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Bariatric Surgery as first line treatment for diabetes????


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Ok, it says Yahoo but the source is Reuters - so a bit more legit

 

https://www.yahoo.com/news/specialists-call-gastric-surgery-standard-diabetes-treatment-140230828.html

 

Opinions?

 

Experiences?

 

Is this really the direction we should go?

 

Personal responsibility for behavior? Worldwide dietary changes?

 

Long term issues? What happens in 30-40-50 years after surgery?

 

Would love to hear thoughts.

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The "personal responsibility" argument irks me. You have a serious asymmetry of information between the consumer and the producer when it comes to food. The producers spend millions of dollars designing their food to be as satisfying, and habit forming/addicting, as possible while providing a barrage of advertisement aimed at triggering hunger in consumers. The consumer is sold misinformation on how to eat right (low fat, high carb) that is based on bunk "science" and "well that makes sense" assumptions. The consumer has to be very educated and well off to afford to eat well, and those people are not in the majority. Further the consumers who need healthy food the most are the ones who most frequently have limited or no access to that food

 

So while there is obviously a choice to put that burger in your mouth the majority of the population starts their life already at a disadvantage. Getting a person to lose significant weight is incredibly difficult, takes a very determined individual, and resources that many people don't have access to. Given the enormous costs of obesity and NIDDM to society as a whole, and to the individual, my gut reaction to bariatric surgery as a first option is that it's probably not a terrible idea.

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The "personal responsibility" argument irks me. You have a serious asymmetry of information between the consumer and the producer when it comes to food. The producers spend millions of dollars designing their food to be as satisfying, and habit forming/addicting, as possible while providing a barrage of advertisement aimed at triggering hunger in consumers. The consumer is sold misinformation on how to eat right (low fat, high carb) that is based on bunk "science" and "well that makes sense" assumptions. The consumer has to be very educated and well off to afford to eat well, and those people are not in the majority. Further the consumers who need healthy food the most are the ones who most frequently have limited or no access to that food

 

So while there is obviously a choice to put that burger in your mouth the majority of the population starts their life already at a disadvantage. Getting a person to lose significant weight is incredibly difficult, takes a very determined individual, and resources that many people don't have access to. Given the enormous costs of obesity and NIDDM to society as a whole, and to the individual, my gut reaction to bariatric surgery as a first option is that it's probably not a terrible idea.

 

 

I don't disagree that there is a significant lack of understanding of proper nutrition in this country (heck, my nutrition knowledge isn't the greatest).  However, if you simply turn to bariatric surgery as your first option for obesity and NIDDM, and don't address the reasons for the conditions (following your logic, the lack of knowledge, and succumbing to manipulative practices by the food industry), won't the patient simply be back in the same place they started in a few years?  The core issues haven't been addressed.  We need to have better access to nutrition counseling, and if these patients are going to receive it after their bariatric surgery, why not give them that same counseling before and see if some of the patients may not need the surgery?  

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I have four family members who got some variation of bariatric surgery over ten years ago, and they all gained the weight back. One had major issues with reflux issues and was constantly throwing up during that time - had to have it reversed (stomach band).

 

I think education is a huge part of the problem. Most people don't realize that their diet plays a bigger role than exercise when losing weight. It doesn't help that food industries like Coca Cola encourage exercise (Let's move!) and rewarding oneself with a nice refreshing glass of soda afterwards - downplaying the dietary role. Instead of turning to extremes like crossfit or gourmet Instagram meals, most people just need a simple exercise routine and simple/fast/healthy meals.

 

Mental health also plays a pretty big role, even with just basic things like coping with stress or depression. Techniques like mindfulness could actually help regain a little more self control when it comes to food choices.

 

I think a more wholistic and supportive approach to weight loss would be much more effective than jumping right to surgery (unless it was something emergent).

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From the National Weight Loss Registry website:

 

You may find it interesting to know about the people who have enrolled in the registry thus far.

 

  • 80% of persons in the registry are women and 20% are men.
  • The "average" woman is 45 years of age and currently weighs 145 lbs, while the "average" man is 49 years of age and currently weighs 190 lbs.
  • Registry members have lost an average of 66 lbs and kept it off for 5.5 years.
  • These averages, however, hide a lot of diversity:
    • Weight losses have ranged from 30 to 300 lbs.
    • Duration of successful weight loss has ranged from 1 year to 66 years!
    • Some have lost the weight rapidly, while others have lost weight very slowly--over as many as 14 years.
  • We have also started to learn about how the weight loss was accomplished: 45% of registry participants lost the weight on their own and the other 55% lost weight with the help of some type of program.
  • 98% of Registry participants report that they modified their food intake in some way to lose weight.
  • 94% increased their physical activity, with the most frequently reported form of activity being walking.
  • There is variety in how NWCR members keep the weight off. Most report continuing to maintain a low calorie, low fat diet and doing high levels of activity.

    • 78% eat breakfast every day.
    • 75% weigh themselves at least once a week.
    • 62% watch less than 10 hours of TV per week.
    • 90% exercise, on average, about 1 hour per day.

 

I do not argue the fact that healthier foods cost more, come in smaller quantities and take more time to prepare, store for shorter times and are not "filling" to some.

Years ago I lived in a pocket neighborhood in an urban area. The local grocery was predominantly serving food stamp recipients. I would often watch their carts compared to mine and see that the cart was filled with quantity, not quality because dollars had to feed many mouths for extended periods on a very limited budget. Lots of processed foods and bulk = carbs and sugar. Nothing could keep very long or would rapidly consumed and then there would be no more.

 

It is already hard to teach patients to give viruses time to heal without the unnecessary antibiotics and that there is no magic pill. Now, stating - hey, you are obese - have surgery - alarms me.

 

I have dealt with blown gastric pouches from overeating, horrible vitamin deficiencies, patients having their hair fall out, dumping syndrome, neuropathy and chronic pain --- all AFTER some form of bariatric surgery.

One patient went to Mexico - paid cash - and nearly died from sepsis and spent 3 weeks intubated in the ICU - a seriously bad weight loss plan being on TPN and than a feeding tube.

Most patients DO revert to some form of poor habit.

 

The initial eating restrictions of a Roux en Y procedure are 1 teaspoon of peanut butter and taking 20 minutes to consume it. 

 

These folks often cannot swallow pills or absorb them. Finding liquid versions of medication can be very difficult. 

 

I think jumping to surgery as a first approach should be reserved for those whose life is in imminent danger from a life threatening problem - maybe sleep apnea with Afib and failure on CPAP.

 

I fight the weight battle. It is not as though I am a skinny person telling people to lose weight. I know the battle.

 

I would love to see a more profound educational effort on foods and easier access to food that grew from the ground or off a tree. 

 

Personal responsibility is a big issue with me and my patients. I am not saying blame - I am asking for responsibility and effort to change. It is too easy for a patient to blame anything else but their own choices and then say that their efforts won't work - just give me surgery. There ARE changes that anyone can make. You don't need a gym membership or an expensive pair of shoes to walk. Canned vegetables are certainly better than boxed processed noodle dishes and cost about the same in a lot of cases. I have patients lift canned food for arm curls for exercise.

 

As medical practitioners, we need to do what is best for our patients but not necessarily adopt the "latest tech or study" as the Holy Grail. 

 

I still tell my patients that 1-3 pounds a week of loss is best and the old exchange plan with minimum amounts of types of foods has shown promise over time. 

 

What has anyone else had work?

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A couple of thoughts about your original post.  First, yahoo (and reuters) are not medical guidelines.  I would recommend not looking at them for practice recommendations.  Second, reviewing your link shows that whatever source this article is drawing from states that people with a BMI of greater than 40, or 30 and above whose blood sugars are not controlled by lifestyle changes and/or medications should be considered for surgical options,  which is close to the recommendations from the American Association of Clinical Endocrinologists, which show that lifestyle therapy, including medically assisted weight loss, be initially offered to all diabetics, regardless of A1C, and surgical therapy be considered with BMIs greater than 35 with severe complications (although not an initial treatment modality).

 

 

 

So: anything on yahoo is there for clicks and not news.  Follow real guidelines and your medical training.  None of the sources in that article are "legit".

 

Now, one could make a good rebuttal that patients will read this, and come to you with it.  They will think it is real science, and ask- perhaps demand, weight loss medications or surgery.  This is a good opportunity to take a step back and actually face them, and talk about weight and diabetes. 

 

Personally, I tell patients that the first thing they have to do is move, actually get off their ass and move.  I don't go for fast pills, because there isn't any.  If they start any sentence- regarding weight loss efforts, pain control, whatever- with "I've tried them all, they don't work", then I know they haven't. 

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As a bariatric medicine specialist (PA), and having owned  my own medical weight loss clinic for 8 years, I've treated over 12,000 patients, and my mantra is as follows; "You can't change your weight, until you change your mind!" Not your anatomy!

 

Bariatric surgery fixes the symptoms (body fat), but not the cause; sugar addiction and insulin resistance. Just because you have a piece of anatomy taken out of your body, doesn't mean you're going to stop carb craving, or change your way of thinking. Bariatric surgeons fail to tell their patients that. I wonder why? 

 

I treat many post-bariatric surgery patients who've gained all of their weight back, because they haven't treated the sugar addiction. By the way, most bariatric surgery patients gain their weight back for this reason. It's a "J" curve, they lose to a certain point, then the curve starts coming back up.Why? because they haven't changed their thinking and treated their addiction to sugar. Princeton published a paper titled; "Sugar is as addicting as heroin or cocaine."

 

I'm not saying bariatric surgery is not indicated in those patients who will die without it, but to use it to cure diabetes is not the way to go. We treat diabetes with weight loss and exercise. No quick fix. And, if you fix the diabetes (which is possible with Bariatric surgery), how about all of the other comorbidities associated with gaining the weight back? Especially the heart!

 

Just my thoughts from treating 12,000 patients and passing the board certification exam in Bariatric Medicine in 2009. One of four mid-levels to do so.

 

There's no quick fix!

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I have had a few dinners with probably the smartest doc I've met.  He's an endo that's done numerous overseas medical missions trips and specializes in diabetes.  His take on the diabetes epidemic is simply this.  Our bodies were made for survival, and that the vast majority of the world's population "has diabetes."  Emphasis on the quote marks.  It's just that diabetes doesn't become "known" until there is a more than adequate food supply.  In other words, diabetes is a survival mechanism in limited food supply environment.  It's only a "disease" when food is plentiful.

 

Now consider that and combine it with government campaigns about "food insecurity," (whatever that means) designed purely to get votes, when those who are supposedly "food insecure" have a BMI of 40, swipe their EBT cards for donuts, bags of chips, and Pepsi.  Sorry, when your BMI is 25+, you are NOT "food insecure" and you do NOT need more government benefits.  Tell that to truly starving people in East Asia.  Not being able to afford a bag of Doritos is NOT starving.  And not having fresh broccoli in your neighborhood is not starving (like anyone would swipe their EBT for broccoli.).

 

So yeah, bariatric surgery is not the fix for diabetes.  Eating fewer calories is.

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