Bariatric surgery curing Type II diabetes

[Bill Glasheen]

Stomach stapling, "banding", or similar procedures are approaches used now for the morbidly obese. It has been assumed that significant weight loss would have a beneficial effect for the patient vs. the roughly 1 in 1000 risk of death from the procedure.

We know that obesity leads to:

• hypertension
• high cholesterol
• Type II diabetes (insulin insensitivity rather than insulin no longer being produced)
• A risk of heart attack, stroke, and various cancers

The question remains though as to whether the dramatic and highly invasive gastric (bariatric) surgery would slow down or even reverse the constellation of conditions that come from being obese.

Well... Part of that question has been answered.

Gastrointestinal Surgery as a Treatment for Diabetes

David E. Cummings, MD; David R. Flum, MD, MPH

JAMA. 2008;299(3):341-343.

Approximately one-third of adults in the United States are obese,1 and largely because of this, at least as many have diabetes or prediabetes.2 With these escalating twin epidemics, the health care community has been challenged to develop novel treatment strategies.

In this issue of JAMA, Dixon and colleagues3 report a 2-year study in which patients with recently diagnosed type 2 diabetes and a body mass index (BMI) of 30 to 40 were randomly assigned to receive conventional medical/behavioral therapy (medical therapy and a focus on weight loss through lifestyle modification) or laparoscopic adjustable gastric banding (LAGB) plus conventional medical/behavioral therapy. The results were clear and striking. Complete remission of diabetes at 2 years was achieved in 73% of the patients in the LAGB group vs only 13% of those in the medical/behavioral therapy group

{snip}

That's wonderful news.

However...

What exactly does bariatric surgery do? Well... It keeps people from overeating.

Wouldn't it be nice if people could live healthy lifestyles so they don't need this invasive and dangerous surgery to turn their lives around?

And for what it's worth... More than a few who undergo gastric bypass surgery will eventually reverse the benefit of the procedure over time via extreme eating measures.

It's your life. It's your choice.

One day, some of these interventions are going to be considered as ridiculously invasive as they are. In the mean time, it's a sad state of affairs that the only way we can cure most of these people of serious illnesses is basically to staple or band their stomachs. If people had their mouths partially stapled shut, they'd achieve roughly the same benefit. Ponder that thought...

- Bill

[Bill Glasheen]

Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes
A Randomized Controlled Trial

John B. Dixon, MBBS, PhD; Paul E. O’Brien, MD; Julie Playfair, RN; Leon Chapman, MBBS; Linda M. Schachter, MBBS, PhD; Stewart Skinner, MBBS, PhD; Joseph Proietto, MBBS, PhD; Michael Bailey, PhD, MSc(stats); Margaret Anderson, BHealthMan


JAMA. 2008;299(3):316-323.

Context Observational studies suggest that surgically induced loss of weight may be effective therapy for type 2 diabetes.

Objective To determine if surgically induced weight loss results in better glycemic control and less need for diabetes medications than conventional approaches to weight loss and diabetes control.

Design, Setting, and Participants Unblinded randomized controlled trial conducted from December 2002 through December 2006 at the University Obesity Research Center in Australia, with general community recruitment to established treatment programs. Participants were 60 obese patients (BMI >30 and <40) with recently diagnosed (<2 years) type 2 diabetes.

Interventions Conventional diabetes therapy with a focus on weight loss by lifestyle change vs laparoscopic adjustable gastric banding with conventional diabetes care.

Main Outcome Measures Remission of type 2 diabetes (fasting glucose level <126 mg/dL [7.0 mmol/L] and glycated hemoglobin [HbA1c] value <6.2% while taking no glycemic therapy). Secondary measures included weight and components of the metabolic syndrome. Analysis was by intention-to-treat.

Results Of the 60 patients enrolled, 55 (92%) completed the 2-year follow-up. Remission of type 2 diabetes was achieved by 22 (73%) in the surgical group and 4 (13%) in the conventional-therapy group. Relative risk of remission for the surgical group was 5.5 (95% confidence interval, 2.2-14.0). Surgical and conventional-therapy groups lost a mean (SD) of 20.7% (8.6%) and 1.7% (5.2%) of weight, respectively, at 2 years (P < .001). Remission of type 2 diabetes was related to weight loss (R2 = 0.46, P < .001) and lower baseline HbA1c levels (combined R2 = 0.52, P < .001). There were no serious complications in either group.

Conclusions Participants randomized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss. These results need to be confirmed in a larger, more diverse population and have long-term efficacy assessed.

[Shana Moore]

Hmmmm...While my personal goal is to be medication free through weight loss, I think I'll stick to the lifestyle changes for eating and exercising. It's harder, and probably takes longer, but I think it's much more satisfying. It also is teaching me long term strategies so I can stay where I want to be.

I think the popularity of bariatric surgery lies with the rise of a "quick fix" mentality and a general physical ennui of much of the populace. Never been a "quick fix" gal, but I do have to kick myself out of that lazy mentality occasionally!

Another big issue that I see mentioned but not fully addressed is the long term effects. I've known at least two people who have had this surgery. One had dramatic weight loss and last I heard had kept most of it off. The other had very fairly dramatic weight loss, and then gained about 20 lbs back. He is now trying to lose weight the old fashioned way.

Unless the surgery is paired with nutrition counseling and physical training, I'm dubious on it's long term effects. Does anyone know if nutrition and phyisical counseling are part of the process? Of the two folks I knew, one had some good nutrition counseling and minimal phyisical theraphy (was tearing up his knees with the weight). I don't think the other received anything but a list of eat this/not that.

[Bill Glasheen]

The jury is still out on a lot of this, Shana.

The good news for the surgery is that it gets results. For some, it's the best approach.

The bad news is that with some procedures such as the gastric stapling, the patient can actually force the stomach to stretch enough that they're right back where they started from.

With the gastric banding, the prognosis may be different. Instead of creating a smaller gastric chamber, the banding restricts the flow of food. One could try to defeat it by nibbling all day long I suppose.

You bring up a good point though. Unless someone counsels the patient on portion control and content quality of food, bad things will happen. By the time these lessons are learned, the patient is halfway there anyhow.

Bill

[JimHawkins]

In the mean time, it's a sad state of affairs that the only way we can cure most of these people of serious illnesses is basically to staple or band their stomachs. If people had their mouths partially stapled shut, they'd achieve roughly the same benefit. Ponder that thought...

Bill,

You often show disdain for those who are over weight and can't seem to control their eating habits.. Tsk, tsk..

Some folks clearly are chemically and/or psychologically disposed to over eating and eating the wrong foods.. It reminds me of how some folks talk about homosexuality.. Some homosexuals have stated: If I could be straight don't you think I would be??? Implying that if they could just choose to be "normal" they would be in order to "fit in".. Now I know over eating isn't being gay, but I do think that it's just as hard for some folks to stay in control of what and how they eat, which has as much to do with chemistry, DNA and culture as do many other "diseases"..

Just say no!!! Never did work.. These folks need help and understanding!!!

[Shana Moore]

I believe that nutrition counseling should be a first step. I remember some horror stories from the woman who had this because she simply couldn't resist having more than a cup full of food at a time. If you eat more than the stapled stomach can handle you get....sick.

Also, she was still eating nutrition poor choices (at least at first). She'd have a cup of high fat mac n cheese or a McD's burger instead of something that actually had some nutritive benefit. Because of the severe restrictions to her eating, I would think high nutrition content would be vital to success.

Honestly, besides my determination to do this on my own ( ), watching what these two people went to has me saying...no...just no.

[Shana Moore]

I do think that it's just as hard for some folks to stay in control of what and how they eat, which has as much to do with chemistry, DNA and culture as do many other "diseases".. Just say no!!! Never did work.. These folks need help and understanding!!!

Jim,
I happen to agree that changing your eating habits is very hard work and that help and understanding are a must! But I also believe we, as a society, focus overmuch on quick fixes.

That's why I keep emphasizing nutritional counseling as a first step. It bothers me that teenagers are having this procedure done (yes, it's true). I would think some medical intervention and nutritional counseling should be seriously tried first (and some psychological counseling). This, IMHO, should always be a last resort and should NEVER be done in a vacuum.

[Bill Glasheen]

This is a sensitive subject, Jim.

The liberal guilt trip is an interesting angle, I admit. But I'm not so sure I'm going to go there just yet.

I have mixed feelings about all of this.

• When I put my scientist hat on, I realize that bariatric surgery produces RESULTS for many of the morbidly obese. Other methods have failed for this population. Results count.
• When I put my libertarian hat on and think about society as a whole, I see people who make choices and suffer from the consequences of those choices. Then I see them wanting society to rescue them from those consequences. Yep... MY health insurance premiums pay for someone else's inability to control their eating habits. Should I be happy about that? Shouldn't there be some incentives with teeth in this picture? (Oops... bad pun. )
• When I put my public health hat on, I see a society exposed to high fat, high sugar food. Saturated fats are everywhere. Hydrogenated fats are everywhere. High fructose corn syrup is in every piece of food that I'm yanking away from my boys. I know better, and wage the battle with my boys attempting to eat like their peers who are part of the obesity EPIDEMIC. Most do not know any better.

If we don't call it like we see it, Jim, we are doing a disservice to an entire society.

If we in the traditional martial arts community don't stand for SOMETHING in this picture, then what the hell are we all about?

- Bill

[chef]

It is a whole lot easier when you are gifted with good genes. For example, my sister and I are two years apart. When young she took after my Mom's side of the family (ie. curvy, precocious) and everything I wanted to be. I took after my Dad's side with a wiry, athletic build, looking more like a young boy at 15, flat-chested with no curves. I hated it then but love it now. After three kids, you fill out and attain more curves.

She struggles so hard now to keep her weight and blood pressure down, only eats chicken and seafood (no pork or beef) and hates that she is more like my Mom's side.

It also has a lot to do with your socio-economic background. Heathier food is usually more expensive. Low income have to feed families more rice, potatoes, pasta as staple items to feed families cheaply and quickly.

So many people were raised eating fried foods and often cook the way their parents did....which can be changed. I did. I don't have fried foods like I was brought up eating. We do have control over that.

A third thing is that food is psychologically a comfort thing many times. When depressed we eat to feel good. I get down, I eat chocolate. It is a easy quick fix and we seek pleasure to alleviate the pains that trouble us...be it food, sex, alcohol. People escape in many unhealthy ways...often reading for hours or in front of a TV or computer, losing themselves. We can control that...we can get off our butts and get in the gym or set something up at home, free-weights, soup cans, big exercise bands...what ever.

Those things that we can control, we should and those that we cannot, we need to research to see what can be done.

Just some thoughts.

Regards,
Vicki

[chef]

and it gets to the point of deciding this: am I doing everything I can to be healthy? Am I eating well? Am I exercising? Am I willing to do what it takes in an normal healthy amount of time? Healthy weight is usually 1-3 pounds a week. If you are then you have to come to grips with whether or not you are healthy. At this point, then medical intervention may be necessary for health reasons.

If one is doing everthing one can then he/she has to come to grips with the reality of accepting the body God gave you. If you don't like what you see then maybe you should consider medical procedures under a doctors care and in strict adherence to the rules...or there may be some psychological issues that need to be dealt with.

Funny thing, when I was having coffee this am in McDonalds with some seniors and friends that meet up there in the am, some over heard me talking about getting back on my Weight Watchers diet and excercise regimen. Their reaction is "you don't need to lose weight, you look fine". You know your body and clothes hide a lot.

I am used to being slim and in good physical shape...it's relative to what you are accustomed to. I know I have put on weight, feel uncomfortable, and can do something about it...it is within my control. I choose to take an active role or I choose not to. In the end, it's about choices and genetics. You have to decide which factors you are dealing with and, as Bill says NIKE, just do it.

Regards,
Vicki

[JimHawkins]

I have mixed feelings about all of this.

• When I put my scientist hat on, I realize that bariatric surgery produces RESULTS for many of the morbidly obese. Other methods have failed for this population. Results count.

I agree and agree that it's a rather drastic and sad measure.

[*] When I put my libertarian hat on and think about society as a whole, I see people who make choices and suffer from the consequences of those choices. Then I see them wanting society to rescue them from those consequences. Yep... MY health insurance premiums pay for someone else's inability to control their eating habits. Should I be happy about that? Shouldn't there be some incentives with teeth in this picture? (Oops... bad pun. )

No doubt this results in a lot of health issues and a high cost..

[*] When I put my public health hat on, I see a society exposed to high fat, high sugar food. Saturated fats are everywhere. Hydrogenated fats are everywhere. High fructose corn syrup is in every piece of food that I'm yanking away from my boys.

And carbs, carbs, carbs.. IME I see the carbs and sugars as a huge and major contributor..

I know better, and wage the battle with my boys attempting to eat like their peers who are part of the obesity EPIDEMIC.

You're right the junk is everywhere, in everything, and the messages sent and the products made are highly pervasive and damaging--it's horrible..

Still, IMO the folks who are seriously effected with what I would call an overeating disorder need help and compassion. I don't think we fully understand or are aware of the extent to which some are driven to eat in ways that will finally kill them.

I saw a program a week or two ago about fat camp--lots of sad cases.. What I thought was so telling is how some folks although desperate to lose weight and fit in--even after loosing some of the weight they couldn't resist going to the ice cream place to pig out.. They reported that after fat camp the majority of the folks would put the weight back on before long.. What does this say about this condition--it does appear very much like a disease or genetic disposition equating almost to the symptoms of hard core drug users.. And in reality fat folks are indeed discriminated against as well as facing all kinds of medical problems.. This is a complex problem that we have to see goes beyond simple life choices for some and needs a serious solution.

[Bill Glasheen]

It does indeed have every indication of being like an addiction, Jim. And here's something that one of the researchers in my company just uncovered.

Long term

..... Most studies have suggested that 10 years after surgery, only 10% of patients maintain a minimum weight loss of at least 50% of their total excess weight at the time of their initial surgery. Some patients regain weight. Others are unable to adjust their eating habits and fail to lose the desired weight. Successful results depend on the patient’s willingness to adopt a long-term plan of healthy eating and regular physical activity. According to an episode of Oprah Winfrey that aired on October 24, 2006, 30% of people who undergo weight loss surgery such as VBG or Gastric Bypass suffer from addiction transference, which is transferring the previous addiction to food with a new addiction to alcoholism. The show stressed the importance of examining the root causes of addiction in order to avoid the phenomenon

Wow!

Here's another thought worth pondering. The following groups of people are representative of clusters of individuals who have chosen to study traditional martial arts with me.

• People with eating disorders (obesity, bulimia, etc.)
• Women who have been sexually assaulted
• Men who have been attacked
• Boys and teenagers who are being bullied
• Women who were the victims of familial sexual predatory behavior (e.g. step fathers).

What is the common motivating thread amongst these groups of people? Why do they choose to approach martial arts to resolve some of their issues?

- Bill

[Shana Moore]

What is the common motivating thread amongst these groups of people? Why do they choose to approach martial arts to resolve some of their issues?

It's all about control, Bill.

Finding it for the first time
Getting it back from some real or imagined thief
or regaining what you once had

It's all about a sense of control, really.

[JimHawkins]

What is the common motivating thread amongst these groups of people? Why do they choose to approach martial arts to resolve some of their issues?

The desire to get control over their lives--manage their issues, etc..

[Bill Glasheen]

Almost in two-part harmony!

Therein lies an important tie that binds us all together in a common purpose. We may not be seeking the same specific results, but we're all on a very similar journey.

Think of the various motivating issues above. What were the short-term issues? What were the long-term issues? What were the quick, dramatic fixes? The crisis points?

When do we achieve that "inner peace" that we're all struggling for?

Is it a destination, or a journey?

I think we each know the answers to these various questions. And IMHO, there really isn't a one-size-fits-all solution. It ultimately is an individual journey, with good friends found along the path.

- Bill