Monday, April 27, 2009

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


AngryGrayRainbows said...

Sue, I don't think I've commented here before, but I do follow your blog often... and you do great work. Thanks for teaching those of us who don't know research 101 about how to weed out the chaff of study bunk.

Unknown said...

Excellent points, Sue! Obese people have high levels of just about every cardiac risk factor, but that translates into only slightly higher risks of heart disease. What that means is that extra points on the blood pressure scale, while always bad, are not as severe for a fat person as a thin person.
Also, why are risk factors so high in the control group? Were they denied access to medication? Anyone's blood pressure and cholesterol numbers can be controlled, and that is almost true for blood sugar in diabetes. Drugs work almost every time with some individual tailoring. Surgery for weight loss does not work every time and often works for only a short time! Then you can't use the medications because they are not absorbed!

Scattered Marbles said...

This reminds me of a documentary I watched about a lady who went through the gastric bypass surgery. there was one part of it that just stuck out in my head and I still can't get out of my head. After she had the surgery she developed complications and ended up passing away before it aired.

The comment that was made was, "well she was gonna die sooner anyway, having the surgery probably gave her a few extra months"
Before the surgery she really didn't have any major health problems just mobility issues and the total callous nature of that statement kind of made me see how to many in this world, people who are obese like me are quite "disposable" and deaths are not as tragic as others. what frightens me is it seems alot of the people in the medical/weight loss surgery field seem to hold this veiwpoint and so it doesn't matter if it is successful or not because as they see it, we were gonna die anyway might as well.