Thursday, December 29, 2011

Does Obesity really cause brain damage?

Obesity might cause inflammation in the brain, shouts out the latest headliner coming out of the NPR News.

According to the NPR article:

...some provocative research suggests that a part of the problem might be that obesity could change the area of the brain that helps control appetite and body weight.

The study was published in the Journal of Clinical Investigation and since my trust of media reporting on studies is about zero, I decided to look up the original study to see what it really found.

Not surprising, the study report article differed completely from the news article.

In this study, the researchers found that when rats were fed a diet high in fatty foods, even before they became overweight, there was evidence of inflammation in the rat hypothalamus gland, a gland in the brain which is thought to regulate body temperature and metabolism.

The scientists wondered whether humans reacted similarly, so they MRI-ed the brains of 34 humans and found more evidence of damage to the hypothalamus in the 12 humans who were obese than in those humans of normal weight.

Michael Schwartz, one of the researchers on this rat study was very shocked at the results, he told NPR. Schwartz is the head of the Obesity and Diabetes Center of Excellence at the UW School of Medicine.

I do see some possible issues in the study such as, can it be assumed that normal weight humans did not consume as much fatty food as obese humans?

But unlike the media, the scientists commented that this damage may be a factor in developing obesity and not that obesity caused damage as the NPR article stated. The scientists named their article, "Obesity is associated with hypothalamic damage". The media in their typical fashion of misreporting, headlined their article "Could Obesity Change the brain?".

Actually, I am not surprised that the hypothalamus glands of some overweight people might be damaged but of course, the study never stated that the obesity proceeded the damage - either in the rat study or in the human study.

Interestingly, this study may dovetail another recent study which found that a rather alarming percentage of people developed obesity after their tonsillectomies (which may be due to hypothalamic damage). The scientists in that study stated they did not know what caused this but suggested it might be that swollen tonsils caused difficulty in swallowing before they were surgically removed. I was one of those who packed on the pounds after my tonsillectomy and no, I had no difficulty in swallowing before that surgery! I also was very active, spending most of the day, running around, riding my bicycle etc. However, I was more hungry after my tonsillectomy which could be the effects of a damaged hypothalamus.

The study at the UW seems a landmark study, the first which suggests that damage to the hypothalamus might be a factor in obesity, which is a pretty shocking result as Dr Schwartz suggested however, with the media misreporting the study to something totally different, the public may never know what the real study found!

Obviously, the rat brain is quite different from the human brain. And the scientists admitted they cannot really generalize from how the rats reacted, that humans would react in the same manner but they did suggest more research along this line would be appropriate.

As an aside, it would be nice if, for once, the media would consider accurately reporting about the scientific research instead of totally changing what the study was even about. (the photo is of the Olympic weight lifter and medalist, Cheryl Haworth)

Wednesday, August 10, 2011

Better Watch Out for Those Hot Dogs, says Dr Hu

Does anyone remember the professor/researcher at Harvard Medical School, Dr Frank Hu, who came up with the conclusion that if a person was overweight, exercise did not help them at all?

In 2005, Frank Hu and JoAnn Manson (Harvard) published a study in the JAMA "proving" that an overweight person cannot be physically fit even if they regularly exercise.

This was an epidemiological study (notoriously inaccurate) but it hit the news in a big way. Not surprising since the news thrives on this sort of headline.

Dr Hu and associates have again hit the news with a study which will be published in the "American Journal of Clinical Nutrition".

This study concludes that if you eat red meat at all and especially hot dogs, you have a significantly higher risk of developing diabetes. (the risk factors quoted in the news range from 21% greater risk to 50 percent greater risk).

If we get picky about things, there is a big difference between lean steak and a hot dog but no real proof that either, eaten in moderation will be our demise.

As is with all epidemiological studies, the numbers of the cohort are impressive but we must remember that not enough information was collected specifically for this study. That is, you can prove pretty much anything with an epidemiological study done with an existing cohort - even likely prove that as much as eating a hot dog can raise the risk for diabetes so can that risk be increased by riding a bicycle (assuredly most in the cohort have done both!) :)

But making headlines is what researchers want to do because it assures them of continued funding and the news doesn't want to see what science really comes up with i.e. possibilities that this or that might be true but rather foregone conclusions.

"Scientists", reminds Dr Roy Spencer, PhD and author of "CLIMATE CONFUSION", "are human too", doing what is necessary to obtain funding. Coming up with an attention getting headline is a good way of assuring continued financing for other studies.

The problem is, that some folks perhaps, take studies like this seriously, which isn't a good idea. Rather, it's best to smile and move on and eat our hot dogs and red meat with no worries. Dr Hu's study proves nothing except he likes to get paid, and coming up with a sensational news story is a good way to do that.

Sunday, June 26, 2011

what is and what isn't about weight loss surgery

In case you haven't heard of the Obesity Action Coalition, they are a group determined to rid the world of obesity by way of weight loss surgery. Recently they had a conference which was at least in part, underwritten by Ethicon Endo which manufactures lap (gastric) bands and also surgical instruments for doing gastric bypass. And by at least one of the conferences which is online, it appears they are definitely selling the surgery.

Which of course, is their right. But what I felt compelled to blog about is, while reading through the transcript on line in an easily readable form thanks to "Melting Mama", it struck me how one bariatric surgeon, Dr Stegemann of Texas, appeared to give some misleading answers.

Here are the ones which jumped out at me (there may be others):

Question: "I have high blood pressure and diabetes this runs in my family, can this surgery really help me..."

Dr Stegemann answered "Absolutely. Significant weight loss improves many of the medical problems that come along with carrying extra weight!"

There is some evidence that weight loss can help health but equal evidence that it's lifestyle which is the key and not what you weigh. However, what he didn't say is, there is no evidence that doing something unhealthy or risky to lose weight improves health. And plenty of evidence to the contrary. And the questioner asked about surgery specifically and not generally about weight loss.

When asked which surgical option is the safest, Dr Stegemann's answer was very evasive and very non informative.

He began by saying that all surgery has risks. (no brainer) And then, went on to say that the risks of "most" bariatric surgery operations is similar to gall bladder surgery. While that has been said to be true of the lap band, it is not true of any of the other surgeries. The risks of the gastric bypass surgery have been compared (by the Fresno Hospitals for one) to open heart surgery.

The commentator of the session saw that Dr S had not really answered the lady's question about which option is the safest so he asked the doctor to be more specific.

But the good doctor again appeared to evade (as he did later in the session when someone asked a similar question). He responded by saying: "The most common weight loss surgeries done in the US would be the adjustable gastric band, gastric bypass, and sleeve gastrectomy."

Notice he still never gave the risks of each procedure which was the original question. The moderator gave up and went on.

The next question was asking how it feels to have a lap band.

Dr S's answer is worth quoting:

"The band works by controlling hunger and controlling the amount of food you're able to eat. So, you'll be able to eat the same foods, but smaller amounts will make you feel satisfied."

There is no evidence that putting a band around the top of your stomach does anything to the appetite unless of course the idea of it growing into your stomach (which happens in a number of cases) scares you and you lose your appetite that way.

Also it doesn't control the amount of food either - it just makes it uncomfortable to eat healthy foods like meat, vegetables and fruit. Cake, milkshakes and cookies slip right down and you can eat any amount of these comfortably. (and many patients do).

And there is no evidence that with a band or even a gastric bypass, smaller amounts of food make you satisfied. With the gastric bypass, you spend a long time healing and during that time, just like when you recuperate from any major surgery, you might have less appetite especially as your digestive system has been very rearranged, but after that healing process which may take as long as a year or a few months, the appetite returns (in most patients unless they become seriously ill) with a vengeance. At least one clinical study found that in many gastric bypass patients, the blood sugar levels are "irratic" and many patients experienced "voracious" hunger a couple of months after surgery. (Roslin - who is a bariatric surgeon -Roslin M, et al "Abnormal glucose tolerance testing following gastric bypass" Surg Obesity Related Dis 2009; 5(3 Suppl): Abstract PL-205.)

Dr S went on:

"If you overeat, then you generally feel pain in your chest, usually followed by vomiting."

It really depends on what food you overeat. Mostly, the pain after eating comes from a piece of food like meat, getting stuck and not going down right. The pain part is correct. I've seen it in band patients (also happens in gastric bypass patients). But patients aren't always able to vomit since the bottom of the stomach which pushes the food up is far away from the "stuck" food (and the muscular pylorus - lower stomach valve- which causes vomiting, is totally missing in gastric bypass patients). Usually band patients and gastric bypass patients endure a couple of hours of intense pain before the stuck piece either goes down or comes up. Occasionally a 'scope is required to fix things. Can be scary, can be nasty and is very likely to happen with a piece of badly chewed steak. You can fill up on cake and milkshakes and potatoes all day with no repercussions.

It is true however, if gastric bypass patients overfill the tiny stomach pouch, they will upchuck, often without notice. Again it's not really vomiting because there is no warning or sickness before. The food just comes up. Many learn the feeling and run to the bathroom. But most gastric bypass patients can tell tales about the "barf bags" they carry in the car or upchucking at a restaurant table.

Fooling with such a complex system as the digestive system has a very dark side.

The next question was about the gastric sleeve, a procedure in which 85-90% of the stomach is stapled off and removed from the body.

Dr S admitted there is no long term data about the safety or efficacy of this procedure but said since other stomach surgeries are safe and short term data on weight loss looks good, this surgery is likely safe and effective.

However, Dr Robert Davis of the "Big Medicine" TV show, admitted that the weight loss data with the sleeve had been poor and that's why they had to go to removing so much of the stomach. The recalcitrant stomachs tend to stretch out apparently.

So bottom line, there is no information available about whether this procedure is either safe or effective. There are many things digested in the stomach and from the information we have about the duodenal switch, Dr Hess, the inventor, stated that it was to significantly cut down stomach acid (and reflux) that they went to removing most of the stomach but without enough stomach acid, most of the stomach produced enzymes will not work either (see "digestion" in any Anatomy and Physiology book).

Then Dr S states that "After a gastric bypass, approximately 85% of patients are able to maintain at least 50% excess weight loss long term."

First keep in mind the average weight loss surgery patient is looking to lose 100 lbs so the doctor is saying here that most patients can keep off 50 lbs with a gastric bypass - but is 50 lbs worth the surgical changes to the digestive tract and lifetime vitamin deficiencies? Most folks can keep off 30 lbs with no surgery!

Second, many studies I've seen do not show this high a percentage of patients even keeping off 50% of the excess weight. Some of the studies by bariatric surgeons can be misleading because obviously those who regain (many patients!) do not report in and are listed as M.I.A. and not tallied in the statistics. More likely this statistic is 85% of those who reported back to the doctor can ...

Finally, there is the doctor's statement that: "Studies show that in 80-85% of people who undergo gastric bypass, their Type 2 diabetes resolved."

Studies on TWO YEAR POST OPS found this. However, the one longer term study (10 year post ops) found that only 35% of diabetics remained disease free (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).

There is a lot of good information about repercussions, side effects, post op care etc in this speech so it's worth reading - just watch out for the affore mentioned statements - as they are misleading.

Wednesday, June 08, 2011

The People of Walmart emails

Every so often someone sends me an email, entitled "The People of Walmart". Apparently, these are supposed to be uproariously funny. The people pictured are real people and the folks who like these emails, tell me that these people are dressed in - shall we say - less than fashionable outfits and that they "should know better" (and thus, deserve to be ridiculed?). Which isn't true of the greeter above, by the way, who simply is wearing the Walmart uniform.

It is assumed, I guess, that none of these people have computers and thus will never see the emails ridiculing them. However, today, more and more folks do have computers and so if they see photos of themselves in an email with comments like "I can't stop laughing at this", would they be very hurt? I suspect they might and if the world is hurtful enough, why take the chance of hurting someone more than life might have hurt them previously?

And we must ask, does anyone "deserve" to be ridiculed, regardless of what they wear, how old they are or the size of their bodies?

What really bothers me about these mails is the underlying "elephant in the room" which no one wants to mention, and that is that although I'm certain that outlandish clothing is worn by people of all sizes and ages, the only individuals who get pictured in the "People of Walmart" emails, are overweight and/or elderly.

So what are we saying with this email - that people of size or over a certain age, should be "open season" for ridicule? And since many of those who have sent those emails would fall into both those categories (elderly and overweight), are they laughing at their fellow humans in an effect to say "well, look how bad these people look - I know *I* don't look that bad!"?

By laughing at the "people of Walmart" , we seem to be not only reinforcing our negative feelings about our own looks or girth but letting those around us know, it's "ok" to ridicule the elderly and/or people of size. Whereas if we viewed these fellow humans, in the way emphasized in a recent EWTN "Catholic View for Women", looking for the inner beauty instead of judging them by their exterior, we might become more aware of our own inner beauty which is not contingent on having a size 0 figure or being 20 years old!

The other side of the "People of Walmart" emails and the prevalent attitudes about size, is that our children who should be nourishing well, in their developmental stages, are increasingly coming down with eating disorders and/or disordered eating, in a sad effect to avoid being like "the people of Walmart", an object of ridicule. The average 8 year old is already on a diet and restricting the very nutrition they need to grow strong and healthy!

I think we need to realize that these emails are not only hurtful to those who may be pictured in them and hurtful to some of those receiving the emails who wonder when they will be pictured but also, hurtful to the sender who is ridiculing fellow humans on the superficial basis of size and/or age.

Respect for all human beings will build respect for ourselves!

Wednesday, May 04, 2011

Sick Gastric bypass patient - not so rare

Malissa Jones of the UK first made the news in 2008 when she became the youngest person to have a gastric bypass in her country. At the time, she weighed over 400 lbs and by her own admission, had a taste for candy and not the greatest food choices. (She told the news, she's consumed 10 chocolate bars in a day!). Typical teenager but with her genetics this type of teen eating did not work. So she had become very obese. Malissa complained about being teased and bullied in school but she apparently had some health problems also. She had trouble breathing and when she was 15, she went to the ER with chest pains which is why the NHS decided to do a gastric bypass on her when she was 17 years old. Typically they don't do bariatric surgery on anyone younger than 18 years old

Her surgery did not initially go easily for her. She was in intensive care for 36 hours but she did survive and began to enjoy her honeymoon year.

In February 2009, she was again interviewed. In a blog which reprinted a news article, now no longer available, it was reported that she had lost over 200 lbs and said that this surgery had saved her life. She weighed around 196 lbs and took a size 14, a great improvement over the size 28 she used to take. She talked about night clubbing and discovering a whole new world. "I've had a lot more boyfriends because I feel much more attractive and confident.", she told the news reporter. She mentioned that she was saving up to have the loose skin removed in a private surgery (it was not covered by the NHS).

But sadly, Camelot wasn't going to last for her.

By December 2009, apparently been unable to save up for the $40K surgery she required (Lower body lift, tummy tuck etc) to remove 28 lbs of loose skin which remained after her quick weight loss, she was not a very happy camper. Life continued on a downward trend, when she became pregnant at the age of 20 but they had to take the baby prematurely because they feared that carrying fullterm might be too risky for Malissa. Henry, a little boy did not survive.

Malissa recently made the news again. She now has been diagnosed anorexic - she weighs only 112 lbs (she's 5'8") and is unable to eat more than 300 calories a day. The news stated she was afraid to eat but she said in addition to being terrified of regaining, she suffers pain and sick stomachs when she tries to eat more food.

There are a number of gastric bypass patients I've met like this - who are unable to eat a couple of years after surgery. This inability to eat is sometimes combined with a phobia of food in general as is the case with Malissa.

One might ask why NHS doesn't give her a reversal and perhaps they have done that, but a reversal won't help the fear of food she has developed since her surgery. Again the NHS is worried for her life. She's much too young to die but this time around there is no surgery which can save her life except intensive psychotherapy.

This is not as unusual a case as providers would like us to think it is. I've actually, met quite a few patients who suffer from something similar to Malissa.

And in a 2001 news article, clinical psychologist and eating disorders expert, JoAnn Mann,RN, told the Fresno Bee,

***"I've seen massive infection, I've seen people hospitalized for malnutrition. I've seen people obsessed with food. I've seen people unable to stop vomiting. I've seen people develop massive eating disorders, I've seen people who are terrified of gaining weight. Terrified. It runs their lives." ***

Dr Jen Berman,a Los Angeles psychotherapist and an expert on eating disorders, has counseled many gastric bypass patients over the years. She told the news media that some patients have developed eating disorders and are afraid that if they eat too much, they will be sick.

***"I have seen people become terrified of food. They feel like their body is out of their control because they lose the weight so fast. I have seen people develop terrible phobias of gaining weight or losing weight." (IBID)***

SO Malissa Jones isn't alone in her food fears, but her road back to health will be a long lonely one, and much harder to trod than it would be had she remained overweight.

Definitely a case (one of many) when the cure is far worse than the original disorder.

Monday, May 02, 2011

bariatric surgery - neither safe nor effective?

In a metastudy in Canada, researchers found that in initial weight loss, the intestinal bypass was the most effective and running close second was the DS/BPD (also a long limb intestinal bypass but with a greatly reduced stomach) and the minigastric bypass which has a greatly reduced stomach and a bypass of about half the small bowel.

Even bariatric surgeons admit that long intestinal bypasses are associated with liver and kidney failure on the long term.

So what is this saying... if you have a procedure which destroys your ability to digest vitamins and cripples one of the most important organ systems in your body, you might lose a lot of weight in the first year? You can do that with cancer also - without surgery even. :(

The last sentence is interesting - the lap banding was the least effective in initial weight loss but, they admitted, delivered the least amount of adverse repercussions. That being said, many lap banders have to have the bands removed after a few years because eventually, the constant rubbing of the band on the soft tissue of the stomach can partially destroy the stomach.

In the one study which was drawn out to 10 years post op, the Swedish Obesity Study, they found that the average BMI for all surgeries, was 35, still very obese. (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) Which seems to suggest that the more risky surgeries are not any more effective in the long run than the gastric banding which is a lot less risky but none of them are really effective. ("Success with weight loss surgery is 10% the surgery and 90% the patient" Dr Terry Simpson, MD and bariatric surgeon)

Another study found that within 10 years, 34% of those who started with a BMI higher than 50, had regained all or most of the weight. (Annals of Surgery. 244(5):734-740, November 2006. Christou, Nicolas V. MD, PhD; Look, Didier MD; MacLean, Lloyd D. MD, PhD)

Bottom line, there is no shortcut and to keep the weight off everyone has to do the same thing - count calories, make mostly healthy food choices and exercise.

In the Hebrew University study they found that only 7% of gastric bypass patients could keep off all their excess weight (follow up was 6-9 years on 600 patients) and another video from a provider I recently watched, the bariatric surgeon stated that WLS of any kind does not take off all the excess weight and people should not expect to get "slim" from it.

About 5% of people who follow a program, non surgical can keep off all of their excess weight so with risky procedures which all damage the digestive tract, one only gets a 2% greater chance of keeping off all their excess weight unless they diet and exercise or unless the procedure makes a person unable to eat (cancer does that also).

I think maybe more folks should do the math. :(

Here's the abstract on that metastudy:

Obes Rev. 2011 Mar 28. doi: 10.1111/j.1467-789X.2011.00866.x. [Epub ahead of print] Bariatric surgery: a systematic review and network meta-analysis of randomized trials. Padwal R, Klarenbach S, Wiebe N, Birch D, Karmali S, Manns B, Hazel M, Sharma AM, Tonelli M. Department of Medicine, University of Alberta, Edmonton, Alberta, Canada Department of Surgery, University of Alberta, Edmonton, Alberta, Canada Department of Medicine, University of Calgary, Calgary, Alberta, Canada. The clinical efficacy and safety of bariatric surgery trials were systematically reviewed. MEDLINE, EMBASE, CENTRAL were searched to February 2009. A basic PubCrawler alert was run until March 2010. Trial registries, HTA websites and systematic reviews were searched. Manufacturers were contacted. Randomized trials comparing bariatric surgeries and/or standard care were selected. Evidence-based items potentially indicating risk of bias were assessed. Network meta-analysis was performed using Bayesian techniques. Of 1838 citations, 31 RCTs involving 2619 patients (mean age 30-48 y; mean BMI levels 42-58 kg/m(2) ) met eligibility criteria. As compared with standard care, differences in BMI levels from baseline at year 1 (15 trials; 1103 participants) were as follows: jejunoileal bypass [MD: -11.4 kg/m(2) ], mini-gastric bypass [-11.3 kg/m(2) ], biliopancreatic diversion [-11.2 kg/m(2) ], sleeve gastrectomy [-10.1 kg/m(2) ], Roux-en-Y gastric bypass [-9.0 kg/m(2) ], horizontal gastroplasty [-5.0 kg/m(2) ], vertical banded gastroplasty [-6.4 kg/m(2) ], and adjustable gastric banding [-2.4 kg/m(2) ]. Bariatric surgery appears efficacious compared to standard care in reducing BMI. Weight losses are greatest with diversionary procedures, intermediate with diversionary/restrictive procedures, and lowest with those that are purely restrictive. Compared with Roux-en-Y gastric bypass, adjustable gastric banding has lower weight loss efficacy, but also leads to fewer serious adverse effects.

PMID: 21438991 [PubMed - as supplied by publisher]

Wednesday, April 20, 2011

Alli / Orlistat linked to kidney, pancreas damage

GlaxoSmithKline has announced it's dropping the OTC version of Orlistat i.e. Alli, a diet drug from those drugs they sell. Ironically this announcement came after a study found a link between this drug and kidney damage as well as several cases of pancreatitis (last year the FDA warned of a possibility of liver toxicity from Orlistat):

The study reporting adverse effects of kidney and pancreas damage in a percentage of those using Orlistat or Alli

Cite: Weir MA, Beyea MM, Gomes T, et al. Orlistat and acute kidney injury: An analysis of 953 patients. Arch Intern Med 2011; 171:703-704. Abstract

New diet drug, Qnexa a breakthrough? NOT!

Interestingly enough, the news article in many news services including the NY Times, suggesting a "new breakthrough" in obesity drugs, appeared recently - cheerleading a drug which was not approved by the FDA - what's going on?

First of all, it's true that those on a combination of the drugs - topamax and phentermine (i.e. the "PHEN" of the somewhat risky potion - Phen-Fen) lost more weight than those on either one of those drugs or those on placebos (no drugs).

However, the most weight lost on the highest dose of the two drugs, Topamax - a drug used in lower doses for migraine control and Phentermine, was 18 lbs over a period of a year and a month (56 weeks). In other words, that's less than 1/2 lb a week! You can actually lose more weight with a Richard Simmons exercise program and no diet! And without endangering your health with a drug which already has been suspected to cause heart problems and another drug about which people have complained bitterly of the psycho- side effects including dizziness and brain fog!

Not surprising, the studies concluded that the difference in weight loss between those on the drugs and those in the placebo group (the latter lost 5% of their weight), was "of nominal statistical significance". Not exactly earth shaking as the news story would like us to believe, is it!

Furthermore according to an article in the LA Times, this is one of the studies done for FDA approval (which has not been given at this time) and not a new study!

And finally, predictably, it was funded by Vivus, the pharmaceutical which is trying to market the drug.

Notice the little plug about diabetes in the article - diabetics seem the new target group. Using old statistics about diabetic repercussions (like what people in the 1960's before modern medications sometimes suffered), these groups are scaring people with diabetes into drastic and sometimes unsafe solutions.

In a society which allows pharmaceutical companies to advertise risky drugs on the open market, the consumer must be very careful - a wrong decision in buying such a drug might result in a lifetime devastation of one's health - as those who trustingly took Phen-Fen can attest to.

Thursday, March 03, 2011

And another revolutionary new surgery for obesity... or is it?

ABC News broke the story with the headline, "Stomach Pacemaker could help obese lose weight!".

A new device, they continued, recommended for clinically obese people (BMI 35-55) fools you into thinking you are full ... yada yada, yada.

Their poster kid, a young man who lost 20 lbs with the device had "just tried everything" to lose weight and nothing worked until this doctor came along (was the doctor riding a white horse?) with the stomach pacer. The young man lost 22 lbs with it. (OK, all together now... "W-O-W") He's a mail carrier in Germany and 20 years old (one wonders if he had to lose weight at all except to perhaps get a set of washboard abs and "P90X" might have done that more effectively and without surgery).

The British Health Service has approved this device and it's being sold across the European Union although the news articles admitted that none had been placed commercially yet.

The problem here, is the idea of a gastric pacer is neither new nor effective for the population for whom they are suggesting it and the fact that an already physically fit 20 year old lost 22 lbs after it was implanted, might be less than impressive to both patients and/or the American surgeons who were excited about the Transneuronix version in the early 2000's and who personally saw the abysmal failure of the device to be either effective OR safe in the American trials.

There is a new wrinkle to this pacer and that is that it's invasive, much more so than the lap band. How? Because it has two leads, one of which lies on the stomach like the older pacer and another of which is inserted though a hole made in the soft stomach tissue into the stomach (it's supposed to detect when food comes into the stomach and then, it sends a message to the other lead which starts the vibration). This brings in the possibility of leaks and sepsis later on. One does not have to leak much stomach contents into the abdominal cavity to cause serious problems! In contrast, the lap band does not require a hole into the interior of the stomach.

Obviously, some well meaning surgeons are unaware of the hefty lawsuit suffered by Transneuronix after one individual had a nightmarish experience with the older (less invasive) pacer. The surgeons who did not hear about the people involved in the American trials, for whom the pacer was uncomfortable (it vibrated throughout their arms) and ineffective (they lost 5-20 lbs with it), some of whom experienced complications like the pacer traveling to other places in the body and all of whom were revised to gastric bypass or lap band. When the pacer failed totally, it was not headline news as were the announcements of it or the adverts for folks for the trials. In fact, the trials failing didn't hit the news at all. The only reason I know about it, is I was following several of the trials and in touch with some of the participants and I know the person who ended up suing.

If you were unimpressed by the poster kid featured in the news, there is another poster kid on the Abiliti website, another young man - a fire fighter. He lost an "impressive" 15 lbs with the device and from his photo where he looks very slim, he also, may not have been fat to begin with and yet, they are recommending this for clinically obese folks?

Sadly, there have been 65 patients who have had these implanted in 2 trials in the United States, however interestingly enough, in searching the web today, I could find no articles or announcement of the trials nor mention of the surgeons involved. As an MSNBC article stated:

So far, about 65 patients in two studies have received the device from U.S. pacemaker manufacturer Intrapace. Only about half of those have had the pacemaker for at least a year, and most lost about 20 percent of their weight and kept it off.

I really hate to see a repeat of history or worse. For it is said that "who does not study history is doomed to repeat it" but then when our news services do not totally report the story, it makes it hard to study history.

"Conspiracy? No conspiracy - only businessmen doing what businessmen do best, selling product" (Bernie Goldberg,a former network anchor in his book "BIAS") Only this isn't a car or a piece of clothing - this has the potential to hurt humans.

Tuesday, February 15, 2011

The TOGA procedure - new hope for weight loss surgery or ?

A recent announcement stated that the UK had done 450 TOGA procedures for treating obesity.

The TOGA procedure offers an "incision-less" weight loss surgery. What is done is basically stapling the stomach from the inside (a surgical instrument is inserted through the mouth).

American surgeons have appeared to not have greeted this procedure with the same enthusiasm as those in the UK.

Click here to see an animation of the TOGA procedure.

A surgeon's description of "minimally invasive" can be misleading to patients. They simply mean no incision. They do not mean the surgery is lightweight or not complex. This procedure calls for stapling the stomach from the inside into a narrow sleeve and step two is narrowing the lower end of the sleeve so food doesn't go through well. This is supposed to cause the patient to feel full with a lot less food.

It's interesting to note that all the procedures and medications are aimed at cutting appetite but since when do people only eat when they are hungry? The type of appetite we mostly have, is in the head and not fixed by feeling full in the tummy.... which may explain why even the more complex procedures are somewhat ineffective in a number of patients.

As the websites about the TOGA do not seem to be recently updated, it seems that the TOGA may not have become popular in the USA yet, and one wonders whether the weight loss results were less than expected or whether there were a lot of complications in the American trials.

Even if the TOGA holds better than the Rose or the StomaPhX, it may cause a lot of discomfort for the patient. In fact, patients complained of a lot of pain with both the Stomaphx and the Rose procedures but not much additional weight loss. And with the Rose and the stomaphx, they had problems with the staples or clips pulling out after a year or so. The tissue inside the stomach is very soft tissue, so it makes sense that staples or clips would not hold well.

Apparently a study in 2008 did not result in the weight losses claimed by the manufacturer. Also as you notice in the quote, even in a small number of patients (6), researchers observed in some cases "Partially stapled sleeves". In other words, in at least a couple of the members of the cohort, the staples had already begun pulling out.

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.

Endoscopy. 2008 May;40(5):406-13.

In reading about this procedure, I somehow am reminded of the title of a book that Susan Powter wrote --- "STOP THE INSANITY".

Saturday, February 05, 2011

Less Heart risk, gastric bypass - new study

A study which followed 400 gastric bypass patients, found that the average BMI at the 2 year point, was 32, still obese. The study was conducted at the Medical College of Georgia.

That the patients had mostly not lost all their weight was predictable but the study's lead researcher, Dr. Sheldon Litwin, chief of cardiology, reported that the patients had a reduced risk of heart disease.

Explaining that the size and mass of the patients' hearts had greatly decreased, Litwin stated this suggested that their hearts were not working as hard to pump blood and therefore, less "stressed" than before surgery. Dr Litwin also said that the hearts of the patients were more normal size.

The problems with this theory are many - first, the heart is a muscle and working it is not a bad thing which is why many overweight people have strong hearts. Second, what caused the reduction of heart tissue? Was it less stress due to a lower weight (which remember, was for most patients, still in the "obese" range) - or was it that in the first year or so, gastric bypass patients take in very little food (300-500 calories day, thus causing a very rapid weight loss) and what their bodies can no longer get from food, is leeched from their bodies. Protein and iron, both poorly digested in gastricbypass patients especially in the post surgery stage, can be obtained from the heart tissue and this would much more likely explain the loss of heart mass however, loss in this manner would not be a good thing. On the contrary. It is this type of tissue loss which is suspected to be a factor in the heart attacks observed in 25% of anorexics.

I have known several gastric bypass patients to come down with heart disease after surgery (some require a pacemaker for example).

I notice in the article they quote Dr Lee Kaplan saying that only 1 percent of those qualified for weight loss surgery get it. But I'm wondering if that quote was taken out of context because in the Self Magazine article, Dr Kaplan said:

*** "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 ***

The article points out that the risk numbers, cholesterol and blood pressure are down on the gastric bypass patients. These numbers also go down in people with terminal cancer. However, I doubt that cancer patients are at lower risk of coronary disease.

Finally, they emphasized the diabetes "cure" (really a remission not a cure) which has been observed in 72% of patients at the 2 year point, however, what they don't mention is that the studies have found that by the ten year post op point, most cases of diabetes have returned.

Whatever the case, it seems like the media is using this study to sell the surgery than anything else (as someone on one of my listserves pointed out).

Friday, January 21, 2011

Dying from elective surgery

Surgery used to be something done to save lives. But now it's often done for other reasons like to lose weight.

Recently a 52 year old woman died after a lap band procedure - probably a complication of the general anesthesia required for weight loss surgery. She was only 50 lbs overweight.

In another story, a woman who was 100 lbs overweight opted for liposuction to remove 50 lbs and now has a body which is very deformed even after she spent some $6000 bucks for chiropractic treatment and more.

As Weight Loss surgeries go, the lap band has the best safety record. In this procedure, a band is placed around the top of the stomach to form a "pouch" which fills up quickly. This is supposed to send signals to the brain that you are "full" when you have eaten only a small amount of food. The procedure, unlike the gastric bypass, includes no intestinal bypass and no cutting of the stomach, and unlike the gastric sleeve, does not call for the removal of most of the stomach. In the lap band procedure, things are pretty well left in tact.

But like all the other weight loss surgeries, the lap band has its downsides. Many patients find that if they are not pretty strict about dieting from the get-go, they don't lose any weight. And of course, there are many foods which are delicious and low bulk which slip right through the lap band like Dairy Queen blizzards etc. To feel full if you have a lap band, you have to eat bulky foods and if you do not measure them, you can suffer a repercussion called a distended esophagus (when food overflows the pouch). A distended esophagus can lead to perforation which is a serious life-threatening condition and also is difficult to fix. Finally, in a percentage of patients, the lap band adheres to the stomach but the percentage on the long run may be higher than we have been told.

Sharon Osborne who used the lap band to lose 90 lbs and has kept most of it off, had her lap band removed a couple of years ago. "I was tired of vomiting every day," she explained to the press. Her famous rock star husband, Ozzy, told the press he was sick of listening to his wife upchuck so often.

Obviously, Sharon may not have followed some of the rules all weight loss surgery patients are told to follow about "measure twice, eat once, vomit never" but doesn't the way it's sold on TV make it all look like it works pretty automatically? They never go into details about all the work the patient has to do which is very similar to any weight loss program, even the non surgical ones.

About 5% of people on non surgical weight loss programs can keep off the weight. With weight loss surgery it's only 7% even with more invasive procedures like the gastric bypass. Many weight loss surgery surgeons don't expect patients to keep off any more than half their excess weight on the long run even when they are putting in the work, but again, how many seminars tell that to prospective patients who are typically 100 and 200 lbs over their "goal weight"? I know a person who regained 100 of the 200 lbs initially lost with their gastric bypass and they couldn't for the world, take it off, even with diet and exercise. Apparently their metabolism had been so damaged that eating anything more than 700 calories a day, caused a gain.

How many people would agree to major surgery like weight loss surgery if they knew it would mean a lifetime of dieting and exercise as well as supplements, B12 shots, possible iron infusions, frequent doctor visits and more... and then, to only lose 50 percent of what they initially wanted to lose (for most patients)?

How many people would agree to a gastric bypass if they knew that they had a chance, even a small one, of getting a seizure disorder afterward or reactive hypoglycemia?

How many people would agree to a gastric sleeve surgery (the newest one they are touting) if they knew it called for the removal of 90 percent of their stomach, leaving a pouch the size of a thumb and that if they had any acid in their stomach, they might easily get an ulcer which could quickly ruin the stomach and require the removal of the rest of their stomach or else if they had no acid in their stomach, it could cause all kinds of things including auto-immune disorder (including MS by the way) because of "leaky bowel" syndrome where bacteria from the food eaten is not killed and instead, recirculated into the bloodstream?

How many people would go into a major surgery even with a lower death risk (the lap band has a death risk of 1 in 7000) if they really thought they might be the one to die? As for those surgeries like gastric bypass where the risk of death is much higher (1 in 50 in some studies), how many people would choose this procedure being fully aware of the death risk?

And finally, how many would agree to surgery if they knew they might not die right away but instead become ill, or require additional surgery like losing their colon from sepsis due to perforation (a sometimes repercussion of laparoscopic surgery) or lose their ability to walk?

Truly some might say "yes" to this but perhaps, not enough people to provide a steady income for many surgeons. (The average weight loss surgery surgeon has an annual income of 1.5 million dollars or more)

Perhaps we should consider going back to reserving surgery for when it's necessary and avoiding it when it's not necessary. Dying or getting a severe disability from a procedure we could have lived without, may not be a good idea for most people.

For sure, those who choose major surgery, should be very sure they ask and get answers for the question, "What can go wrong?" and not just trust new ops or those successful at surgery who may not be sharing the whole story, or least of all, the TV.