Thursday, March 29, 2012

Diabetic Surgery Uncovers Irrational Weight Biases

In case you missed the news, two recent studies (here and here) published in the New England Journal of Medicine demonstrated dramatic superiority of surgery over intensive medical management in the treatment of type 2 diabetes.

Now I'm not going to get into the studies here and dissect them for you, but I think that they were well done studies, and while admittedly we still don't know what their long, long, term benefit will be, at 2 years out, they look damn good with surgery coming out worlds better than "intensive medical therapy" for the treatment (and remission in many cases) of type 2 diabetes.

Of course time's definitely a fair concern. Meaning what if 5 or 10 years down the road the folks who had the surgery are no better off than those on medical therapy? Thing is, based on what we know already about the surgeries involved, all have well known 5 year data, and the bypasses and diversions much longer than that, and those studies, while they weren't specifically designed to look at diabetes alone, did look at weight and medical comorbidity regains, and I certainly don't recall anything that suggested diabetes returned with a vengeance.

So basically here we have a surgical intervention that is dramatically better than a medical one, for a condition that causes cumulative damage and can wreak havoc on a person's quality and quantity of life.

Yet many MDs, allied health professionals and health reporters, including some who I know, respect, and admire, are taking this opportunity to discuss how we shouldn't be looking to surgical solutions for diabetes because patients could instead use their forks and feet. While there's no argument about the fact that in a ideal world everyone would take it upon themselves to live the healthiest lives possible, there's two problems with that argument. Firstly, not everyone is interested in changing their lifestyle, and secondly, statistically speaking, the majority of even those who are interested and successful with lifestyle change will ultimately regress - the simple fact remains that we don't yet have a proven, reproducible and sustainable approach to lifestyle change.

And what of those folks not wanting to change?  I say, "so what?".   Since when did MDs, allied health professionals or health columnists earn the right to judge others on their abilities or desires to change? Our job is to provide patients with information - all information - including information on lifestyle change, medical management and surgery. We can even provide patients with our opinions as to which road we think may be best for them, and why, but honestly, given the results from these studies, I'm not sure how anyone could make an evidence based case that surgery isn't a very real and powerful option that ought to be discussed with all of their obese or overweight type 2 diabetics.

Unless of course that someone has some form of weight (or simply anti-surgery) bias.

Let me give you another example. Let's say there was a surgical procedure that folks with breast cancer could undergo that would reduce their risk of breast cancer recurrence by roughly 30%.  Do you think anyone would question a woman's desire to have it? I can't imagine. And yet lifestyle - weight loss and exercise has indeed been shown to reduce risk of breast cancer recurrence by 30%. Think people would dare suggest the women choosing surgery were, "taking the easy way out", that they should just use their forks and feet?

We've got to get over ourselves.

Until we have a proven, remotely comparable, reproducible, sustainable, non-surgical option, if you bash the surgical option on its surface for being "easy", or "wrong", you might want to do a bit of soul searching as to whether or not you're practicing good medical caution, or if instead you're practicing plain, old, irrational bias.

[and for new readers to ensure there's no confusion - I'm not a surgeon]

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  1. Very well said!

    This post reminded me. Did you see the BBC show Horizon's program on obesity? It was called "the truth about fat" and was on a few weeks ago. Not sure if you can get it online where you are, but I found in really intersting to hear how they explained the benefits of weight loss surgery. It was a great example of translation of research into easily understandable language.

  2. Anonymous7:11 am

    Personally, I'm surprised the medical establishment doesn't embrace surgical options. Let's face it, the obesity crisis isn't going away, and the surgical option appears to be the one effective option that medicine has. Counselling has the same woeful cure rate for obesity than it has for other addiction diseases, like alcoholism, drug abuse or gambling. All medications come with side effects that make lifelong compliance to any existing drug therapies unlikely, and have fairly limited success.

    Honestly, without surgery, I can't imagine why an obese person would even bother asking for medical help to solve the issue. Take away surgery, and medicine has about as many arrows in the quiver as a personal trainer and a gym and the Ephedrine/Caffeine stack.

    Also, the environmental issues that triggered the obesity epidemic aren't going away. In fact, as far as all the addiction based diseases, it is the one I can think of where the addictive substance are subsidized, rather than tightly regulated or made illegal. I can't imagine the type of war on tobacco that cut adult smoking rates in half will ever be waged on sugar/fat/salt.

  3. Roman Korol7:25 am

    Yoni, can you provide a link where one might read about it? Thanks!

    1. Added links to first paragraph of the blog post. Thanks for pointing out I hadn't!

  4. Anonymous9:13 am

    well said - the breast cancer analogy is pretty vivid - cardiac internventions are also a valid comparison.

  5. Anonymous10:56 am

    Ok...just can't help myself BUT just perhaps the "obesity crisis" is all a part of a natural evolution-when food/resources get limited the skinny people will die off and only the fat will survive. Mmmmm perhaps it's not a disease after all but a form of self preservation.
    Wouldn't that make being "fat" something to be proud of? GR

  6. I have been reading and commenting for DAYS on this exact thing (see my "Storming the Web! section on my blog:

    I'd be curious if the doctor you referenced here is the same one I've been arguing with. It seems like an absolutely ludicrous point of view from a medical professional, and he's of course selling a book about eating and living well. I take NO issue with his point of view, his own personal belief on what's the best route (note: best, not ONLY) to take in treating diabetes. I take issue with exactly what you've mentioned here - it's weight bias, loud and clear.

    At 311 lbs, it was astonishing how much food I could consume - endless. I could also barely walk 10 minutes with gasping for air and being in pain. I take full responsibility for getting myself to that point, but once I was there - it was near impossible to get myself out. So I had weight loss surgery and I was rid of my pre-diabetic condition, rid of gout, heel spurs, sleep apnea, hypertension, and PCOS.

    And here's the kicker: I now eat a very healthy diet and I exercise almost daily. My entire lifestyle changed because of that surgery. Once the weight was off, and once I wasn't able to eat the things that got me there, I became healthy. I am a success story, but not a exception to the rule. There are MANY of us, and it boggles my mind that these doctors are trying to not only discount the benefits of the surgery, but paint us as taking the easy way out or just being too gluttonous to follow his program.

    You can't cure obesity with weight bias. End of story.

  7. What about the selection process for these patients? My understanding is that the patients who are chosen for this type of surgery are selected based on the likelihood they will be able to stand the results of the surgery. Does this selection process not bias the result? Also, what about all the people who can't handle having their stomach stapled or banded and have the procedure reversed? It seems like the ones that this works for are somewhat "special" to begin with, no? I don't mean to dispute what you're saying - I genuinely wonder about how the selection of patients for this procedure affects the results.

    1. You're band on right.

      Pre and post surgical education are crucial, and I'm sure these folks got good ones.

      Any surgical program worth its salt ought to have rigorous education and a means to test pre surgically to ensure patients understand the ramifications of their choices and that in fact they haven't chosen a, "quick fix" but one of lifelong commitment to change.

  8. I agree but it took me working with weight loss surgery patients to get over the sterotype (I'm a dietitian). For individuals with diabetes not having success with conventional treatment, surgery is an option they need to know about. Thanks for the post!

  9. Bob Johnston11:14 am

    Now wait just a cotton-pickin' minute here. I hate for my first comment on your site to be negative but supporting surgery as a treatment for weight loss in diabetics based upon these studies is very premature.

    First off, I think we should examine the methods involved:
    "All patients received intensive medical therapy, as defined by American Diabetes Association (ADA) guidelines, including lifestyle counseling, weight management, frequent home glucose monitoring, and the use of newer drug therapies (e.g., incretin analogues) approved by the Food and Drug Administration (FDA).2,12 Every 3 months for the first 12 months, patients returned for study visits with a diabetes specialist at the Cleveland Clinic. Patients were counseled by a diabetes educator and evaluated for bariatric surgery by a psychologist and encouraged to participate in the Weight Watchers program."

    What this is saying is that patients in the control group were told the eat the typical ADA diabetic diet, which is 50% or more carbohydrate. Can anyone explain to me how eating the same food that caused your disease is now expected to be a major part of the cure? Is it any shock that these people had no success in controlling their disease?

    Patients who underwent bariatric surgery are given another diet. It's not laid out in the Methods (I wonder why...) but with a little research you can find that these patients are put on a low-carb diet. From the Lap Band website:

    "The second phase of the Lap-Band diet consists of 5 to 6 weeks of a modified full liquid diet; the key component of this phase is consuming two ounces of a protein shake every hour for ten to twelve hours a day with two ounces of other liquids such as soup, baby food, or sugar-free gelatin three times a day.

    During the second six weeks following Lap-Band surgery patients may eat food that is shredded in a food processor prior to eating. The basic foods on the Lap-Band diet include meats or other forms of protein, vegetables, and salads.

    After Lap-Band surgery the stomach will never hold more than 4 to 6 ounces per meal, so making every bite count is essential for healthy and nutritionally rounded weight loss success. Protein is especially important following Lap-Band surgery. The Lap-Band diet does not include most bread, potatoes and other starchy vegetables."

    Sounds like a low-carb diet to me. So did their diabetes markers improve because of the surgery or did it improve because they eliminated carbs from their diet. I'm thinking the latter.

    Second I think it's important to remember that these are observational trials and we all should know by now that "correlation does not mean causation". How about some clinical trials be run before we start having people gouge their insides out.

    Lastly, did you happen to check out the disclosures listed for the STAMPEDE study? I'm betting not...

    1. Bob, you're always welcome to disagree, especially given that you do so politely!

      Thing is, my post has nothing to do with the results of the studies, but rather the commentaries it generated that suggested an approach to medicine that I feel is relegated only to those with obesity.