When you don't know, estimate

In the realm of weight loss surgery, we have a kind of new phenomena in medicine. Instead of real results, we have the estimate. That is, when a claim about weight loss surgery is unproven, then studies are offered, estimating what that claim MIGHT be.

Take the 2006 Mayo Clinic study on heart disease and bariatric surgery (study results were presented in Atlanta at ACC '06, the scientific sessions of the American College of Cardiology.). According to this study, the claim is made that having gastric bypass surgery reduces the chance of dying of a heart attack within 10 years post op.

The study took 197 people with a BMI of 40 or over and/or a BMI of 35 with a cardiac risk who had RNY gastric bypass and followed them for 3.3 years. It compared a control group of 163 people who had enrolled for a weight loss program (non surgical).

Predictably, since gastric bypass patients, are likely to have a very low caloric intake during the first few years post operative, the so called risk factors, cholesterol, A1C and blood pressure are likely to go way down.

And equally predictably, these same numbers in the controls on a diet, would initially go down somewhat but be back where they were due to the likely regain in the second and third year, after dieting.

Which is what the researchers found. That is, in the control group - the blood pressure, A1C and cholesterol ended up pretty much the same after 3 years but in the gastric bypass patients, within 3.3 years, these numbers were still "down".

And from this, the researchers announced that having bariatric surgery was estimated to significantly decrease your 10 year risk of heart disease. Whereas if you just go on a diet (like the 163 controls) your risk of heart disease in 10 years would remain about the same.

Other than, from these figures, it's obvious that the folks in the gastric bypass group had a higher risk to begin with (37 percent) than the controls (30 percent), and it was not taken in consideration that the diet group probably regained the lost weight faster than the gastric bypass patients so that in 3 years they likely were a similar weight to their start weight, the interesting word in this all, is "estimated".

We should keep in mind that there is a high rate of regain in gastric bypass patients (34 percent among patients with a BMI of 50 or higher, regained all or most of the weight, a 10 year study found -- REF: Annals of Surgery. 244(5):734-740, November 2006. Christou, Nicolas V. MD, PhD; Look, Didier MD; MacLean, Lloyd D. MD, PhD) but it takes a bit longer than the regain in dieters. A classic example of this is Ron, from the TV show, "THE BIGGEST LOSER" who had a gastric bypass several years ago and had regained almost all his weight, weighing in at almost 500 lbs.

But besides all it's other deficiencies, the Mayo Clinic study really proves nothing since the "risk numbers" are also very low in people with terminal cancer and AIDS and yet, I don't think we can say those folks (usually slim by the way) are at less risk for anything including heart attack.

That is, the jury is still out on how much the so called "risk numbers" can predict heart disease.

For example, several studies have suggested that heart attacks happen in people of all cholesterol levels. So much for cholesterol predicting heart attacks.

Diabetes risk factors have more to do with heredity and lifestyle than girth and with today's array of medical treatments for diabetes, it is no longer listed as shortening life span. Diabetics are thought to be in higher risk for heart attack but other than a few epidemiological studies using old or existent data, this remains mostly unproven.

Yet based on these numbers, the researchers tell us that the risk of heart attack if you do not have a gastric bypass, is significantly higher. They estimate it.

The sad thing is people make their decisions to re-configure their digestive systems permanently, based on "studies" like this which really found no unpredictable results and tell us nothing other than the researchers' estimates.

And I noticed the Mayo Clinic study because today at the Woman's expo, I chatted with a general surgeon from the Mayo Clinic who had switched to doing weight loss surgery, 3 years ago and still thought it was the greatest thing since apple pie and she refused to even listen to my quoting some studies which brought the efficacy of bariatric surgery greatly into question. She tried to dissuade me from continuing, by sneering at me and when that didn't work, she walked away saying she didn't want to have this conversation.

And this person is encouraging fat people to have weight loss surgery? A person who refuses to listen to what the studies (not the "estimates") really say? Like several others, she was unaware of the large percentage of gastric bypass patients who eventually end up iron deficient, protein deficient, with vitamin deficiency diseases like beri beri, with peripheral neuropathy and many other ailments, in addition to weight regain. And worse yet, she wanted to remain unaware. That's the part which concerns me.

Surgery to create illness and maybe even shorten life. That's a new wrinkle isn't it especially as some still call the gastric bypass, "lifesaving surgery".

Despite what the TV says, fat people who do not exercise and are very fat, may only slightly, shorten their lives like being a "light smoker" might, according to Dr Paul Ernsberger, an associate professor at Case Western Medical School. So the usual scare tactic stated to fat people i.e. that if you don't have surgery, you are doomed to die within 5 years, is totally untrue! And for some folks, remaining overweight, might be a much better quality of life than grappling with not only vitamin deficiency disease and things like bowel obstruction and more but also possibly a shortened lifespan.

"I have outlived 48 of my fat friends who had weight loss surgery" says Daphne who describes herself as a "super sized" lady.

These days, not everyone who has the title "MD" may be concerned about your future or may have enough knowledge to know how the procedure, he/she might be doing on you, will effect your future or longevity. We as patients must be aware of this. Times have changed from the family doctor who came out to the house and was only concerned with getting us well.

No wonder Dr Kaplan stated:

"Because it's risky, it's only appropriate for a tiny fraction of people with obesity—the sickest 1 to 2 percent. The idea that all obese people should get [WLS] surgery is insane."
Lee Kaplan, M.D., director of the Massachusetts General Hospital Weight Center in Boston in "Self MAGAZINE: 'The Miracle Weight Loss that isn't' AUG 2008

Biggest Loser - an exercise physiologist weighs in

This is a guest blog by Laura Gideon, an exercise physiologist who was kind enough to write this for us. You can contact her on her website:
www.bamboobalance.com

Q:Who really is “The BIGGEST Loser?” A: The Viewing Audience…
The most “Non- Reality” Show on Television

By: Laura Gideon M.S., CPT Exercise Physiologist & Owner Bamboo Balance LLC –

Fitness Training Company - Los Angeles, CA

From the minute this so called “reality” show came on television, I have been annoyed. With every season that goes by and this show remains on the NBC network, new desperate, unknowing victims are being subjected to cruel punishment (disguised as exercise) and my annoyance grows deeper. The bar keeps getting raised after each “winner” takes home their quarter million dollar prize, cover of People magazine and talk show interviews. Seasons go by and viewers keep tuning in. As long as the ratings stay high, the network and the producers are happy, money‘s being made and who gives a crap about the message being sent.

Well..I DO!

And so do many of my Fitness /Health/ Wellness colleagues out in the real fitness world. We have remained virtually silent and in the background way too long and it is now time to speak up and let the public know what is reality and what is hyped infotainment disguised as Reality TV.

Another season - another the new crop of willing volunteers (or shall I call them victims) line up to get on and bare their souls to millions of TV viewers. Little do these poor unsuspecting, overweight contestants know the danger they will be subjected to physically, mentally, medically and most of all emotionally. The sad part is - that is exactly what the producers want in order to have this show be viewed as “authentic” while pulling at the heart strings of the unsuspecting public. Meanwhile, the actual beating heart muscle of every contestant is being put to a very dangerous test the entire time they are on the ranch. The saying “desperate people do desperate things” is very evident regarding this show. Contestants are clearly desperate and that is what makes them vulnerable and so easy to prey upon.

I recently read an LA Times article published this past November titled “The Biggest Loser: Should you mimic its weight-loss methods at home?” The article included perspectives from experts in the fitness industry (including a kinesiology professor and an IDEA fitness trainer of the year) along with the show’s co-creator/ executive producer and medical consultant. The two opposing opinions could not be more polar opposite with the fitness industry professionals comments airing on the side of “viewers beware this show may cause severe injury or heart attack” to the show’s producer and medical consultant touting that its “inspiring the obese to lose weight and they should not feel hopeless anymore because on this show people learn things no one has taught them before, like how to exercise.” That comment came from the show’s medical consultant.

Has he actually watched the show?

I would love to hear what he has to say when the first contestant actually does die of a heart attack as a result of this show. By the way, is a crash cart within arm’s reach? Do Bob and Jillian have CPR certifications and know how to operate a defibrillator? Unfortunately, it will probably take more than one person to suffer something life threatening before NBC takes notice to the dangers these contestants are subjected to. Apparently a recent stress fracture of the hip of one contestant (Laura) is not enough to send up a red flag. Little does she realize how fortunate she is to be sent packing.

As a fitness professional in this industry for more than 28 years I was curious as to how my colleagues in the health arena felt about this show. The impetus for writing this article came after reading a recent commentary in the IDEA (International Dance Exercise Association) monthly Fitness Journal regarding the “distortion of reality” of the Biggest Loser Show. The comment was written by a well respected fitness professional and educator who’s appalled at this TV reality series, and could not hold in his anger one more moment. Needless to say, I did a happy dance after reading it! -FINALLY…someone was speaking out in our trade journal – YES! His final words: “I am furious that the profession I have cultivated for 28 years is portrayed in this fashion.” I could not agree with him more.

I decided to take the baton and run with it.

I perused the internet to read everything I could about how other fitness professionals felt about this show and the comments were all very similar – mostly disdain. I decided to post a discussion question to my fitness professional groups on LinkedIn (one is the IDEA fitness group): “In your professional opinion what do you think of the show The Biggest Loser and the trainers Bob and Jillian…Do you feel the message being sent to the public is inspiring or dangerous?” The response was over whelming!

These are some of the comments:

“The biggest downside to this show is that it sets up unreal expectations of weight loss”

“As fitness professionals we need to stop associating exercise with punishment! (The simplest example is in public schools where the gym teacher will make a student do pushups when they are fooling around or not performing well).”

“The main problem I have is the lack of risk messaging that I see on the show”

“I am troubled with their choice of incentives for losing weight-using money as a prize encourages people to cheat or lose weight through unhealthy measures such as diuretics”

“The show does not explain often enough that for the average person, obese or not, anything beyond 2pounds of weight loss per week is counterproductive”

“The yelling…it makes for great ratings - but at the expense of what?”

“Great question simple answer…DANGEROUS, DANGEROUS, DANGEROUS.”

I could go on and on, but you get the picture. We are fitness professionals who tune in for five minutes and instantly realize the danger in the message being sent. However the viewing public does not. That is why this show is going into its what? Eighth season? A well informed viewing audience who knows what genuine fitness training is, along with proper nutrition and sustainable healthy weight loss practices, would never buy into this load of crap. All they see is in three months an “amazing” transformation from obese to buff and none of the smoke and mirrors. Viewers don’t see how they are being manipulated through emotional, gut-wrenching stories and crocodile tears to pull at the heartstrings.

Never mind the heartstrings. Here are some things to wrap your brain around….

Scientific fact: Healthy FAT loss is no greater than 2 pounds per week – period. For every 3,500 calories you do not consume or a 500 kcal deficit per day amounts to a 1 pound (fat) weight loss. That’s ONE POUND per week! The shows results are completely unrealistic according to basic human physiology. The weight loss numbers do not add up – it is totally impossible for this rate of FAT loss (which the show alludes to as FAT loss) to occur. Contestants show a supposed 7 day weight (fat) loss sometimes in excess of 20 pounds. A 20 pound weight loss (of FAT) in one week is 70,000 calories, which is a 10,000 calorie deficit PER DAY. An Iron Man athlete would have trouble doing that, even Michael Phelps during the Olympics would have trouble doing that and these people are unfit, overweight individuals NOT elite athletes. They should NOT even be working out 6-8 hours a day! To burn off that amount of calories would mean constant fueling. You can’t exercise 6-8 hours a day without fuel – period. Am I clear here? The contestants are NOT losing fat – they are losing mostly everything but that (like water weight). The people who are actually losing weight slowly with a more realistic number for of weight loss are penalized, humiliated and punished by being sent home with their tail tucked between their legs as if they did something horrible. How sick is that?

Have we as a society become so desensitized that we do not recognize torment and torture to individuals disguised as “made for reality TV?”

These contestants are ridiculed and yelled at by their “trainers” (which by the way is NOT the way you get someone to embrace exercise), asked to participate while being subjected to highly injurious workouts and bated with rewards of being able to choose who gets to be eliminated while being enticed by highly caloric cupcakes. I have seen negligence regularly on the part of both trainers with regard to safety, improper technique and form in execution of movement while resistance training, spinning and kettlebell training in addition to numerous other workout routines. Nutrition education seems to be almost entirely excluded on this show in addition to any emotional (eating) issues being addressed by a professional (which I would think would be of the utmost importance). Don’t you think there are deeply rooted emotional and psychological issues that should be addressed here? What is NOT seen leaves the mind to wonder? When the Biggest Loser does do a “follow up” show they seem to glaze over the fact that most of the contestants have re-gained weight (some almost back to the size they were pre-show) in addition to the feelings of embarrassment that overwhelmed them enough to feel sequestered in their own home.

Why is this show still on the air?

Now tell me. Is this show really about health? Being socially acceptable? Or is it about making bucks by marginalizing a segment of the population based on appearance?

I say it is the latter of the three and wholeheartedly believe that all the real fitness professionals out there would absolutely agree.

Contact Laura at www.bamboobalance.com

Does Gastric bypass lengthen lifespan?

I received a comment on an old blog today and the misunderstandings in it are so great that I felt the need to answer this comment because many others may have the same misconceptions.

First point... the writer whose name is Jason, maintains that gastric bypass lengthens lifespan and uses the Swedish Obesity study to prove his point. Here is the quote:

The fact of the matter is that having gastric bypass has dramatically reduced deaths in patients who had the surgery versus patients who didn't! These are in PEER REVIEWED studies, with many patients. Swedish Obesity study on longevity

First of all, 10 years post op is not very long and keep in mind that only 13 percent of the surgical patients had had RNY (gastric bypass)... the rest were some kind of gastric banding. In gastric banding of any kind, there is no intestinal bypass as there is in gastric bypass and also, there is normal digestion in the stomach (although long term data on these patients shows a high percentage of paralysis of the stomach etc after 25 or 30 years). So even if the death rate WAS lower among weight loss surgery patients, this study would NOT prove that the gastric bypass increases longevity!

Second, there were not a significantly higher number of deaths in the controls (those who did not have weight loss surgery) than in the patients. (only 1.3 percent more deaths in the non surgical patients - has to be 2.0 or more to be significant according to statisticians.)

But let's take a closer look at the Swedish Obesity study because I'm going to prove that there was actually a MUCH lower mortality rate in the non surgical group in reality than in the surgical group.

This is because the study was not "randomized" meaning they picked and chose their participants. Here's why NOT randomizing the study makes it flawed as far as comparison between surgical and non surgical patients:

Randomization, where study participants are randomly selected and grouped by chance, is the most important way to help ensure that intervention and control groups are comparable (even in ways researchers may not have considered) and that the participants haven’t been hand-chosen to manipulate the findings towards a predetermined conclusion. Randomization prevents stacking the deck, so to speak. Source: Was This Really Proof that bariatric surgery saves lives

In this study, those chosen for the non surgical group had 25 percent higher incidence of heart disease than the surgical patients. They also had 6 percent more diabetes than the surgical patients and they averaged 18 months older. All of which can raise their risk factors.

And even with all of that, the difference in deaths in the surgical and non surgical group... were 1.3 percent more deaths in the non surgical group... with 25 percent more heart disease in the non surgical group, on the contrary, the non surgical patients were living LONGER than the surgical patients! That is, to be even with the surgical patients, the non surgical group with 25 percent more heart disease coming into the study, should have had 25 percent more deaths but in fact there was only 1.3 percent more deaths in the non surgical group.

So the Swedish Obesity study did not prove that weight loss surgery increases lifespan at all. On the contrary... (ibid)

The second comment Jason made was providing "proof" that calorie restriction prolongs lifespan.

Because we cannot obviously easily study humans for this, all the research "proving" calorie restriction has been done with rats and mice. These small rodents, though handy for study because of their short life span, don't really resemble humans in many ways.

But even among rat and mouse studies, the results are inconclusive or actually against calorie restriction prolonging life.

The study Jason provided was one done at Harvard Medical School. According to the article on this:

Dr. C. Ronald Kahn of the Joslin Diabetes Center at Harvard Medical School and colleagues genetically engineered a mouse that lacked a gene called fat-specific insulin receptor. This change limited the action of insulin on fat cells.

I don't think these genetically altered mice which lived a 30 percent shorter lifespan than the unaltered mice are very relevant to any humans. But if we are to compare, we should compare them to genetically or surgically altered humans i.e. like gastric bypass patients... will they, like the surgically/genetically altered mice, live 30 percent shorter lifespans than non surgically altered humans? One very large lady who refers to herself at "supersized" (over 500 lbs) tells me that she has outlived 48 of her friends who had weight loss surgery!

And other rat studies have found the opposite - i.e. that calorie restricted animals not only don't live as long as those who ate their fill but got sick faster.

The results of the one study which found that rats fed less calories lived longer than rats allowed their fill, have never been repeated. The other researchers who tried this study, found that rats fed less food, died earlier and got sick before dying. (ref: Stewart, Douglas: "Solving the Aging Puzzle" reference to the studies of Dr Stephen Austad, "Smithsonian Magazine", vol 28, no. 10 Jan 10, 1998)

About those studies which suggested calorie restricted rats lived longer, the author pointed out that the conditions were not normal... rats usually exercise to catch their food but the unrestricted rats were allowed as much food as they wanted and generally didn't exercise much during the day. "In other words", he concluded, "those studies only proved that overfed - under exercised rats did not live as long as calorie restricted rats"

Jason concludes by pointing out that:

Also, you severely downplay the health problems of obesity. True you can be obese and be healthy, but if you continue to be morbidly obese you will not be healthy for long. You WILL get diabetes. You WILL have heart problems. These are indisputable.

Sorry Jason but wrong again. Your facts are VERY disputable!

1. diabetes is hereditary and not a disease of obesity, and although it is thought by some scientists, that the eating habits which can cause obesity in some people may be a factor in some cases of diabetes, evidence for this has been inconclusive so far. Also to note: According to the ADA, 33 percent of type II diabetics have never been fat. I know personally 6 type II diabetics who are very slim. Including my father-in-law.

2. heart problems are also not a given for any group of people, not even those with high cholesterol! Many studies have suggested that heart attacks happen, equally, in people of all weights, sizes and cholesterol levels. For example, a gent who bragged to me that being 71, he weighed 150 lbs which is the same he weighed in High School, and that he walked several miles each day and had done that for years, a non smoker with no risk issues, had a major heart attack and needed a quadruple heart bypass. Yet a very obese relative who is 73 years old (BMI over 60) has no heart problems at all!

In conclusion, Jason, you are believing the ads for the diet industry in the media which often say very different things from what science and medicine has observed!

And about calorie restriction, what evidence we have, tends to suggest that unless it is done very carefully the person not restricting too drastically, not wasting any calories in junk food and fast food and taking lots of supplements, calorie restriction can be very unhealthy.

So much for what the media tells us. We should remember that the TV and the mass media is "for entertainment only" although truly their rants about overweight people are often far from being very entertaining.

The following page has some more of what science says about obesity:

Article: Fat Factoids