Health for life

A cure for diabetes?

Mrs. Jones (name changed) was obese. Her weight remained persistently high despite education and entreaties about diet and exercise. She hated taking all those medications. She dreaded bathing suits.

And then.... she had bariatric surgery. She shed pounds faster than Supreme Court justices spanking a health insurance mandate. Instead of having a corpulent and unhealthy patient, the Disease Management Care Blog had a svelte and healthy patient.

Based on witnessing first hand patient transformations like this, the DMCB knows that bariatric surgery for obesity works.

Despite clinical anecdotes, however, obesity surgery skeptics have pointed out that the evidence has been marred by the lack of any prospective randomized clinical trials. Looking backwards at outcomes data cant rule out the possibility that something else was going on to account for the surgerys apparent success. Most of all, this includes self-selection bias where patients, who are destined to independently do well, select surgery. By leaving assignment to chance, docs and patients are out of the decision-making. This randomization helps researchers be more confident that the surgery, and nothing else, accounts for any observed outcomes.

Enter the New England Journal of Medicine, which published the results from two landmark prospective and randomized trials that compared obesity surgery to conservative medical management:

1. Geltrude Mingrone and colleagues screened 72 and then randomly assigned 60 diabetic persons with a BMI of 35 to either a) conventional medical therapy (targeting an A1c of 7% using a multidisciplinary team with visits every 3 months for a year and then one additional visit at two years) or b) gastric bypass or c) biliopancreatic diversion.  The study occurred at Romes Catholic University. Follow-up lasted two years. At the end of the study, 56 patients data were available for analysis. 15 of the 20 patients who had gastric bypass, 19 of the 20 patients who had the diversion and zero of the medically treated patients were off diabetes medications and had normal blood glucoses. As expected, surgery resulted in a whopping decrease in the BMI down to approximately 29.  In contrast the mean BMI was 43 in the medically treated group. Two patients had the surgical complications of hernia and obstruction

2. Philip Schauer and colleagues screened 218 patients and randomly assigned 150 diabetic obese persons with BMIs ranging from 27 to 43 to either a) medical therapy (life style counseling, weight management home glucose monitoring and medications with diabetes specialist clinic visits every three months that targeted an A1c of 6%) or b) "Roux en Y" bypass or c) sleeve gastrectomy. The study occurred at Cleveland Clinic. Follow-up lasted one year and 140 patients data were available for analysis. 5 of 41 patients in the medical therapy group vs. 21 in the 50 assigned to gastric bypass and 18 of 49 who had the sleeve achieved the A1c of 6%. Whats more, most of the surgery patients who achieved the targeted A1c were off all diabetes medications.  As expected, the surgery groups decreased their BMI down to the 26-27 range, while the medically treated patients BMI remained essentially unchanged.  In contrast to Rome, there was a wider range of complications that included 4 reoperations and 1 patient that developed a gastrointestinal leak with peritonitis.

Based on these data plus less pristine studies, its clinical experience and common sense, the DMCB is convinced that bariatric surgery works. These two studies are an important step forward in building the case for the use of this approach in persons with obesity and diabetes.

That being said, there is still room for some skepticism. That lingering doubt could be enough for a commercial insurer to limit coverage. It may be enough to prompt a PCP to recommend that an obese patient with diabetes should still hold off on surgery a bit longer. It may be enough for patients and families to wait another year until there are more confirmatory studies.

Heres why:

1. The studies were not "blinded." The purpose of "blinding" is to keep patients and doctors from being swayed by a "placebo effect." While thats intuitively silly, there is a possibility that having abdominal surgery made those patients believe they were going to lose weight and be cured of diabetes. After all, sham surgery has been known to help angina chest pains.

2. The studies are not necessarily "generalizable." Both studies were conducted by teams of surgeons from single institutions. While we can take Rome and Clevelands word for it, we dont know if obesity surgery done at Bumkinvilles Our Mother of Holy Deficit Hospital will have the same success and low rates of complications.

3. Speaking of complications, both studies were not adequately "powered" to fully assess mishap rates. While there were small single digit differences in the rates of complications, the small numbers may not tell the whole story. Having more patients enrolled in these studies would have increased the ability to meaningfully quantify all the possible bad outcomes.  That was one of the lessons of the Vioxx catastrophe.

4. Last but not least, the success of the surgery may have been inflated by the relatively poor performance of the non-surgical comparison groups. We know very little about the "intensity" of the medical treatment, other than they had the benefit of accessing a multidisciplinary clinic every three months. Population health management experts know that lifestyle change requires an intense program that includes engagement in a personalized and multidimensional care plan that includes far more frequent in-person and telephonic coaching. We dont know if the medical therapy group achieved this level of excellence.

Despite these limitations, however, the DMCB is more convinced that, for patients in whom nothing else works, bariatric surgery can reverse diabetes.

Hi,

Ive always thought of gastric bypass surgery (GBS) and all its cousins, as "Franken-surgery." The one and only good thing it does is force you to make the kinds of eating changes that make you lose weight. You simply can no longer eat the way you used to. You have no alternative. There are no more lies or head games. The unfortunate part of GBS type operations is that they can still eventually fail and you can still gain back the weight you once lost.  About thirty years ago, my BFF at the time, did that.

I was her support for the entire year that it took her to lose her weight. I watched her throwing up. I witnessed the pain she was in. I saw the agony she went through and I decided that I was NEVER going to do that. I would rather be fat, than to do that. Within a year an a half she had stubbornly fought her way back to eating as she used to and put the weight back on again.

Please do not misunderstand. I am not judging people who have decided to do GBS. It seems that many people are doing it and successfully losing weight from it. If that is the course a person has chosen and it has worked for them, then I say "Hooray, you did it. Way to go!"  It is just that, for me, I dont see it.

But why not adopt that "mind set" of "accepting that you must eat less," and leave out the expense and trauma of Franken-surgery? If you think about it, the whole purpose of GBS is to make you stop eating so much. Why not just decide to "stop eating so much" without the major trauma to your body and your pocket book?

I think I am thinking about this because I am still struggling to lose weight. For a long time I thought it was the "kind" of food that caused the problem. So I cleaned up my eating by cutting out carbs and eating fewer processed foods.

I got my A1C back down to a normal place and my new doctor says that I am no longer pre-diabetic. I am excited about that. But I still have high blood pressure and have not made it past the 30-pound-lost marker. I am still obese.

Ive tried the 16-hour per day fast for a few weeks and still not seen any real weight loss that lasted on my scale. After reading the "Anything Goes Diet" and focusing on it for a few days I think I really need to focus simply on eating less in a way that works for me. It now makes sense to me to eat, say, once day, and the rest of the time, just stop eating.

We dont come with a tattooed label on us that says we MUST EAT THREE MEALS A DAY, or even we MUST EAT FIVE SMALL MEALS A DAY.  There are really no rules but the ones we or someone before us has made up.

I had been considering eating as I do now and trying a once a week 24-hour fast... and I may still do that. But Im also thinking about just eating a nice normal meal once a day, with a protein snack thrown in sometime during the day, and the rest of the time, just not eating. Ive discovered that I can go for long periods of time without eating which I had thought was not possible. And not only can I do it, I like doing it. I like the way it feels. I really dont like that "bloated" feeling that comes from eating large, especially carb-laden meals. It is so much more pleasant to have an empty stomach. It provides almost an odd sense of freedom.

Maybe I could do the opposite of the 24-hour fast. I could eat once a day for six days and on the seventh day, have two, perhaps even three meals. Then go back to the once a day meals. I could eat whatever I wanted. I know how important it is to me to eat healthy, so I would make sure my one meal had both protein and vegetables. I would still eat salads for the fresh raw veggies.

I could add to the salad a moderate size of animal protein (beef, pork, chicken, fish, or eggs) plus a serving of cooked veggies with some nuts or a fist-sized portion of some carb. A small portion of carbs. And I dont have to do the carbs each day. I wonder how long it would take me to begin to see a weight loss if I did that. I wont know if I dont try it.

I feel like trying it. I feel frustrated by all the things Ive tried and not being successful at the one thing I really wanted: the weight loss. I am a human being, I should be able to lose weight just like other human beings are doing. I need to do something that I can do. I use to do Franken-surgery, (as my doctor suggested) but that does not mean I cannot focus on achieving the same kind of total calorie reduction in a way that makes better sense to me.

I am sure there are folks who will have objections to this idea. Im sure that if someone had mentioned this to me a while ago, I would never have even thought of being open to the idea. But Ive gone down the road and ended up somewhere else. I need to do something that works -- for me.

From my reading I know that cutting out food, as in fasting, does no harm to the body if done in a controlled manner. It has been scientifically proven that small daily fasting does not even lower the bodys metabolism or reduce muscle. The body will only cannibalize itself after extremely long periods of time without food. Im not talking about that. The fasting Im talking about simply gives the body a rest. Im not talking about fasting for 40 days and 40 nights. Im talking about eating a good healthy meal once a day, plus a protein snack at some other time during the day.

I think this would accomplish the goal of reducing the daily caloric intake without all the fuss and measuring and counting and control. I hate the fuss, measuring and counting and the control. When I do that my whole day is spent focused on food. Im not interested in spending my life being focused on food. Im interested in eating a good meal and then moving on to other stuff. Thank God!!

Ok. It makes sense to me. Im going to try it. I can drink unsweet tea, and water all day long. I suppose diet sodas would work, too, but I hate soda, so why even bring it up? The only juice will be watered down cranberry juice (with no sugar or other sugary fruit juice added) -- and that only when I feel it is "medically" necessary. So, water it is. And a cup of tea now and then. And that is my new plan.

Ill be back soon with any news flashes...

LOL

Hope you are well,

Marcia