Thursday, December 18, 2008

Surgeons pressured based on flawed studies

Based on a couple of studies suggesting increased lifespan in weight loss surgery patients, those studies being short and inconclusive and not randomized and flawed, surgeons are being pressured to do gastric bypass surgery on people of all ages. A recent news article quotes one surgeon who was being pressured to operate on people as old as 78 years old (which is ridiculous because a lot of evidence suggests that doing gastric bypass on anyone over 60 is a risky deal and may SHORTEN - not lengthen lifespan).

"I am being asked to operate on 78-year-olds with co-morbidities of heart disease and diabetes," said Dr. Edward H. Phillips, executive vice chairman of the Department of Surgery and a surgeon at the Center for Weight Loss at Cedars-Sinai Medical Center in Los Angeles. Phillips questions whether these patients will benefit..."

The surgeon continued...

"So, while it is obvious a 30-year-old will benefit, at what age is too old?" he asked.

Problem being it's NOT obvious at all that a 30 year old will even benefit from losing weight without surgery, let alone having a surgery which causes vitamin deficiencies for life and more ...

***Gastric surgery for weight loss causes nutritional deficiency in nearly 100% of individuals who have it done. The most common deficiencies are Vitamin B12, Iron, Calcium, Magnesium, Carotene (beta-carotene and other carotene vitamins) and potassium.****

Kaiser Permanante Release form for gastric bypass

All the studies I know about which suggested an increased lifespan for gastric bypass patients were flawed. One study (David Flum (Study title: The Impact of Bariatric Surgery on Patient Survival: A Population-Based Study)
compared 62,000 healthy fat people who entered the hospital for gastric bypass to 3000 seriously ill fat people who were hospitalized for other reasons (had he compared the gastric bypass patients to 3000 seriously ill slim people hospitalized for other reasons, I'm sure he would have found that the healthy fat people outlived the seriously ill slim people also). This same study was the one which found that the real death rate of gastric bypass patients was 2 in 100 or 1 in 50 died within 30 days of surgery and another 2-6 percent (depending on age) died within the first year. Did he average those deaths in with results? Probably not.

And the Utah study which compared 9500 gastric bypass patients with 9600 "seriously fat people" who applied for drivers licenses and found a "40 percent less death rate among gastric bypass patients". (Long-Term Mortality after Gastric Bypass Surgery Ted D. Adams, Ph.D., M.P.H., Richard E. Gress, M.A., Sherman C. Smith, M.D., R. Chad Halverson, M.D., Steven C. Simper, M.D., Wayne D. Rosamond, Ph.D., Michael J. LaMonte, Ph.D., M.P.H., Antoinette M. Stroup, Ph.D., and Steven C. Hunt, PhD.) In this study, there were several flaws. First of all, most people lie by a lot on their drivers' licenses about their weight... and the heavier they are, the more they shave off. In a survey I did of fat people, I found most over 300 lbs were putting their weight as 100 lbs less than they really weighed which means finding people of "comparable weight" based on driver's license weights, weren't really comparable because actually, they were likely much heavier than their WLS counterparts.

The worst thing wrong with this study is the way it LOOKS i.e. 40 percent more deaths sounds impressive until one looks at the facts.... there were 57 deaths in the control group (the non surgical) and 37 deaths in the gastric bypass patients so that is only 20 deaths more in the controls and they did NOT count the gastric bypass patients who died immediately after surgery or within the first year after surgery. They took them at the 5 year point when those who probably survived the first few years were going to survive. Had they taken them (as they should have done) right after surgery, I'm certain they would have found that the mortality rate was much higher among gastric bypass patients. They also did not count long term patients either - only 5 years post surgery which is before the co morbidities like anemia etc show up in many patients.

Definitely not a study to "prove" anything about the lifespan of gastric bypass patients and nothing to justify doing surgery on elderly with heart conditions etc.

And so far, there isn't even any "proof" that losing weight will prolong lifespan. Two studies of over 50 year olds, all obese - one group which dieted and the other which maintained their current weight, found that the dieters had a 50 percent greater chance of heart attack than the controls. For as many studies that suggest that obesity is "dangerous" there are an equal number of studies which suggest that obesity alone does not pose co morbidities and co morbidities are either contingent on lifestyle or "serendipity".

Even the release form for gastric bypass warns about this:

****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)

It's time Americans realized that anything in the mass media is for "entertainment only" and NOT a good source of information, especially for making medical decisions.

art credit: art in photo by Char - used with permission

Tuesday, December 16, 2008

diabetes but what type?

What is the cause of type 2 diabetes? We all can answer that by rote much as we can recite TV ads for cereals from the 1960's. "being fat and/or gaining weight and bad eating habits".

Well, then, what causes type 1 diabetes? "that's when your immune system or something else destroys cells in your pancreas".

Where things seem to get confusing is how they distinguish between two. I used to think it was something like "if your father had diabetes or your mother or your grandmother, it's type 2 because type 1 is obviously not hereditary". Or maybe if you walk into the doctor and have a blood sugar reading of 1000, at the first reading, you might have type 1. Or if you are a kid, of course, it's type 1 because kids don't get type 2 (that's why it's called "adult onset diabetes" dummy - didn't you know that from the 1950's?... ok I'm being sarcastic here... I admit it. My bad)

But a recent Discovery Health CME was extremely confusing. A young ballerina (15 years old) came in with a blood sugar reading of 400. Now _that_ seems to suggest she has a partially functioning pancreas, doesn't it, especially since her mother also has diabetes also...which suggests a genetic factor, very typical of type 2 diabetes or insulin resistance, right?

But it appears that because both the mother and daughter are very slim and eat healthy etc (well supposedly - many slim people actually do NOT eat healthy - they just "get away" with eating poorly), and the girl is a kid (15 years old) it must be type 1 diabetes, decides the doctor and puts this kid on 7 shots of insulin a day (and 8 pricks).

Later, you see the kid with some friends, one of whom asks "but you look so good, how come you have diabetes?"

"no no no no no no no!" exclaims the young girl, "I don't have that kind of diabetes that fat people get!" (she wrinkles her nose in disgust as she utters the words "fat people".) "I have type 1 diabetes!" Listening to this, I cringed.

And I wonder. Did they ever try her on metformin? Did it ever occur to her medical providers that insulin resistance which is a gene, can occur in a slim person also? Is it worth it to these people to not "brand" them as "fat" or "formerly fat"? Obviously if metformin worked, wouldn't that be a whole lot better quality of life for the young girl to take a couple of pills a day than to take 7 shots of insulin throughout the day and test her sugar "umpteen" times? Also, metformin is a better treatment - she's essentially being treated the same way they treated diabetics in the '50's and '60's.

I have a friend who is slim. But his mother was extremely overweight. So he noticed the usual signs of diabetes - thirsty, and so forth. He went to the doctor and because of his age and girth, got diagnosed with type I diabetes (and his mother by the way, had diabetes type 2). Was on insulin for several years until some smart doctor decided to try metformin and now, he only takes one insulin shot a day and pills which is a whole lot nicer.

My question to medical providers - are you really in tune with the fact that a slim person can have type 2 diabetes because it's essentially a genetic disorder? Even if they are not fat (because fat is largely genetic as well)? Or are you putting young kids through a horrible medical regimen just to assure their parents and/or them that they do not have the "fat person" kind of diabetes?

Fat phobia hurts everyone - even slim people. And that is why we _all_ have to fight it.

If you come in with a blood sugar level of less than 800, even if you are a kid or slim, ask your medical provider to try metformin (the pills) first. Because 33 percent of type 2 diabetics are slim - never were fat in their lives - and those are the ones we know about. How many more type 2 diabetics who were misdiagnosed because they were young and/or slim are there around?

Tuesday, November 25, 2008

a buzz of bogus studies on fat and weight loss surgery

So you are wondering why I have not blogged in a while. Truth being we have been lately inundated with fat and weight loss surgery studies which are obviously flawed. And sometimes it feels like mentioning them is similar to trying to lower the level of the ocean by taking out tea cups full of water.

This morning I saw a study which was questionable enough that I had to report on it. It appeared in the JAMA that is, the Journal of the American Medical Assn, Nov 19 2008. (here I recall the issue of the same magazine - after numerous studies had already suggested smoking was unhealthy - which pictured several doctors on the cover, all smoking cigarettes as an accompaniment to an article about how cigarette smoking was a healthy way to lower stress!).

The Conclusion of this latest study was that women who get pregnant after gastric bypass, have LESS complications in their pregnancies.

First thing to question is it comes from the Rand Corporation, the same group which, a few years ago, announced that one of their studies had suggested that smoking was less dangerous than being fat (this was based on a few thousand people called by telemarketers and asked 8 questions, including height, weight, age, whether they smoked and 6 more about their health). Needless to say, even the diet industry no longer quotes THIS study.

Second, two complications were mentioned - gestational diabetes and high blood pressure (the latter which isn't really a complication of pregnancy anyway).

What is NOT mentioned is that these do not necessarily affect the baby at all (I can attest to that personally knowing a lady who had gestational diabetes and delivered perfect, healthy bright kids).

The researchers, we are told, looked at 75 studies which they selected out of 260 studies. And likely they only selected the ones which gave them the favorable results they wanted.

Some studies I've seen, which suggested the gastric bypass patients tend to have smaller babies and a higher rate of still borns, even if they DO NOT have gestational diabetes or high blood pressure, were likely not selected to be "reviewed".

It's kind of a no brainer that if the mother is not digesting vitamins, it might negatively affect the baby.

Another show called "Extreme bodies" on the Discovery Channel, might have been an infomercial for Dr Rabkin and the Duodenal Switch/Bileo Pancreatic diversion. Ironically, the patients shown in the film were still rather large and Manny Yarborough, the ex Sumo wrestling champ who is up to 750 lbs now (after keeping up his exercise after retiring from the ring for a while) and has decided to NOT have WLS. He states in the end of the film that his friend who died from WLS, told him on his death bed, to "not let them do that to you". So far, he's taken this advice.

Tuesday, October 21, 2008

The new non surgical WLS which isn't - non surgical!

You have probably seen by now, the media hype. "New WLS - no cutting needed".

Transoral Gastroplasty the so called TOGA procedure, has already been hawked in the media as the latest and greatest.

What the TOGA is, is that they stick a bunch of flexible staplers down your esophagus and pleat part of the inside of your stomach (with staples) into a small pouch:

The TOGA System (Satiety, Inc), a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch (similar to other restrictive pouches) along the lesser curve of the stomach.
The news media lost no time in hawking this as the latest and greatest WLS with no cutting:

Unlike other bariatric procedures, the TOGA does not require any incisions. That translates into quicker recover times, shortened hospital stays, and a decreased risk of complications.

Decreased risk of complications? Well, partially true. That is, decreased risk of complications from incisions like hernia and wound healing. We won't talk about complications which may arise from stapling the interior soft tissue of the stomach and of course, other complications which generally arise from WLS.

Other sites have called this procedure 'non surgical'. Again the term may be misleading - that just means there is no incision. But it certainly IS surgery. For example, if a surgeon does a vaginal hysterectomy would that be "non surgery" just because there was no incision?

Below is the best description I could find of it - Medscape news (requires free membership in Medscape to read this)
There were no complications; all but 2 instances of procedure-related adverse effects (nausea, vomiting, pain, dysphagia, pharyngitis) resolved within 5 days and none were serious. The most recent follow-up visits (endoscopy at 3 or 6 months) showed persistent full or partial stapled sleeves in all patients. Weight loss averaged 17.5 lb at 1 month and 24.7 lb at 3 months after treatment (excessive weight loss [EWL], 14.9% and 20.5% at the respective time points). At 6 months, average weight loss was 31.1 lb and EWL was 24.9% for 6 patients followed up so far.

According to Dr. Scott, "Gaps between staple lines [negatively] affected weight loss. The gaps were dependent on stomach anatomy. As we gained more experience with the instruments and the procedure, we made adjustments, and weight loss increased."

... Dr. Scott reports a financial relationship with Satiety, Inc. Dr. Zundel reports financial relationships with Ethicon and Inamed.
One is left with many questions about this procedure. First of that, that's soft tissue inside the stomach and also has a lot of important digestive cells, much softer than rather than the outside of the stomach which is stapled. Secondly the Rose and Stomaphyx procedures which are used to revise gastric bypass patients who have experienced regain, apparently have a problem with the tacks (Stomaphyx) or sutures (Rose) coming out. The Stomaphyx has been all but dropped because the tacks came out pretty soon. (The two patients I know personally who had it say not only was it ineffective in helping them to lose weight again but had a painful aftermath). In doing the Rose procedure, surgeons tell patients the sutures are only guaranteed for a year after surgery.

And a major issue ... the Vertical Banded Gastroplasty which is more permanent than the TOGA but similar in concept, was EXTREMELY ineffective for keeping weight off.

I have known one patient who kept off her weight for 9 years but after that, it started piling on as she became increasingly ill with autoimmune disorder and a host of other things (which many of her medical team DID attribute to repercussions of her WLS). At the 22 year point when this patient had to have her pouch amputated because her stoma stayed shut and she could not even swallow saliva, she was 15 lbs heavier than she had been on the day of her WLS, 22 years ago.

Typical of these patients are things like losing all their teeth, gastroparesis and atrophic gastritis and more.

It's true that the VBG was safer than the gastric bypass (which is why Mason invented it- he wrote) and many of those patients are still around at the 25 year point but I have not met one long termer VBG who is a happy camper. On the contrary.... and every one of them has regained all the weight.

Of course, this TOGA procedure has no silastic band and no stoma. But even after a few months they found (by their own admission): "partially stapled sleeves". In other words, the staples seem to last less time than the sutures....

What damage does this do to the patient's stomach, I wonder....

Studying history is helpful here. The vertical banded gastroplasty which seemed much more permanent was neither effective in the long run nor complication free. For instance here is a patient case history with endoscopic photos:

And even the horizontal gastroplasty which was extremely ineffective as far as weight loss, had its own set of long term complications which interestingly enough resemble the VBG long term. Here is a case history of a 30 year post op horizontal gastroplasty patient. NOTE: although she is very ill, she has been told that any type of take down or reversal will destroy her stomach and put her under risks of dying on the table:

NOTE: both these courageous patients have requested of me that I include their real names AND their photos because they very much wish to warn those considering similar surgery....

The weight loss seems typical of what we have seen with other gastroplasties. Even in the medscape article, the average loss per week by the 6th month was 5 lbs per month or approx 1 lb a week. (this was omitted from the media hype about the procedure - how surprising!) :)

So I would wonder why do they even run a trial of this because it seems doom to fail, even at keeping off the weight any length of time.

The answer may be in the funding they are getting from the manufacturers...
Dr. Scott reports a financial relationship with Satiety, Inc. Dr. Zundel reports financial relationships with Ethicon and Inamed.
And of course, as Roy Spenser remarks in "CLIMATE CONFUSION" (he was senior scientist and climatologist for NASA), any newspaper reporter will jump at "big news" (like "NEW WLS") in hopes of the typically elusive Pulitzer Prize. "Scientists are human" writes Roy continuing that proclamation of "truths" is likely to get scientists, more and better funding. But writes Roy, dourly:

"If you want possible explanations of nature, go to science. If you want truth, go to church!" (Spencer, Roy, PhD: CLIMATE CONFUSION, NY, 2008)

Monday, September 22, 2008

Bariatric surgery, stress eating, marginal ulcer and PTSD

Here is something not talked about EXCEPT in medical journals (where it's OFTEN talked about): (from Melting Mama's blog)

... [she] had roux en y gastric bypass a couple years back. She's been having burning "acid" pain and discomfort and took her concerns to her Bariatric Surgeon. He says it's a "Marginal Ulcer." The doctor said there will be NO denying when it perforates, and to get to the hospital.

My reaction here is that many Weight Loss surgery (WLS) post ops especially longer term post ops, are living with a form of "Post Traumatic Stress syndrome" - i.e. when things "just happen" to you suddenly, rather unusual things which do not happen with such regularly, frequency or severity to the general public, or like the individual above, you are WAITING for "things to happen", it tends to cause a type of stress which can lead to catastrophic thinking (and fear and anxiety) on a daily basis.

Again this is NEVER discussed at pre op seminars and seldom discussed when post op depression (which many post ops I know, have) is encountered. They are given medications which they may or may not absorb and sent home. If they eat to help their stress, they are often verbally abused by medical providers.

Meanwhile the ads and promos and seminars for WLS continue to brag that it will help depression to lose weight with WLS! I guess they hope folks won't read some of the yahoo listserves where longer term post ops hang out....

Also, I know cases where overeating has gotten folks through periods of extreme trial and stress, in their lives when, without this method of stress management, they might have had nervous or physical breakdowns.

Again, medicine almost never acknowledges stress and how it can be the MOST devastating thing to a person's health - much MORE devastating than some extra pounds (to put it mildly).

One person on another list talked about being recently hospitalized for "being suicidal". I've known this person for quite some time now, and she is usually an upbeat, cheerful, optimistic person and also of very high intelligence. So when I heard she had been thinking of the ultimate bad ending, I was more than a bit shocked. Did anyone ever consider that her "suicidal ideation" might be because of her gastric bypass which not only did NOT produce the weight loss she was promised (despite her being a model patient) but also has caused numerous NEW comorbidities which are difficult to impossible, to treat? I bet not one person who has treated my friend ever asked these questions. :(

By the way, the Junkfoodscience blog has an excellent analysis of the latest study suggesting that bariatric surgery (weight loss surgery) is more cost effective for insurance companies than treating obesity. I love her title "
No evidence that bariatric surgeries save healthcare costs or save lives" Seems this study has more holes in it than swiss cheese. Bravo to this blog and its author for exposing these um...less than scientifically sound (how's that for politically correct) studies!

Finally by way of news, the young lady who made the headlines a while ago for getting a lap band (after lipo suction etc) in her early teens, appeared on the new show, "The Doctors". Seems she (not the parents!) is looking to get more plastic surgery. "I want my arms done," she told those watching the show, pinching a small bit of skin under her arms. She admitted she wanted a few other procedures also. I found myself wondering whether she, like so many of us, is getting into the "hooked on plastic surgery" thing. Of course, this attitude seen in many American women, keeps plastic surgeons in business, but so often the bottom line is the inner feeling that "I will never look good enough" a possibly correllary of which is "I will never BE good enough". Many people who get WLS are also motivated by looks and highly disappointed with the results when they don't come out looking like the air brushed models in the magazine with totally flat abs etc, even if the surgery produces a weight loss close to the so called "ideal". This young lady, now at the age of 15, remains a lovely naturally good looking young lady who, because of societal pressure, may well not be enjoying what nature gave her, and just the exhilaration of being young with her life ahead of her, instead looking for happiness in places where perhaps happiness may not be found. Should she be looking for inner happiness which may make her feel a lot better than yet-more surgery?

Friday, September 12, 2008

WLS providers misrepresent - who loses?

Occasionally (ok not so occasionally) I listen to an interview with a weight loss surgery provider which misleads from start to finish. And this upsets me and I think it upsets the many providers out there who truly care about their patients and try to follow up and make themselves available. It upsets everyone because it could give folks a very bad impression of providers in general. Folks tend to make decisions based on very limited contact. That is, _if_ their limited contact is a provider like the following one, it could lead to not only bad decisions but also a bad name for the industry.

I actually came across this provider whom I will call DR X, because one of his patients wrote to me and she is not a happy camper. She had a gastric bypass 3 years ago and has been ill ever since and worse yet, she hardly lost any weight from it. This provider who told her it was easily reversed and that he would be there for her, immediately dropped her with his last communication being several rude comments about how she had broken the "tool" and all her illness was her fault. She now is looking for a provider to give her a take-down so she can have some quality of life again and not be so ill.

I am not blaming the surgeon for her illness - it could be that her body just really objected to having her innards so drastically rearranged - many bodies do object to having the stomach cut in two pieces and most of it bypassed and the gut cut into three pieces and put back together in a very different manner than it came from the factory (despite the fact that the media hype tries to convince us that it's a total "walk in the park" and the "weight falls off" etc).

What I do fault the surgeon for, is not supporting her when she did become ill and also she told me that the surgeon really did not give her any detailed instructions on how to manage, what supplements to take, B12 shots and a myriad of other facts gastric bypass patients should be in possession of, before they take the big plunge. To be sick and without a provider who understands can be one of the loneliest positions one can be in and yet, I have met quite a few ill gastric bypass patients in this exact position.

In the radio program I listened to, this provider made the following comments:

When asked if a gastric bypass wasn't a really extreme solution, he answered that living with a BMI of 43 was much more extreme than having a gastric bypass.

I think picking that BMI was an unfortunate choice for him. I lived with a BMI of 44 for quite some time and found that it wasn't extreme at all and that even being in my 60's I was totally not ill or even mobility impaired as he suggests. He never dealt with the fact that the gastric bypass has a 2 in 100 risk of death within 30 days of surgery (report delivered to the College of surgeons in Oct 21, 2003.[Study title: The Impact of Bariatric Surgery on Patient Survival: A Population-Based Study]) and a 2-4 percent risk of dying within the first year plus a 20 percent reoperation rate and a 34 percent risk of gaining all or most of the weight back within 10 years. (Annals of Surgery. 244(5):734-740, November 2006. Christou, Nicolas V. MD, PhD; Look, Didier MD; MacLean, Lloyd D. MD, PhD) Now that's extreme!

But the comments were about to get better or more um..misleading...

He dismissed all the "bad stories" about gastric bypass comparing pregnancy to gastric bypass "everyone gives them the horror stories. People in general want to share your misery."

I don't have to comment about this one except the least this comment is, is highly insensitive to those folks for whom the WLS does not work or makes them ill. Of course, there is every evidence that this surgeon drops patients who are not happy campers so he may not really be concerned with anyone but those who are happy with the surgery.

And of course, pregnancy is a very natural condition whereas the gastric bypass is a very unnatural condition. That's kind of a no brainer.

Next comment....

He pointed out that all WLS patients had tried dieting and failed but then, made another unfortunate analogy. He stated that "you don't buy a car without taking walks, getting rides from friends, taking the bus and riding a bicycle"

In case Dr X didn't know, most people never try out bikes etc before buying cars - indeed, a large percentage of teens already have cars and use them to drive as short a distance as 1 mile to school which would be a walk for me! And actually, most ill patients have told me that they really didn't give dieting as hard a try as they gave WLS, so perhaps his analogy while unfortunate for proving his case, may have been more correct than he meant!

Finally to make his point which was obviously to go buy a bariatric surgery, hopefully from him he made the classic comment of all times. I quote him here:

"It isn't extreme. I'd much rather have bariatric surgery than being obese. I'd rather have AIDS than diabetes. I know that people don't die from AIDS in the USA anymore..."

Excuse me? People don't die from AIDS anymore? What planet does he live on, I wonder. Has he ever seen a terminal aids patient? There is nothing quite so bad as that. Diabetes while not a walk in the park, is totally no comparison to Aids and I really wonder how a physician can make such a bad error without making it on purpose, hoping the public is extremely ignorant.

Physicians like this scare me because people believe them and can get very hurt by their misrepresentations.

In the course of the discussion, it turned out this surgeon, Dr X, had gained 70 lbs at one time in his life and had lost it by exercise and extreme eating. In other words, some of his judgmental attitudes definitely resemble the ex-smoker who is intolerant of everyone who has not yet given up smoking.

He is not the first surgeon I have encountered who is fat phobic - actually I have over heard remarks from a few WLS surgeons which are extremely disparaging (to say the least) about the patients who provide their bread and butter. One surgeon, for example (who is retired now) told the nurses to not pick up a bariatric patient if they fell. "Just leave them on the floor and call the paramedics and let them deal with it" he told the nurses, an attitude which annoyed even very slim nurses. He was the one who laughed when he said "Oh, if they overeat after surgery, it WILL come up!" I think the vomiting after gastric bypass isn't a laughing matter by any stretch of the imagination. Not withstanding his assumption that all fat people are that way from stuffing themselves which in my observation simply has no relationship to reality.

In the as yet unpublished Russell Williams studies, he asked several caterers who had catered NAAFA conventions where the average BMI is well over 40, how the amount of food consumed compared to those conventions attended by a cross section of the public, many at so called "normal weight". He found that 3 caterers said the fat folks had consumed about the same amount of food as the so called normal weight folks and the other three caterers said that the fat folks had consumed less food than the slimmer folks!

So we wonder does a surgeon's fat phobia spill over to his/her performance in the OR? One would hope not and frankly, I had never considered the possibility, until I watched a "Whipple procedure" which is done for pancreatic cancer and much less invasive than a gastric bypass. The surgeon refused to do it laparoscopically (he said it was too delicate and too much might be injured), he took 5 hours to do it, doing most of the anastomosis with sutures and not with staples and painstakingly, avoided injuring organs, causing a lot of bleeding and not connecting blood vessels. The Whipple procedure provides for cutting a section of the pancreas and a section of the duodenum, the first section of the small bowel which is a small percentage of the digestive tract which is cut and rearranged in a gastric bypass. So I really wondered how they can do a gastric bypass in 30-90 minutes when there is a lot more cutting involved? Is it because fat people considered disposable in our fat phobic society? I was shocked to say the least but in thinking about it, it's logical that fat phobia would carry over, at least in some cases, as does any bias.

If you are considering any of these procedures particularly the gastric bypass (RNY) or duodenal switch/bileopancreatic diversion (DS/BPD), take your time. Get your information from informed consent documents or from a gastroenterologist. Someone who does not stand to profit if you decide to go ahead with it. That's only common sense. Sadly, we often take a lot more time and care, buying a car than we do, buying a surgery.

Friday, August 22, 2008

Biggest losers - the people or the show?

In this month's TIME MAGAZINE was a short article about "Reality shows which aren't really reality" in reviewing a movie about teens.

That phrase struck me because they've been really hawking the new season of the TV show, "THE BIGGEST LOSER". And somehow, for no reason I can fathom, this show is wildly popular.

I not only cannot understand fat people volunteering to be on this show and apparently losing much of their dignity in front of TV cameras but I cannot understand why people watch the show because the dynamics of dropping someone every week often for no apparent reason or the cameras showing these people fighting with each other or wincing during the hours of grueling exercise, all tend to annoy me to the point where I cannot stand to watch the show.

Worse yet was when I did some research on the show and found out that the way they lose so many pounds a week was that they worked out for 5 hours or more a day and were sequestered on a ranch somewhere with personal trainers who appear as if they got their training from the Spanish Inquisition or any other place of torture. They appear to enjoy seeing their clients suffer untold pain to race for the biggest weight loss of the week.

Susan Powter tells us that the body can only process 2 lbs a week of fat so guess what folks who lose 7-10 lbs a week are losing? Muscle tissue, bone mass and organ meat. Not exactly what I would call healthy.

How pray-tell, are these folks going to have a chance to keep the weight off when they get back into the real world and have to do other things besides starve and work out for hours a day? And will the sore muscles and somewhat sadistic personal trainers render them sour on exercise for life? (Studies have shown that moderate exercise is a very good thing!)

One of the "biggest losers" did take an interview a while ago and he said when he had to do real things like work, he ended up re-gaining a significant amount of weight. I suspect that's the fate of most, if not all of the folks on that show. Kind of a no brainer if you think about it. After all, if we lived in the Amazon Jungle without refrigerators, cars and fast food, we'd all be slim. And a large number of us would also be dead.

In 1900 when people worked 12 hours a day for 6 days a week and didn't have refrigerators or fast food or real tasty food (let alone time to eat it) there was little to no obesity. But the average lifespan was 45 years. Now despite the "deadly obesity epidemic" our lifespan is 78 -80 years. Big difference.

Does anyone care about the health of these people which probably is seriously threatened by this type of regime suffered on "The Biggest Loser" show?

Are people aware of the fact that people occasionally die on these reality weight loss /get fit shows?

For example, a gastric bypass patient was picked to be in the Fit TV show "Ship out and Shape Out" She was a pretty lady named Jennifer who had a kindly sweet personality. She had lost a bunch of weight with her surgery but was still over 200 lbs and wanted to lose more. Her personal trainer mentioned she had "health problems" (likely from the bypass). She did not participate in all the exercises and those she did participate in, seemed a big strain on her body. And about 6 months after the show was first aired, she died. (I found that out because when the show re-ran, they had a memorial to her in the credits).

She wasn't the only person on the show who suffered. An over 40's man almost had a heart attack on one of the hikes they took (you cannot just suddenly be fit - you have to work up to it). He got all red in the face, and half collapsed. Not surprising, he didn't show up for the reunion of the group, 3 months after the show was finished filming.

And "Ship out - Shape Out" was tame and conservative compared to the horrors they put the people through on the "Biggest Loser" show.

5 percent of the population can keep their weight off after losing a bunch of it.
95 percent of the population thinks they are in this 5 percent.

Maybe people watch the "Biggest Loser" show because they dream of the weight just dropping off. The same reason, people ignore all the friends who regained or got sick or died with weight loss surgery, ignore the warnings in release forms and hop on the table to have a gastric bypass. They only think about that first year when the weight is automatically dropping off because they are too injured and sick inside to be able to eat much or have an appetite. They don't seem to think about what the 2nd and 3rd year will bring or the 20th year when they might have re-gained most of their weight but still have another set of co morbidities from the weight loss surgery. I've talked to many older post ops who say they are taking more meds now than they did when they were very overweight. But 200,000 people have this surgery yearly (in the USA), seemingly ignoring all the evidence (and the non guarantees from the medical profession about what life with weight loss surgery will really be like or even the expectations of retained weight loss which are not much better than dieting).

I think it's the same thing which inspires people to watch the "Biggest Loser" show. It's a rationalization that a daydream is reality. A rationalization that becomes so strong in some that they are willing to play Russian Roulette with their lives and future rather than face reality. A bit like the movie, "The Matrix" where the reality of humans lying in a bed, having their energy slowly zapped by a machine was totally different from the world the machine created for their brains and how some individuals, when faced with the reality of a somewhat, desolate world, willingly became prisoners of the machine again. "The Matrix" although having a less than great, plot line, was so deep in meaning and significance as to our generation that I've found several books written about it.

Reality shows which are not really reality. Time Magazine said it well. But when that non reality becomes a motivation for people to take insane chances with their lives, it's time to stop and re-think the whole schema.

Maybe the "Biggest Loser" is not the group of people thus tortured for several months for the delight of the TV audience or even the show itself but those who watch the show and begin to believe the myths spewed out therein.

Not a new thing of course. Hitler stated "Say something over and over and people will begin to believe it" Doubtlessly, he would have loved modern communications and manipulative media like TV - scary to think of what he would have done with these powerful tools.

He also said "It is very good for rulers that people do not think" and that was in the 1930's.

Wednesday, July 23, 2008

The Melborne Monash U study - diabetes and obesity surgery

You have to understand that I consider the adjustable lap band a far superior WLS to any of the earlier procedures. It's much safer (about 10 times safer), inserts no staples into the body, no intestinal bypass (as is true of the gastric bypass) and is adjustable which can be a plus if the person does not experience the loss they wanted. But to sell any WLS with misleading statements bothers me because any WLS is serious surgery, even the lap band. I cannot help it.

I recently found out that the show, "60 MINUTES" is as misleading in Australia as it is in the USA. At least in Australia, they are a bit more civilized than they were in the USA and are advocating the lap band which is a MUCH safer surgery than the gastric bypass and they also pointed out that the sugar levels in diabetes could be reduced through a non surgical program like Weight Watchers. But the transcript of that show does contain a few whoppers (i.e. misleading statements - I'm being polite here) which I'd like to go over here. Also I'd like to talk a bit about the Monash study which is now available to read on the AMA site.

First the 60 minutes show in Australia.

Statement: Weight loss surgery cures diabetes and they quoted the study as a backup and a WLS surgeon also confirming it.

REALITY: That's false. Because diabetes is a genetic disease so only changing your genes will cure it.

Not surprising, the study from Monash did not use the word "cure". They used the word "remission". Here is a statement from their study abstract:

Remission of type 2 diabetes was achieved by 22 (73%) in the surgical group and 4 (13%) in the conventional-therapy group.

We will return to this study later but first more misleading statements from "60 minutes".

statement: "That lifestyle, though, has led to him getting diabetes"

REALITY: FALSE. Diabetes is a gene. While there is some evidence that a healthy lifestyle which includes daily exercise and slight calorie restriction can delay the need for medication, it is also true that 33 percent of type II diabetics have never been fat in their lives and many of those exercise a lot.

statement: "if he doesn't have surgery, the diabetes will get worse"

REALITY: The diabetes will get worse regardless of what treatment he has because it's a gene and the pancreas gets progressively worn out as a person ages.

Statement: that you must lose weight to "cure" the diabetes.

REALITY: As we said before diabetes is a gene and not curable. And if losing weight "cures" diabetes, how do we explain the 33 percent of folks with type II diabetes who have never been fat? (I know several of these myself actually).

Finally: Statement: the suggestion - they didn't say this but strongly implied it - that WLS and/or weight loss would cure the erectile dysfunction often seen with diabetes.

REALITY: Weight loss doesn't do a thing for erectile dysfunction- don't expect a remission on that if you have it.

Now let's talk a bit about the study. It was a randomized study - this is good and appears to have been a clinical study i.e. the cohort were examined periodically by the researchers. Participants were divided into two groups. One group was given diet and exercise advice and the other group was given the same advice with the addition of lap band surgery. No one was paid for participating in the study. And the study lasted 2 years. The results were that whereas a remission of symptoms (as decided by the A1C) was observed in both groups, the percentage of remission was significantly higher in the lap band group. (13 percent in the non surgical group and 73 percent in the surgical group).

As far as the study went, it seemed better designed than some but here are what I see as the shortcomings, some of which could still be "fatal flaws".

  • The cohort was small - only 60 people, 55 of whom completed the study at the 2 year point. The researchers themselves stated that larger studies needed to be done.
  • None of those in the cohort had been diagnosed diabetes more than 2 years ago i.e. they were very newly diagnosed. This is a time when it's relatively easy with mild lifestyle changes including dietary modifications and cardio at least 5 days a week to keep the A1C at normal. Where the problems really begin is after several years. For example, a diabetic family member kept his A1C normal for 13 years with no medications (after that, he required oral meds).
  • Lifestyle changes were self reported so we have no idea if the "controls" in the study i.e. the non ops were really exercising as much as they said. Probably they didn't.
We have two things going here. The researchers never claimed a cure - they claimed a remission only. The cure part was a misreprensentation on the part of the media and sadly enough the WLS surgeon interviewed in the media.

Second, we by seredipity found out something very interesting about surgery and diabetes. This family member, my hubby, diagnosed 14 years ago, had a brain hemorrhage in Feb - and no, his team of doctors assured us that it was NOT caused by diabetes or hypertension. He had surgery to insert a shunt to drain his spinal cord fluid and went home a day later. In the ICU, his sugar levels were extremely high - stress was apparently a major factor in that. (another interesting thing we learned about diabetes).

But very oddly enough, even after having totally unrelated surgery (but surgery in which he was intubated etc), by the time he got home, his sugar levels totally tanked! So he went on a fun food kick, eating all the things he had been denying himself for 14 years: Dairy Queen, fast food every night, desserts, ice cream whatever. And every morning for about 3 weeks, even with his bad eating and only minimal exercise (not daily), his morning sugar readings were at normal i.e. 80 or so.

But after that on the same non diet, they started to climb and finally he realized it was back on the old program of daily cardio and watching what he eats.

The suspicion remains however, is that somehow surgery seems to affect the sugar levels whether it's WLS or something totally unrelated. No one can really explain it but I think this is only temporary (the only reason WLS patients may sustain it is if they follow the lifestyle changes). And nice as his "honeymoon" with all the "bad foods" and couch potatoing was, I think he would not have chosen as his preference, to have the 13 days in ICU or the brain hemorrhage.

It's a shame that so many people buy the hype from TV without even checking it out (like pulling up the study etc).

As long as people feel there are quick fixes and easy ways out and "something for nothing" there will be snake oil salespersons right there to sell them something. Only with surgery, it may poorly affect the body for the rest of one's life besides possibly not being effective.

I guess my main concern is spewing forth extremely misleading statements about diabetes in order to frighten people into having obesity surgery.

Caveat Emptor - "let the buyer be beware" is a phrase which we seem to have forgotten in today's society driven by media hype.

Tuesday, July 08, 2008

Teens, weight loss and obesity surgery

Clyde was an ordinary teen. When he was in 7th grade, he was intelligent, talented and liked video games far more than exercise. He lived the American lifestyle. In his family, there aren't many veggies available and a lot of fast food and pizza. He tried the swim team but it didn't appeal and he felt a bit odd in a bathing suit because he was about 15 lbs overweight. And back then, the obesity hype for kids had just started.

When reflecting on High School at the end of his 8th grade year, he told me, "The kids in school are MEAN!" I didn't ask details but assumed that, like all kids who are not the "ideal" size, he had taken his share of teasing and nasty comments. He had, already at that young age, learned to dress in cover up clothing.

Today Clyde is a senior in High School and he is relatively slim.

Is this a success story? I wonder. Because how he did it was NOT through eating 5-9 portions of veggies a day, avoiding fast food and junk food, and trying to do 60-90 minutes of cardio daily. He, instead, continued to live the American lifestyle with some modifications.

He drinks a lot of tea (caffeine speeds up the heart and makes it easier to lose weight and by cutting the calories - it may also, in the long run, be a factor in Parkinson's disease as are all stimulants - see the book, PROZAC BACKLASH for one).

And he smokes cigarettes.

If he went to the doctor, the doctor would probably be pleased at his BMI but at what cost did he attain his "ideal weight"?

Does he know the proven dangers of smoking i.e. hardens the arteries, strains the heart, and shortens lifespan as much as 15 years? Yes he does. "I know it's dangerous," he told me a bit sadly, "but it's hard to stop."

He does not receive any support from his parents. They want him to stop smoking but do not help him to accept himself at his natural size. And they don't understand that when you are a teen in school, the pressure is 1000 times what it is in life and right now, there is a lot of pressure and heat given to all of those who are overweight regardless of age.

The sad thing is most kids will keep within the "normal zone" if they eat healthy, avoid foods like potato chips and fast food which are extremely calorically dense and not particularly nourishing and if they exercise 1-2 hours a day. However, most kids are not really enthusiastic about this type of program and do not often get a good example of a healthy lifestyle at home.

Clyde is not alone. Statistics tell us that more teens are starting to smoke now, than in the 1960's before the dangers of smoking were known.

In considering kids like Clyde, is it really hard to understand that teens simply do not care if they are doing something unhealthy to keep thin because that is most important in the narrow minded society of High School?

Starting with Junior High School, "bulimia clubs" are flourishing, use of "uppers" are common and an alarming percentage of kids are already dieting or more extremely cutting calories. Very often it's the models in the magazines who are blamed, totally ignoring the heat overweight kids get from parents, teachers and the medical profession.

And now, with the encouragement of our wonderful news media and the surgeons who stand to profit, teens who are very overweight, have discovered Weight Loss Surgery.

As recent as a decade ago, the thought of doing something like a gastric bypass on anyone under 18 was considered unethical - inducing vitamin deficiencies in a body which has not yet matured, partially disabling a healthy digestive tract was considered bad medicine but now it's considered good medicine, the surgeons reciting the song of how the teen "was in danger" of a variety of ailments, many of which are non issues or not caused by obesity.

The "Today Show" recently, featured a teen, around 256 lbs who got a gastric bypass. In her before photos she was shown running around a field playing with a dog and smiling. A year later, she had lost 100 lbs and was of "socially acceptable size". But now she was not smiling. Even when the doctor told her she was a success, one saw only a hint of a smile on her face.

"I have to eat very differently now" she told the Today Show, "there are many foods which no longer go down right." She concluded, "It's not an easy road."

The rationale for giving this 17 year old a surgery which cut her stomach into two pieces and her bowel into 3 pieces, rearranging them in a very unnatural manner, a surgery which some studies show to pose a risk of serious complications in 40 percent of patients, by the 8 year point, complications like bowel obstruction, ulcer, pancreatitis and more... the rationale for doing this on the young lady was she had "sleep apnea", "high blood pressure" and "was in danger of going blind" (they never told us what endangered her).

Sleep apnea is a fairly new diagnosis. I don't doubt that some extremely large folks may have breathing problems, but I think the diagnosis of "sleep apnea" in everyone with a BMI over 35, may be way exaggerated.

I had an overweight friend diagnosed of that. She was given a C-PAP machine and found it way too noisy so she gave it back and went on and she was just fine without intervention. I think we CAN stop breathing for a few seconds without a problem and probably many people who are not fat might be doing that also.

So that left the "high blood pressure" (which can be easily regulated by medication) as their sole rationale for ruining this young lady's digestive tract for life, giving her lifetime problems which may really be biting her at the age of 30 when she would be in the prime of life had she not had the surgery, even if she was very overweight.

Sober faced, the young girl told the Today Show that it was "so nice to not worry about future health problems." How ironic that the procedure she had is, indeed, going to give her a new set of health problems which she might have never had to worry about.

It's time that the media and also adults stop pressuring our children. If they want to help them, they should encourage exercise (to be healthy) and eating veggies and healthy foods and most important, help them to understand that health and beauty is not about size. But when even our medical profession starts condoning unhealthy ways of getting thinner, things are out of control in my opinion.

On the Today Show, the resident doctor obviously approved of this young girl's gastric bypass. "Today's obese children are in the unique position of really having a shortened lifespan," she told the viewers.

With all due respect, the only reason that might be true is because society is pressuring teens to the extent that they are doing unhealthy things to lose weight, like smoking or gastric bypasses. That's a no brainer, isn't it? Apparently not to many folks.

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...

Tuesday, May 27, 2008

bogus claims in the news - gastric bypass extends life?

Today I was chatting with some friends and someone brought up that some media column writer said you didn't have to put mayonnaise in the fridge. Mayonnaise has eggs in it for one and in my experience, gets rancid fast if not refrigerated. Everyone in the discussion did feel that it _should_ be refrigerated and since a media person said it didn't have to be, everyone seemed to feel that must be right.

Media is seldom if ever right. If they are not selling something, they often do poor research (this is partially because of tight deadlines which precludes doing careful research so they often look up the subject in other media articles which are just as poorly researched - a case of the blind leading the blind?). But the fact remains that too many people actually believe what the media prints regardless of how "over the top" it is!

Case in question. Here is a paragraph I found in one of the blog searches:

A Gastric Bypass Really Can Extend Your Life

If you are contemplating having a gastric bypass then a recent US study might just help you to make up your mind. The study looked at no fewer than 16,000 obese people and found that when people in the study group opted for gastric bypass surgery their long-term mortality rate dropped by as much as 40%. This should not really be a surprise since weight loss surgery also cures, or at least improves, a host of other conditions such as high blood pressure and diabetes and the change in diet and increase in exercise which follows surgery has got to be a good thing. Nevertheless, it is always nice to see what we already know put down in black and white as confirmation.

Of course the study is not cited and it all sounds good - if you don't think about it. A gastric bypass provides for the stomach to be cut into two pieces - one tiny piece which becomes the "pouch" and the rest of it (about 90 percent or more) which is bypassed along with the attached first segment of small bowel. The bowel is cut into pieces and rearranged in a way very different from the way nature made it. All this causes a quick weight loss during the first year or so and lifelong problems including vitamin deficiencies, osteoporosis, anemia, protein deficiencies and much more.

As Dr Terry Simpson put it:

***The RNY [gastric bypass] trades one disease for another: it trades obesity for malabsorption. By re-arranging your guts you sometimes have severe side effects, and can have long-term problems such as iron deficiency anemia, calcium deficiency leading to osteoporosis. (Dr Terry Simpson, MD, WLS surgeon)
So how would this extend your life? Well, the idea here is that fatness is so deadly that any way to slim down regardless of unhealthy it is, is better than being fat. But there are no real studies which prove fatness in itself is deadly! And when they mention all these ills which are supposedly exacerbated by fat, does anyone question that slim people have the same ills i.e. high blood pressure, diabetes etc? I think the problem is people don't question something they read in the media. And that is where the problem starts.

But let's take a closer look at the study they referred to. It was one led by a WLS surgeon, Dr David Flum and he found in the study (which the media happily ignores) that the first month after a gastric bypass, 2 percent die and that another 5-7 percent of patients die within the first year (these were older patients so had bodies less tolerant to the extreme internal rearrangement done in the gastric bypass).

So how does he conclude that gastric bypass extends life? He compared these 16000 healthy fat people in for gastric bypass to 2000 seriously ill fat people in the hospital for other reasons and observed that since there were a small number of more deaths among the seriously ill fat people than the gastric bypass patients, that meant that the gastric bypass must have extended the lives of those who got it.

What he hoped the public would not realize is that had he compared the gastric bypass patients to 2000 seriously ill slim people in the hospital for other reasons, he would have also found that the healthy fat people who had gastric bypass survived better than the seriously ill slim folks. So would that mean that slim people should have a gastric bypass to "extend" their lives?

In another blog article
A nice looking couple is pictured. They are fat but not terribly so - they are both having gastric bypass surgery. The lady, it said, has high blood pressure even with being on 4 medications and the man has bad knees ("worn out from carrying all that weight").

Here's another which should be questioned. Most of the people I know with really bad knees are not fat. Some have never been fat in their lives - so how did their knees get bad without the "great weight" weighing down on them? And if a person's blood pressure is that high with 4 meds, did they really think a gastric bypass is going to bring it down that much? Again I know several slim people with very high blood pressure. The bottom line is, will introducing a surgical disease into their digestive tract make their health better? Perhaps or perhaps not - it all depends on whether their present comorbidities are greater than the comorbidities added by the bypass. But the media tells us that the bypass is some kind of magic bullet which fixes all ills and no one questions this and that is what is of concern.
***** "By doing this surgery, you're creating a medical disease in the body. Before you expose someone to that risk, you have to be absolutely sure that you are treating an illness which is equal to or greater than the one you are creating."
(Dr Edward Livingston, bariatric surgeon in Self Magazine, 4-2001) *****

Today I saw an ad for something about diabetes featuring as a poster kid, Randy Jackson. I did a double take. Jackson had a gastric bypass a year or two ago and that was supposed to have cured his diabetes (if you believe what the media tells us). I read the ad carefully. It said he was taking less diabetes meds now after his bypass but that is a totally different story than his diabetes getting "cured".

Fact remains, we are suffering from many old age diseases including worn out knees and high blood pressure because now we are living to the age where people start wearing out, fat or slim.

I commented on the widespread practice of smoking in Indonesia. "Doesn't that shorten their lifespan," I asked my hubby. He answered, "They don't live long enough to die from the repercussions of smoking."

I have known countless people who had gastric bypass to fix their knees only to find that the malnutrition and vitamin deficiencies made things worse if anything.

We need to start questioning seriously what we read in the media. If we follow their advice to not refrigerate our mayonnaise, we might get an upset stomach. But if we follow their advice to get a gastric bypass, the repercussions can be much more devastating.