Gastric Bypass

[benzocaine]

Is it me or has anyone noticed how many people have chosen this as the "easy way out". Everywhere you look someone has had their stomach stapled. I'm sure many of us know people who have gone under the knife and have practically melted away to being a thin person.

I've seen a few cases that have gone bad. Apparently it isn't the easy way out. The people are disabled for life due to the complications. But then people die in car crashes every day, and we keep driving. People get mugged every day and yet we keep going out into cities.

Gastric Bypass

Since your behavior toward food is a very important aspect in determining the amounts and type of food you eat, a full psychological workup is a necessary component of this program and your ultimate success. The best weight loss will happen for those who not only have the surgery, but change many aspects of their behavior (behavioral modification).

[Bill Glasheen]

Ben

As part of my work, I get to see the health trends in the commercially insured. Gastric bypass operations are in the top 10 for greatest percent increase year/year.

It's obscene when you think about it. One could accomplish the same thing by not eating, or even clamping the mouth shut. But these folks would rather have their GI tract re-engineered instead. Make the stomach so small that you puke if you eat much more than a mouthful.

It works, but there is a price to pay. They risk complications and even death. We all pay higher insurance premiums.

I could go on and on about the "why" here. The food industry is interested in profits over nutrition, so will produce the kinds of food (high sugar, high fat) and amounts that cater to food addictions. Consumers continue to choose taste and quantity over common sense.

Sigh...

- Bill

[IJ]

Actually, they did try wiring people's jaws shut. Didn't work--they increased their liquid caloric intake. Basically, these are just compulsive eaters. My question is, what differentiates their behavior from cocaine addiction? They continually engage in a behavior which is selfdestructive but at least temporarily gratifying, and they're unable to stop. The body adapts to a variety of different metabolic situations in ways that can perpetuate the problem--if, for example, the sodium is chronically low, the body can reset its standards for a normal sodium and perpetuate the low sodium once the inciting problem is gone. Maybe these people rewire their brain after years of chronic eating and develop intake inertia.

Some thoughts:

Wouldn't it be nice if we had a noncaloric, flavorable substance of some kind we could dress up to look like food and let us chomp away at indefinitely?

Wouldn't it be nice if we could rewire the neurotransmitters in the brain (not just hunger signals, becuase people ignore them and overeat despite signs of fullness) to correct whatever is making these people chow down so hard?

Wouldn't aversion therapy based on nausea (like antabuse for alcoholics) after eating certain or too much food be nice? It could be cheaper and safer than aversion therapy set up by major surgery with a 1-2% death rate and high bill.

And wouldn't it be nice if, untril these things come along, we make it clear that eating less is a responsibility of the patient and the family and ultimately of the society (rethinking tax breaks for corn syrup for example, and or substituting sin taxes for the 2/3 of food at the store that is trash)? Too much of this is being blamed on genes or circumstance. Even if it IS an addiction, we must stress the volitional component of it.

[benzocaine]

Maybe these people rewire their brain after years of chronic eating and develop intake inertia.

That makes sense! It's probably like you say about it being compared to crack addiction. Alcoholics Anonymus has a saying "one is to many, a thousand is never enough". I don't doubt that the brain can be rewired forever. Adiction specialists say once an adict, always an adict.



Bill, The statistics you see concerning Gastric Bypass must be astounding. I am on the front lines so to speak. I would guess my hospital does around 3-4 a week, most with no complications. But I've had a couple sucking on the end of an endo tracheal tube

The reason I posted this was a girl I worked with had the procedure. She has lost 250 lbs. She was recently at a Respiratory Therapy conference where she was seen drinking multiple drinks and eating just as much as the next person. So basically she is stretching her little pounch out to accomidate more food! SAD.

There is a proverb in the Bible that says " As a dog returns to it's vomit, so a fool returns to his folley".

[benzocaine]

Just for the record, I'm not exactly skinny But I'm slowly whittling the weight away though diet. (I already do Karate)

[Bill Glasheen]

Ben

You aren't skinny, but you are far from morbidly obese.

Ian, they HAVE come up with indigestible food. I believe it was that oil they fry chips in (Olase??) that is an isomer of digestible food. Problem is, it runs right through your system. Literally. Major brown-out issues...

Bulemics also have their techniques. Too bad about the ulcers and the burning of the tooth enamel from years of regurgitating stomach acids...

Ben, you are right about some stretching the food pouch out. All that cutting, all that risk, and you screw it all up with the same overeating problem. Where there is a will, there is another 200 pounds.

And so we get back to the root of the problem - eating too much. I think Ian hit it on the head when he characterizes it as a brain or brain chemistry issue.

Funny how you have to be so careful, so PC these days. I'm out here in the Minneapolis area this week. I was joking with another fellow there about when we climbed Camelback a few weeks ago in Phoenix. He told this woman "Bill beat me on the way up, but I beat him on the way down." "Yea," I said, "you had gravity working for you." And then...I realized the woman in our conversation group weighed about 350 pounds.

Mary Chant got on me one time about my language. I'm glad Mary's around; she's a good egg. But you know... Sometimes I think you just need to call it like it is. Too much enabling behavior in our society, in the interest of protecting people's dignity.

- Bill

[Mark Weitz]

I agree that there is something wrong in our society when you can circumvent the problem behavious and get an operation that re-engineers your stomach. I'm bothered by the fact that the procedure is allowed. I suppose one can argue that a person should be able to do this in a free society but I think medicine has to be held to a high standard that includes not being allowed to perform disfiguring or innately damaging operations on people's bodies.

Mark

[benzocaine]

Another reason why I've been thinking on this subject is that my brother and his G.F. are visiting. I'd guess their combined weight is close to 600 lbs My wife them and I piled into our Nissan X terra and that baby strained to climb a couple hills. No Lie.

I want to say something tactfully to him about diet and excersize, but then I realise that it's his life and not mine. There is no use being the holier than thou Big Brother.

Bill, I can totally relate to your experience with the big woman. I've been on egg shells all week.

Ian, I agree that a sin tax could be useful.

Any one had an Adult Happy meal yet??

[Mark Weitz]

I can actually relate to this. My mother-in-law, who I'm very fond of, is morbidly obese. I drive a small Saturn SL1 and, due to her age, weight, and girth she has great difficulty getting in and out of the front seat. To make a long story short, she's broken the hinge piece that keeps the door open twice, and while not the most expensive thing to fix it's a little aggravating. I haven't bothered to fix it recently because I figure she'll break it again soon. I'm "not allowed" to raise the issue.

Strange and sad how people will let their bodies go to such an extent. She has adult-onset, Type II Diabetes, high blood pressure, and is probably a heart attack waiting to happen, which I pray I'm wrong about.

Mark

[IJ]

I'm not sure we should say the procedure shouldn't be allowed....

I mean, we allowed M. Jackson to cut off his nose 17 times, didn't we? People are free to make medical decisions in this country.

Further, we do a lot of things that replace willpower with assistance. A lot of them come off AS willpower because they represent efforts:

--Nicotine patches, gum, buproprion for smoking
--Chronic methadone for narcotic abuse
--Antabuse for alcoholism
--pill beepers and cases to improve adherence

The fundamental principle is the same. Doing something that makes it harder to screw up or easier to comply. The bypass is just extreme because of a risk of death (also seen in antabuse, patch misuse; there are seizures with buproprion) and because we don't usually think of food as an addiction so we look at this of volitional fatness. But, these behavioral problems are all on a range of controllability.

In the end, we should do the thing that works best, even if that is sometimes a bypss--but I think that stressing responsibility (as a society) and coercing better diet by changing the appearance of our stores through laws will be better overall than bypasses. That to me is just a symptom of how diseased our approach to health truly is.

[Mark Weitz]

I agree that we should be careful about restricting people's rights to harm themselves, but there are some things, such as cigarettes, that I have no problem with banning. Marijuana is not legal, but cigarettes are despite their being a leading cause of the big three killers, heart disease, cancer, and stroke.

It's one thing to allow a person to assume right to risk. I think it's another to allow medical professionals, who understand the full nature of what they're doing to a person's body, to be allowed to perform operations and/or procedures that are innately harmful to a person. This merits a closer look at medical ethics but I think it's a reasonable question to ask why a doctor should be allowed to operate on a person's face when the risks, both in terms of disfigurement and function (Jackson's nostrils are collapsing), outweigh benefits.

Mark

[IJ]

One could argue that ANY plastic surgery runs risks and offers no medical benefit. However, there may be enormous psychological benefits--especially when the person is really disfigured, which is interfering with their socialization rather than just being Michael Jackson, who by all appearances had Body Dysmorphic disorder. (There is no bright line between a normal desire to approve your appearance and a pathological one). People should be free to weigh these risks and benefits with all the relevant information, and make their own decisions. Afterall, there's a lot of arguable decisions that bear on health:

--you can have a bad reaction from tanning beds, or heck, get an allergic reaction to foundation
--you can sprain your knee playing basketball or even die climbing or swimming and recently I learned you can get mauled by a mountain lion just riding your bike.
--you can drop your blood pressure from Viagra, or forget to mention it to the doctor when you have chest pain, and the nitrates they use can potentially kill you if that happens.

When are sports, makeup, viagra worth the risk? When the informed consumer decides so.

As for gastric bypass, there are dangers. There are also dangers to weighing 700 pounds. Some people do extremely well with bypass and have no doubts the procedure saved their lives. I'd proceed with study, caution, and full disclosure. Certainly there is a potential for abuse and there are better ways to lose weight, but not everyone is capable of dieting. Evidently.

Cigarettes are the number one killer in the united states. Obesity was just ranked #2. Outlaw cigs--> outlaw twinkies? Who decides? Did prohibition resolve our problems with alcohol abuse or simply add the criminal element? I think cigs should stay legal and we should discourage use with taxes pushed to a point where they DON'T encourage a black market. Plus we should continue to educate kids and use vigorous antismoking education to prevent the companies from expanding their markets with children, which is what the profit motive has been making an absolute imperative for them.

[Mark Weitz]

I'm not opposed to cosmetic surgery outright. I'm suggesting that there needs to be a greater effort by the medical/legal establishment to explore the ethics of some procedures. Peforming a nose job is one thing. Allowing surgeons to perform procedures that are obviously disfiguring and/or have no innately therapeutic benefit is another.

I admit gastric bypass surgery is not a black/white case since, as you point out, obesity is a major health problem and can kill. One approach may be to assess people more re psychological profile and motivation to determine suitability for the surgery. It's probably true that the procedure itself does not pose a major risk to most patients and we do have informed consent laws that allow people to assume right to risk.

I have a personal bias against cigs as a family member died of lung cancer caused by smoking. That bein said, through it's political/legal institutions, our society - whatever that means or is defined - has decided that many drugs are illegal, such as, cocain, crack, heroine. Cigarettes are far more lethal than this short list of banned substances, more due to their widespread use (they're legal) and the relatively slower rate at which they kill. But why should we measure or base the extent of our free society on whether people have the right to kill themselves with government sanctioned and supported lethal substances? Like Heroine and crack, cigarette tobacco cuases terrible illness and kills. I have no problem with tobacco becoming a black market item but perhaps decriminalize - I've never believed people should be in jail for harming themselves, that's their business.

Alcohol is not in the same camp as tobacco. Moderate amounts of alcohol are not harmful to the body - some studies suggest small amounts of red wine may have a circulatory benefit. Cigarettes are harmful every time you smoke.

Mark

[IJ]

"Allowing surgeons to perform procedures that are obviously disfiguring and/or have no innately therapeutic benefit is another."

Which are these, other than MJ's nose? There will always be a complication rate... people just need to understand it.

"One approach may be to assess people more re psychological profile and motivation to determine suitability for the surgery. It's probably true that the procedure itself does not pose a major risk to most patients and we do have informed consent laws that allow people to assume right to risk."

There IS a lengthy and thorough evaluation process, and there is 100% understanding of the risks by participants. Alterntives are explored, they speak to previous patients before they have it, and they go to support groups. People are turned down all the time.

"But why should we measure or base the extent of our free society on whether people have the right to kill themselves with government sanctioned and supported lethal substances?"

Well, teh substances aren't supported--they're discouraged with tax actually, and states also sponsor quitting education and support lines. But otherwise, yes. The whole point is that people get to make decisions, whether or not you agree with the choices. There's no choice if you only give them one option. We deal with this in medicine all the time, when some patient refuses a very important medicine on principle, because they think cholesterol lowering is a "crutch," or they decline lifesaving surgery, etc. But our job isn't to force people to live longer or take risks we want. It's to help them reach THEIR goals. As for dangerous substances, you want the government outlawing your weekly glass of wine, or a motorcycle, amusement parks, rock climbing, scuba, butter, sex? Where's the line drawn?

A glass of wine a week is indeed harmless. Many glasses a day is dangerous. Is a pipe once a week dangerous every time? Sure. Significantly? Maybe not. What about butter? it's dangerous everytime, more so in larger quantities. Who do you want deciding?

[Mark Weitz]

Is the answer, then, to say we should have a free and open market for everything that is either beneficial and harmful? This is not a simple black and white issue of having jackboot, fascistic government controlling every substance we wish to make choices about on the one hand and having absolutely no control over obvious harmful substances and procedures on the other.

Clearly, we do have standards and controls and most of these are established by either government bodies, arms-length professional regulatory bodies, judicial proceedings, or some combination of these. I don't think you're implying that all substances should be legally available to anyone who wishes to try them and ruin their bodies with them, or that medicine should be completely unregulated. Who decides indeed? Evidently, decisions are made all the time and there is, depending on which decision-making body that is relevant to a particular case, usually some degree of exclusion in most cases. I wish there was a pure and perfect form of democractic process for all occasions but there isn't.

Let's keep it simple, say, for smoking. Do you have a problem with government outlawing tobacco growing and selling but not criminalizing it for the user? As I've said, nobody who wishes to make stupid decisions about what they wish to imbide should be in prison or have a criminal record. But I don't think it's proper that goverment allows the industry to thrive given that this industry produces illness and death. To my way of thinking that is perfectly reasonable. Goverments make decisions in the public interest all the time and we elect them to do just that. The test is obviously that they do so in manner that is fair and in the public interest. Unfortunately, the tobacco industry is very estabished and powerful so I do not see this form of government sanctioned mass death ending any time soon.

But I digress. Gastric bypass - I concede that this should be up to a person to decide. Perhaps you know the details re the professional standards of what constitutes justifiable risk for a medical procedure to be sanctioned. Do you feel that the current practice of counselling and screening people for this procedure is adequate?