In Yet Another Win, Bariatric Surgery Reduces Cancer Risk In Long Term Study

Before you read any further know that I'm NOT a surgeon.

I think it could be fairly argued that as far as surgical impact and benefits go, there are few that rival bariatric surgery.

Shown to prolong life, regularly push many chronic diseases including type 2 diabetes, hypertension, sleep apnea (and so many more) into remission, and dramatically improve subjective quality of life, for so many, bariatric surgery provides a new lease on life.

Well add to the aforementioned list a reduced risk of cancer. While not particularly surprising of course given the relationship between weight and some of our most common cancers, here's new data from the now over 2 decades old SOS study which demonstrates reduced cancer risk in patients who opted for surgery vs. weight matched medically managed controls. 

For those of us who have the good fortune of working with patients who've had bariatric surgery, we know just how life changing it can be. What's shocking though, is the comfort of those who don't work with this category of patients to look down on surgery, or fearmonger about it, and this sadly also includes people in the health care community..

The data is clear. Bariatric surgery is remarkable. That said, I'm hopeful that in 20-30 years, it'll no longer be necessary and will be replaced by medications that lead to surgical degrees of weight loss without the surgery. Until then however, I'm thankful the option of bariatric surgery exists, and if you're not, you're either ignorant or an ideologue.

Book Review: The Complete Guide to Weight Loss Surgery

Today's guest post comes from our office's newest RD Alex Friel who has reviewed a book for people considering or having bariatric surgery (full disclosure, was provided with a feee copy of the book by the authors)

Thinking about weight loss surgery? You’re not alone. Bariatric surgery has been shown to be one of the most effective treatments for obesity and the number of people who undergo the procedure is steadily rising every year. Here at BMI, I work with many different clients. Some are considering bariatric surgery, others are actively preparing for it, and still more have undergone the procedure and are adjusting to life with a new anatomy. At every stage of the weight loss journey, it helps to be well informed.

Last week I was introduced to a new book written by registered dietitians Lisa Kaouk and Monica Bashaw. It’s a worthwhile read so I thought I’d share it with you. ‘The Complete Guide to Bariatric Surgery’ draws from their experiences as Weight Loss Surgery (WLS) dietitians and the many patients they have counseled over the years. Here’s what I liked:

• It’s from a trusted source. The registered dietitian (RD) credential means that Lisa and Monica are trained in the science and physiology of human nutrition. Their training and practice is regulated in much same way as that of our doctors and nurses so you can rest assured that the recommendations they make are tried, true, and grounded in evidence.
• Written in a conversational style, the book is an easy and entertaining read (or at least as entertaining as a book about a surgical procedure can probably be). There’s no jargon and you won’t need a degree in medicine or nutrition to make sense of the topics covered.
• Because the topics are drawn from the real life concerns and questions of more than 5000 patients, the book provides an honest glimpse into the realities of life after WLS. It’s a useful reference, not only for those who are considering WLS and those who have had it, but also for the friends and family who are their cheerleaders and support system.
• If you’ve ever anxiously wondered if your experience is normal, this book can provide some fast reassurance. The table of contents allows you to quickly skim questions at a glance and is organized into topic sections that range from ‘Tolerance Issues’ to ‘Hair Loss’ to ‘Emotional Changes and Support.’
• Much like this post, it’s short, sweet, and to the point. You won’t need to set aside hours of time to get through it.

My only critique is that the authors don't provide much information on additional resources, support groups, or further reading. It’s good to be aware of what’s available. Obesity Canada, for example, functions as a resource hub for professionals and lay people alike. In addition to educational webinars and videos, they also link to tools you can use to access greater health benefits for obesity care. The Bariatric Cookery, run by food writer Carol Bowen Ball, hosts a wonderful collection recipes to try at every stage of the WLS journey. As a former WLS patient herself, Carol’s first-hand experience lends the site a level of authenticity that is hard to top. Finally, a quick search on Google or Facebook will undoubtedly reveal a whole host of virtual WLS forums and support groups. Find one that resonates with you.

The Complete Guide to Bariatric Surgery is available for purchase on Amazon. It’s also available as an e-book at www.baritricsurgerynutrition.com.

Alex Friel, MSc, RD is a nutrition science nerd and one of the newest dietitians to join the BMI team. She’s convinced that everyone has a passion for food (even if they don’t know it yet) and is always on the lookout for her next favorite recipe. Alex spent six years living in Atlanta, Georgia where she completed a BSc and MSc in Nutrition Science at Georgia State University. Much to the chagrin of her dinner guests, she also gained an appreciation for collard greens and okra that persists to this day.

Small Study Suggests Body Contouring Surgery Augments Bariatric Surgery

Source: Kayla Butcher's GoFundMe page for skin removal surgery

One of the nearly inevitable adverse effects of bariatric surgery is loose, excess, skin, and generally speaking, the only recourse for dealing with it is more surgery.

Here in Canada, whereas bariatric surgery is covered by our healthcare system, with the exception of medically necessary panniculectomies, post bariatric surgery body contouring surgery is not.

Putting aside both quality of life and aesthetics as rationale for skin removal surgery (and there are very reasonable arguments supporting both), here's a new one (at least for me). If the outcomes of this small study hold true, body contouring surgery may dramatically enhance long term weight loss outcomes.

The study was retrospective and it sought simply to compare the long term weights of those who had both body contouring surgery and bariatric surgery with those who only had bariatric surgery.

Interestingly, the study found that while weight loss was comparable between subjects 2 years post bariatric surgery at 35.6% in the bypass/contouring group and 30.0% in just bypass group (with the 5% additional difference perhaps explicable simply on the basis of the weight of removed skin), with time, the just bypass group regained significantly more weight. By 5 years (the duration of the study), the bypass/contouring group were maintaining a 30.8% loss, while the just bypass group had regained such that they were only maintaining a 22.7% loss.

Now this was a small study, and retrospective rather than randomized - in turn this might mean that the association is related to other factors (for instance socio-economics as body contouring is expensive and clearly those that can afford it, may well have other privileges and circumstances that might be beneficial to post-surgical weight management). Also worth noting that the 5 year losses of the just bypass group aren't as high as seen in other bariatric surgery studies.

Am looking forward to more research on this (ideally randomized), as for many post bariatric surgery patients, excess skin has a dramatically negative effect on their quality of life, and perhaps, if it was shown that body contouring surgery helped patients maintain their losses, insurers and governments might cover the procedure.

Should We Be Treating Type 2 Diabetes With Bariatric Surgery?

Photo By Mr Hyde 

I'm resurrecting and tweaking this piece, for the third time now, consequent to the publication in the New England Journal of Medicine of the 12 year data that continues to strongly support the use of bariatric surgery to treat type 2 diabetes.

In case you missed the news, a recent study published in the New England Journal of Medicine demonstrated dramatic benefits of bariatric surgery in the treatment of type 2 diabetes.

Now I'm not going to get into the study here in great detail, but it followed 1,156 patients from for 12 years and divided them into 3 groups. Those who sought and chose not to have bariatric surgery. Those who sought and had bariatric surgery. And those who did not seek nor have bariatric surgery. Researchers examined all of them at baseline, 2 years, 6 years, and 12 years in terms of whether they had type 2 diabetes, hypertension, or hyperlipidemia.

The results were striking.

With a follow up rate of 90% at 10 years researchers demonstrated that not only were patients 12 years post bariatric surgery maintaining an average loss of 77lbs/26.9% (the non-surgical groups at 12 years lost an average of nothing), but that amoung those patients who had diabetes pre-surgically, 12 years later, 51% were in remission. And for those who are curious about such things as odds ratios, the odds ratio for the incidence of type 2 diabetes at 12 years was 0.08 (95% CI, 0.03 to 0.24) for the surgery group versus the non-surgery group.

(and though they weren't quite as striking, the surgery group at 12 years also had markedly higher remission rates and lower incidences of both hypertension and hyperlpidemia)

So basically here we have a surgical intervention that is dramatically better medical management for type 2 diabetes - 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, regularly 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 of any sort.

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 patients with type 2 diabetes and obesity.

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 women 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]

Should We Be Treating Type 2 Diabetes with Surgery?

Photo By Mr Hyde 

I'm resurrecting this piece, for the second time now, consequent to last week's online first publication in the New England Journal of Medicine of the 5 year data that continues to strongly support the use of bariatric surgery to treat type 2 diabetes.

In case you missed the news, a recent study 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 study here in great detail, but it's a continuation of a trial that's been running for 5 years now that is regarded as being well designed. And while admittedly we still don't know what their long, long, term benefit will be, at 5 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 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 10 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 patients with type 2 diabetes and obesity.

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]

Knee Replacement Surgeries Should Not Be Precluded By Obesity

CC BY 3.0, https://en.wikipedia.org/w/index.php?curid=17923328

At least that's what the results of this new study would suggest.

The study looked at knee replacement outcomes, after 5 years of follow up, among 689 patients who were divided into those whose BMIs were <30, 30-35, or >35.

The findings were important and easy to describe.

While absolute outcomes were better among those with lower BMIs, the degree of improvement in quality of life and knee functionality was not different between groups.

That finding led the authors to plainly conclude,

"surgery should not be denied to patients that are obese, given that they obtained similar benefit than non-obese patients."

Over the years I've seen many patients in my office who were there because they were denied the opportunity to have a knee replacement until such time that they lost a particular amount of weight.

I've also seen patients who were told they would be denied fertility treatments, and even renal transplants, unless they lost weight.

While it is certainly the responsibility of physicians to protect their patients' safety, I welcome studies like this one, which question policies that on their surface may seem thoughtful, but when examined more carefully, may simply reflect weight bias, however well intentioned.

The Aspire Assist: Surgical Bulimia Or A Case Study In Weight Bias?

I can't tell you how many people have contacted me about the Aspire Assist. What's been genuinely shocking to me is that the sentiment surrounding the online commentary, as well as the emails I'm receiving, is hugely reflective of weight bias - including from colleagues who I know are champions in the fight against weight related stigma. I wrote this post when the Aspire Assist was first launched, and I'm updating and reposting it in the hopes of triggering at least a little bit of reflection.

Is this new device simply a condemnable medical bulimia machine?

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 early data's interesting. Now this isn't peer reviewed published data, just a presentation, but in it they describe the 111 patients who were randomized to receive an Aspire Assist. 74% of them completed the year long study (vs. only 50% of the control group who received the same lifestyle counselling as the Aspire Assist group but no Aspire Assist).

The results were dramatic. This 15 minute long outpatient endoscopic procedure led completers to lose nearly 40lbs on average representing a loss of 15% of their presenting weights. The completers of the control group meanwhile lost on average just 4lbs.

Not surprisingly, there were post-operative adverse effects - the most common being irritation or granulation of the stoma (the exit port). There were only 4 subjects who reported "serious" adverse effects and all were quickly resolved.

Eating behaviours were also monitored. Pre-surgically subjects were screened for binge-eating, bulimia, and night eating syndrome. None of the Aspire Assist patients were reported to experience worsened eating behaviours, while one control subject developed bulimia.

Interestingly, self-reported data actually demonstrated improvements in Aspire Assist subjects' eating behaviours with more thorough chewing, more water consumption greater meal planning, more mindful eating, and decreased calorie consumption (confirmed by the fact that losses were greater than would be predicted by simple aspiration).

And as far as tolerability goes, the vast majority reported satisfaction with the device, with 93% of survey respondents reporting that they would be somewhat or very likely to recommend it to others.

Comparing the Aspire Assist to the other endoscopic bariatric procedure, the intra-gastric balloon (a procedure that has not been raked over society's coals) the Aspire Assist appears to lead to markedly larger losses with greater response rates and fewer serious adverse effects.

So yes, back to the shock, horror and repulsion, while I readily agree that on its surface both the premise and procedure is less than appetizing, I'm pretty sure that safety and efficacy, not grossness, are what determine the utility of an intervention. If larger, longer, studies reproduce these results whereby the Aspire Assist 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 those incredibly healthful lifestyles guaranteed weight loss (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.

Guest Post: The Unexpected Side Effects of Significant Weight Loss

You can buy this photo here.

The other day in my office a patient of mine was telling me about some of the surprises she's faced since losing a great deal of weight. Having known her for some time and familiar with her insight and writing abilities, I asked if she was interested in writing a guest post (anonymously or as she chose, with attribution) about them. Happily she agreed, as I imagine will you when I tell you it's terrific, powerful, happy and sad all at the same time.

Nine months ago, I had a gastric bypass. When I told people what I was going to do, they were shocked. I wasn't that big. Was I really sure I wanted to do something so drastic? Couldn't I try just one more time to lose weight? Shouldn't a gastric bypass be reserved for people who are sick and fat, instead of just sick and tired of being fat?

Here's my response: the decision to have major surgery with very real consequences was not taken lightly. It took an entire year from the time Dr Freedhoff first suggested it until I was ready to be referred to the program. But once I made the decision, I wanted it to be done with. I wanted my new life to begin.

I did everything right - I researched, I read, I went to a psychologist, I made sure that both my head and my heart were ready for the significant change in my life. I followed every instruction that my surgeon gave me to the letter. And my results have been spectacular.

I went from a BMI of 41 to a BMI of 25, or exactly normal. My body fat percentage went from the high 40s to the low 20s. My blood pressure went from an average of 126/85 to 106/55. I lost almost 90 pounds, and went from a size 20 to a size 8/10. In short, I am "normal", though in reality, I think I'm actually smaller than average. I look taller and 5 years younger. And I'm happier than I've ever been before.

Still, there is something about my weight loss that upsets me in a fairly fundamental way - I have moved from being invisible to visible, and it is both uncomfortable and enraging.

When I was fat, I was invisible. I could go into a high end store (like Holt's or Coach) and never have a sales person approach me, never get asked if I need assistance. I could go to the gym and do my thing in total isolation, giving the chin nods to the few other plump ladies working out at the same time as me, commiserating in our matching t-shirts (because Canada is not polite enough to sell more than one style/colour of a plus sized work out shirt).

Now when I go to a store, salespeople fawn over me. I went into a store one day and a sales person brought me every single dress they had in my size, one after another. I went into another and they ran down this list of hidden sales that I would never even have dreamed existed. This enrages me - was I not deserving of fashion, style, taste, good deals, lovely accessories? Was I not deserving of being treated like a human being? This part of my weight loss makes me angry, and reminds me to never, ever ignore someone because they are fat.

Now when I go to the gym, people look at me. Not just my other round sisters, but men. They look me up and down and assess me, they try to engage me in conversation, they offer me tips on my squat form. This makes me so uncomfortable - it's not something I've ever experienced and, although my friends tell me this is modern flirting, it makes me feel dirty, like an object. It makes me feel unsafe for the first time in my life. I went from a sisterhood of the invisibles to being an object of the male gaze. I still give my chin nods to my ladies, and I still tell them that they're doing great. Now though, they look at me like I'm not one of them, like I have no right to applaud their efforts, and this makes me a little bit sad - I lost my gym-going community.

And then there are the well-meaning, the beneficent, the ones who cannot understand what their words mean.

"You look so much younger.. taller... better... prettier... smarter" (that one was tough).

"You're not going to lose more weight, are you? You're done, right? Maybe you should eat more - you don't want to lose too much."

"I wish I could have that surgery - it's such an easy way to lose weight."

These are my friends, my colleagues, the people with whom I casually interact. I don't know what to say to them other than that my body will regulate itself, I'm eating until I'm full, I eat all sorts of foods but some of them randomly make me sick and I'm still learning about my new digestive system and do you really think this is easy, because it isn't.

I take a ton of B12 (injections and pills) and special calcium that I have to order from the US and a whole lot of vitamin D and iron and folic acid and I can't take anti-inflammatories and have you ever tried to use tylenol for back pain because it really doesn't work. I tried to go for brunch last week and had to bail out in the middle of a great conversation because my stomach suddenly rejected what I put in it and yes, that means I vomited it up. I can't eat salted caramel, which should be a crime against humanity. I can't drink too quickly because that traps gas in my system, and I can't eat something that's too sweet because that causes me to feel queasy and start sweating, like I'm having a major panic attack. I have wrinkles of extra skin on my inner thighs and under my chin and my brilliant white stretch marks are like a ECG tracking its way across my abdomen. This isn't easy. I just make it look that way.

Do I regret my gastric bypass? Not for a second. I feel like losing the weight has allowed the real me to be seen by more than just my intimates. It's just going to take a long while to get used to not being invisible anymore.

Kerry Colpitts is an Ottawa resident and proud public servant, a fan of finding the right balance between being active and laying on the sofa, watching Netflix.

Should We be Treating Type 2 Diabetes With Bariatric Surgery?

I'm resurrecting this piece consequent to yesterday's online first publication in the New England Journal of Medicine of the 3 year data that continues to support the use of bariatric surgery to treat type 2 diabetes.

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 type 2 diabetics with overweight or obesity.

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]

The Weight Loss Surgery Foundation of America and Me in May in Vegas

On Saturday May 18th I'll be speaking in Las Vegas on behalf of the Weight Loss Surgery Foundation of America (WLSFA) at their annual Meet and Greet. I certainly won't be the only speaker for this two day event and the keynote speaker this year is Carnie Wilson.

So who are the WLSFA?

They're a charitable organization that raises money to help pay for bariatric surgeries for those who can't afford them.

For those of you who don't know, I'm not a surgeon, but I am a supporter of bariatric surgery. Despite the public's regular knee jerk negativity to bariatric surgery (that folks who need simply aren't trying hard enough, that it's an easy way out, that it's the path of laziness, etc.), when performed by skilled surgeons, and when supported by well designed pre and post surgical education and appropriate patient selection, it increases life expectancy, decreases or cures many medical co-morbidities and improves many aspects of quality of life. I've covered this strange bias before on my blog when it came to the surgical management of diabetes, and if you're in the camp of surgery is just plain wrong, every time and for everyone, I'd encourage you to read it, as the message therein applies wholeheartedly to bariatric surgery as well.

Now bariatric surgery isn't a miracle and it has both risks and adverse effects, but I'll tell you, if I were unable to lose weight and maintain that loss any other way, and if my weight was negatively affecting my quality and quantity of life and health, I wouldn't hesitate to explore it as an option.

My talk will be the first one I'm giving from the pages of my upcoming book, The 10 Day Reset: Why Everything You Know About Dieting is Wrong and How to Fix It, and I'm excited to be able to donate my time, energy and thoughts to this worthy cause. If you or a loved one has bariatric surgery or are considering bariatric surgery, I'd encourage you to come on out.  If you'd like to attend you can either click that link up above, or contact the WLSFA directly by phone at 415-234-9074, or via email at: info@wlsfa.org

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.

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]

Guest Post: Surgeon Chris Cobourn Defends Lap-Bands

Readers of my blog might remember a post from just last week in which I detailed the results of a case-matched sample of folks who received gastric bypasses vs. those who received gastric banding where the results were exceedingly favorable to the bypass. One of my readers and colleagues, Dr. Chris Cobourn the medical director of Toronto's Surgical Weight Loss Centre (where both lap-bands and gastric balloons are inserted) read the post and responded with a thoughtful rebuttal.

As is my practice here, I asked if it'd be alright if I posted it on the blog, and I've done so without commentary:

Good Morning Yoni:

I read your blog this morning with a little more than the usual interest and would appreciate the opportunity to give you some feedback on the Gastric Band vs. Gastric Bypass article that you reference, and some of the more relevant literature on this subject.  As a surgeon with extensive experience in Lap-Band surgery (LAGB), I think it is important to ensure your readers that Lap-Band surgery is nowhere near being “destroyed”.

The decision to have bariatric surgery is a serious one, and it is important that individuals be presented with a balanced approach and current information.  The senior author is Dr. Michel Suter from Switzerland.  Dr. Suter has published previous  articles (1)  in this field and has a reputation as being very critical of the Lap-Band.   Due to his early experience with the gastric band, Dr. Suter is no longer performing the procedure, so the current study is another reiteration of his original and now outdated experience.  I debated Dr. Suter on a panel at the IFSO meeting in Capri a few years ago, when he presented his series of 300 Lap-Bands performed over a 10 year period.  It is unfortunate that the results of such a limited experience, a number of years ago are published as representative of today’s technique and experience in high volume centres.

My specific concerns about this paper are:

·         This study is described as a Case-Matched study.  Although better than a random comparison, it does not have the strength or validity of a prospective randomized trial.  There have been very few randomized controlled trials comparing RYGB and LAGB.  I have included two of them as attachments for you to review.  Although these studies show better weight loss with RYGB compared to the Lap-Band, the authors raise important questions as to whether the difference in weight loss is clinically relevant.  Both procedures induce weight loss substantial enough to resolve comorbidities and improve health which is the obvious goal. 

·         All of the patients in this report had Lap-Band prior to June 2005 and thus all had the procedure prior to the introduction of the latest model of Lap-Band.  As well, an undisclosed number had their Lap-Band procedure with a technique that is no longer used.  The peri-gastric technique that was used was shown to have a higher risk of complications and has not been used for at least 8 years.

·         Recent research into the mechanism of action of the Lap-Band has changed the way we manage post operative counseling and band adjustments for our patients.  Again this has been shown to have a significant effect on reducing post operative complications.  The patients in this paper did not have the opportunity to benefit from this new knowledge and this has likely contributed to some of the problems that were discussed.

·         The authors spend very little time discussing the short term complications of the either procedure.  This is a significant omission when comparing LAGB and RYGB.  The short term complications of RYGB have been consistently demonstrated to be more common, and more severe when compared to LAGB.  As well, there is a definite mortality risk associated with RYGB that is not discussed or identified in the study.  The failure to define and document “major morbidity” is a conspicuous deficiency in this study.  The relevance of this study is diminished without this discussion.

In regards to the discussion of long term LAGB complications, I have a number  of comments:

o   The authors report a 10% incidence of esophageal dilatation.  This is extremely high when compared to the current literature.  It likely relates to the principles used in band adjustment and the type of older model of band that was used in this series.

o   The authors report a 7.7% incidence of band erosion. This again is extremely high.  At the Surgical Weight Loss Centre (SWLC), in our first 3500 bands our erosion rate is 7/3500 = 0.2%

o   Port catheter leak rate of 6.8%.  Once again this is very high.  Our rate in 3500 bands is 1.5%

o   The authors report a 6.8% incidence of band removal for various reasons.  Band intolerance at SWLC leading to explantation is < 1%.  The authors have a high rate of conversion  from band to other procedures such as RYGB and BPD.   In our practice, where quick and easy access to RYGB is not available, we continue to work with patients to resolve their problems rather than remove the band or convert.  This is a major contributing factor as to why our band removal rate is so low.

o   No comment is made about long term nutritional issues after RYGB, which are well described.  Failure to acknowledge and discuss this potentially serious complication is a weakness of the study if their intent was to truly compare the procedures.

o   The methodology used to compare long term complications is not well described.  Some of the LAGB complications may be duplicated.  As well, the severity of the complications is not accounted for.  It is not appropriate to assume that all complications are “equal” when some can lead to major surgery and major morbidity and others require only minimal intervention.

One of the areas not discussed in the Suter paper is the well recognized rate of weight regain, starting at about 3 years after RYGB surgery.  You get a hint of it by looking at Figure 1 in the paper but it was not discussed by the authors.  This is an important issue for bypass patients that is unfortunately rarely mentioned.  There is a good paper by O’Brien and colleagues comparing both band and bypass in the long term (2) that shows no statistical difference in excess weight loss after the first few years.

Despite the attention that this paper will attract, it is not a definitive statement on the subject.    I am not sure that there will ever be such a paper.  RYGB and Lap-Band are different procedure both designed to produce sustained and significant weight loss.  Both have been shown to be effective at doing so in high volume centres of excellence that provide the operations using the latest techniques and that provide comprehensive follow up care.

We are in the process of publishing our results showing weight loss results comparable with other major centres, and with a very low rate of both long and short term complications.  We have already published our low rate of short term complications with Lap Band surgery (3).

Lap-Band surgery is a reversible procedure which is a significant benefit, the benefit of which is underestimated.  If research leads to an effective non-invasive or pharmaceutical treatment for obesity, patients could have their La-Bands removed with a simple procedure and then embrace the new treatment option.  This option is not available to any other bariatric surgical procedures.

The risks of bypass and band are very different and well understood.  Although the weight loss may be more rapid, and potentially a little better with bypass, I do not believe there is consensus that the difference is clinically relevant.  Although band patients may have a higher chance of revision surgery, the revision procedures are rarely performed for serious or life threatening complications.  Lap Band surgery is reversible which may be a benefit, but may also  lead to a higher rate of conversion to other procedures if the  results are less than anticipated.  Realistic expectations should be established, and a full and frank discussion of the short and long term risks are critical and mandatory for both procedures.

I appreciate your time and would be happy to discuss this paper and all the issues around it at your convenience.

Best Wishes

Dr. Chris Cobourn | Medical Director and Surgeon

Surgical Weight Loss Centre

www.swlc.ca

References

1.      A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates    Obes Surg. 2006 Jul;16(7):829-35.

2.     Systematic review of medium-term weight loss after bariatric operations.  O'Brien PE, McPhail T, Chaston TB, Dixon JB. Obes Surg. 2006 Aug;16(8):1032-40.

3.    Laparoscopic gastric banding is safe in outpatient surgical centers.  Cobourn C, Mumford D, Chapman MA, Wells L. Obes Surg. 2010 Apr;20(4):415-22.

Gastric Bypasses Destroy Lap-bands in Head to Head Study!

While this wasn't a randomized or blinded trial, the results were striking.

442 case-matched patients were followed for 6 post-operative years. Half received a gastric bypass, and half a gastric band.

While early minor complications were higher in the gastric bypass group (triple the rate seen in banding), major complications were similar. Aside from that, it's all bypass with the bypassed patients enjoying quicker losses, larger maximal losses and significantly better maintenance of losses.

How much better?

After 6 years, for every failed gastric bypass, there were 4 failed lap bands (with failure determined by BMI greater than 35 or reversal of the procedure). For every 1 long-term bypass complication there were 2 lap band complications, and for every 1 re-operation of a bypassed patient, there were 2 of lap banded ones.

Given how damning these results were, the journal invited noted band surgeon Jacques Himpens from Brussels to try to provide some balance in an after article commentary.

Dr. Himpens critiques?

• The study could have used surgeons known to be leading experts in banding and bypass.
• The mechanistic failing of banding to impact on weight related gut peptides might turn out to be an advantage in the very long term.
• The band is more readily reversible.

Of course Dr. Himpens also clearly stated that he himself agrees gastric bypass is a "better" procedure than gastric banding.

Seems like the decision of which surgery to have just became a great deal clearer for those who are considering one.

Romy, S., Donadini, A., Giusti, V., & Suter, M. (2012). Roux-en-Y Gastric Bypass vs Gastric Banding for Morbid Obesity: A Case-Matched Study of 442 Patients Archives of Surgery DOI: 10.1001/archsurg.2011.1708

SunTV and the gluttonous slob obesity narrative.

Last week I was invited onto Brian Lilley's Byline, a SunTV prime time news hour. I had contacted SunTV in response to a discussion that had aired the night before - one between Byline's host Brian Lilley and Ezra Levant. They were discussing Lillian Coakley.

For those of you who aren't familiar with Lillian's story, she's a Nova Scotian with extreme obesity, who out of frustration with her Province's 10 year bariatric surgical wait times, penned a mock obituary which I posted on my blog.

Ezra, when considering her case, suggested that while she doesn't want to be a burden on her children, that she, "apparently wants to be a burden on everyone else." Ezra then claimed that not only does Lillian have obesity, she has, "entitle-mania", suggesting it was an inflated sense of entitlement to health care that led her to believe bariatric surgery should be expeditiously covered (or even covered at all).

Brian then opined that he didn't think that Tommy Douglas (the father of socialized medicine in Canada), would have wanted bariatric surgery covered and Ezra agreed, "I don't think that in Tommy Douglas' time , even being fat was considered a health care issue, it was a personal responsibility issue". Next Ezra offered advice to folks like Lillian, "If you don't want to be fat, exercise, or eat less", and concluded by asking, "Why doesn't she take some personal responsibility".

I couldn't embed the video, so if you'd like to watch it yourself, click here.

I was glad they invited me to provide some balance to their chat, but here it's important for me to point out that their take on the story wasn't particularly unique, nor was it particularly ugly. Now don't get me wrong, it was ugly, but it was not any more ugly than the vast majority of commentators' takes out there, and certainly not unique to right wing viewpoints as evidenced by the commentators over at the Toronto Star.

It was important to me to go on the show to address their 3 main arguments.

The first had to do with burdening our health care system. I pointed out that statistically speaking, it's a far greater financial burden on our health care system to let Lillian wait on a waiting list for 10 years than to operate, with surgical costs being fully recouped in just 3.5 years.

Next, regarding responsibility I pointed out that virtually everyone who tries to intentionally lose weight on their own gains it back, and even putting aside the fact that commentators as a whole have no idea what Lillian has, or hasn't tried for weight loss, it's a fair bet that even were she to successfully lose weight, she'd gain it back and that here we're basically condemning her because she's incapable of doing something that pretty much everyone else is also incapable of doing.

Lastly I pointed out that it's an incredible double standard to suggest blame and personal responsibility be considered when determining if obesity treatment is worthy of public funding. Even if you were to continue to believe that obesity is entirely preventable/treatable by means of personal responsibility, the fact is a huge proportion of our health care expenditures are spent on patients who could have avoided or prevented their maladies. Perhaps the easiest example would be the incredible number of patients who require interventions as a simple consequence of their not bothering to take their prescribed medications. Whether it's diabetics, hypertensives, or hyperlipidemics who don't take their meds, - these folks cost our system an incredible fortune in dialysis, strokes, heart disease, and more, and yet no one, not even Ezra or Brian, is going to suggest we not treat them, or that we grill them about their medication use prior to providing them with life saving care. And here their issues stem from simply not taking their meds daily, whereas Lillian's stems from her inability to do something more than 95% of us fail to do - sustain a significant weight loss.

Saddest of all though had to be the graphic that SunTV chose to run to promote my piece. That's a still of it up above.

And it's the attitudes behind that image that we're fighting against. We're fighting against a society where the media feels comfortable promoting blatant, ugly stereotypes - because while I can certainly understand Brian and Ezra's views in regard to Lillian's case (they're pretty common off the cuff views after all), they don't excuse the hateful bias of the gluttonous slob obesity narrative that their graphic supports.

Cartoon gluttony aside, it's a shame that SunTV, despite choosing Brian and Ezra's anti-Lillian rant for posting on their website, didn't choose to provide their web viewers with balance by posting my interview as well.

If you want to watch my piece, you can do so here (or see it embedded down below).

Medicine isn't about blame, it's about treatment

Yesterday this blog saw a guest posting from Lillian, a Nova Scotian who fears she'll likely die before she reaches the head of her province's 10 year cue for bariatric surgery.

A great many folks left comments (both here and on my Facebook page). Some were supportive. Some were full of self-righteous indignation. Others I chose not to publish as they were incredibly rude and hurtful.

The bottom line for virtually all of the upset commentators was that Lillian just ought to do something. That she ought to fix this problem herself. That clearly she'd just given up. That she wasn't trying hard enough.

It was the good ole, pull herself up by her bootstraps and take things into her own hands crap, or a variant of I did it, so so can she, and while I'm thrilled for the folks who've experienced their own successes, they don't necessarily translate to others.

For readers who don't know, I'm not a surgeon. I'm the medical director of a behavioural weight management program. And while I've seen with my own two eyes many a person lose enough weight to preclude surgery, I don't delude myself into thinking that downloading the solution to extreme obesity onto personal responsibility is everyone's answer.

If there were a non-surgical, reproducible and uniformly effective plan for the management of extreme obesity, I'd agree with you, but the fact is, there is no such plan.

Of course, even if you do want to embrace personal responsibility as the sole cause of obesity, medicine isn't about blame. We patch up drunk drivers and folks who don't wear seat belts. We offer smoking cessation programs. We treat asthmatics who don't bother keeping up with their puffers, pneumonias exacerbated by the early discontinuation of antibiotics, and the psychotic breaks of folks who stop their antipsychotics.

Oh, you want surgical examples?

How about lung reduction surgeries in smoking induced emphysema; liver transplants in former alcoholics; or how about one that doesn't involve a so-called vice at all - heart bypasses on folks who simply didn't bother to take their blood pressure, cholesterol or diabetes medications?

We operate on them all in a timely manner, and so we should, and the public doesn't generally say boo.

But yet in the case of bariatric surgery, many people are up in arms about its timely provision.

Why?

Because for obesity, many folks feel justified discussing its treatment on the basis of blame based causation.

The thing is, aside from obesity it would seem, medicine isn't about blame, it's about treatment, and if there's a proven and viable treatment option, at least here in Canada, people believe it should be readily accessible by our heavily taxed population, regardless of how and why their conditions developed in the first place.

At the end of the day, Lillian rightly sees bariatric surgery as hope. Emotionally it would see her bolstered by a success which for whatever reason, and it's not for anyone to judge, you haven't walked in her shoes, has eluded her. Economically it would save Nova Scotia likely tens of thousands of dollars of care and may improve the Province's GDP by increasing Lillian's ability and duration for gainful employment. Statistically and medically, it will prolong her life, cure her diabetes and sleep apnea, and potentially provide her with a springboard to retool her world, meet her grandchildren, and enjoy a fuller life.

Can you think of any other area of medicine, with an equally dramatically effective treatment option, where people would feel comfortable preaching about personal responsibility trumping a patient's desire or right to access said treatment?

I sure can't.

Lillian shouldn't have to wait 10 years on a wait list for a gastric bypass, and blame has no place in the ethical practice of medicine.

Nova Scotian on 10 year wait for bariatric surgery pens her own obituary

Today's guest post comes from Lillian, a Nova Scotian who is currently on their province's 10 year wait list for bariatric surgery.

She doesn't think she's going to make it 10 years and so she decided to write her own obituary to raise awareness about the lack of funding for bariatric surgery - a procedure proven to prolong life, improve quality of life, and markedly reduce weight-related co-morbidity in those with extreme obesity.

What a sad and salient statement about our health care system.

"To whom it may concern,

Today I am sending you a copy of my obituary so when I die on a waiting list for weight loss surgery that is 10 years long you can see that I tried to get the help and attention needed and its NOT there for me or for anyone. My province's health care failed me and many others who struggle with weight and obesity. Thanks in advance for reading this but please pass this on to anyone who will listen and support this case. WE as tax payers and humans need to be heard and helped. People need to stop putting a stigma and sweeping weight loss surgery under the carpet and realize people are going to die on this waiting list. HELP us help ourselves. I will continue to send this off to anyone who will listen and media included.

Yours truly

Lillian

Lillian's Obituary

We are sad to inform you of the untimely passing of a young mother, sister daughter and friend. She died at a young age due to complication with obesity that she fought for years to overcome. She was the youngest child of 7 and she leaves behind her 2 sons, who both lived at home with her. Her entire life was lived for her boys who she loved immensely and were her pride and joy. She was survived by her 3 sisters and 3 brothers, along with many nieces and nephews and great nieces and nephews. She loved to sew and do crafts and was an awesome cook and loved to help others and would give what she could to anyone in need. She enjoyed comedy and good laughs. Lillian suffered many years with asthma, server high blood pressure, pain due to stress on her joints from her weight and in the last while was diagnosed with sleep apnea and diabetes. There will be no flowers at her request and the body will be cremated as she would hate to be a burden on her family and have to be carried away to her final resting place by a tractor so she spared her family with finding a mass amount of pallbearers and more stares and jokes about her weight as her beloved family mourns the loss of her as they did throughout her life. She would appreciate if you speak out and support Obesity Weight Loss Surgery and obesity awareness and write a letter to your local MLA and to anyone who will listen.

Your rights and Ontario's bariatric surgical wait times

Today's a guest post from an anonymous writer who has sadly had first hand experience of how poorly Ontario's bariatric surgical program is being run - a frightening state of affairs given that Ontario is far and away the most progressive province in Canada when it comes to bariatric surgery.

Here this writer recounts his experience in getting Ombudsman Ontario involved where according to Ontario's Ombudsman's website,

"The Ombudsman’s job is to ensure government accountability through effective oversight of the administration of government services."

Health care of course is indeed a government service and if you remember from a post a ways back, Ontario's target wait times for a Priority II general surgery (like a gastric bypass), is in fact a scant 4 weeks, and even if you want to try to make the case the bariatric surgery is "elective", 26 weeks is the wait time target.

The writer believes that perhaps if more people made Ontario's Ombudsman aware of not only the incredibly long wait times, but the bureaucratic run around often associated with bariatric surgery in Ontario (for instance when my office called Ottawa they out right refused to provide us with any information at all regarding wait times, waiting lists, appointments etc. and stated clearly it was their policy to never disclose such information to anyone), that perhaps things might improve.

Here's what he had to say:

Bariatric Surgery Wait Times and Customer Service

Long wait times and poor customer service do not need to go hand-in-hand in Ontario, but it sure feels that way. Fortunately, there is a way to dramatically increase your chances of being treated with some respect by having your calls returned and perhaps finding out where you are on the waiting list.

What you need is an influential friend. Let me introduce you to Ombudsman Ontario, and how they helped my wife, and how they might be able to help you. These are the same folks who investigated police actions at the G20 summit, and found that the Ministry of Health and Long Term Care's policy on one cancer treatment "verges on cruelty", with their communications in the matter being "blatantly misleading".

They haven't really been aware of the problems in the bariatric system because nobody has been complaining to them. It's time to start. Complaining to the Ombudsman is not an appeal, with a lot of requirements. You can phone them, email them, write them... and they respond... promptly.

Within a week of my wife's letter, they were calling to follow up and investigate. Within two days, they had contacted both Windsor and Hamilton to find out what was going on. Another two days, and there a call from Windsor with information from Hamilton about a missing test, and an expected wait time.

There was a lull and the Ombudsman's office thought they were done and everything was going well, except that it looked like Hamilton was gearing up for a repeat of the assessment done in Windsor, and not willing to set an appointment with a surgeon until after that.

My wife called the Ombudsman again to explain that it looked like this was going to be wait time upon wait time. They stepped in again.

I'll cut to today's highlight. There was a call from a representative at the Ministry of Health to make sure that my wife received the message from Hamilton Bariatric for two appointments including one next Tuesday with the surgeon because Hamilton's coordinator had not yet heard that my wife had already confirmed with booking clerk.

My wife's complaint to the Ombudsman was treated as a Customer Service issue. The Ombudsman will not make medical decisions, or dictate to either the Ministry of Health or the bariatric centers. From my perspective, what they will say to the Ministry and bariatric centers is, "This is your system. Make it work."

A large number of complaints might cause the Ombudsman to escalate their investigation to one that looks at the system itself instead of just service for a single patient. This could benefit all of the patients stacked up awaiting assessment or surgery.

If you are stuck on Ontario's wait list, then you probably have something to complain about. It could be not having calls returned, not being told when to expect an appointment, having to re-do assessments, bad wait time data, or just excessive wait time. Even if contacting the Ombudsman doesn't speed up the process, you may be pleasantly surprised at being treated with respect.

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