Surgery for Type 2 Diabetes with Obesity?

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Who would have thought that the most effective available treatment of a metabolic medical disease (that is, type 2 diabetes) could be a surgical solution? A new study in JAMA showed that patients who have type 2 diabetes and who are obese, were far more able to come off their diabetic medications than those who were treated by non-surgical means.

From Melbourne, Australia, an article titled "Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes - A Randomized Controlled Trial" is published in the January 23, 2008 of the Journal of the American Medical Association (JAMA). The aim of the study is to determine if weight loss surgery resulted in better control of type 2 diabetes than medical (non-surgical) approaches to weight loss and diabetes control. Among 55 patients who completed the follow-up (out of 60 patients), remission of type 2 diabetes was achieved by 73% in the surgical group and 13% in the non-surgical group. In this study, the surgical procedure was laparoscopic adjustable gastric banding (Lap Band). Remission meant being able to keep normal diabetic blood tests while not taking diabetes medications anymore. Please notice that the participants' BMI was more than 30 and less than 40. So, the surgeons accepted lower BMI than the usual cut-off of BMI of 35 that is mostly recommended. Furthermore, the study excluded BMI above 40.

This study adds to other pointers from previous research. Dr. Henry Buchwald in his frequently quoted study: "Bariatric Surgery: A Systematic Review and Meta-analysis" reported that weight loss surgery resulted in complete resolution of type 2 diabetes in 76.8% of patients. To my knowledge, not a single conventional non-surgical treatment of diabetes reported anything even close.

Diabetes treated by surgery? Well, this is not a new concept. Actually, in 1992, an article was published under the provocatrive title: "Is type II diabetes mellitus (NIDDM) a surgical disease?". This is one reason why the professional organization for bariatric surgeons in North America changed its name from the "American Society for Bariatric Surgery" (ASBS) to the "American Society for Metabolic and Bariatric Surgery" (ASMBS)

The authors of the reference article, John B. Dixon, MBBS, PhD; Paul E. O’Brien, MD; Julie Playfair, RN; Leon Chapman, MBBS; Linda M. Schachter, MBBS, PhD; Stewart Skinner, MBBS, PhD are from the Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia

References:

Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, Proietto J, Bailey M, Anderson M. Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes: A Randomized Controlled Trial. JAMA. 2008 Jan 23;299(3):316-323 (Abstract)

Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004 Oct 13;292(14):1724-37. PMID: 15479938 (Full Text)

Dixon JB, Pories WJ, O'Brien PE, Schauer PR, Zimmet P.Surgery as an effective early intervention for diabesity: why the reluctance? Diabetes Care. 2005 Feb;28(2):472-4. PMID: 15677819 (Full Text)

Pories WJ, MacDonald KG Jr, Flickinger EG, Dohm GL, Sinha MK, Barakat HA, May HJ, Khazanie P, Swanson MS, Morgan E, et al. Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg. 1992 Jun;215(6):633-42; PMID: 1632685 (Full Text)

Abdominal Pain after Gastric Bypass

Let's start with a bottom-line statement: Abdominal pain after gastric bypass (other than the early postoperative recovery) is not normal. You are not expected to have on and off severe pains, nausea or vomiting. Chronic abdominal pain is debilitating and may lead to avoiding eating, and, therefore, unnecessary malnutrition.

Here are some causes of pain after gastric bypass:

1. Bowel obstruction from internal herniation. This condition can be very serious, and may lead to loss of bowel or life. A loop of small bowel glides (herniates) into a defect inside the peritoneal cavity, then becomes trapped. The herniated loop may become strangulated, cutting off the blood supply, which could lead to death of that part of the bowel. I placed this as #1 not because it is common, but because it is probably the most serious and dreaded of all causes of later pain after abdominal surgery.

2. An ulcer, either in the pouch, on the anastomosis, or in the bypassed stomach or duodenum. Ulcers can cause not only severe pain, debilitation and malnutrition, but also may lead to bleeding. An ulcer may even perforate, causing peritonitis. Smoking and chronic intake of non-steroidal anti-inflammatory medications (NSAIDs) are risk factors for the development of ulcers.

3. Gallstones and gallbladder disease.

4. Abdominal wall hernia (incisional hernia, also called ventral hernia) my entrap a loop of bowel causing severe pain. When a hernia does not reduce itself, it is called "incarcerated". An incarcerated hernia may become strangulated, cutting off the blood supply to that loop of intestine. Incisional hernias can occur after any abdominal surgery, and bariatric surgery is no exception.

It is important to not accept pain after gastric bypass surgery as a normal sequence. Make sure that you seek expert help.

Hair Loss after Weight Loss Surgery

Here is a common question: Will I lose all my hair after gastric bypass? How do I keep my hair from falling out? The reality is that hair loss after bariatric surgery is common. But patients do not lose all their hair. In the most severe cases, patients may find clumps of hair in their hair brushes, or in the shower drain. However the hair loss normally corrects itself. The most accepted explanation is inadequate protein intake. Hair loss tends to start about three to five months after surgery. The best way to prevent hair loss is to make sure that you take your proteins first, with each meal.

Hair loss after bariatric surgery is considered a type of Telogen Effluvium. To explain, we need to talk a little bit about the normal phases of the cycle of hair development. Each strand of hair goes through three stages of development. These stages are Anagen – the growing phase, Catagen – the intermediate or transitional phase, and Telogen – the resting phase.

Anagen (The Growth Phase): Lasts 2-6 years. About 85% of all the hairs are in the growth phase at any given period of time.

Catagen (The Transitional Phase): The outer root sheath of the hair follicle shrinks and stops producing hair. The catagen phase usually lasts 2-3 weeks.

Telogen (The Resting Phase) The hair does not grow at all. This phase lasts about 3 months (100 days). An average of 5-15% of all hair is in the resting phase at any given period of time. At the end of this phase, the hair follicle starts a new Anagen phase. The resting (telogen) hair remains in the follicle until it is pushed out by growth of a new anagen hair, unless it was shed earlier. There is some recent evidence suggesting that shedding of a telogen hair might be an active process, independent of an emerging anagen hair.

Telogen effluvium occurs when an event prematurely terminates anagen and causes an abnormally high number of normal hairs to enter the resting, or telogen phase. Not all hair enters the telogen phase, but the percentage is much higher than normal. The hairs that are shed due to telogen effluvium are in the telogen phase. Examples of such events include childbirth, gastric bypass surgery, crash diets with inadequate protein intake, acute blood loss, and high fever. Notice that the follicle is not diseased. Simply, the hair follicle’s biologic clock has been reset. On the average, telogen hair loss occurs 3 months after the event.

For the record, this is very different from another type of hair loss called "Anagen Effluvium". The latter is abrupt loss of hair in the anagen phase, which may be caused by cancer chemotherapy and irradiation therapy. This is very different from telogen effluvium.

In conclusion, hair loss after bariatric surgery (a form of acute telogen effluvium) is fully reversible. Patients never completely lose all their scalp hair, although the hair can be very thin. The hair follicles are not irreversibly affected. With restoration of the nutritional balance, helped by increasing the intake of proteins, hair regrowth is expected within 3 - 6 months.

Roundup - What's the Problem?

"... as an adult, we understand even if you ruin an appetite, there's another appetite coming right behind it. There's no danger in running out of appetites. I've got millions of them." --Jerry Seinfeld. The "Heart Attack" episode.


Fact: When food is in short supply, obesity as a public health problem does not exist. As a matter of fact, being obese under those circumstances signifies being wealthy or of higher economic status than the average population. Look at countries where some are living in poverty, and others are more affluent. Which segment of that society has a problem with obesity?

Fact: When food is made available and affordable, in the presence of abundance, the average person will eat more. Much more. Bigger portions. It is surprising to see people who immigrated as adults from less affluent countries continuing to eat the portions and at the times that they were used to, and stay slim. They have already developed the habits and controls and they stay satisfied with the portions and types of food that they used to consume. Their first generation kids, however, who were not raised in such a controlled environment, may become overweight or obese.

Fact: When food is not only made available in abundance 24 hours a day, but is also advertised all day long, people tend to consume even more. And branding does affect their choices.

Fact: Social networks can strongly enhance the spread of obesity.

One conclusion I can draw here is that: External influences tend to have a stronger effect on controlling how much we eat than spontaneous internal influences, in the average person. It takes a conscious effort and proper habit building and modifications to overcome those external influences. That we are victims of an environment and a culture that facilitates (or may even encourage) habits that will make us unhealthy, the only true refuge is our own ability to change habits and behaviors that developed under those circumstances. Although I stress on over-eating as a deadly habit, it is important to notice that serious under-eating as in anorexia nervosa is at least as deadly, if not more.

Remember, weight control is achieved through three elements:

1. Diet (portion acontrol and quality control)

2. Exercise or physical activity

3. Behavioral change towards healthy habits

Everything else (a diet program, a trainer, a pill, a surgical operation) is a tool that helps you control your energy storage (and, consequently, the weight of fat) through one or more of the above mechanisms.

Stay healthy! Happy Holidays!

Childhood and Adolescent Obesity - A Real Concern

Well, this is another blog entry that is not a bariatric surgery issue, but a real public health and epidemiology concern. The New England Journal of Medicine issue of December 6, 2007, has three excellent articles:

1. Childhood Obesity — The Shape of Things to Come by Dr. D.S. Ludwig (Link) from Harvard Medicalo School
2. Childhood Body-Mass Index and the Risk of Coronary Heart Disease in Adulthood by Dr. J.L. Baker and others (Link) from Copenhagen, Denmark
3. Adolescent Overweight and Future Adult Coronary Heart Disease by Dr. K. Bibbins-Domingo and Others (Link) from the University of California, San Francisco

The Journal is making the full text of those articles (not just the abstracts) available for free.

In the perspective article "Childhood Obesity — The Shape of Things to Come", Dr. David Ludwig (Director of the Optimal Weight for Life Program, Children's Hospital Boston, Harvard Medical School) views the obesity epidemic as consisting of four phases. The first phase (began in the early 1970s) witnessed a progressive increase of the average weight among children from all socioeconomic levels and geographic areas in the United States.

The second phase, which we are now entering, is characterized by the emergence of serious weight-related problems in adolescents, including type 2 diabetes, fatty liver, orthopedic problems, sleep apnea, social isolation, anxiety, and depression.

Phase 3 will signal opening the doors for the medical complications of obesity to lead to life-threatening or limb-threatening disease. There will be an increased risk of coronary heart disease in adulthood, a high risk for limb amputation, kidney failure requiring dialysis, and premature death. The article quotes that the risk of dying by middle age is already two to three times as high among obese adolescent girls as it is among those of normal weight. Dr. Ludwig has predicted that pediatric obesity may shorten life expectancy in the United States by 2 to 5 years by midcentury, which would be equal to that of all cancers combined.

Phase 4 of the epidemic, if allowed to take place, will lead to even higher obesity rates because of transgenerational mechanisms.

Those articles are a highly recommended reading for anyone who feels that childhood obesity is hitting home.

CDC: Adult Obesity Prevalence - No Significant Increase

The Centers for Disease Control and Prevention (CDC) has announced the new obesity prevalence statistics in a report titled, "Obesity Among Adults in the United States -- No Change Since 2003-2004". There was no "significant" change in obesity prevalence between 2003-2004 and 2005-2006 for either men or women. I would consider this "encouraging", but far from being exactly "good" news.

Some have declared that the media headlines should, at the very least, be shouting: “Obesity Epidemic Over!” (1). In literal terms, and based only on this piece of information, an obesity epidemic may, indeed, be over. After all, the definition of "epidemic", according to Webster's New World Medical Dictionary is "The occurrence of more cases of a disease than would be expected in a community or region during a given time period." Well, so what? Should we be proud of the current number of 34% being obese, knowing of the adverse health effects of obesity? According to the news release, more than one-third of U.S. adults -– over 72 million people -- were obese in 2005-2006. This includes 33.3 percent of men and 35.3 percent of women. The reality is that the lack of statistically significant increase in prevalence does not mean at all that we are OK. At the very best, we are just maintaining a peak high prevalence of obesity. Actually, the 2007 report of the Trust of America's Health (posted in the Bariatrics Lounge blog), using a different methodology, concluded that adult obesity rates showed an increase in 31 states last year. So, where is the truth. I would say, at the very best, and if we take only the CDC report, we are maintaining a dangerously high prevalence of obesity. And that all is about obesity in adults. Folks, we are not even talking about childhood obesity. Epidemic or not, it is already pretty bad.

(1) Please note: This blog does not endorse the Junkfood Science blog, which is mentioned here purely as a reference to an article that indicated one point of view.

Is it really important to do the follow-up visits after bariatric surgery?

After weight loss surgery (let's say gastric bypass or Lap Band), the majority of patients will initially lose some of their excess weight very well. In fact, they may do so well that they take for granted their weight loss trend, and some become less and less compliant with their follow-ups. Does it make a difference? Should patients do their follow-ups with their bariatric surgery programs, in addition to the usual check-ups with their own family doctors? We always felt that patients benefit tremendously from being committed to their long-term follow-ups. Is there any evidecne that long-term follow-ups make any difference? A study is published in the Nov-Dec 2007 issue of the journal "Surgery for Obesity and Related Diseases" titled "Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass". It is another addition to a mounting evidence. The authors, (Gould JC, Beverstein G, Reinhardt S, Garren MJ) from the University of Wisconsin School of Medicine, Madison, Wisconsin, looked into the data of patients with 3-4 years of follow-up data after laparoscopic gastric bypass. The patients were divided into 3 groups:

Group 1 patients: had attended every scheduled postoperative appointment
Group 2 patients had attended every appointment for 1 year, then were lost to follow-up
Group 3 patients had been lost to follow-up before 1 year.

Although the excess weight loss (EWL) did not differ at 1 year of follow-up, a significant difference in the EWL was observed at 3-4 years (74% for Group 1; 61% for Group 2; 56% for Group 3). The authors found that the most common explanation for missed follow-up appointments was a lack of insurance coverage. They concluded that on-going, multidisciplinary care is likely a critical component in maintaining the benefit after surgery.


Source Article:
Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surg Obes Relat Dis. 2007 Nov-Dec;3(6):627-30. PMID: 17950045 (Abstract)

Other References:

Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg. 2004 Apr;14(4):514-9. PMID: 15130229 (Abstract)

Harper J, Madan AK, Ternovits CA, Tichansky DS. What happens to patients who do not follow-up after bariatric surgery? Am Surg. 2007 Feb;73(2):181-4. PMID: 17305299 (Abstract)

"Surgery for Obesity and Related Diseases" (SOARD) is the official journal of the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Brazilian Society for Bariatric Surgery (SBCBM - Sociedade Brasileira de Cirurgia Bariátrica e Metabólica).

"Obesity surgery" is the official journal of several international societies including, among many others, the International Federation for the Surgery of Obesity (IFSO) , the Obesity Surgery Society of Australia and New Zealand and the French Society for Obesity Surgery (Société Française de Chirurgie de l'Obésité)