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.