Thursday, January 17, 2013

The Aspire Assist: Brilliant or Brutal? Surgically Assisted Weight Loss or Mechanized Bulimia?

So how do you think the boardroom table discussion went when this idea was first being kicked around?
"Um......so maybe we could make a hole in people's stomachs and then hook that hole up to a machine that hoovers up food before it can get digested?"

"Are you effin' kidding me?"

"No, I mean think about it, there are tons of people who aren't bulimic who think about being bulimic, this way we could make it all medical and stuff
".
That's certainly the tenor of the discussion out there as generally the reports on this are either pretty angry or simply express revulsion.

Superficially it really does sound horrifying, and undeniably, at first blush it's not what I would consider to be the intervention I'd always hoped for. But when researching the story of course I needed to know - what type of studies have been done on it to date?

Believe it or not, their very preliminary data's interesting. Now this isn't peer reviewed published data, just a poster presentation, but in it they describe the 11 patients who were given an Aspire Assist (that's what they're calling it) for a year. 10 of the 11 completed the year and from the poster it would appear they lost 44lbs on average.

So yes, back to the shock, horror and repulsion - I readily agree that on its surface both the premise and procedure is less than appetizing (honestly when considering this post before delving into it I had expected the post to be extremely negative), but if larger, longer, studies suggest it's well tolerated, doesn't lead to or exacerbate disordered eating, involves minimal risk, has minimal adverse metabolic or nutritional consequences, and leads to sustained losses which in turn had demonstrable medical or quality of life benefits, why wouldn't I consider it?

As I've written before it'd be wonderful if everyone lived incredibly healthful lifestyles and in turn that living incredibly healthful lifestyles guaranteed desired weights (they don't BTW), but I think my job as a physician is to ensure people are equipped to make informed decisions, not to make decisions for them, or to judge the ones that they make. If the Aspire Assist proves to be both safe and efficacious in the long run, I'll happily discuss its pros and cons with each and every suitable patient. I'll also happily discuss more traditional bariatric surgery, pharmacotherapy, purely behavioural therapy and also the option of doing absolutely nothing with them. And I'll do it all in a nonjudgmental manner too - because my job is to ensure my patients are aware of the risks and benefits of all of their treatment options, including watchful waiting, and then to support them in whatever informed decision they make. To do otherwise in my mind is contrary to the spirit of medicine and suggests one of two exceedingly common and unfair weight biases. First the one that often angrily asserts that unless a person is willing to make formative lifestyle changes, they're not worthy of being helped, or the second - that if only patients wanted it badly enough, they'd just fix themselves. Honestly, if desire were sufficient is there anyone out there who'd struggle with anything?

So is the Aspire Assist brilliant or brutal? Given it's just been born, it's going to be at least a decade before we'll even have the chance of having the robust long term data to make an informed decision. Until then all I can really say is that I'm looking forward to reading it.

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12 comments:

  1. Question: I have zero medical training, but isn't it a bad thing to have a hole into your stomach? What if stomach acid leaks out? Wouldn't there be an increased risk of infection?

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    1. Anonymous9:02 am

      I was thinking that if there is a tube that goes outside of your body, I don't see how that would work without causing infections in great numbers of people. I work in dialysis and the nurses tell me that people who have the peritoneal catheters (which is a tube that comes out of the abdomen) will get infections, it is not a question of if, but when. And those infections are serious, they require serious interventions and sometimes hospitalizations. I just don't see how that risk of infection would ever be worth whatever weight loss would come from this.

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  2. Okay, but since I'm not a doctor and don't have to directly deal with patients, I reserve the right to go, "Ewwww!" and say things like, "Really? You'd rather have a tube and a sack of partially digested food permanently attached to you than do some healthy diet and exercise adjustment?"
    But then, I'm not as practiced as you are at this "not judging people" thing.

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  3. Marina9:36 am

    OK, great new weight loss idea!
    Before every meal, read the description of how this device works. It put me right off my breakfast, and potentially lunch.
    Really, truly nauseating concept.

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  4. As a nutrition support dietitian who regularly works with people who have tubes in their stomach and similiar devices which relieve the symptoms of serious stomach and intestinal disorders, I, too, was horrified at first to see this used as an avenue for intentional weight loss.

    However, like Dr. Freedhoff, after reading the article and considering it a while, I came to the conclusion that it is really no different, in fact it seems far less barbaric, than the all-too-common gastric bypass surgery. In addition to reducing the size of the stomach, the surgery also bypasses a portion of the small intestine, intentionally causing malabsorption and diarrhea of undigested food. The result of the intestinal bypass also results in hormonal changes that are thought to be "beneficial" to weight loss.

    By comaprison, IMHO, gastric bypass surgery is far more barbaric and certainly more risky. In my field of practice, I see what happens when these surgeries go terribly wrong. Patients who have chronic nausea, vomiting, severe abdominal pain, and malnutrition. I've also seen patients develop anorexia nervosa, bulimia, and alcohol and drug addiction following gastric bypass surgery. Sadly, I've also witnessed death in the weeks, months, and years as a direct result of complications from gastric bypass surgery.

    If given a choice, I'd choose something like this device over the far more invasive, permanent gastric bypass surgery. No, I don't work for the company, but this idea might not be as awful as it sounds on the surface.

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    1. I believe part of the point of this post was to look past your personal bias or gut reaction. I'm not sure that my colleague succeeded here, and the misinformation and fear mongering in her reply is unfortuante.

      Bariatric surgery is well studied, and is currently the only effective treatment for obesity. Yes the complications can be lethal, and given where you work it's understandable how you might have the feelings you've expressed. However, this is not the 'norm', and the actual rates of life-threatening complications are low.

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  5. Food waste is a public health issue that should be considered in evaluating this device: the cost of obesity versus the cost of waste. It's not just about the individual

    http://blogs.plos.org/publichealth/2013/01/15/food-waste/

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  6. This method fails to take into account the physiological effects of 1) thinking about food, 2) seeing food, 3) smelling food, 4) tasting food, and 5) swallowing food — all of which impact insulin and thereby, fat storage. So the body is robbed of its ability to derive nutrition from a complete ingestion-to-elimination process and essentially left with the side effects of food: fat storage. How is a person going to work towards a healthy lifestyle once they're committed to depriving their body of fuel while not addressing other food issues?

    It commits a person to a lifestyle of NEVER trying to learn to eat well, NEVER listening to their body's signals, and NEVER being nutritionally sound again. It's trading one dysfunction for another.

    As a person who's been overweight most of my life, I've felt this level of desperation. I'll admit that I've had food issues when I was fat and when I was skinny, when I was bulimic and when I didn't care what I looked like. Issues like not understanding how to eat well, now knowing how to make healthy selections, and overriding my body's hunger and satiety signals. This system doesn't correct that at all. Please recognize this as yet another company's willingness to profit from an overweight person's desperation.

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  7. Alexie4:51 pm

    My question would be whether it would be healthy to prioritise food over anything else. People who wear colostomy bags suffer sexually and socially from the consequences of a bag hanging on their outside. Why would anybody want to have that experience if they didn't really, really need to?

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  8. Anonymous11:44 pm

    When I've started to eat something I know I shouldn't, I have occasionally thought how great it would be to be able to chew on it then spit it out, but it's very hard not to swallow. This device sounds very intriguing to me, and much better than bulimia or mutilating surgery which can't be undone.

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  9. It's unreasonable to think people will not use a device like this to eat indulgent foods with the expectation that they can simply vacuum them out. They can also pat themselves on the back for not getting that barbaric, mutilating surgery that's saving lives and driving permanent lifestyle change.

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  10. Anonymous11:13 am

    I think the Endobarrier is a better choice, what are your thoughts on this device Dr.

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