gastric acid to continue food processing.
  • Emptying of the stomach contents into the small intestine.
  • Secretion of digestive pancreatic enzymes that enable absorption of calories.
  • Sensations of hunger, satisfaction or fullness
In plain terms, the V-bloc not only gives you a horrendous case of indigestion but also can induce a  simulation of "gastroparesis" (stomach not emptying due to partial paralysis), and can interfere with the pancreatic enzymes as well as with stomach acid which will not only affect fat digestion but also protein digestion and vitamin digestion!

In another place on the same website, it stated that the idea for the V-bloc (and probably the gastric pacer also) was that before they had the medication to stop the stomach acid for ulcers, the so called PPIs, they would go in and cut the vagus nerve to help ulcers.

Before the availability of proton pump inhibitors (drugs that reduce the amount of gastric acid released into the stomach for persons with ulcers), surgeons routinely cut the vagus nerves near the stomach to treat ulcers. This procedure is called a "vagotomy." For a period of time following surgery, many of the people who underwent this procedure absorbed fewer calories from fat, lost weight and had decreased appetite.

Notice for a "period of time after surgery". That is, it did not work indefinitely to stop the appetite.

Other than the battery pack (it's carried on a case the size of a compact disc, one nurse told me) worn around the chest (which I suspect might be inconvenient at times) which is an improvement over surgery every nine months to change the battery, it seems the V-bloc is pretty much the "same dog, different fleas" as the devastatingly unsuccessful and risky in its own way, gastric pacer. And something which the TV said has been added i.e. wires in the esophagus (I don't know how accurate the TV report is but since the Enteromedics folks are not giving much information, it's all we have).

The new device might have a smaller battery....

"He who does not study history, is doomed to repeat it" and "doing the same thing repeatedly hoping for a different result is insanity" (said Albert Einstein) so take a tip from those who struggled and suffered with the gastric pacer a few years ago, and consider waiting on the V-Bloc! Its predecessors interfered with digestion as much as the gastric bypass but did not even produce good weight loss results for most people.

At best scenario, the weight loss promised is 15-20 percent of the bodyweight in the first year. Doing the math, 15 percent of 300 lbs is 45 lbs. And likely the real results will be more like 10 percent or less. (as they were with all trials on the gastric pacer).

Surely a horrendous case of indigestion, food rotting in the stomach, heartburn and nausea may slow the appetite but at what price? You can do that without expensive electrical devices and multiple wires implanted in your body.

If you did not come here from the new blog - it's been re-introduced in 2015 ... click here to see the new blog on it...