It’s not vanity and it’s not easy: NHS agrees

Posted on July 13, 2014 by K Eckland

As reported on Sky News and the New York Times, there has been a radical turn around regarding the use of bariatric surgery to prevent/ control and even “cure” diabetes.

Not a vanity procedure

Once relegated to the category of a” vanity” procedure, bariatric surgery has emerged as a legitimate, life-saving intervention which has been scientifically proven to have multiple major health benefits.

For years, patients have had to jump numerous hurdles to be considered for this procedure. One of the biggest hurdles was often that patients were not considered fat enough to qualify for this procedure. The traditional guidelines restricted surgery to morbidly obese people, and then required these patients to perform numerous tasks to be considered eligible candidates of surgery such as attaining a diagnosis of “carbohydrate addiction” and losing weight prior to surgery as a sign of “commitment” to weight loss. This was in addition to several months of therapy with nutritionists and counselors.

A punitive process

While including this ancillary education may have assisted patients post-operatively, it also felt punitive to people who were seeking medical help. No one forces lung cancer patients to attend smoking cessation courses or counselling before having their cancer treatment nor do we require several sessions of pre-operative classes prior to a bowel resection.

New guidelines – perform surgery earlier (2012)

But as the data started to emerge that showed long-lasting health benefits of surgery-assisted weight loss, debates raged between International and American physicians. Several years ago, several international organizations such as the International Diabetes Federation began to recommend lowering the eligibility criteria for bariatric surgery – particularly for patients with documented complications of obesity present (diabetes, coronary artery disease, severe orthopedic injuries). But these recommendations were ignored by American medical societies and many physicians including the doctors responsible for initiating referrals to bariatric surgery programs. Americans. it seemed were reserving the the more effective treatments (like gastric bypass or gastric sleeve) for the super-obese, and the prototypical 600 pound patients.

Obese patients who did not meet these rigid guidelines were often sent for less effective procedures like lap-band or balloon placement. Insurance companies often denied payment stating that surgery in these patients were ‘not medically necessary’ and thus it was considered a ‘vanity’ procedure. Additionally, in most cases, the procedures failed to produce meaningful or long-lasting results.

Adding stigma and shame to a medical condition

Patients who were overweight and seeking definitive treatment were often made to feel “lazy” for being unable to lose weight without surgical assistance. They were also told to return only if they continued to fail (or gain weight).

The Diabetes Pandemic

But as the obesity pandemic continued to escalate at breakneck speed along with obesity-related complications (and healthcare costs skyrocketed), the evidence began to become too overwhelming to ignore.

New guidelines were passed for eligibility criteria for gastric bypass procedures. These guidelines reduced the necessary BMI to qualify for surgery, especially in patients with co-morbidities such as diabetes. But it still ignored a large segment of people; non-morbidly overweight people with early diabetes – the very group that was most likely to have a high rate of success and immediate normalization of blood sugars*.

But now the government of the United Kingdom and the National Health Service (NHS) have adopted some of the most progressive recommendations world-wide; aimed at stemming the tide of diabetes and diabetes-related complications such as heart attacks, strokes, renal failure, non-alcoholic fatty liver disease (NASH) and limb ischemia leading to amputation.

The NHS should be commended for their early adoption of eligibility criteria that lowers the BMI requirement to 30 in diabetic individuals and eliminates this requirement entirely in diabetes of Asian descent**. Conservative estimates believe that this change will make an additional one million British citizens eligible for bariatric surgery.

* As a ‘cure’ for diabetes, gastric bypass is most successful in people who have had the disease for less than eight years.

Surge of patients but few surgeries

But can supply keep up with demand? Last year, according to the our source article (NYT), only 9,000 bariatric procedures were performed in the UK.

**Diabetics of Asian and East Indian heritage (India, Bangladesh, Pakistan) often develop a more severe, aggressive, rapidly progressive form of diabetes which is independent of BMI or obesity.

More from the Diabetes & Bariatric Archive:

Life after bariatric surgery

Bariatric surgery and the family

Bariatric surgery and CV risk reduction

The Diabetes Pandemic

Part II

Diabetes as a surgical disease

Gastric bypass as a cure for diabetes

New recommendations on the bariatric surgery and diabetes

Posted on August 8, 2013 by K Eckland

Re-visiting a previous blog post on our sister site on the use of bariatric surgery in the war on diabetes.

New recommendations on the bariatric surgery and diabetes

Posted on May 3, 2013 by K Eckland

New recommendations out of a recent conference in Austria as reported by the Heart.org. This comes on the heels of the most recent changes in BMI recommendations, as we reported last month.

As reported by Steve Stiles over at the Heart.org, in”Case made for metabolic bariatric-surgery eligibility criteria,” new evidence and recommendations suggest that surgery should be done earlier in the course of the disease process (diabetes) in patients with lower BMIs. Currently the BMI restriction criteria enforced in North America and Europe prevent the majority of diabetic patients from receiving gastric bypass surgery, which is the only proven ‘cure’ for diabetes. That’s because the majority of type II diabetic patients are overweight but not morbidly obese.

As reported previously on this site, Latin American bariatric surgeons have been at the forefront of the surgical treatment of diabetes. Many of the surgeons previously interviewed for numerous projects here at Cartagena Surgery were involved in several early studies on the effects of surgery in moderate overweight patients with diabetes.

More interestingly, researchers at the conference are also suggesting possible gastric bypass procedures for patients with ‘pre-diabetes’ or patients with an hemoglobin A1c greater than 5.7 % but less than 6.5% (6.5% is the cut off for diagnosis of diabetes.)

This is wonderful news – it means committees and such are finally getting around to following all of the research that has been published and presented over the last ten years.. But then it just one more important step…

Call it by its name

So I have my own suggestion to doctors and researchers – and it’s one that I’ve made been – a nomenclature change. We need to stop calling it “pre-diabetes”, because the name is a falsehood – and leads everyone (patients, nurses and doctors astray.)

– Greater than 95% of patients with ‘pre-diabetes’ will develop diabetes – so without a drastic intervention (far beyond diet and exercise) it’s pretty much a certainty.

– Many of the devastating complications of diabetes develop during this so-called pre-diabetic period.

– Doctors are now recommending surgical treatment to cure this “pre” disease state.

So….

if almost everyone who has ‘pre-diabetes’ gets diabetes, and it’s already causing damage PLUS we now recommend a pretty radical lifestyle change (surgical removal of most of the stomach) —> that sounds like a disease to me. Call it early diabetes, call it diabetes with minimal elevation of lab values, but call it what it is….Diabetes..

This is critical because without this firm diagnosis:

– insurance won’t pay for glucometers, medications, diabetic education, dietary counseling (or surgery for that matter). That’s a lot of out-of-pocket expenses for our patients to bear, for something that is treated like a ‘maybe’.

– patients (and healthcare providers) alike won’t take it seriously.. Patients won’t understand how crucial it is to take firm control of glucose management, patients won’t be started on preventative regimens to prevent the related complications like renal failure, heart disease and limb ischemia.

– Patients may not receive important screening to prevent these complications – and we already know that at the time for formal diagnosis (usually SEVEN years after initial glucose derangements are seen) – these patients will already have proteinuria (a sign of kidney disease), retinopathies, vasculopathies and neuropathies..

I work with providers every day, and the sad fact is that too many of them (us) shrug their shoulders and say – yeah – he /she should eat better, get more exercise, shrug.. But they don’t treat the disease – they don’t start checking the glucose more often, they don’t start statin drugs, the don’t screen for heart disease and they don’t consult the specialists – the diabetic educators, the nutritionists, the endocrinologists – and yes, the bariatric surgeons…

Chances are if your doctors and your nurses don’t take it seriously; and don’t make a big deal out of it – and don’t talk to you, at length about what “pre-diabetes” IS and what it really means for your life and your health –

then neither will you.

For related content: see the Diabetes & Bariatric tab

the Weight of a Nation: the obesity epidemic

Bariatric surgery and non-alcoholic fatty liver disease

The Pros & Cons of Bariatric Surgery

Gastric bypass to ‘cure’ diabetes goes mainstream

Talking with Dr. Jhon Jairo Berrio about vascular disease and Prostaglandin E1

Posted on October 9, 2012 by K Eckland

XXIX Congreso Latinoamericano de cirugia vascular y angiologia

Santa Cruz de la Sierra, Bolivia

Dr. Berrio, Vascular Surgeon, Tulua, Colombia

Dr. Jhon Jairo Berrio is the Chief of Vascular Surgery at the Clinica San Francisco, Tulua, Colombia, which is a small community outside of Cali. He attended medical school in Colombia, completing his general surgery residency at Hospital clinics for Carlos. He completed additional training at New York University and he completed his vascular surgery residency in Bogota at the Hospital de Kennedy and trained under the instruction of Dr. Albert Munoz, the current president of the Association of Latin American Vascular Surgery and Angiography (ALCVA) . He does a range of vascular procedures such as aortic aneurysm repair, fistula creation as well as endovascular surgery but his favorite procedures are limb salvage procedures such as aorto-femoral bypass, femoral-popliteal bypass and other treatments designed to prevent amputation.

He is here in Bolivia giving a presentation on the use of Prostaglandin E1 for critical ischemia / and last chance limb salvage.

Today we are talking to Dr. Berrio about the use of prostaglandin E1 (Iloprost/ iprostadil) for peripheral vascular disease (PAD). In the past, we have used a myriad of treatments including statins, pentoxifylline, clopidogrel and even quinine for the prevention and relief of claudication symptoms. However, all of these previous agents are designed for early PAD and are only minimally effective at treating later stages of disease. Treatment of severe disease (rest pain or ulceration/ ischemia wounds) has been limited to stenting (angioplasty) and surgical revascularization – but this strategy often fails for patients with microvascular disease (or disease that affects vessels that can not be operated on.)

Last effort at Limb Salvage in critical ischemia

No – Prostaglandin E is not some magic ‘panacea’ for peripheral vascular disease. There is no such thing – but it is a medication in the treatment arsenal for vascular surgeons – and it has shown some promising results particularly in treating limb-threatening ischemia. In fact, the data goes back over 20 years – even though most people in the United States have never heard of it. That’s because prostaglandin E1 is more commonly used for other reasons in the USA. It is a potent vasodilator, and in the US, this medication is often used in a different (aerosolized form) for primary pulmonary hypertension. It is also used for erectile dysfunction. Despite a wealth of literature supporting its use for critical ischemia it is not currently marketed for such use in the United States – and thus – must be individually compounded in a hospital pharmacy for IV use. Supplies of this medication in this form are often limited and costly.

Intravenous Prostaglandin E1

This medication offers a desparately needed strategy for patients with critical ischemia who (for multiple reasons) may not be surgical candidates for revascularization and is a last-ditch attempt to treat ‘dry’ gangrene and prevent amputation and limb loss. Since more than 25% of all diabetes will undergo amputation due to this condition – this is a critical development that potentially affects millions of people. (Amputations also lead to high mortality for a variety of reasons not discussed here.)

What is Prostaglandin E1?

As mentioned above, prostaglandin E1 is a potent vasodilator – meaning it opens up blood vessels by forced the vessels to dilate. This brings much-needed blood to ischemia tissue (areas of tissue dying due to lack of blood.)

Treatment details:

A full course of treatment is 28 days. Patients receive 60 micrograms per day by IV.

Patients must be admitted to the hospital for observation for the first intravenous administration of prostaglandin E1. While side effects such as allergic reactions, rash or tachycardia are rare – since this medication is given as an IV infusion, doctors will want to observe you for the first few treatments. The most common side effect is IV irritation. If this occurs the doctors will stop the infusion and dilute it further to prevent discomfort. Once your treatment has been established, doctors may arrange for you to have either out-patient therapy at an infusion center, or home health – where a nurse comes to your house to give you the medication.

The surgeons will evaluate your legs before, during and after treatment. If the ischemia or rest pain are not improving, or worsen during treatment – doctors may discontinue therapy.

Prostaglandin E1 therapy is compatible with other medications for PAD such as clopidogrel, aspirin, pentoxifylline and statins, so you can continue your other medications for PAD while receiving this treatment. However, if you are taking nitrates such as nitroglycerin, (Nitro-dur, Nitropaste) or medications for pulmonary hypertension or erectile dysfunction – please tell your surgeon.

In Colombia, the average cost of the entire course of treatment (4 weeks of daily therapy) is 12 million Colombian pesos. At today’s exchange rate – that is a little under $ 7000.00 (seven thousand dollars, USD).

While this is a hefty price tag – it beats amputation. In some cases, arrangements can be made with insurance companies to cover some of the costs. (Insurance companies know that amputation-related costs are higher over the long run, since amputation often leads to a lot of other problems due to decreased mobility).

Additional Information about Dr. Berrio:

Dr. Jhon Jairo Berrio, MD

Vascular surgeon

Calle 414 – 30

Buga, Colombia

Tele: 236 9449

Email: vascular@colombia.com

Speaks fluent English, Espanol.

References/ Additional information about peripheral arterial disease (PAD) and prostaglandin e1

Pharmacotherapy for critical limb ischemia Journal of Vascular Surgery, Volume 31, Issue 1, Supplement 1, January 2000, Pages S197-S203

de Donato G, Gussoni G, de Donato G, Andreozzi GM, Bonizzoni E, Mazzone A, Odero A, Paroni G, Setacci C, Settembrini P, Veglia F, Martini R, Setacci F, Palombo D. (2006). The ILAILL study: iloprost as adjuvant to surgery for acute ischemia of lower limbs: a randomized, placebo-controlled, double-blind study by the italian society for vascular and endovascular surgery. Ann Surg. 2006 Aug;244(2):185-93. An excellent read – even for novices.

S Duthois, N Cailleux, B Benosman, H Lévesque (2003). Tolerance of Iloprost and results of treatment of chronic severe lower limb ischaemia in diabetic patients. A retrospective study of 64 consecutive cases . Diabetes & Metabolism, Volume 29, Issue 1, February 2003, Pages 36-43

Katziioannou A, Dalakidis A, Katsenis K, Koutoulidis V, Mourikis D. (2012). Intra-arterial prostaglandin e(1) infusion in patients with rest pain: short-term results. Scientific World Journal. 2012;2012:803678. Epub 2012 Mar 12.e Note extremely small study size (ten patients).

Strecker EP, Ostheim-Dzerowycz W, Boos IB. (1998). Intraarterial infusion therapy via a subcutaneous port for limb-threatening ischemia: a pilot study. Cardiovasc Intervent Radiol. 1998 Mar-Apr;21(2):109-15.

Ruffolo AJ, Romano M, Ciapponi A. (2010). Prostanoids for critical limb ischaemia. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006544.

Volteas N, Leon M, Labropoulos N, Christopoulos D, Boxer D, Nicolaides A. (1993). The effect of iloprost in patients with rest pain. Eur J Vasc Surg. 1993 Nov;7(6):654-8.

New NAFLD (nonalcoholic fatty liver disease) resources from Medscape

Posted on August 9, 2012 by K Eckland

On the heels of a previous post about NAFLD/ NASH (nonalcoholic liver disease) – Medscape just published new treatment guidelines along was part of an on-going series of articles on fatty liver disease.

While Medscape is free – it does require a subscription to view, so I’ve re-posted the articles (as downloadable pdfs) here for interested readers. I would also like to encourage people to sign up with Medscape.com on-line.

Guidelines:

Diagnosis and Management of NAFLD: New Guidelines – David A. Johnson

Summary of new guidelines for treatment of fatty liver disease – Laurie Barclay

However, there are some concerns related to these new guidelines – primarily the recommendations for Vitamin E and other supplements for biopsy-proven NAFLD. The biggest concerns relate to the availability and purity of these products. Caution is advised in the use of unregulated over-the-counter supplements since the purity and efficacy of these products may vary widely.

In the ‘Ask the Experts’ readers ask Dr. William F. Balistreri, MD – Is the Prevalence of NASH Really Rising? In another article, Dr. Balistreri addresses, How Can I Convince My Patients That NASH Is Serious?

As we’ve discussed before, the incidence of fatty liver disease is on par with the expanding obesity epidemic – and histological evidence of liver disease is apparent in over 70% of bariatric surgery patients (at the time of surgery.)

Now doctors are seeing in younger patients – as the more and more kids become obese. In the article [below] by Helwick, 10% of all adolescents in the USA are estimated to have fatty liver disease.

A Fat Kid With a Fatty Liver: Case Challenge – Valerio Nobili, MD; Massimiliano Raponi, MD

Prevalence of NAFLD Increasing Among American Adolescents -Caroline Helwick

Of course, some of this is old news to long-time readers, who read Charlotte Rabl and Guilherme M. Campos’ article, The Impact of Bariatric Surgery on Nonalcoholic Steatohepatitis here at Cartagena Surgery, way back in April 2012 as part of our on-going discussions on bariatric surgery.

This article was just this beginning; with another article published just a few weeks later by Sindu Stephen; Ancha Baranova and Zobair M Younossi. Their article, Nonalcoholic Fatty Liver Disease and Bariatric Surgery reinforced the idea of bariatric surgery as a reasonable option for obese patients with liver disease.

For everyone looking for information on fatty liver disease, I hope these articles get you started.. Then head over to Medscape for the full library of resources.

Dr. Marco Sarinana and Dr. Joel Ramos,Bariatric surgeons

Posted on July 3, 2012 by K Eckland

Busy day yesterday – spent the morning shift with Jose Luis Barron over at Mexicali General.. Then raced over to Hospital de la Familia for a couple of general and bariatric cases.

The first case was with the ever charming Drs. Horatio Ham, and Rafael Abril (who we’ve talked about before.) with the always competent Dr. Campa as the anesthesiologist. (Seriously – Dr. Campa always does an excellent job.)

Then as we prepared to enter the second case – the director of the hospital asked if I would like to meet Dr. Marco Sarinana G. and his partner, Dr. Joel Ramos.. well, of course.. (Dr. Sarinana’s name has a tilde over the first n – but try coaxing that out this antique keyboard..)

So off to the operating room with these three fellows. (This isn’t my usual protocol for interviewing surgeons, etc. but sometimes it works out this way.) Their practice is called Mexicali Obesity Solutions.

Dr. Marco Sarinana and Dr. Joel Ramos, Bariatric surgeons

Dr. Alejandro Ballesteros was the anesthesiologist for the case – and everything proceeded nicely.

After that – it was evening, and time to write everything down!

Today should be another great day – heading to IMSS with Dr. Gabriel Ramos for a big case..

Coffee as a superfood round-up

Posted on May 17, 2012 by K Eckland

Update: New article published on MSNBC – 25 May –underscores health benefits of coffee – and further proves premise of optimal coffee ingestion at five to six cups. (Previous studies showed the majority of benefits at five cups/ day.)

Posting this for a friend, who wasn’t quite convinced by my arguments for coffee.. Added the video just for a light-hearted touch..and who doesn’t like David Bowie..

Happily, the majority of people have gotten away from the incorrect notion that coffee is somehow harmful, the “I gave up cigarettes and coffee” mentality.. It always irks me a bit when coffee drinking is lumped into a group of unhealthy behaviors….Stay away from coffee… and crack cocaine, people… But seriously, this is one beverage that has been mislabeled over the years – undeservedly.

With so many honest – to- goodness harmful food additives, fast food and other ‘junk‘ we put in our bodies – misidentifying coffee is a tragedy (albeit, a small one.) Admittedly, it is hard on my dental enamel – but otherwise, it is a welcome part of my daily routine.

So today, we are going to review some of our previous posts and the latest published information on coffee and it’s health effects..

For starters, we are going back to a post dated March 2011 – where I first reviewed my love of the hot, rich beverage, along with a summary of health benefits..

We talked about preliminary research suggesting coffee may be protective against strokes.. An additional study on this was actually just published last month, as reported in Medscape.com, Moderate coffee intake protects against stroke, (11 May, 2012) on a meta-analysis presented at the European Society of Hypertension (ESH) European Meeting on Hypertension 2012 by Dr Lanfranco D’Elia.

Then – a year ago (May 2011) we brought you more information about coffee as a potent anti-oxidant, and potential implications for preventing cancer (and refuting claims that it caused cancer.)

Following that – in July of 2011 – we went as far as proclaiming ‘superfood status’ when preliminary research suggested coffee ingesters were less likely to have MRSA colonization.

We haven’t even touched on the diabetes, and pancreatic cancer angle today, but suffice to say that research shows that the pancreas has a definite affinity for coffee..

Now, on the heels of reports of the underdiagnosis and increasing incidence of fatty liver disease – comes a study in the Annals of Hepatology entitled, “High coffee intake is associated with lower grade nonalcoholic fatty liver disease: the role of peripheral antioxidant activity.” Translated for readers, this small study by Gutierrez – Grobe, et. al (2012) suggests that high coffee intake is actual beneficial and may have a protective effect on the liver. Now – don’t get too excited – since it was just a very small study, of 130 subjects – coffee and noncoffee drinkers, 73 without liver disease and 57 with liver disease. So clearly, we need to look at this more closely..

But in the meantime, you can keep drinking your coffee.

Back in the OR with Drs. Ham & Abril, bariatric and general surgeons

Posted on May 17, 2012 by K Eckland

My first case this morning with another surgeon was cancelled – which was disappointing, but I still had a great day in the operating room with Dr. Ham and Dr. Abril. This time I was able to witness a bariatric surgery, so I could report back to all of you.

Dr. Ham (left) and Dr. Abril

I really enjoy their relaxed but detail oriented style – it makes for a very enjoyable case. Today they performed a sleeve gastrectomy** so I am able to report – that they (Dr. Ham) oversewed the staple line (quite nicely, I might add). If you’ve read any of the previous books, then you know that this is an important step to prevent suture line dehiscence leading to leakage of stomach contents into the abdomen (which can cause very serious complications.) As I said – it’s an important step – but not one that every doctor I’ve witnessed always performed. So I was a pleased as punch to see that these surgeons are as world-class and upstanding as everything I’d seen already suggested..

** as long time readers know, I am a devoted fan of the Roux-en-Y, but recent literature suggests that the sleeve gastrectomy is equally effective in the treatment of diabetes.. Of course – we’ll be watching the research for more information on this topic of debate. I hope further studies confirm these results since the sleeve gives patients just a little less of a drastic lifestyle change.. (still drastic but not shot glass sized drastic.)

Dr. Ham

They invited me to the show this evening – they are having several clowns (that are doctors, sort of Patch Adams types) on the show to talk about the health benefits of laughter. Sounds like a lot of fun – but I thought I better catch up on my writing..

I’ll be back in the OR with Los Doctores again tomorrow..

Speaking of which – I wanted to pass along some information on the anesthesiologist for Dr. Molina’s cases since he did such a nice job with the conscious sedation yesterday. (I’ve only watched him just yesterday – so I will need a few more encounters, but I wanted to mention Dr. Andres Garcia Gutierrez all the same.

the Weight of a Nation: the obesity epidemic

Posted on May 14, 2012 by K Eckland

There’s a new series on HBO that is a collaboration between the Institute of Medicine, the CDC and the National Institute of Health (NIH) that begins airing tomorrow night. This is a huge undertaking that took over three years to bring to the screen.

As many of you know – Obesity, diabetes and bariatric surgery are some of the topics that have been covered fairly extensively here at Cartagena Surgery. In fact – it’s the heart of Cartagena Surgery – since the very first surgeon interview I ever performed back in 2010 was Dr. Francisco Holguin Rueda, MD, FACS, the renown Colombia bariatric surgeon. (Shortly after that first leap – came Drs. Barbosa and Gutierrez – which is how we ended up here today.)

I’ve also been spending time, both last week and this week in the company of several bariatric surgeons here in Mexicali. MX and plan to go to several surgeries this week – so it seemed only appropriate to publish a few articles on the topic.

Talking with Dr. Horacio Ham – Bariatric surgeon, part 1

Talking with Dr. Ham, part 2

(I’m still transcribing notes from another one of my recent interviews – with Dr. Jose Durazo Madrid, MD, FACS).

I’d also like to encourage readers to take a look at HBO’s new mini-series (four episodes over Monday and Tuesday).

In the OR with Los Doctores, Dr. Ham & Dr. Abril

Posted on May 10, 2012 by K Eckland

Haven’t had time to sit down and write about my trip to the operating room with Dr. Horacio Ham and Dr. Rafael Abril until now, but that’s okay because I am going back again on Saturday for a longer case at a different facility. Nice surprise to find out that Dr. Octavio Campa was scheduled for anesthesia. Both Dr. Ham and Dr. Abril told me that Dr. Campa is one their ‘short list’ of three or four preferred anesthesiologists. That confirms my own impressions and observations and what several other surgeons have told me.

Dr. Campa (left) and another anesthesiologist at Hispano Americano

That evening we were at Hispano – Americano which is a private hospital that happens to be located across the street from the private clinic offices of several of the doctors I have interviewed. It was just a quick short case (like most laparoscopy cases) – but everything went beautifully.

As I’ve said before, Dr. Campa is an excellent anesthesiologist so he doesn’t tolerate any hemodynamic instability, or any of the other conditions that make me concerned about patients during surgery.

Dr. Ham and Dr. Abril work well together – everything was according to protocols – patient sterilely prepped and draped, etc..

laparoscopy with Dr. Ham & Dr. Abril

I really enjoy talking with the docs, who are both fluent in English – but I won’t get more of an interview with Dr. Abril until Saturday.

with Dr. Horacio Ham in the operating room after the conclusion of a successful case

Then – on Wednesday night – I got to see another side of the Doctors Ham & Abril on the set of their radio show, Los Doctores. They were interviewing the ‘good doctor’ on sympathetectomies for hyperhidrosis – so he invited me to come along.

Los Doctores invited me to participate in the show – but with my Spanish (everyone remembers the ‘pajina’ mispronunciation episode in Bogotá, right?) I thought it was better if I stay on the sidelines instead of risking offending all of Mexicali..

on the set of Los Doctores; left to right: Dr. Rafael Abril, Dr. Carlos Ochoa, Dr. Mario Bojorquez and Dr. Horacio Ham

It really wasn’t much like I expected; maybe because all of the doctors know each other pretty well, so it was a lot more relaxed, and fun than I expected. Dr. Abril is the main host of the show, and he’s definitely got the pattern down; charming, witty and relaxed, but interesting and involved too.. (my Spanish surprises me at times – I understood most of his jokes…) It’s an audience participation type show – so listeners email / text their questions during the show, which makes it interesting but prevents any break in the format, which is nice. (Though I suppose a few crazy callers now and then would be entertaining.)

Dr. Ochoa did a great talk about sympathectomy and how life changing it can be for patients after surgery, and took several questions. After meeting several patients pre and post-operatively for hyperhidrosis, I’d have to say that it’s true. It’s one of those conditions (excessive palmar and underarm sweating) that you don’t think about if you don’t have – but certainly negatively affects sufferers. I remember an English speaking patient in Colombia telling me about how embarrassing it was to shake hands -(she was a salesperson) and how offended people would get as she wiped off her hands before doing so. She also had to wear old-fashioned dress shields so she wouldn’t have big underarm stains all the time.. This was in Bogota (not steamy hot Cartagena), which is known for it’s year-round fall like temperatures and incredibly stylish women so you can imagine a degree of her embarrassment.

It (bilateral sympathectomy) is also one of those procedures that hasn’t really caught on in the USA – I knew a couple people in Flagstaff who told me they had to travel to Houston (or was it Dallas?) to find a surgeon who performed the procedure.. So expect a more detailed article in the future for readers who want to know more.

Tomorrow, (technically later today) I head back to San Luis with the good doctor in the morning to see a couple of patients – then back to the hospital.. and then an interview with a general surgeon.. So it should be an interesting and fun day.

Dr. Horacio Ham, and Los Doctores

Posted on May 9, 2012 by K Eckland

Just finished interviewing Dr. Horacio Ham, a bariatric surgeon with the DOCS (Diabetes & Obesity Control Surgery) Center here in Mexicali. Later this evening, we’ll be heading off to surgery, so I can see what he does first-hand.

Tomorrow sounds like a jam-packed day for the young doctor, he’s being interviewed for a University television series on Obesity in addition to his normal activities (surgery, patients) and of course, the radio show. Turns out his guest doctor tomorrow evening is none other my professor, the ‘good doctor.’

Sounds like a great show – so if you are interested it’s on 104.9 FM (and has internet streaming) at 8 pm tomorrow night..

I’ll report back on the OR in my next post..

Bariatric surgery and non-alcoholic fatty liver disease

Posted on April 23, 2012 by K Eckland

Interesting article over at Medscape on the role of bariatric surgery in the treatment of non-alcoholic fatty liver disease (NAFLD) and (NASH).

For the uninitiated, non-alcoholic fatty liver disease is a serious condition where functional tissue of the liver (used to metabolize and detoxify everything we ingest including medications) is replaced with fat tissue, and eventually fibrosis. As more and more healthy tissue becomes fatty & fibrotic, the liver function deteriorates until it progresses to cirrhosis and eventual liver failure.

Currently, the only treatment for cirrhosis and liver failure is liver transplantation (which is still only a temporary measure, even in the best case scenarios*.)

But why is the happening? and who does it affect? Obesity and obese patients.

To better understand what’s going on – we need to review some basic pathophysiology:

First, lets look at food. Not in cultural or psychosocial way, or even in food preferences, but food as the body sees it: Fuel for all of our cellular functions. Just as we run our houses, appliances and cars on different types of fuel – gasoline, natural gas, electricity etc. our body runs on different types of fuels (proteins, fats, sugars) that all get broken down to serve as energy. Like fossil fuels – the metabolism of each of these fuels requires different mechanisms (ie. gas-powered versus electric cars) and creates different by-products.

Now I want you to think of a scale.

No, not this kind of scale

No – I want you to think of a scale, as in a delicate balance between differing metabolisms for different fuels.

Think of a multi-tiered scale, where a delicate balance between the types of metabolism and waste products is required for continued good health – anything that upsets the balance such as diabetes – throws everything out of whack.

Normally, as fuel (food) in consumed – the body uses insulin to transport the fuel into the cell for processing (metabolism), so think of insulin as a wheelbarrow carrying in complex carbohydrates (sugars) into the cell.

Now, in a person with obesity & diabetes – two things are occurring – too much fuel and not enough wheelbarrows**. These means that:

1. Excess fuel is converted into fat (adipose tissue – which we are all familiar with).

2. Without the wheelbarrows, the body has to find another way to break down the fuel. This other pathway – for fat metabolism has a lot of by-products – namely free fatty acids (cholesterol and triglycerides.) This leads to numerous problems (hypercholesterolemia and cardiovascular disease for one), and fatty liver disease.

(This is a gross oversimplification of a series of very complex mechanisms, but for today’s discussion – it is sufficient.)

Just as the rates of obesity, and diabesity (diabetes caused by obesity) have skyrocketed, so has cardiovascular disease (which we’ve talked about before) and the prevalence of non-alcoholic liver disease. In fact, the authors of the study below found that 70% of the people with a BMI greater than 35 have some degree of non-alcoholic liver disease, and over 30% have the more severe form – NASH.

The article by Rabl & Campos (2012) looks at the literature on the outcomes (progression or regression of disease) after bariatric surgery in patients previously diagnosed with NAFLD. (I’ve linked a pdf version of the entire article under the full reference.)

They looked at the current bariatric procedures including the ever popular lap-band procedure and it’s effectiveness in treating NAFLD. What they found was that in the majority of cases – with certain procedures (formal gastric bypass surgery aka Roux en Y, and biliopancreatic diversion procedures) the disease process was not only halted, but regressed as a result of both weight loss, and a reversal of altered metabolism. They also found that as a result of a reduced stomach surface area (in comparison to lap-band procedures where the stomach remains intact) – reduced ghrelin leads to increased weight loss.

(If you don’t know about ghrelin – think of it as an evil gremlin (the one that makes you want cookies when you know you are about to eat dinner) – since it is a potent appetite stimulant produced by the stomach. The larger the stomach – the more ghrelin released – so the surgical procedures such as gastric bypass where a portion of the stomach is actually surgical removed are significantly more effective overall that lap-banding procedures.)

This is a significant advancement for medicine and the treatment of obesity related disease – since as we suggested above, multiple authors including Burianesi et. al (2008) suggest that the true prevalence of non-alcoholic fatty liver disease is much higher than we realize, (thus affecting a lot more people.)

Notes

* There is a tendency in American society to ‘gloss over’ many of life’s harsh realities, and no where is this more evidence than in the public perceptions of organ transplantation as a ‘cure’ or permanent solution for organ failure. Transplanted organs do not have the same life expectancy as native organs (even in the best case scenarios) – and for most people who need non-kidney transplants – they get one opportunity, not multiple. Transplanted organs last ten years – maybe fifteen at the outside – so this is not a cure (particularly in young patients). Transplantation also carries a whole host of other problems with it – such as the development of opportunistic infections and cancer from the drugs used to prevent rejection, or rejection itself. The very drugs used to prevent rejection of some organs may cause failure of others – so relying on transplantation as a ‘cure’ for a disease that is becoming more and more prevalent is a pretty poor strategy.

** This balance between mechanisms can be upset in other ways – by starvation, for example, when the body starts catabolizing proteins.. Catabolizing – think cannibalism – as the body consumes it’s own muscle tissue because there is nothing left for it to eat, after it has exhausted all other sources of fuel.

References and Resources

Rabl, C. & Campos, G. M. (2012) The Impact of Bariatric Surgery on Nonalcoholic Steatohepatitis. Semin Liver Dis. 2012;32(1):80-91 [Article under discussion above].

Body Mass Index calculator – West Virginia Dietetic Association.

Bugianesi et. al. (2008). Clinical update on non-alcoholic fatty liver disease and steatohepatitis. Annals of hepatology, 2008; 7 (2): April – June 157-160. The authors ask, “What is the real prevalence of disease?”

Goldstein, B. J. (2001) Insulin Resistance: Implications for Metabolic and Cardiovascular Diseases. This is a good presentation that explains how alterations in glucose metabolism (from diabetes) affects fat metabolism.

Overview of NASH/ NAFLD with classifications, diagnostics, prognostics : University of California, San Diego – Dan Lawson, 2010 [notes]. Good reference for medical students, health care professionals wanting a brief review.

Salt, W. B. (2004). Nonalcoholic fatty liver disease (NAFLD): A comprehensive review. J Insur Med, 2004; 36: 27 -41.

For more about Bariatric surgery – including the Pros & Cons

The Pros & Cons of Bariatric Surgery

Posted on April 14, 2012 by K Eckland

As my loyal readers know, I do my best to try to give fair and balanced depictions of surgical procedures, as well as reviews of medical and surgical news and research. Over at Medscape.com – there is a new video discussion by Dr. Anne Peters, MD. Dr. Peters is an endocrinologist and a certified diabetic education. In this video – she talks about the realities of bariatric surgery, and these are things I think that people need to hear.

For more on Bariatric surgery – see my other posts

One of the points that she makes, is (in my opinion) critical. While bariatric surgery has been shown to cure diabetes in many individuals – there is no medical/ surgical or other treatment to cure much of the pathology related to the development of obesity in the first place. Obesity is more than poor dietary and exercise habits – it is a psycho-social and cultural phenomenon as well.

For people who don’t want to go to the Medscape site – I have re-posted a transcript of the video from Medscape.com below.

Bariatric Surgery a ‘Magic Bullet’ for Diabetes?

Anne L. Peters, MD, CDE

Originally posted on Medscape on: 04/05/2012

Transcript
Hi. I’m Dr. Anne Peters from the University of Southern California. Today I’m going to talk about the role of bariatric surgery in the treatment of type 2 diabetes.

There have been a number of recent studies that show just how good bariatric surgery can be for patients with type 2 diabetes.^[1,2] In many cases, it seems to cure type 2 diabetes (at least for now), and I think it is an important tool for treating patients with obesity and diabetes.

However, I also have concerns about bariatric surgery, concerns that go back for years as I watched its increased use. When I was a Fellow, I developed a sense of the benefit of extreme caloric restriction for the treatment of type 2 diabetes. I will never forget the first patient I had, an extremely obese man with type 2 diabetes who was on 200 units of insulin per day. His blood sugar levels remained high no matter what we did. He was a significant challenge in terms of management.

One day, he got sick. I don’t remember how or why he got sick, but he ended up in the hospital and I thought that his management would continue to be incredibly difficult. In fact, it was miraculously easy. Within 2 days, he was completely off of insulin and his blood glucose levels remained normal for the entire time he was in the hospital.

This was only a short-lived benefit, however. After he was discharged, he went back to his old habits. He started eating normally, regained the weight, and went back on several hundred units of insulin per day. But it really impressed me how acute severe caloric restriction could, in essence, treat type 2 diabetes.

I have seen many overweight and obese patients with diabetes over the years, and I have seen the frustration as patients go on drugs (such as insulin) that are weight-gain drugs, and they keep gaining more weight. Although I am a big advocate for lifestyle change, many patients can’t do much better. They can’t lose appropriate amounts of weight by their own will or through weight loss programs, or increase their exercise. Therefore, bariatric surgery remains a reasonable option.

For many of my patients who have a body mass index > 35 and type 2 diabetes, I recommend that they at least consider bariatric surgery. Interestingly, very few of my patients actually go for the procedure and I ponder why this is. In part, I think it’s because of the initial evaluation, when you are told what bariatric surgery is like and how much you have to change your habits after the procedure. Before surgery, you are eating however you want to eat and, although you may be trying to diet, there is no enforcement of that diet. After surgery, you have to change how you eat, the portions you eat, and when you eat. I know that people feel fuller, and this is a lot more than just changing one’s anatomy. I think there are significant changes in gut hormones that regulate appetite and satiety. Nonetheless, it is a big change, and many people don’t want to change their habits that much. I know I would be somewhat leery if I were to undergo a surgical procedure that would change my whole way of being. For lots of people, food has many different associations. It’s not just caloric intake; it’s festival, it’s party, it’s joy, it’s sadness. It’s something people like to do, and it hasn’t a lot to do with just maintaining a positive or neutral caloric balance.

I find that people are reluctant to change, and that is understandable. We also don’t know the long-term complications of the procedure. As an endocrinologist, I see 2 things. First, I tend to get sicker patients, so my patients who are on insulin when they undergo bariatric surgery may not get off insulin entirely. They become very disappointed because they think that bariatric surgery will cure them of their diabetes. I also see patients who are too thin, who are nutritionally deficient, who have severe hypoglycemia, or who have significant issues from the surgery itself. In some cases, these patients have needed a takedown of the surgical procedure, restoring them back to their native anatomy.

I think of bariatric surgery as a tool. It is one of many ways to treat our patients with type 2 diabetes. I am a little concerned because we don’t have long-term follow-up data. I think that all bariatric surgery programs, in addition to doing a very thorough preoperative evaluation and counseling, need to do long-term, lifelong follow-up of these patients to see how they do, to see if their obesity returns. In many cases, this does happen. [Patients need to be followed up] to see what happens to their lipids, their blood pressure, and their blood sugar levels over time, and to monitor for other complications.

I think [bariatric surgery] is something that we need to recommend to our patients, and for those in whom it’s appropriate, it is a reasonable step. This has been Dr. Anne Peters for Medscape.

References

Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012 Mar 26. [Epub ahead of print]
Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; Mar 26. [Epub ahead of print]

About the Author – including industry affiliations

Dr. Anne Peters, MD, CDEProfessor of Clinical Medicine; Director, Clinical Diabetes Programs, Keck School of Medicine, University of Southern California, Los Angeles, California Disclosure: Anne L. Peters, MD, CDE, has disclosed the following financial relationships: Served as director, officer, partner, employee, advisor, consultant, or trustee for: (current consultant): Amylin Pharmaceuticals, Inc.; Eli Lilly and Company; Novo Nordisk Served as a speaker or member of a speakers bureau for: (current speakers bureau member): Amylin Pharmaceuticals, Inc.; Eli Lilly and Company; Novo Nordisk; Takeda Pharmaceuticals North America, Inc. Served as a consultant or ad hoc speaker/consultant for: AstraZeneca Pharmaceuticals LP; Abbott Laboratories; Boehringer Ingelheim Pharmaceuticals, Inc.; Bristol-Myers Squibb Company; Dexcom; Medtronic MiniMed, Inc.; Merck & Co., Inc.; Roche; sanofi-aventis

Life after Bariatric Surgery

There is also an excellent article by two nurse practitioners about the long-term interventions and health monitoring needed for wellness promotion and health maintenance after bariatric surgery. While this article is written for other health care providers – it gives an excellent look at life after bariatric surgery, as well as an overview of the surgical techniques, pre-operative evaluation and anticipated post-operative outcomes.

Thomas, C. M. & Morritt Taub, L. F. (2011). Monitoring and preventing the long-term sequelae of bariatric surgery. J of the American Academy of Nurse Practitioners, 2011, 23 (9).

Metformin and Cancer

Posted on April 7, 2012 by K Eckland

The news about Metformin as a possible ally in the fight against cancer has finally taken wings. (This was first reported in the literature several years ago.)

As we’ve spoken about in the past – these discoveries about the ‘side benefits’ of this powerful oral anti-glycemic are finally getting some well-deserved press. As a drug that’s often been shunted aside despite it’s low cost, and impressive safety profile for the more pricey and flashy (but less clinically-proven) alternatives (Yes, Byetta, I am talking about you) this could serve as a boon to consumers..

The other thing we should take from this research is that it remains critical to aggressively control diabetes – for more than just the usual cardiovascular risks – but to reduce the risk of our patients developing cancer. While insulin is a godsend to patients with uncontrolled glucose – metformin should remain on the menu even after the initiation of insulin therapies. Too often, metformin falls off the roster. We also need to impress upon our patients to potent nature of this innoculous sounding medication. Frequently patients inform me that they have abandoned metformin for various reasons in favor of the more pricey, and heavily advertised medications. Unfortunately, they are really just short-changing themselves: both their wallets and their health.

Coming soon – more about the ‘magic bullet’ of Aspirin – as both a cancer-fighter and an essential element for cardiovascular health.

Unleash Metformin: Reconsideration of the Contraindication in Patients with Renal Impairment – Wenya R. Lu, PharmD.

Gastric bypass to ‘cure’ diabetes goes mainstream

Posted on March 28, 2012 by K Eckland

A full year after we reported it here (and several years after initially being reported in the literature), mainstream media has finally picked up the story about gastric bypass surgery for the definitive treatment of diabetes. The story made all of the heavies; the Washington Post, the Wall Street Journal, and the Los Angeles Times.

Unfortunately, all of these outlets seem unaware of the existing literature in this area – these results while encouraging, are not surprising. Similar results have been demonstrated in several other (but smaller) studies for the past ten years, which led to previous recommendations (last summer) for the adoption of gastric bypass surgery as a first-line treatment for diabetes in obese patients.

The publication of two new studies showing clear benefits for diabetics undergoing bariatric surgery has brought this news to the forefront. In both of these studies, diabetic patients were able to stop taking oral glycemics and insulins after surgery within days..

As this front page story from the New York Times notes – these results do not apply to the more widely marketed ‘lap-band.’ This comes to no surprise to dedicated followers at Cartagena Surgery, who have been reading articles on this topic since our site’s inception in late 2010.

You heard it here first. For more information on this topic, see our tab on Diabetes & Bariatrics under the ‘surgery’ header. We’ve included a small selection from our archives here.

Bariatric surgery headlines – August 2010

Gastric bypass surgery gets the international federation of diabetes approval.

Gastric bypass as treatment for diabetes

High-fructose corn syrup is dangerous by any other name

Posted on March 20, 2012 by K Eckland

Not as innocent as the Corn Refiners Association would have you believe.

In a courtroom in Los Angeles, a fierce battle is being pitched right now – one that affects almost every person in this nation.. It’s a lawsuit from the nation’s sugar producers accusing the corn industry of false advertising.. That’s right – it takes industry giants to take on those ridiculous, and mis-leading ads.

You know, those ads that ridicule consumers for their health concerns related to the use of high-fructose corn syrup? (We’ve discussed these health concerns previously in a series of posts that you can see here and here.)

Link to ad by Corn Industry

But, here (finally) is a response to those ads – that uses science, not fallacy to refute those claims.

At the same time, the Corn Refiners Association has filed a petition with the Food & Drug Administration to change the name of their product from ‘High-fructose corn syrup” to the more innocuous-sounding “Corn Sugar,” which is just another attempt to deceive the American public.

This move comes just as a new medical study links the consumption of a single daily soda with a 20% increase in heart attacks in men. There’s a great article over at the Heart.org that summarizing these findings, which I have re-posted below for readers. (the original study was published in Circulation).

Unfortunately, corn syrup in our everyday products in not usually so easy to identify.

A soda a day raises CHD risk by 20% – Lisa Nainggolan

March 12. 2012

Boston, MA – Sugary drinks are associated with an increased risk of coronary heart disease (CHD) as well as some adverse changes in lipids, inflammatory factors, and leptin, according to a new analysis of men participating in the Health Professionals Follow-up Study, reported by Dr Lawrence de Koning (Children’s Hospital Boston, MA) and colleagues online March 12, 2012 in Circulation [1].

“Even a moderate amount of sugary beverage consumption—we are talking about one can of soda every day—is associated with a significant 20% increased risk of heart disease even after adjusting for a wide range of cardiovascular risk factors,” senior author Dr Frank B Hu (Harvard School of Public Health, Boston, MA) told heartwire. “The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda, not only in the US but also increasing very rapidly in developing countries.”

The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda.

The researchers did not find an increased risk of CHD with artificially sweetened beverages in this analysis, however. “Diet soda has been shown to be associated with weight gain and metabolic diseases in previous studies, even though this hasn’t been substantiated in our study,” says Hu. “The problem with diet soda is its high-intensity sweet taste, which may condition people’s taste. It’s still an open question whether diet soda is an optimal alternative to regular soda; we need more data on this. ”

Hu says water is the best thing to drink, or coffee or tea. Fruit juice is “not a very good alternative, because of the high amount of sugar,” he adds, although if diluted with water, “it’s much better than a can of soda,” he notes.

And Hu says although the current results apply only to men, prior data from his group in women in the Nurses’ Health Study [from 2009] were comparable, “which really boosts the credibility of the findings.”

Inflammation could be a pathway for impact of soda upon CHD risk

Hu and colleagues explain that while much research has shown a link between the consumption of sugar-sweetened beverages and type 2 diabetes, few studies have looked at the association of these drinks with CHD.

Hence, they analyzed the associations of cumulatively averaged sugar-sweetened (eg, sodas) and artificially sweetened (eg, diet sodas) beverage intake with incident fatal and nonfatal CHD (MI) in 42 883 men in the Health Professionals Follow-up study. Beginning in 1986 and every two years until December 2008, participants answered questionnaires about diet and other health habits. A blood sample was provided midway through the study.

There were 3683 CHD cases over 22 years of follow-up. Those in the top quartile of sugar-sweetened-beverage intake had a 20% higher relative risk of CHD than those in the bottom quartile (RR 1.20; p for trend <0.001) after adjustment for age, smoking, physical activity, alcohol, multivitamins, family history, diet quality, energy intake, body-mass index, preenrollment weight change, and dieting.

Adjustment for self-reported high cholesterol, high triglycerides, high blood pressure, and diagnosed type 2 diabetes only slightly attenuated these associations, which suggests that drinking soda “may impact on CHD risk above and beyond traditional risk factors,” say the researchers.

Consumption of artificially sweetened drinks was not significantly associated with CHD (multivariate RR 1.02; p for trend=0.28).

Intake of sugar-sweetened drinks, but not artificially sweetened ones, was also significantly associated with increased triglycerides and several circulating inflammatory factors—including C-reactive protein, interleukin 6 (IL-6), and tumor-necrosis-factor receptor 1 (TNFr1)—as well as decreased HDL cholesterol, lipoprotein (a) (Lp[a]), and leptin (p<0.02).

“Inflammation is a key factor in the pathogenesis of cardiovascular disease and cardiometabolic disease and could represent an additional pathway by which sugar-sweetened beverages influence risk,” say Hu et al.

Cutting consumption of soda is one of easiest behaviors to change

Hu says that one of the major constituents of soda, high-fructose corn syrup, is subsidized in the US, making such drinks “ridiculously cheap” and helping explain why consumption is so high, particularly in lower socioeconomic groups.

Doctors should be advising people with heart disease or at risk to cut back on sugary beverages; it’s almost a no-brainer.

“Doctors should set an example for their patients first,” he stresses. “Then, for people who already have heart disease or who are at high risk, physicians should be advising them to cut back on sugary beverages; it’s almost a no-brainer, like recommending that they stop smoking and do more exercise. The consumption of sugary beverages is a relatively easy behavior to change.”

And although this particular study included mostly white subjects and there are few data on the risk of cardiovascular disease associated with the consumption of soda in people of other ethnicities, there are data on its effect on type 2 diabetes in these groups, he says.

“It has been shown for minority groups—such as African Americans and Asians—that they are more susceptible to the detrimental effects” of sugary drinks on diabetes incidence, he notes.

And if you think soft drinks are the only culprits containing high-fructose corn syrup – you’ll be surprised. Livestrong has published a list of corn syrup containing products – and you’ll see with even a quick glance, that it’s everywhere, and in everything.

Another blog talking about the harm of Corn Syrup

Mended Hearts & Aggressive Risk Factor Reduction for people with Hyperglycemia

Posted on February 19, 2012 by K Eckland

Busy day today – I am giving a talk with the local Mended Hearts chapter as part of “Heart Month.” Mended Hearts is a patient-run organization/ support group for people who have had heart attacks, stents or heart surgery. It’s a place where people can go for encouragement, education or support after a life-changing cardiac event. I’ve worked with Mended Hearts in the past, so I was pleased when they invited me to give one of my favorite talks this weekend. (I’ve been giving variations on this talk since 2008).

(Some people might consider it a bit ironic that I am giving a lecture on prevention to a group of people who have already been diagnosed with CAD – but we are also talking about overall wellness/ and preventing future events.)

It’s one of my favorite lectures because it’s an informal style presentation – so I encourage listeners to participate in the discussion – and ask questions. We also review a case study at the end – where we have a bit of role reversal as I invite listeners to be the NP for a minute and devise treatment strategies for the imaginary patient.. (and my audience usually does a great job – which just proves how powerful a motivated person can be when it comes to healthcare.. If all people were like my audiences, people would be a lot healthier.) I’ve included a quick summary of my lecture here for interested readers. (Just the basics – for more specific or detailed information such as information on lipo-proteins, see your doctor.)

Aggressive Risk Factor Reduction

When talking about healthcare and risk factor reduction, we need to use measurable, and achievable goals.. No ‘nebulous’ statements like ‘improve blood pressure’, or ‘lose weight.’ Instead – we give concrete, and specific goals based on the most relevant and up-to-date clinical evidence.

1. Hypertension / Blood pressure control – normal B/P is 110/ 70. National guidelines for diabetics recommends systolic blood pressure less than 130, and a diastolic b/p less than 90.

2. Hyperlipidemia/ dyslipidemia

LDL cholesterol less than 70

HDL greater than 50

– statin therapy recommended for all diabetics.
3. Microaluminuria – small protein particles found in urine. This is an early indicator of on-going kidney damage. All diabetics should be on an ace-inhibitor (the ‘prils’ such as lisinopril, fosinopril, enalapril).

These medications will help SLOW the damage, but the best treatment is TIGHT glucose control.

4. Hyperglycemia – (not diabetes)

Hyperglycemia causes damage. Period. This includes so-called ‘pre-diabetes’ and gestational diabetes (see slides for more information.)

– Check your hemoglobin A1c, and control your glucose

– Fasting and post-prandial (2 hours after meals) glucose testing. Remember that post-prandial readings will rise earlier in the course of the disease, so if you re only testing in the mornings – you might miss crucial information needed for your treatment.

– Currently ONLY metformin and insulin therapies have been shown to have long-term benefits. (The twenty – plus other medications may make ‘the numbers’ look pretty – but there is little long-term evidence to support their use.

Previously, we skirted around to test ALL of our cardiothoracic patients as part of a screening protocol – new guidelines recommend screening of all hospital patients.

5. Endothelial inflammation – hyperglycemia ‘encourages’ endothelial inflammation and vascular damage (it’s the hallmark of the disease) so the best way to treat this is with anti-platelet therapy such as a baby aspirin (ASA). Recent literature suggests that ASA may do more harm than good in some people, so check with your doctor..

There’s a lot more information to go over (it’s a 45 minute talk) so I’ve decided to post my lecture slides here for anyone to use, but I do ask that people please give appropriate credit. Cardiac Complications of Diabetes ppt slides.

More references:

Australian treatment guidelines

Bariatric Surgery Safety: More than your weight is at risk!

Posted on January 22, 2012 by K Eckland

Dying to be thin? These patients are… A look at the Get-Thin clinics in Beverly Hills, California..

This series from LA Times writers, Michael Hiltzik and Stuart Pfiefer highlights the importance of safety and the apparent lack of regulation in much of the bariatric procedure business here in the United States.

In these reports – which follow several patient deaths from lap-band procedures, both surgeons and surgical staff alike have made numerous reports against the ‘Get Thin” clinics operating in Beverly Hills and West Hills, California. These allegations include unsafe and unsanitary practices. One of the former surgeons is involved in a ‘whistle-blower’ lawsuit as he describes the dangerous practices in this clinic and how they led to several deaths.

Regulators ignore complaints against Beverly Hills clinics despite patient deaths – in the most recent installment, Hiltzik decries the lack of action from regulatory boards who have ignored the situation since complaints first arose in 2009!

House members call for probe into Lap-Band safety, marketing – California legislators call for action, but the clinics stay open. (article by Stuart Pfiefer)

Plaintiffs allege ‘gruesome conditions’ at Lap-Band clinics – mistakes and cover-ups at the popular weight loss clinics. (article by Stuart Pfiefer) This story detailing a patient’s death made me ill – but unfortunately reminded me of conditions I had seen at a clinic I wrote about in a previous publication.. The absolute lack of the minimum standards of patient care – is horrifying. This woman died unnecessarily and in agony. It proves my point that anesthesiologists need to be detailed, and focused on the case at hand.. (not iPhones, crosswords or any of the other distractions I’ve seen in multiple cases.. Now this case doesn’t specifically mention a distracted anesthesiologist – but given the situation described in the story above, he couldn’t have been paying attention, that’s for sure.

Are we jaded – or is it unsurprising that the lawyer for ‘Get Thin’ is a total slime, who was recently disbarred for attempting to bribe witnesses to suppress / change their stories about conditions at Get Thin clinics?

The doctor won’t see you now..

Posted on November 19, 2011 by K Eckland

Ironically, just a few days ago we were talking about lung cancer and discrimination against patients with lung cancer in the post, The Pearl Ribbon. Now a new article published in Physicians Money Digest, suggests that one of the latest trends is discrimination against the obese. As obese people can tell you – this discrimination has always existed in some form, and from all avenues in society including medicine.

However, this new trend consists of doctors avoiding accepting obese patients in their practice, mainly to avoid the increased workload related to obesity related complications. That’s right – as discussed in the article by Laura Mortokowitz, which I have re-posted below -some doctors are avoiding caring for obese patients because they do not want to provide care to patients with higher risks of certain complications – diabetes, heart disease, etc.

As someone who works in heart surgery, I can see this issue from both sides. As many of you know – I am sometimes disheartened by the sheer overwhelming volume of disease (due to diabetes) and the amount of suffering involved for my patients. I am particularly distressed at times when I see the amount of preventable suffering, and damage my patients experience from not controlling their blood pressure, checking their glucose or taking their medications. But my patients are already sick – that’s why the are seeing a heart surgeon. So, I often mourn these lost opportunities to prevent disease (heart attacks, strokes etc.), and I can see how primary care providers, and other providers may feel emotional fatigue and frustration at times.

But, other the other hand – not every obese person is a stroke or heart attack waiting to happen. Many of these people can be helped – by education, counseling or even bariatric surgery. If these people are aggressively followed and cared for, risk reduction can help prevent catastrophic complications – by managing medical conditions that may develop – with aggressive cholesterol control, blood pressure management, etc.

Lastly, medicine is not an exact science – while risks may be greatly increased in many obese people – it is not a guarantee.. Just as it’s a false assumption that all overweight people are sedentary (ie. ‘fat and lazy’), not all overweight people will develop any or all of the complications we’ve discussed before. But it is guaranteed that these obese patients will suffer, if this trend continues and more and more doctors shun them.

But my door is always open.

Turning a Blind Eye to the Obese

By Laura Mortkowitz, Wednesday, November, 16th, 2011

A recent move by Florida ob-gyn physicians to begin turning away overweight patients on the grounds that they were too risky might be the beginning of a new trend. According to Michael Nusbaum, MD, FACS, the health reform bill’s Accountable Care Organizations essentially de-incentivize physicians from taking on morbidly obese patients.
As they stand now, ACOs look at quality measures and they base reimbursements on complications. Doctors already know that a high complication rate will mean less money, and obese patients are considered high-risk patients by definition.
“Under the current bill, the Accountable Care Organizations are looking strictly at outcome measures, so unless that changes I don’t see the perception by physicians changing toward who they’re going to want to treat and who they’re not going to treat,” says Nusbaum, the Medical Director at The Obesity Treatment Centers of New Jersey.
This new practice is not something that would have occurred in the past for two reasons: one, physicians might be reluctant to treat an obese patient, but it was rare to turn them away completely; and two, it was very rare to treat a morbidly obese patient a couple of decades ago.
However, over the last 10 years, the percentage of the population that is overweight has increased dramatically. Today, close to 70% of the population is at least overweight, according to data from the Centers for Disease Control and Prevention. Even more concerning, is the fact that pediatric obesity has tripled over the last 20 years.
“Is the health care system to take care of morbidly obese patients? I would argue that it’s not,” Nusbaum says. “Pretty clearly it’s not. The problem with the health care system is that it lacks infrastructure.”
Most machines and tables can only hold up to 350 pounds, and any patients that exceed that weight might not even be able to get treated at a hospital that doesn’t have the equipment to handle an obese patient. According to Nusbaum, it should be a requirement that hospitals are equipped to treat any morbidly obese patient.
“Nobody is even talking about it,” he says. “Everybody is afraid to even talk about this.”
And it doesn’t seem as if new health laws are encouraging to the treatment of obesity. Under the new health bill’s Essentials Benefit Package, bariatric surgery is not covered because morbid obesity is being considered a poor lifestyle choice. As a result, insurance companies “have become emboldened to say, ‘Well, we’re not going to cover it either,’” Nusbaum says.
In New Jersey, Blue Cross/Blue Shield has 14 insurance policies, and eight of them do not cover bariatric surgery at all.
“What you’re seeing happening is a change in attitude to bariatric surgery and in my opinion a discrimination against those people who have weight issues,” Nusbaum says.
However, there was a rather positive turn of events in Michigan, where bariatric surgery will be covered in 2012 after it was dropped for all of this year.
“They noticed that while they were making money in the short term — they were saving money — they were losing more money by not taking care of these patients,” Nusbaum says. “[The patients] were getting sicker. It was very short sighted.”

Bariatric surgery for the whole family?

Posted on November 6, 2011 by K Eckland

No, researchers aren’t suggesting that entire families undergo bariatric surgery. But a new study by Woodward, Encarnacion, Peraza, Hernandez – Boussard & Morton (2011) published last month suggests that when one family member underwent bariatric surgery – the rest of the family reaped benefits as well.

As explained in this article by Kristina Fiore at Medpage – there is a family-wide health benefit after bariatric surgery. After one family member had surgery, other adult members in the family tended to modify their eating habits as well, and subsequently lost weight. While this study was small, with just 35 families – it shows the huge impact that sociological factors (such as family dietary practices/ habits) have on obesity and health.

The real reason you aren’t getting your metformin..

Posted on October 19, 2011 by K Eckland

As we’ve mentioned before on this site – metformin is an amazingly powerful yet safe diabetes drug that has also been shown to have additional cardiovascular benefits.. This doesn’t mean metformin has no side effects or contraindications (all medications have side effects and contraindications) but in comparison to all of the other available oral anti-diabetic medications, metformin continues to have the best safety profile.

The evidence is also overwhelming clear what are effective treatments for diabetes – and national guidelines reflect this. (Nowhere in these guidelines are januvia, byetta and these other pricey medications listed.) However, these guidelines are subject to change (along with anything else).. But who’s writing the guidelines?

But – it seems like that hasn’t stopped anyone from prescribing, and prescribing some of these very costly medications.. Now, on Medscape (and re-posted here for you) Reed Miller explains why as he reviews the recent paper by Jennifer Neuman, MD.

From Heartwire

Conflicts of Interest Abound in Diabetes Guidelines Committees

Reed Miller

October 12, 2011 (New York, New York) — About half the experts serving on the committees that wrote national clinical guidelines for diabetes and hyperlipidemia over the past decade had potential financial conflicts of interest (COI), and about 4% had conflicts that were not disclosed [1].

Dr Jennifer Neuman (Mount Sinai School of Medicine, New York, NY) and colleagues reviewed the financial ties to industry of 288 panel members who served on 14 guidelines committees in the US and Canada between 2000 and 2010. Results of their study were published online October 11, 2011 in BMJ.

Five of the guidelines did not include a declaration of the panel members’ conflicts of interest, but 138 of the 288 panel members (48%) reported conflicts of interest at the time of the publication of the guideline. Eight reported more than one conflict. Of those who declared conflicts, 93% reported receiving honoraria, speaker’s fees, and/or other kinds of payments or stock ownership from drug manufacturers with an interest in diabetes or hyperlipidemia, and 7% reported receiving only research funding. Six panelists who declared conflicts were chairs of their committee.

Of the 73 panelists who had a chance to declare a conflict of interest but declared none, eight had undeclared COI that the researchers identified by searching other sources. Among the 77 panel members who did not have an opportunity to publicly declare COI in the guidelines documents, four were found to have COI.

The study also found that panelists on government-sponsored guidelines committees–such as those organized by the Veterans Administration or the US Preventive Services Task Force–were less likely to have conflicts of interest than panelists on nongovernment guidelines panels (15/92 [16%] vs135/196 [69%]; p<0.001). However, the researchers point out that the government-sponsored guidelines committees were less likely to have rigorous COI transparency policies.

A recent study of COI among members of American College of Cardiology/American Heart Association (AAC/AHA) – sponsored guidelines found that about half of guidelines committee members reported potential conflicts of interest. Neuman et al point out that their study includes a wider range of guideline-producing organizations and that it “exposes the problem of incomplete disclosure and highlights the important relation between sponsorship of guidelines and presence of COI.”

“In contrast to government-sponsored panels, we found that COI were very common among panel members for guidelines produced by specialty societies,” Neumann et al write. Neumann cites a 2000 study [2] by Dr Roberto Grilli (Istituto di Ricerche Farmacologiche, Milan, Italy) as evidence that “guidelines produced by nongovernment-sponsored organizations have been shown to be of poor methodological quality; however, they contribute substantially to the guideline pool in the United States and Canada . . . [and] may have broad international influence. The high prevalence of COI among panel members of guidelines sponsored by specialty societies combined with the less rigorous development process may adversely affect the independence and the evidence base of the recommendations issued.”

One of the authors of the ACC/AHA study, Dr James Kirkpatrick (University of Pennsylvania, Philadelphia) told heartwire that he was pleased that the study by Neuman et al appears to confirm the main finding of his group’s study: “There are plenty of people who participated in the guidelines process who reported no disclosures. The implications are that it would not be too difficult to construct a guidelines panel without COI, or at least–as we suggested, and the authors also seem to suggest–with only COI related to research grant funding, exclusive of direct financial payments to members.” Kirkpatrick said he was surprised but reassured to see that Neumann et al found so few undeclared conflicts of interest.

“It is important to note that some governmental organizations don’t publish disclosures, which I believe they probably should,” Kirkpatrick said. “This problem is fairly widespread, not only among governmental organizations, but also other societies. It has the potential to erode public trust in the guidelines process as much as a relatively high rate of disclosed COI.”

How to Change the Culture of Conflicts

In an accompanying editorial [3], Dr Edwin Gale (Southmead Hospital, Bristol, UK) observes that the proportion of guideline committee members declaring a conflict of interest has increased recently, but the proportion of members with a potential conflict has not decreased.

The common suggestion that that guideline committees should include only experts with no conflicts of interest has “a charming sense of unreality,” Gale argues. “Money from drug companies is the oxygen on which the academic medical world depends. The income of the professional societies that publish guidelines largely derives from their annual conferences, which depend on the rents charged to exhibitors and the registration of company-sponsored delegates,” he observes. “Let us therefore forget the hand-wringing and confront the reality of the world in which we live.

Gale believes the conflicts on committees cannot be eliminated unless fewer experts take money from industry. “Legislation will not change the situation, for the smart money is always one step ahead. What is needed is a change of culture in which serving two masters becomes as socially unacceptable as smoking a cigarette. Until then, the drug industry will continue to model its behavior on that of its consumers, and we will continue to get the drug industry we deserve.”

Kirkpatrick agrees that the “culture” must change, but notes “there are other ways to make the process better.” For example, guideline-writing groups should follow the recommendations for COI laid out by the Institute of Medicine and Council on Medical Subspecialty Societies. “There needs to be a clear distinction between research and other payments,” because research grants are usually administered through third-party organizations that have “at least a semblance of improved oversight,” he said. However, Kirkpatrick believes that guideline committee members could be completely excluded from owning stock in affected companies or accepting fees for consulting or serving on corporate speaker’s bureaus for these firms. “I don’t see a problem with telling people they need to choose between this income and being on a guidelines committee.”

Neither Neumann nor Gale reported any conflicts of interest.

References

Neuman J, Korenstein D, Ross J, and Keyhani S. Prevalence of financial conflicts of interest among panel members producing clinical practice guidelines in Canada and the United States: cross sectional study. BMJ 2011; DOI: 10.1136/bmj.d5621. Available at: http://www.bmj.com.
Grilli R, Magrini N, Penna A, et al. Practice guidelines developed by specialty societies: The need for a critical appraisal. Lancet 2000; 355:103-106. Abstract
Gale EAM. Conflicts of interest in guideline panel members. BMJ 2011; DOI: 10.1136/bmj.d5728. Available at: http://www.bmj.com.

** metformin is usually safe from these considerations – it’s been out since 1977, has been generic years, and is currently featured on most $4 prescription plans – so it’s not pushed heavily by pharmaceutical reps.

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Update: February 2013 – A recent analysis on the safety recommendations and contraindications for use of metformin in patients with advanced kidney disease has been presented by a Pharmacy resident at the University of Texas – and he makes a compelling case that we should reconsider many of the current restrictions on using metformin in renal failure.

“Unleash Metformin: Reconsideration of the Contraindication in Patients with Renal Impairment” by Wenya R. Lu, PharmD

Diabetes – Global epidemic, part II

Posted on September 14, 2011 by K Eckland

As reported at Medpage – the latest Diabetes estimates were released by the International Diabetes Foundation (IDF) this week at the EASD (European Association for the Study of Diabetes) as the news was even grimmer than predicted just a few short months ago: Researchers now estimate 366 million people HAVE diabetes worldwide – greatly surpassing all previous estimates – causing 4.6 million deaths every year.

Leading physicians at this year’s conference continued to stress the importance of Early diagnosis and treatment of Diabetes to prevent serious complications (and death). This is something we’ve talked about here at Cartagena Surgery – the need for early diagnosis, prompt treatment and aggressive risk reduction.

Preventing diabetes remains a key element of this strategy, but one which we are failiing miserably. Simple dietary changes such as reducing the consumption of sugar-laden beverages appears to be impossible to implement as we are hopelessly entrenched in American diets (and Indian, Chinese and other nations – as they adopt our fast-food habits).

As many of my face-to-face patients already know, one of the best lines of defense is also one of the oldest in our arsenal of oral anti-glycemics. For all of my patients who have heard my metformin spiel in person, feel free to skip ahead. As we’ve discussed in lectures and presentations – Metformin, that simple drug from the 1970’s (one of my $4 faves) has so many side benefits – and the potential cancer benefits are encouraging.. [what’s not encouraging – is the difficulty getting patients to take their medications regularly – even humble Metformin which is one of the safest, most effective – (clinically proven!) and cheapest diabetes drugs available.]

*as many readers and patients know – this is the one topic where even Cartagena Surgery gets overwhelmed at times.. There is just so much disease/ disability and suffering but it seems like no one is listening or cares enough about themselves to change their habits.** Please – dear readers – prove me wrong, and write me letters to let me know how you are taking control of your diabetes and your health..

Sugary drink follow up (as promised!)

Posted on September 12, 2011 by K Eckland

If you remember, in my blogs about the health benefits of coffee (here, here and here) as well as a previous blog on the health risks related to sugary soft drinks, I promised to bring you more information about our favorite devil-in-disguise, Starbucks. (I will give them credit for making this information easily accessible, even if it is tiny print.)

I call Starbucks this because on initial consideration..

Coffee: Good! Big super-sized coffees: Even Better! and look – a Regular black coffee, no cream, no sugar, any size (including their super-size Venti) is only FIVE calories..

Coffee loaded with cream and sugar: Not so good. (How bad is it – you ask? or you should be asking)

well once you start drinking their specialty drinks (and I must be the only person who drinks regular coffee anymore) – that’s when you get into trouble.. so knowing that everyone loves their super-sized coffees, I’ve skipped right to the “Venti” calorie counts..

Cafe Latte with skim milk: 170 calories

Cafe Latte with 2% milk: 240 calories and NINE grams of fat

Cafe Mocha (without whipped cream in these examples)

with nonfat-milk: 280 calories

with 2% milk: 340 calories and 10 grams of fat (that’s a reasonable sized salad with a vinaigrette dressing and maybe cheese or not-so-healthy add-ons)

Vanilla (or other flavored) Lattes:

with non-fat milk: 250 calories (all sugar)

with 2% milk: 320 calories and eight grams of fat

Even the ‘skinny’ lattes have 160 calories..

The specialty espressos are no better (in fact – some are worse, as you will see)

Carmel macchiato:

with non-fat milk: 240 calories, one gram of fat

with 2% milk: 300 calories, 8 grams of fat

White chocolate mocha (without whipped cream – I think they were afraid of putting the whipped cream calorie counts on this brochure)

with non-fat milk: 450 calories and 7 grams of fat (that’s a decent meal’s worth of calories!!)

with 2% milk: 510 calories and fifteen grams of fat – for a ‘coffee’ ! (I think you can see here how a few of these coffees a week can certainly pile on the pounds.)

Now, if you think that’s no big deal – go on over to www.Fitday.com (and don’t lie to yourself about your exercise) and put in your information (they have free accounts) and figure out how much walking, jogging or aerobics you have to do to equal out that one coffee.. Hint: It’s a lot more than you’d think – or we wouldn’t be in this mess!

The other items on the menu (including the teas) are no better once you pile in the milks, sugars and other garbage.

What about coffee with soy milk? Isn’t that supposed to be good for you? Well, in theory, perhaps.. But actually, for some products, the fat and calorie counts for Starbucks products with soy milk go way, way up.

Cafe Latte with soy milk: 220 calories, 6 grams of fat

Cafe Mocha (no whipped cream) with soy milk: 320 calories, 8 grams of fat

Vanilla Latte with soy milk: 300 calories with 6 grams of fat

Carmel macchiato with soy milk: 280 calories with 6 grams of fat

White chocolate mocha: (no whipped cream): 490 calories, 12 grams of fat

all of this – for a little eye-opener in the morning – time to stick with the regular coffee!

In fairness – I am not picking on Starbucks, they are just the most popular. Even the local 7 – 11 has a coffee flavored slushy drink that is packed full of sugar and calories. Of course it’s delicious – but really, that’s besides the point. Obesity and diabetes are just a mathematical formulation – and it seems many of us are failing the subject entirely.

The Lancet, a well reputed medical journal has just published a series on Obesity, and the numbers are frightening – researchers estimate that by 2030 – (really not that far away) over 165 million Americans will be obese.

The costs of this to society are enormous, and frankly staggering. Bloomberg published a story estimated an additional 66 BILLION dollars PER year in obesity related costs. That isn’t just a threat to our health as a nation, but our financial future.

Bariatric surgery and cardiovascular risk reduction: Meta-analysis

Posted on September 9, 2011 by K Eckland

The American Journal of Cardiology just published a new meta-analysis (a study looking at a collection of other studies) that evaluates the effectiveness of bariatric surgery for cardiovascular risk reduction. As we’ve discussed before, meta-analyses are often used to sort through large numbers of studies to look for trends and weed out aberrant results or poorly designed studies. (This is particularly helpful when a poorly designed study gives conflicting results in comparison to the rest of the existing studies.) So, we are going to talk a bit more about the meta-analysis.

In this case, the authors started with 637 studies to evaluate, but ended up using the data from only 52 studies involving almost 17,000 patients. The first step of a meta-analysis is to find every single study even remotely related to your topic. So the authors pulled out, printed and looked at every single study they could find talking about bariatric surgery.

Then the authors start eliminating studies that aren’t relevant to their topic because once you take a closer look; a lot of the studies initially gathered aren’t really related to your topic at all. (For example: If the authors gathered all studies talking about Bariatric surgery outcomes – on closer examination – a study about the rate of depression in bariatric surgery patients wouldn’t have any information usable to evaluate cardiac risk in these patients.) Otherwise it would be like comparing apples to oranges.

Once authors have narrowed the pool to studies that are only looking at relevant topics, with measurable results – the authors then examine the studies themselves. The authors evaluate all aspects of the studies: what is the study design, what does it measure, (is it designed to measure what it is supposed to measure?), what are the results? (were the results calculated correctly?) what are the conclusions? what are the limitations of the study?

Then the authors summarize all of the findings, and draw conclusions based on the results. (if 50 studies involving 16,900 people show one thing – and 2 studies involving 100 people show something completely different – the authors will discuss that.)

The strengths of meta-analyses are that they summarize all of the existing studies out there – and provide readers with fairly powerful results because they involve large numbers of people.

For researchers, meta-analyses are cheap – particularly in comparison to designing, conducting a large-scale study with hundreds or thousands of subjects. A meta-analysis doesn’t require federal grants or institutional permissions. It just requires a computer and journal access (along with a good knowledge of study design, statistics).

As you can imagine, the downside of meta-analyses is that they don’t generate NEW knowledge, since they are summaries of other studies. Meta-analyses are also limited by the AMOUNT of data already published. If few researchers have written about a topic, then a meta-analysis isn’t very effective or powerful. (A meta-analysis on three studies involving only 25 total patients, for example).

Now that we’ve discussed the purpose and function of the meta-analysis, let’s discuss the results of Heneghan’s reported results.

Now, readers need to be very careful when reading blogs, and other articles like mine reporting results such as this – because this is filtered, third-hand information by the time it’s published on blogs, or newspaper articles. (First source is the meta-analysis itself – which as we’ve discussed is actually a summary evaluation of other work). Secondary is the Medscape article which summarizes and discusses the results of Heneghan’s study.

Now, that means that anything you read here is essentially third-hand information – if it’s based on the Medscape article. That’s why we provide links to our sources here at Cartagena Surgery – so readers can read it all first-hand. This is important because just like the children’s game of telephone, as information is passed from source to source, it is edited, filtered and subtly changed (for reasons of space, editorial preference etc.)

heneghan’s meta-analysis results showed significant reductions in weight, blood pressure, cholesterol and hemoglobinA1c (blood glucose levels) after bariatric surgery. The Framingham risk score (a score developed based on the landmark Framingham study) which predicts the risk of cardiovascular events (heart attacks, strokes) also showed a significant reduction (which would be expected if all the risk factors such as hypertension were improved).

Framingham Risk Score Calculator

Now, a lot of readers might say, “Wait a minute – isn’t this self-evident? If you lose weight – shouldn’t all of these things (glucose, blood pressure, cholesterol) improve?”

Yes .- logical reasoning suggests that they should – but in medicine we require hard data, in addition to logical reasoning (ie. A should lead to B versus a study with ten thouand patients proving A does lead to B.)

We need to be particularly careful when suggesting or assuming causality from treatments (surgery) for conditions. A good example of this is liposuction. Since liposuction involves the removal of subcutaneous fat – and may result a (a small amount) of weight loss – many consumers assumed that this limited weight loss conferred additional health benefits associated with traditional weight loss. Wrong!

Sucking fat out of your behind (liposuction) will not lower your blood pressure, cholesterol, or blood pressure and does not replace the health benefits of weight loss or exercise. I can hear readers snickering now – but that’s because of my phrasing. For years – many people, some health care providers themselves thought that weight loss, any weight loss lead to the above mentioned health benefits, and that included liposuction related weight loss. It took several studies to disprove this. So, in medicine – nothing is obvious – until we prove it is obvious! (Remember: much of what was “obvious” in 1950’s medicine – is now considered absurd.)

Original Research Article Citation:

Heneghan HD, et al “Effect of bariatric surgery on cardiovascular risk profile” Am J Cardiol 2011; DOI:10.1016/j.amjcard.2011.06.076. (abstract only – article for purchase).

Medpage Summary Article:

Bankhead, C. (2011). Medical News: Bariatric Surgery gets high marks for CVD risk reduction. Medpage Today.

Lifestyle Modification after Bariatric Surgery

Posted on July 19, 2011 by K Eckland

Lifestyle modification after bariatric surgery is one of the cornerstones for successful and sustained weight loss, and healthy living. However, the majority of emphasis is placed on dietary changes – as a result of the surgical alterations to stomach capacity. While dietary modification for healthy eating (energy intake) is extremely important – we are also going to talk about the other part of the equation for both weight loss and healthy living: Exercise (energy expenditure).

Exercise and physical fitness are critical for multiple reasons – beyond initial weight loss, but many people often question the ability of the morbidly obese to exercise vigorously (and safely). A new study by Shah et. al (June 2011) in Obesity magazine examines this concept. Shah and his team of researchers divided gastric bypass patients and gastric banding patients into two groups ; a control group receiving standard therapy and a high intensity exercise group. The findings confirmed that physical fitness is both possible and beneficial for these patients.

Since both the original article and several articles discussing these finds are paid/ subscription sites, I have re-posted from Medscape (which is more freely accessible for most people.)

For more articles on Bariatric Surgery, see the sidebar for our archives.

Rigorous Exercise May be Feasible after Bariatric Surgery

– Laurie Barclay (Medscape)

July 15, 2011 — Rigorous exercise may be feasible and beneficial to maintain weight after bariatric surgery, according to the results of a randomized controlled trial reported online July 7 in Obesity.

“[W]e didn’t know until now whether morbidly obese bariatric surgery patients could physically meet this goal,” said senior author Abhimanyu Garg, chief of nutrition and metabolic diseases at University of Texas Southwestern Medical Center at Dallas, in a news release. “Our study shows that most bariatric surgery patients can perform large amounts of exercise and improve their physical fitness levels. By the end of the 12 weeks, more than half the study participants were able to burn an additional 2,000 calories a week through exercise and 82 percent surpassed the 1,500-calorie mark.”

The investigators studied the tolerability and efficacy of high-volume exercise program (HVEP) in 33 obese, postbariatric-surgery patients who had undergone Roux-en-Y gastric bypass and gastric banding. Mean body mass index (BMI) was 41 ± 6 kg/m². Participants were assigned for 12 weeks to an HVEP (n = 21) or to a control group (n = 12). All participants were advised to limit energy intake, and the HVEP group was also counseled to take part in moderate-intensity exercise resulting in energy expenditure of at least 2000 kcal/week. Repeated measures analysis allowed determination of treatment effect.

In the HVEP group, more than half (53%) of participants expended at least 2000 kcal/week during the last 4 weeks of the study, and 82% expended at least 1500 kcal/week. Compared with the control group, the HVEP group had significant improvement at 12 weeks in step count, reported time spent and energy expended during moderate physical activity, maximal oxygen consumption relative to weight, and incremental area under the postprandial blood glucose curve (group-by-week effect: P = .009 – .03).

“We found that participants in the exercise group increased their daily step count from about 4,500 to nearly 10,000 so we know that they weren’t reducing their physical activity levels at other times of the day,” Dr. Garg said. “We also found that while all participants lost an average of 10 pounds, those in the exercise group became more aerobically fit.”

Some quality-of-life scales improved significantly in both groups. The groups did not differ significantly in changes in weight, energy and macronutrient intake, resting energy expenditure, fasting lipids and glucose, and fasting and postprandial insulin concentrations.

“HVEP is feasible in about 50% of the patients and enhances physical fitness and reduces postprandial blood glucose in bariatric surgery patients,” the study authors write.

Limitations of this study include short duration, small sample size, dropout rate higher in the control group vs the HVEP group, dietary and exercise counseling provided at an individual level and not at the group level, and use of an unsealed pedometer to measure physical activity.

“Whether a HVEP helps to maintain weight loss and improvement in comorbidities in these patients remains to be evaluated in long-term studies,” the study authors conclude. “The studies also need to assess how exercise over the long-term effects factors that influence energy balance including energy intake, nonexercise activity levels, body composition, metabolic rate, and gastrointestinal hormones related to satiety and hunger.” [end of article].

Interestingly, the exercise group did not lose more weight than the control group – but as many people know – exercise and physical fitness are important for more than just weight maintainance.

Aerobic exercise, in particular is important for cardiovascular health. Physical activity is also important for bone and muscle strength and general performance status and maintenance of activities of daily living (ADLs). All of these contribute to the overall quality of life for individuals.

Sleep Apnea in Bariatric Surgery patients: pre-operative evaluation

Posted on July 1, 2011 by K Eckland

A new study (re-posted below) found that more than 85% of bariatric patients who had pre-operative evaluation before bariatric surgery had significant obstructive sleep apnea. While the study was small (less than 400 patients), the findings of this study suggest two things:

1. An evaluation for sleep apnea should be part of routine pre-operative evaluation but ALSO –

given the very high rates of sleep apnea with increasing BMI – and the increased risks of heart attack, pulmonary hypertension and other serious, life-threatening consequences of untreated sleep apnea –

2. Increase screening for obstructive sleep apnea in ALL obese patients. (during routine evaluations, and as part of pre-operative evaluation before any surgery requiring general anesthesia.) [note: #2 is my personal recommendation – not the recommendation of the researchers presenting at this conference. But as you’ll note below – the preliminary screening questionaire can be done relatively easily, and given the value of findings – additional testing is reasonable even in patients with negative responses to the questionaire.

Due to the strong link between apnea and cardiac events – in our practice, we screened each patient using a series of questions to both the patient and the patient’s significant other (after obtaining patient permission).

To the patient: Do you snore? Have you ever been told you snore? Do you wake up tired, or feel sleepy during the day?

To significant other: Does the patient snore? Do you ever hear long pauses between breathing / snoring while the patient is sleeping? Do you ever think that he/she has stopped breathing?

(Then depending on circumstance, in-patient / out-patient – patients were informally screened using pulse oxymetry either in the cath lab or in the intensive care unit.) This means – we had nurses monitor the patients during sleep:

– Noting each and every time the patient’s oxygen saturation dropped below 92%

– Alterations in heart rate

– Presence of absence of apnea sleeping patterns, snoring etc.

Since our patients were already in the hospital under nursing care (in either the cath lab, or hospital room) the nurses were able to do this easily as part of routine assessment, and monitoring, and there was no extra cost to our patients.

In our case, this information was used for post-surgical management. After extubation, patients* were frequently placed on bipap for several hours to reduce atelectasis, and reintubation. In our at-risk patients, bipap was instituted as part of the sleep routine during their in-patient stay, with a pulmonary medicine referral, and evaluation for home CPAP therapy. In this way, we were able to avoid expensive/ and time-consuming tests prior to surgery, and still effectively treat our patients. to determine the predictive value of having a spouse tell us, “sometimes I can’t sleep because I am worried he won’t start breathing again” as we’ve heard on multiple occasions.

In our experience, the significant other was best able to provide important diagnostic information. Unfortunately, we haven’t recorded these findings as part of a research study

* this therapy was used independent of apnea status

Article Re-post: Presentation of a recent abstract at the American Society of Metabolic and Bariatric Surgery in Orlando, Florida

Sleep Test Needed Before Bariatric Surgery

-Charles Bankhead, reporter

ORLANDO — Most candidates for bariatric surgery have obstructive sleep apnea (OSA), making a case for polysomnography as a part of the preoperative evaluation of every patient, investigators concluded.
Of 359 patients who had preoperative polysomnography, 86% had positive tests, which showed severe OSA in half of the cases.

The patients had a high prevalence of the sleep disorder across the range of body mass index (BMI) values represented by the patient population, although every patient in the highest BMI category (≥60) tested positive for OSA, as reported here at the American Society of Metabolic and Bariatric Surgery meeting.

“Some people think that only patients in the highest BMI categories should be referred for polysomnography, because they are the patients who are most likely to have obstructive sleep apnea,” Abdul S. Bangura, MD, of Staten Island University Hospital in New York, told MedPage Today.

Points to remember

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
Explain that most candidates for bariatric surgery have obstructive sleep apnea (OSA), making a case for polysomnography as a routine part of the preoperative evaluation of every patient.
Note that every patient in the highest BMI category (≥60) had a polysomnographic test showing sleep apnea.

“However, our study showed a high prevalence of obstructive sleep apnea in all BMI categories. Because of that, we think polysomnography is justified during the preoperative evaluation of all bariatric surgery patients, and that is the policy at our institution.”

Obesity substantially increases the risk of OSA, and studies have documented a high prevalence of OSA and other sleep-related breathing disorders among patients evaluated for bariatric surgery. Polysomnography remains the gold standard for diagnosis and assessment of OSA, but practices vary with regard to use of the sleep test in the preoperative evaluation of candidates for weight-loss surgery, said Bangura.

Moreover, patients and physicians alike find sleep tests inconvenient, time-consuming, and expensive, he continued.

At his own center, polysomnography is a routine component of the preoperative workup. However, other centers have adopted a selective approach to use of the sleep test, relying on the level of clinical suspicion of OSA to guide decision making.

“Various scoring systems have been used to screen for sleep apnea, but all of them remain controversial,” said Bangura. “There is currently no standard protocol for screening obese patients for OSA.”

To see whether a routine or selective approach to preoperative testing for OSA is more appropriate, Bangura and colleagues retrospectively reviewed records of all patients who had bariatric surgery procedures at their center from 2005 to 2010. They identified 555 patients, including 359 (65%) who underwent polysomnographic evaluations during their preoperative workup.

Investigators used the apnea/hypopnea index (AHI) to categorize apnea severity, defining mild OSA as an AHI score of 5 to 15 events per hour; moderate as a score of 15 to 30; and severe as a score exceeding 30.

Of the 359 patients evaluated for OSA, 309 (86%) had positive tests, including some patients who had positive OSA tests prior to the preoperative evaluation for bariatric surgery. On the basis of AHI scores, 18% of the 359 patients had mild OSA, 17% had moderate OSA, and 51% had severe apnea.

Analysis of OSA prevalence by preoperative BMI showed that the following tested positive for OSA:

34 of 37 (92%) patients with BMI values of 35 to 39.9
178 of 218 (82%) of patients with BMI values of 40 to 49.9
78 of 85 (92%) of patients with BMI values of 50 to 59.9
100% of patients with BMI values of 60 or greater

“Based on these results, we consider routine polysomnography to be an essential part of the preoperative workup for all bariatric patients,” Bangura and colleagues concluded in their poster presentation.

Randomized controlled trials are required to provide evidence of guidelines on routine use of polysomnography as part of the workup for bariatric surgery patients, he said. Given the lack of a reliable prognostic system to predict OSA, the investigators urged consideration of routine polysomnography as part of the preoperative evaluation of all bariatric surgery candidates.

Diabetes – a global epidemic

Posted on June 26, 2011 by K Eckland

New estimates on the rates of diabetes worldwide were reported in the general media this week. As frightening as these numbers are – 36 million people in the USA, and over 348 million worldwide, I still think these numbers fall short of the mark. This truly is a global pandemic, and as against federal ‘big brother’ regulations (and pro-personal freedoms) as I am – I do think that it has come to a critical point where the governments of these nations (ours included) need to step in. We need to go against the big business of soft drinks, and the fast food giants to save our nation, and save ourselves from the heavy toll of obesity related disease.

Obviously, all the educational efforts and promotional campaigns to encourage healthy eating and activity are falling on deaf ears. Much of the media attention is devoted to the plight of the poor with limited access to healthy habits such as safe areas to walk in inner cities, local grocery stores and the cost of fruits and vegetables in comparison to ‘super-value meals’ but the similarly bad (and deliberate) choices of the more privileged middle-class are ignored.

While I believe that people should take responsibility for their own actions (in all areas of life) we should no longer stand by and allow the damage that is being done to our younger generations. Obesity among teens and children continues to rise due to poor dietary habits, and inactivity. At this point; ‘junk food’ should be regulated like cigarettes and alcohol.

Ten years ago – I would have rebelled as such government intrusion into American life, but ten years ago – I was still relatively new to the devastation caused by diabetes, obesity and related diseases. These last years have been a crash course in human suffering and a primer in (potentially) avoidable disease. It has also been eye-opening in terms of human behaviour – and amazing (to me) that serious complications such as heart attacks, strokes, and heart surgery still fail to motivate people to make even small changes in their lifestyles.

Much is made of new medications and treatments for diabetes – but we fail to grasp the essential truth; that we are eating ourselves to death and destroying mankind. There is no pill for that.

While I generally try to remain upbeat here at Cartagena Surgery, the plague of Diabetes too large for even my sunny nature to overcome.

Diabetes and Soft drinks

Posted on June 21, 2011 by K Eckland

If I can get readers to make one significant change to improve their health today – Stop drinking soft drinks (and juices.) These high sugar containing drinks are more than just empty calories, and this one small change can significantly reduce your risk of developing diabetes!

(P.S.) Substituting for diet drinks is no improvement since diet sodas etc. have been linked to an increased incidence of strokes and high blood pressure (HTN) – switch to coffee, tea or water!!) Coffee has even been shown in several studies as reducing the risk of diabetes, pancreatic disease.

High Fructose Corn Syrup

High fructose corn syrup was a uniquely American product that was initially created as a result of a government subsidy for farmers which has since spread to the UK, Japan and several other nations. With these government subsidies, corn syrup became a cheaper sweetening agent in comparison to cane sugar. This led to the pervasive use of corn syrup in many American food products. Today it is used extensively, and avoiding this additive requires considerable effort and extensive examination of product labeling. One of the main products that uses large amounts of high fructose corn syrup are soft drinks such as Pepsi and Coca-Cola.

As the American obesity (and corresponding Diabetes) epidemics continue unchecked, multiple researchers have attempted to pinpoint causes for these phenomena. High fructose corn syrup has emerged as a likely culprit. (However, even this scientific research is politically charged, as mega-corporations attempt to discredit findings that hurt their bottom line, similar to tobacco manufacturers in the past[1].)

Stanhope & Havel (2010), researchers at UC Davis recently compared the effects of fructose ( high fructose corn syrup is a mixture of fructose and sucrose) to sucrose (regular table sugar.) They found that fructose use increased visceral adiposity (fat around internal organs), dylipidemia and decreased insulin sensitivity. Decreased insulin sensitivity is a hallmark of the development of diabetes and is one of the ways that Diabetes in Americans differs from diabetes in other countries. This means that people need more insulin to do the same job (transport nutrients into the cells). This is also why we see people requiring more insulin that ever before. In the past, patients could often be managed with 5 units of insulin (per meal). Now, more commonly, due to this insulin resistance, similar patients are requiring 50 units of insulin (per meal).

But the problem isn’t just high fructose corn syrup – it’s our overall sugar consumption in general – Americans are just consuming WAY, WAY too much sugar – in “energy’ drinks, colas, designer coffee drinks, ‘sweet teas’ and the so-called ‘healthy fruit juice.’ [I cringe every time I see a parent give their child juice as a ‘healthy alternative.’]

This sugar is KILLING us, by causing a myriad of health problems which in turn have a domino effect causing even greater health problems.. Sugar —-> Obesity/ High cholesterol ——>diabetes , hypertension, atherosclerosis ——-> coronary artery disease (heart attacks), renal failure, vascular disease (ischemia/ limb loss/ strokes).. The obesity epidemic, and sugary drink consumption has also been linked to fatty liver disease.

Now Malik, et. al. (2010) over at Harvard/ Brighams performed a meta-analysis on this subject. Now if it’s been a while since you’ve read a lot of scientific literature, then let me remind you that meta-analyses are fairly high-powered studies because they take ALL of the existing data, compiled it, and report the findings.. This is much stronger evidence that some six person study looking at cinnamon and diabetes. (Yet – the media blazed that study everywhere – so now plenty of people are putting cinnamon in everything.)

Readers:

Starting today – I want you to care about your health, more than drinking that coke, pepsi or kool-aid. Don’t try to cheat – with ‘diet’ options – because you are only cheating/ fooling yourself..

Make this one change: switch to water, coffee (not loaded down with sugar/ cream) or UNSWEET tea.

Try it for at least thirty days.. and let’s start from there.. Just this one small change, not because I asked – but because you love yourself. (And if you don’t love yourself – we need to work on that too!)

Additional references:

This study says diet sodas don’t cause diabetes but does link it to strokes.. It’s from MSN health which is an ‘okay’ site for consumer health information (articles are not always well written.)

Four reasons to avoid sodas – Health content from Yahoo! – it’s actually a reader’s digest article, which I typically avoid because they are usually poorly written, and not factually based.

[1] A good rule of thumb: Whenever an industry starts advertising for their product (versus individual brands) than strong scientific evidence has probably emerged implicating the product in serious health conditions. Think of the recent corn syrup ads, and “Beef – it’s for dinner,” and other campaigns in the past.

Bariatric Surgery: latest headines

Posted on June 20, 2011 by K Eckland

I am traveling all day today so just a quick post today with some new links:

Several headlines recently posted on-line.

Weight loss surgery & depression article states that depression doesn’t prevent weight loss after surgery . Now, what would be interesting – is whether depressed patients were more likely to dispay or revert to disordered/ sabotage behaviors such as the ‘drinking butter’ phenomena.

(Often when weight loss surgery fails – it fails because of maladaptive behaviors. These behaviors are often similar to the behaviors that caused obesity/ overeating in the first place such as identifying “food as love,”using for as a coping mechanism for emotional pain (the so-called ‘comfort food’, which is a concept that needs to be banned from society), and other eating behaviors unrelated to physical hunger.

This is why most surgery patients are required to see a mental health specialist to identify and treat ‘food issues prior to surgery’.) But depression (which may cause overeating for some people) is not the same as neuroses or maladaptive coping mechanisms. This also includes post-surgery behaviors that we have alluded to in the past, such as attemping to ‘trick’ or circumvent capacity restrictions by continuous eating (sipping or eating every few minutes for several hours during the day.)

Weight loss surgery decreases migraines.

Weight loss surgery helps women with Polycystic ovary syndrome and infertility -this article was actually written by another nurse, and talks about the effects of gastric bypass on women with PCOS.

Now, the only thing that concerns me – is having gastric bypass surgery to then boost fertility with pregnancy to follow in a short time is a lot to put a body through. Practically, a person should probably wait a year or two after the surgery to let the person have time to adjust to the new nutritional requirements, and lifestyle changes surgery requires before placing additional metabolic and nutritional requirements that pregnancy demands.

Also, the pathological eating that often occurs during pregnancy needs to be addressed prior t planning a pregnancy. (The “eating for two buffet” mentality often results in pregnancy weight gains of 60, 70 or even 100 pounds which places the mom and developing fetus at risk for additional health problems as well as post-partum obesity.

But gastric bypass surgery, like any medical procedure is not all benefits and no risk – there have just been less headlines this week. But more than half of gastric bypass patients regain the weight – often due to the behavior patterns we briefly touched on above.

Note: some of the articles linked are older (2001, etc) but I try to provide links to free articles, not paid sites (articles average about 30.00 when for purchase.)

More gastric bypass news

Posted on June 17, 2011 by K Eckland

In a new story by Megan Brooks over at Medscape, “Gastric Bypass Has Advantages in Less Obese Patients” – the latest news from an Orlando conference confirms what cartagena surgery fans already know; that gastric bypass surgery is a viable and effective option in moderately obese patients (particularly patients with diabetes.) This is encouraging in the continuing battles between patients and insurance providers.

As we’ve said before – it’s important to treat obesity definitively before patients develop serious and potentially life threatening complications such as diabetes and hypertension, and the sequelae related to this (coronary artery disease, ischemic limbs, stroke, renal failure).

In order to treat this effectively and aggressively, we shouldn’t wait until the problem is out of control. A patient shouldn’t have to be 600 pounds for the doctors to consider bariatric surgery – we should help people before that.

I’ve re-posted the article below. [italics are mine.]

Gastric Bypass Has Advantages in Less Obese Patients

June 16, 2011 — There are benefits to performing laparoscopic Roux en Y gastric bypass (RYGB) in obese patients who have a body mass index (BMI) below 35 kg/m², according to a study reported at the American Society for Metabolic and Bariatric Surgery 28th Annual Meeting in Orlando, Florida.

Among patients who underwent the surgery, the rates of remission of type 2 diabetes were higher in those with a BMI below 35 kg/m² than in those with higher BMIs. The “less obese” patients also lost a greater percentage of their excess weight in the first year after surgery than their peers with higher BMIs.

“The study raises the question of whether early referral leads to better outcomes,” John Morton, MD, director of bariatric surgery at Stanford Hospital & Clinics at Stanford University in Palo Alto, California, and an investigator with the study, noted in a conference statement.

“Bariatric surgery is tremendous for weight loss, but its other big advantage is improving medical problems, in particular type 2 diabetes,” Dr. Morton noted in an interview with Medscape Medical News.

Outcomes Better at Lower BMI

Current guidelines from the National Institutes of Health recommend that gastric bypass be reserved for patients who have a BMI of 35 kg/m² or higher and an obesity-related condition, or who have a BMI of at least 40 kg/m².

Dr. Morton’s team took a look back at 980 patients who underwent laparoscopic RYGB at their institution between 2004 and 2010. “We ask patients to lose some weight before surgery because it’s a good way to make sure they are committed to the program, and it makes the surgery a little bit safer,” Dr. Morton said. “Therefore, we had some patients below a BMI of 35 kg/m² at the time of surgery.”

For the analysis, the patients were grouped according to their presurgery BMI: below 35 kg/m², 35 to 39.9 kg/m², 40 to 49.9 kg/m², and above 50 kg/m².

“When we examined type 2 diabetes resolution rates, we found that those with the lowest BMI had the best resolution rates,” Dr. Morton reported. All 12 patients with a BMI below 35 kg/m² no longer had type 2 diabetes after surgery, whereas patients with higher BMIs had remission rates of roughly 75%.

“We are looking to entertain the idea that maybe obese patients should have the option of surgical intervention for their diabetes sooner rather than later because, as the study showed, as the BMI gradient goes up, your diabetes resolution rate with surgery goes down,” Dr. Morton said.

The researchers also found that patients with a BMI below 35 kg/m² who had the surgery had lost more of their excess weight at 3, 6, and 12 months than patients with a higher BMI.

After 1 year, the patients with BMIs below 35 kg/m² had lost 167% of their excess weight. By comparison, those with a BMI from 35 to 39.9 kg/m² had lost 112%, those with a BMI from 40 to 49.9 kg/m² had lost 85%, and those with a BMI above 50 kg/m² had lost 67% of their excess weight.

Laparoscopic RYGB also took less time in patients with the lowest BMI (170 minutes) than in those with higher BMIs (177 minutes, 182 minutes, and 194 minutes, respectively).

Reevaluation of BMI Guideline Needed

In an interview with Medscape Medical News, John David Scott, MD, a bariatric surgeon at Greenville Hospital System University Medical Center in South Carolina, who was not involved in the study, said that “the BMI level of 35 is an arbitrary standard set many years ago that certainly needs to be reevaluated.”

“Most of the evidence that has been coming out lately has shown not only a positive weight loss benefit for that particular group, but also positive overall health effects,” he added. “In particular, the resolution of diabetes is astounding. To be able to offer patients a surgical cure for their type 2 diabetes is very exciting,” Dr. Scott said.

Dr. Morgan has disclosed no relevant financial relationships. Dr. Scott reports receiving speaker fees from WL Gore & Associates and fellowship support from Ethicon Endo Surgery.

American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting: Abstract P-54. Presented June 16, 2011.

In other news, from the same conference (Megan Brooks reporting) – patients undergoing successful bariatric surgery (with resultant weight loss) had decreased rates of heart attacks and stroke.

“Bariatric Surgery good for the Heart”

June 16, 2011 — Bariatric surgery and the significant weight loss it achieves can significantly reduce the incidence of myocardial infarction (MI), stroke, and premature death, according to a study presented at the American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting in Orlando, Florida.

“In addition to weight loss, bariatric surgery offers patients a whole host of health benefits, including a reduction in the risk of major cardiovascular problems,” study presenter John David Scott, MD, a bariatric surgeon at Greenville Hospital System University Medical Center in South Carolina, noted in an interview with Medscape Medical News.

“There is a long line of studies showing that bariatric surgery affects cardiovascular outcomes,” Dr. Scott noted. “The difference between our study and other studies is that we looked at major cardiovascular events (heart attack and stroke), whereas a lot of other studies have looked at risk for these events.”

The researchers reviewed data on 9140 morbidly obese individuals, 40 to 79 years of age, who had undergone bariatric surgery (n = 4747), gastrointestinal (GI) surgery (n = 3066), or orthopedic surgery (n = 1327) in South Carolina between 1996 and 2008.

The GI group (hernia or gallbladder) and the orthopedic group (joint replacement) served as control groups because of their similar health and risk profiles, the authors note.

All patients had similar a health status before surgery and no history of MI or stroke. The patients were followed to the end points of first MI, stroke, transient ischemic attack, or death.

“Life-table analysis demonstrated significantly improved event-free survival in the bariatric patients within 6 months of surgery, and it was sustained over time,” the authors note in the meeting abstract.

Five years after surgery, an estimated 85% of bariatric surgery patients were free of MI and stroke, compared with 73% of orthopedic patients and 66% of GI patients, the researchers say.

At 10 years, event-free survival was 77% in the bariatric group, 64% in the orthopedic group, and 62% in the GI group (P < .05).

After adjustment for differences in age and relevant comorbidities, bariatric surgery was an independent predictor of event-free survival. Compared with orthopedic surgery, the hazard ratio (HR) was 0.57 (95% confidence interval [CI], 0.47 to 0.69); compared with GI surgery, the HR was 0.35 (95% CI, 0.29 to 0.43).

“Important Area of Emerging Study”

In a statement from the ASMBS, Anita Courcoulas, MD, MPH, director of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center, Pennsylvania, who was not involved in the study, said: “The impact of bariatric surgery on both cardiovascular risk factors and events is an important area of emerging study.”

The findings, she said, are “suggestive of an association between undergoing bariatric surgery and improved event-free survival. This relationship needs to be further explored with prospective clinical data, but still highlights the importance of understanding the broader impact of bariatric surgery on long-term outcomes.”

In an interview with Medscape Medical News, John Morton, MD, director of bariatric surgery at Stanford Hospitals & Clinics at Stanford University in Palo Alto, California, who was also not involved in the study, made the point that “obesity affects every single body part and if you are able to affect the weight, you’re going to help other medical problems — particularly the ones that are inflammatory-mediated.”

“Obesity is really an inflammatory-mediated disease, and stroke, cardiac risk, and even diabetes are now being recognized as inflammatory-related. With weight-loss surgery, direct markers of inflammation go down and, more importantly, these diseases get better,” Dr. Morton explained.

Studies have shown that morbidly obese patients can lose 30% to 50% of their excess weight in the first 6 months after surgery, and 77% as early as 1 year after surgery.

American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting. Abstract PL-105. Presented June 15, 2011.

A frank talk about Diabetes: part one

Posted on June 15, 2011 by K Eckland

We are going to switch gears a little bit today. Instead of our usual discussions relating to surgery, surgical procedures and medical (surgical) tourism – we are going to spend some time talking about Diabetes in a series of posts.

In my role as a nurse practitioner, I became surprisingly familiar with diabetes. I say surprisingly because as an acute care nurse practitioner specializing in surgery, I never expected to have to fill the role of family doctor or family practitioner. However, the prevalence of diabetes in this country (USA) is so incredibly pervasive, particularly undiagnosed diabetes – that every health care provider should become well-versed in the treatment of diabetes, and diabetes related conditions.

Diabetes = Coronary Artery Disease!

Working in heart surgery also means that patient education is critical for diabetics, particularly newly diagnosed diabetics[1]. Now one of the things that complicates the issue significantly is providers’ hesitancy to label people as “diabetics” due to insurance implications and all sorts of other issues. So a lot of primary care providers are dancing around the issue, soft-pedaling the news and generally ignoring or under treating this disease. As someone who treats the complications of these decisions everyday, (heart attacks, ischemic limbs, infections, etc.) I vehemently disagree with this strategy.

How can I get my patient to take this seriously, and treat their diabetes aggressively, if I don’t?

Some of the things we need to do to treat Diabetes effectively are:

1. To detect it (estimates place the number of undiagnosed Americans at greater than 17 million people)

The best way to detect Diabetes is to use the newer generation of tests, specifically the hemoglobin A1c. This test looks at the average glucose levels over several months. This helps to rule out false elevations from acute illness, injury or surgery. It also prevents under diagnosing from the tendency to ‘ignore’ one or two abnormal glucose readings. “Oh, his glucose was 160; we’ll check it again in three months.” That’s three more months that the patient goes untreated. (Despite being abnormal, many of the older guidelines ignore readings of less than 180, and require two or more readings for diagnosis. (Normal glucose is 70 -105 or 110, depending on source.)

2. To treat it – using SAFE and effective medications.

Many people would be surprised to know that the best drugs for treating Diabetes are the older (cheaper) medications such as metformin (Glucophage) which has been used since 1977. It’s readily available on many $4.00 pharmacy plans.

Many of the newer, fancier drugs (Avandia is the best known) have been linked to serious complications such as myocardial infarctions (or heart attacks). Many of the other new drugs have no side benefits[2]. A good prescriber finds the best combination of medications to have the most beneficial effects, limited negative side effects and is cost effective. Why treat five problems with twenty drugs (expensive with multiple drug interactions) when you can do it with four medications?

3. Finally – and most importantly, lets do more to prevent it. Let’s all stop soft pedaling, and speak frankly and truthfully with our patients. Diabetes is a horrible disease, so let’s stop pretending it isn’t.

Instead of trying to be the good, likable provider who turns a blind eye to health destroying behaviors – we need to be direct, and address these issues. A glucose of 200 isn’t ‘good enough’. Testing glucose once in a while isn’t ‘good enough’. You may not like me when I tell you to absolutely, completely stop drinking soft drinks[3] (NEVER drink another soft drink), or to get out and start walking, (or a myriad of other things we’ll talk about) but if that helps reduce your risk of diabetes, prevents diabetic complications and ultimately lengthens and improves your quality of life – then that is a trade-off I am willing to make.

[1] In my previous practice, all patients had a hemoglobin A1c as part of their pre-operative laboratory work-up. Up to 25% of the patients having heart surgery were found to have elevated A1c levels, and were undiagnosed diabetics.

[2] Just as medications have side effects – many drugs such as metformin have side benefits. One of the side benefits of metformin is the protective blood vessel effect – patients that take metformin have fewer amputations than patients on other anti-diabetic drugs. Metformin has also been shown to be an important tool in the treatment of certain cancers. Several research studies show that the use of metformin has been linked to decreased tumor growth in breast cancers.

[3] I am planning for a future article to discuss this in-depth, and present the research. Please contact me if there is other Diabetes related content you would like to see.

American Hospitals get into the act: Bariatric Surgery

Posted on June 3, 2011 by K Eckland

After recent changes in the recommendations for the treatment of obesity and diabetes supporting the use of surgery (as previously discussed here) American hospitals have begun aggressively campaigning for medical tourists.. Several hospitals in Tennessee have created Bariatric programs to steer interested patients to their clinics – and in some cases are using TennCare dollars to do so. (TennCare is the Tennessee medicare program – which has been plagued with problems since it’s inception.)

With the FDA lowering the BMI restrictions for Lap-band procedures in particular, this procedure which is often marketed as the ‘easy bariatric surgery’ has taken off in popularity. This is concerning since much of the research shows this device to be limited in effectiveness, particularly in the treatment of diabetes.

These BMI restrictions which were reduced from a BMI of 35 (with diabetes) down to 30 can also be viewed as a government endorsement of the Lap-Band device since similar recommendations regarding the more definitive procedures such as Roux-en-Y have not been addressed. It looks like a double win for this private company (Allergan) as the FDA prepares to approve this device for use in teenagers as young as 14, despite criticisms from the medical community.

Now in the past, I have strongly advocated for better and more aggressive treatment recommendations for diabetes and morbid obesity – but I have also believe in following the scientific data and research findings – which just don’t seem to support Lap-Banding for permanent / effective weight loss or blood sugar reductions. Like we’ve seen several times before, these ‘easy’ quick fix solutions to try to take short cuts around surgery don’t always work – and in the end, you end off worse off then someone who didn’t have any procedures at all. If patients want effective solutions to real problems – we should give it to them. But we need to stop candy coating the risks and dangers, and hard selling devices, and give patients the actual facts.

I’d also like to recommend that interested readers sign up for Medscape.com accounts – it’s free and they have an entire section devoted to obesity/ diabetes/ bariatric procedures that highlights all of the research related to different procedures, and treatments. I try to re-post when I can but it’s difficult for lengthy articles.

In that spirit – I have re-posted the latest gastric bypass article from Heartwire below. (Interesting commentary that heartwire has a bariatric surgery section now.) It’s another Reed Miller report dated May 2, 2011:

Gastric Bypass Does More than Reduce Weight

April 29, 2011 (New York, NY) — Gastric-bypass surgery may provide benefits to patients with type 2 diabetes beyond the benefits that can be directly attributed to weight loss, a new study finds [1].

According to Dr Blandine Laferrère (St Luke’s Roosevelt Hospital, New York, NY) and colleagues, recent studies that show a strong correlation between the concentrations of plasma branched-chain amino acids (BCAAs) and related metabolites with insulin resistance and loss of insulin sensitivity raise the possibility that the rapid remission of diabetes seen in many diabetic patients after gastric-bypass surgery may be related to the pronounced changes in BCAAs or other metabolites and not the weight loss alone.

In a study published in the April 27, 2011 issue of Science Translational Medicine, Laferrère et al found the total amino acids and BCAAs decreased in the gastric bypass surgery group but not in a similar group of patients who lost the same amount of weight (10 kg) with diet alone. Also, the metabolites derived from BCAA oxidation decreased only in the surgery group. Levels of acylcarnitines and BCAAs and their metabolites were inversely correlated with proinsulin concentrations, C-peptide response to oral glucose, and the insulin-sensitivity index after weight loss, whereas the BCAAs and their metabolites were uniquely correlated with levels of insulin resistance.

These data suggest that the enhanced decrease in circulating amino acids that follows weight loss after gastric-bypass surgery is caused by a mechanism other than weight loss and may be related to why gastric-bypass patients often show more rapid improvement in glucose homeostasis than similar patients who lose weight without surgery, Laferrère et al conclude. However, the authors caution, “Whether the decrease in these metabolites and the implied activation of fuel oxidation is a cause or consequence of the diabetes remission after gastric bypass remains to be determined. . . . Future studies will further characterize the pathways involved in these metabolic alterations and will seek to understand whether the specific metabolic signature of [gastric-bypass surgery] is related to changes in gut peptides after surgery.”

In an accompanying perspective [2], Drs Robert E Gerszten and Thomas J Wang (Harvard University, Boston, MA) agree that “further work is needed to establish whether the reduction in concentrations of circulating amino acids after weight loss is the cause or a consequence of improvements in insulin sensitivity.”

Circulating amino-acid concentrations are likely to be determined partly by genetics and partly by environmental and nutritional factors, they explain, so “dissecting these effects will require nutritional manipulation studies with a variety of amino acids to be conducted in human subjects, especially given the availability of profiling technologies that permit characterization of the molecular consequences of such interventions,” the editorialists state.”

To the multiple readers who emailed me for more bariatric surgery/ diabetes information – I usually post whenever new or interesting information gets published. If you send specific questions about procedures, indications or related matter – I will try and address it in a future post.

More Gastric Bypass News!

Posted on May 24, 2011 by K Eckland

Report round-up from the latest headlines:

For those of you that are new here – read this article first – the author does a great overview of the issues surrounding obesity and gastric bypass surgery.
Gastric bypass benefits teens.

I’ll keep bringing the headlines as news emerges..

International Diabetes Federation supports Bariatric Surgery for treatment of Diabetes

Posted on May 1, 2011 by K Eckland

In a 180 shift from the position adopted by the American Heart Association who remains firmly rooted in the idea of bariatric surgery as a ‘last resort when all options have been exhausted’ the International Diabetes Federation (IDF) has taken the unprecedented and progressive step forward to recommend bariatric surgery as a form of aggressive treatment for Diabetes, (which is now only suboptimally controlled with multiple medications in the majority of people.)

In a re-post from Medscape, an article by Robert Lowes “Bariatric Surgery Recommended for Obese Patients With Type 2 Diabetes” reports that surgery is now being endorsed to prevent the devastating complications of this disease.

In this ground-breaking move, hope is being offered to the millions of people diagnosed with this disease.

Article re-post below:

March 28, 2011 — Bariatric surgery is an appropriate treatment for people with type 2 diabetes who are obese, the International Diabetes Federation (IDF) announced today.

Although such operations cost anywhere from $20,000 to $30,000, they will reduce healthcare expenditures in the long run, according to a new IDF position paper on the subject. The surgery, the IDF explains, often normalizes blood glucose levels and reduces or avoids the need for medication.

Dr. Francesco Rubino

In addition, curbing diabetes can stave off costly complications such as blindness, limb amputations, and dialysis, said Francesco Rubino, MD, director of the IDF’s 2nd World Congress on Interventional Therapies for Type 2 Diabetes, meeting today in New York City.

“When we talk about whether we can afford bariatric surgery, we have to ask what will be the cost if we don’t treat the patient,” Dr. Rubino told Medscape Medical News. “Studies have shown the surgery to be cost-effective. So there is a return on investment.”

The IDF puts the lifetime cost of diabetes in the United States at $172,000 for a person diagnosed at age 50 years and $305,000 at age 30 years. More than 60% of this amount is incurred in the first 10 years after diagnosis.

Under the new IDF guidelines, patients with type 2 diabetes warrant bariatric surgery when their body mass index is 35 kg/m² or higher, or when it is between 30 and 35 kg/m² and their diabetes cannot be controlled by medicine and lifestyle changes. This latter indication is even stronger when there are other major cardiovascular risk factors, including hypertension, hyperlipidemia, and a history of heart attacks, said Dr. Rubino, chief of the Gastrointestinal Metabolic Surgery Program at New York-Presbyterian Hospital/Weill Cornell Medical Center.

The body mass index action points can be reduced by 2.5 kg/m² for Asians.

The guidelines were drawn up by an IDF taskforce of diabetologists, endocrinologists, surgeons, and public health experts who met in December 2010.

Trials Needed to Compare Surgical Procedures

The new recommended indications for performing bariatric surgery on patients who are both diabetic and obese match those announced last month by the US Food and Drug Administration for expanded use of the Lap-Band Adjustable Gastric Banding System (Allergan) to treat obesity.

The US Food and Drug Administration originally approved the product, designed for laparoscopic adjustable gastric banding (LAGB), for adults with a BMI of 40 kg/m² or higher and those with a BMI of 35 kg/m² or higher who have additional risk factors. Under the expanded indications, the LAGB system also can be used for adults with a BMI of 30 to 40 kg/m² and 1 additional obesity-related condition who have failed to lose weight despite diet, exercise, and pharmacotherapy.

The use of bariatric surgery to treat diabetes has sparked controversy in healthcare circles. Critics question the wisdom of wielding a scalpel to solve a medical problem, especially when clinicians have more drugs at their disposal to deal with diabetes.

At the same time, a study published online last week in the Archives of Surgery has raised doubts about the efficacy of LAGB. Researchers following 151 patients who underwent LAGB for obesity concluded that the procedure yielded “relatively poor long-term outcomes,” with nearly half the patients needing their bands removed and 60% overall requiring some kind of reoperation. The authors, who performed the surgeries in question during the mid-1990s, added a caveat: they had used an older dissection technique.

“The band is only one option,” Dr. Rubino told Medscape Medical News, noting that gastric bypass procedures have demonstrated a greater endocrine effect than LAGB. “We are learning that some types of diabetes are well treated by lap-banding early in the disease process. The answer is in patient selection.”

The IDF taskforce calls for randomized controlled trials to compare different bariatric procedures for diabetes between themselves, “as well as emerging non-surgical therapies.”

Robert Lowes

Freelance writer, St. Louis, Missouri

Disclosure: Robert L. Lowes has disclosed no relevant financial relationships.

Gastric banding versus gastric bypass: Easy?

Posted on April 13, 2011 by K Eckland

Another example in the realm of surgery where easiest doesn’t equal most effective: gastric banding (lap-band). This is one of those procedures highly touted in American medicine – and heavily advertised on television as an ‘easy’ way to lose weight..

First, let’s get some things clear – the ‘easy’ mentality needs to go away in medicine, and so does the pushing of this concept with patients.. None of this; not surgery, weight loss drugs, or conventional treatment is easy for the patient..It’s all hard work, so don’t mislead your patients – that sets them up for failure..

In the article linked here (from the LA times, February 2011) the two doctors interviewed do their best to avoid answering the easy/ effective question. “I let the patient decide,” which is a royal cop-out. Patients come to doctors for expert opinions and recommendations not wishy-washy information that doesn’t present the facts and evidence. The picture accompanying the article is disturbing as well, since it’s captioned as a patient awaiting lap-band.. The patient is clearly morbidly obese – yet is undergoing the least effective option available!

What makes this frustrating to me – is that in talking to patients – is that it’s usually such a long road to even get to bariatric surgery.. Contrary to popular belief and tabloid reporting, the majority of overweight people don’t jump to bariatric surgery.. These patients spend years (sometimes decades) dieting, gaining and losing weight..
This isn’t always the case in other countries where surgery is more readily available – but in the USA where insurance coverage or lack there of, usually dictates care – bariatric surgery is usually the end of a long, frustrating road..

I know I’ve discussed this before on the site – but I feel that there needs to be transparency in treatment options – and that we need to do away with the ‘easy’ concept whether it’s bariatric surgery, stents or even medications.. Don’t sell people easy – give them safe, proven and effective.

I’ll be updating the article over the next few days with links for more information – and hard facts about surgical options and obesity surgery.

Related Articles: Free full-text links: (my titles, the actual titles are a bit longer)

1. It’s Not Easy – a study looking at the patients perspective, and perceptions before and 2 years after bariatric surgery.

2. Current treatment guidelines and limitations – a discussion of current treatment guidelines in the USA and Canada

3. German study with 14 year outcomes after gastric banding – this is a nice study because they use terms that are easily understood for laypeople – and shows decent outcomes for patients with this procedure

4. Single port bariatric surgery – this has been a hot topic over at the sister site. This article discusses the most recent innovations in surgical techniques for bariatric surgery.

5. A review of the current data (2008) surrounding bariatric surgery, obesity, and diabetes and the cost of care.
This is a particularly good article (reviews often are) because it gives a nice summary of multiple other studies – so intead of reading about eight patients in Lebanon or some other small group – you are getting a good general overview..also it gives a good idea the scope of the problem..

I’m trying to collect a wide range of articles for patient education; unfortunately, since surgeons in Latin America are on the forefront of bariatric surgery – a lot of the most interesting articles are in Spanish and Portuguese (or paid articles). i haven’t posted the translations since they are secondary source and all of the other citations are primary source.

Diabetes as a surgical disease

Posted on March 30, 2011 by K Eckland

There’s a great new article over at Medscape by David Lautz, MD; Florencia Halperin, MD; Ann Goebel-Fabbri, PHD; Allison B. Goldfine, MD
that was recently published in Diabetes Care 2011;34(3):763-770 entitled

“The Great Debate: Medicine or Surgery: What Is Best for the Patient With Type 2 Diabetes?”

It’s quite lengthy so I won’t repost here – but it’s definitely recommended reading for my diabetic readers out there. I have included some highlights from the discussion – which correlate with much of what we’ve previously discussed here.

Re-post from article:
“Recent observational studies demonstrate that bariatric surgical procedures reduce the incidence of type 2 diabetes and lead to substantial improvement or “resolution” for many patients with preexisting disease. Type 2 diabetes has “resolved” (defined in the surgical literature as maintenance of normal blood glucose after discontinuation of all diabetes-related medications, in most studies with HbA1c 35 kg/m2 and raise the question of whether surgical interventions should be considered earlier in the course of disease or for lesser magnitude of excess weight and specifically for the treatment of diabetes as opposed to treatment of obesity.”

It’s a nice well-balanced article, which discusses the theories behind the resolution of diabetes after surgery (Roux-en-Y gastric bypass), as well as the concerns of endocrinologists about the use of surgery for diabetes management. The authors give a nice detailed description of the various bariatric surgery procedures and nonsurgical treatment options, in a fair and balanced manner. It’s a timely article, coming on the heels of the recent AHA statement – which harks back to an era of blaming the patient and ignoring the problem..

Bariatic surgery, revisited

Posted on March 15, 2011 by K Eckland

In honor of the Latin-American Bariatric Surgery Congress, currently in progress in Cartagena – (since I couldn’t make time in my research to go) I am posting a brand new article about bariatric surgery and the severely obese. It seems American medicine is finally starting to catch up, and take notice..

It’s hard concept out there – and I still have trouble with it myself, sometimes.. In our society, it seems we are too busy blaming ourselves, and others for being overweight and attaching labels; ‘lazy’, to really see how fundamentally things need to change to improve our health as a nation.

From my perspective, down here in Bogota – it’s interesting, because I am seeing Colombians just beginning to start to struggle with obesity – as more and more imported snack foods, and fast foods replace traditional diets. Obese people are still very rare here – and after several months, I can still say I’ve not seen a single super-obese person here, but the ‘chubbies’ are starting to grow in number..

At the same time, by being in such a walkable city, and having access to (cheap!), delicious, ripe fruit every day, I’ve managed to lose over ten pounds with almost no effort.. I’ve been tracking my walking, and I walk about 6 to 10 miles a day with my various errands. But these are things that aren’t readily available – in the urban sprawl of American life.. A week’s worth of fruit for several meals for ten dollars? Not hardly, unless you gorged yourself on bananas every single day..

Surgery as a solution seems drastic to American healthcare providers, myself including.. Removing/ destroying a perfectly functioning organ.. But then – when you look at the drastic effects, and the desperate states our patients are in – Bariatric surgery really is as lifesaving as cardiac surgery for many people.. Until we change society as a whole (which may never happen), we need to help these individuals regain their health,and their lives..

Bariatric Surgery for the Severely Obese

In the meantime, everyone, stay away from soft drinks (all soft drinks, including ‘diet drinks’, juices and fruit drinks, sweet tea) and stick to water, plain tea. Coffee too – if you remember not to load it up with too many calories.. Try it for a month, and I wager you will be unable to go back to the supersurgery drinks you formerly enjoyed out cringing..

Today’s headlines: Obesity Kills

Posted on February 15, 2011 by K Eckland

Everyone knows this already – but finally some scientists sat down and worked it out for the rest of us: Obesity Kills!

Seems like a pretty timely article: Obesity Increases Risk of Deadly Heart Attacks – over on WebMD..

Here I am in Bogota, spending much of the week with Bariatric surgeons; discussing procedures, outcomes, meeting patients..

More news on Bariatric Surgery & Diabetes

Posted on October 20, 2010 by K Eckland

I’ve re-posted the lastest medical article from medscape on Bariatric Surgery in Diabetes Mellitus. As many of you know, I have a special interest in Bariatrics/ Diabetes due to the increased incidence of cardiovascular complications. However, here in the USA – it’s easier to get cardiac bypass surgery then gastric bypass..

So – instead of helping people with real medical problems – we wait for drastic complications (heart attacks etc.) Even then, society in general and medical society in particular can be rather judgemental about obese patients. In stead of judging – make the information more available, and give people an opportunity to decide for themselves.

This is a straight cut and paste, with no editing or editorializing (except my comments above) for my interested readers. Also – please let me know what other surgical procedures you are interested in hearing about and I will post articles with helpful information.

Authors and Disclosures :Journalist Daniel M Keller, PhD Daniel M. Keller is a freelance writer for Medscape. Daniel M. Keller has no disclosures.

From Medscape Medical News:

Remission of Type 2 Diabetes Can Occur Within a Week of Gastric Bypass Surgery

Daniel M. Keller October 1, 2010 (Stockholm, Sweden) — Twelve patients with type 2 diabetes had improvements in insulin sensitivity and beta cell function just 1 week after Roux-en-Y gastric bypass surgery (RYGB), with concomitant reductions in fasting and 2-hour postprandial plasma glucose levels, compared with preoperative levels, according to a poster presentation here at the European Association for the Study of Diabetes 46th Annual Meeting. Lead author Nils Bruun Jørgensen, MD, from the Department of Endocrinology at Hvidovre Hospital in Denmark, showed evidence that the improvements in insulin sensitivity and beta cell function were associated with a 16-fold increase in secretion of glucagon-like peptide 1 (GLP-1). Type 2 diabetes patients with fasting plasma glucose of more than 7.0 mmol/L at the beginning of the study were given a mixed-meal tolerance test 1 to 3 days before and 4 to 6 days after surgery. The 200 mL, 1260 kJ liquid meal provided 15% of energy from protein, 50% from carbohydrate, and 35% from fat. The average age of the patients was 51.8 years, 7 were male, and they had diabetes for an average of 5.2 years. Significant reductions in fasting and in 120-minute postprandial plasma glucose levels occurred after surgery, compared with preoperative values (see table). Similarly, there were decreases in both fasting insulin and C-peptide serum levels. Subject Characteristics and Laboratory Values Before and After RYGB Surgery Variables Pre-RYGB Post-RYGB Change P value Glycated hemoglobin 7.0 ± 0.3 Fasting plasma glucose (mmol/L) 8.8 ± 0.7 7.0 ± 0.3 –21.2% .005 120-min plasma glucose (mmol/L) 11.4 ± 0.8 8.2 ± 0.7 –28.5% <.001 Fasting serum insulin (pmol/L) 132 ± 22 73 ± 9 –44.6% .006 Fasting serum C-peptide (pmol/L) 1542 ± 151 1175 ± 172 –23.8% <.001 Weight (kg) 129.8 ± 4 127 ± 3.8 –2.2% .001 Body mass index (kg/m2) 43.3 ± 1.5 42.4 ± 1.5 –2.1% .001 Waist (cm) 130.8 ± 2.9 131.3 ± 2.6 0.4% .734 Hip (cm) 121.0 ± 2.9 118 ± 2.7 –2.5% .051 Using the homeostasis model assessment of insulin resistance (HOMA-IR), Dr. Jørgensen determined that insulin resistance decreased by 54%, from 6.9 ± 1.0 before to 3.2 ± 0.43 after RYGB (P = .001). The Matsuda Index, a measure of tissue insulin sensitivity, increased in parallel with the decrease in insulin resistance, going from 2.58 ± 0.38 before to 4.16 ± 0.55 after RYGB (P = .01). “We also looked at the C-peptide levels in response to the meal, and although we couldn’t show any significant difference in the individual postprandial sample points, what we did get was an impression of the changed secretion dynamics, and we could show an increased incremental area under the curve for C-peptide,” he said. The area under the curve of concentration for C-peptide over time increased significantly after surgery (P = .04). The disposition index, a measure of the relation between the sensitivity of beta cells to glucose and tissue sensitivity to insulin, “improved dramatically,” according to the investigators. “We found a significant increase in the beta cell function, and when we related this to the ambient insulin resistance, we found a 3-fold increase in the disposition index,” according to Dr. Jørgensen — from 54 ± 12 before to 157 ± 30 after RYGB (P = .001). To determine the underlying cause of these improvements, the researchers investigated secretion of incretins, and “found a significant and very dramatic increase in the GLP-1 secretion after surgery,” he said. GLP-1 peak plasma levels increased 5.6-fold after surgery, compared with preoperative values (P < .001), and the incremental area under the curve for plasma GLP-1 was 16 times greater after than before RYGB (P < .001). There was no observed change in gastric inhibitory polypeptide. In conclusion, “gastric bypass surgery significantly reduced fasting plasma glucose levels and 2-hour postprandial glucose levels. These changes were associated with increased insulin sensitivity and beta cell function, and may involve the increased secretion of GLP-1,” Dr. Jørgensen told the audience. Discussion leader Ele Ferrannini, MD, professor of medicine at the University of Pisa Medical School in Italy, asked Dr. Jørgensen about the potential influence of caloric deprivation on the findings, “which would mimic these data almost perfectly,” Dr. Ferrannini said. Dr. Jørgensen replied that he could not dissect such a proposed mechanism from the results he saw after RYGB. Dr. Ferrannini noted that the literature contains studies of patients with type 2 diabetes who were subjected to low-calorie diets in the range used in this study. “And their findings, with the exception of the release of GLP-1, were precisely what is here, so this is a confounder in this particular finding,” he said. An audience member noted that the patients in this study had diabetes for an average of a little more than 5 years, and wondered what would be the result if one performed RYGB on patients who had their disease and had been on insulin much longer, in essence, questioning whether there would be enough preserved beta cell function to see effects similar to those in this study. Dr. Ferrannini replied that “there is evidence that . . . the longer the duration of diabetes, . . . the lower the remission rate, particularly if you look a year later. Any diabetic will go into remission if you starve them, but when they start eating again [after they lost weight], a year later or 2 years later, some will be in remission, others will not be in remission or will be halfway between remission and nonremission. Those that have had the disease the longest . . . may relapse if they remitted initially.” “And then to the point of the insulin secretion — it’s true that it’s not really very much higher, but this is in the face of lower glucose levels. So if you construct a kind of relationship between the insulin and the concomitant glucose levels, there will be an input, and this can be attributed also to the GLP-1. What you cannot ascribe to the increased GLP-1 levels is any improvement in insulin sensitivity, because of a lack of evidence that GLP-1 has any influence on insulin action,” Dr. Ferrannini said.

Dr. Jørgensen reports that his doctoral studies were partially funded by Novo Nordisk, and that 2 of his coauthors are Novo Nordisk employees. Dr. Ferrannini has disclosed no relevant financial relationships. European Association for the Study of Diabetes (EASD) 46th Annual Meeting: Abstract 668. Presented September 23, 2010. Medscape Medical News © 2010 WebMD, LLC

Bariatric surgery in the medical news

Posted on August 25, 2010 by K Eckland

New article on Medscape (a medical literature website for health care providers) discussing the benefits of bariatric surgery. In this article they cite a surgery cost of at least $30,000 which is out of reach for many of the people who need it; as morbid obesity and related complications push up health care costs for individuals.

I’ve posted the link for you to read it for yourself:

http://www.medscape.com/viewarticle/726966?src=mp&spon=22&uac=63155MX

this website does require registration, (which I think is free.)

But as my readers know, there are more cost-effective alternatives, as mentioned in the entire chapter devoted to bariatric surgery in Cartagena.

As readers know, in that chapter, I introduce you to one of Latin America’s most famous surgeons, Dr. Holguin, a former trauma surgeon at Maryland’s Shock Trauma hospital in Baltimore, MY in addition to several other excellent surgeons. Most North Americans don’t know it but Cartagena is fast gaining a reputation for excellence in bariatric surgery, and is becoming a destination of choice for gastric bypass, lap-band, sleeve resection and other bariatric surgery procedures.

Colombian Culture & Cuisine

Formerly Love, Life and Surgery in Latin America

Category Archives: Diabetes & Bariatrics

It’s not vanity and it’s not easy: NHS agrees

New recommendations on the bariatric surgery and diabetes

New recommendations on the bariatric surgery and diabetes

Talking with Dr. Jhon Jairo Berrio about vascular disease and Prostaglandin E1

New NAFLD (nonalcoholic fatty liver disease) resources from Medscape

Dr. Marco Sarinana and Dr. Joel Ramos,Bariatric surgeons

Coffee as a superfood round-up

Back in the OR with Drs. Ham & Abril, bariatric and general surgeons

the Weight of a Nation: the obesity epidemic

In the OR with Los Doctores, Dr. Ham & Dr. Abril

Dr. Horacio Ham, and Los Doctores

Bariatric surgery and non-alcoholic fatty liver disease

The Pros & Cons of Bariatric Surgery

Metformin and Cancer

Gastric bypass to ‘cure’ diabetes goes mainstream

High-fructose corn syrup is dangerous by any other name

Mended Hearts & Aggressive Risk Factor Reduction for people with Hyperglycemia

Bariatric Surgery Safety: More than your weight is at risk!

The doctor won’t see you now..

Bariatric surgery for the whole family?

The real reason you aren’t getting your metformin..

Sugary drink follow up (as promised!)

Bariatric surgery and cardiovascular risk reduction: Meta-analysis

Lifestyle Modification after Bariatric Surgery

Sleep Apnea in Bariatric Surgery patients: pre-operative evaluation

Diabetes – a global epidemic

Diabetes and Soft drinks

Bariatric Surgery: latest headines

More gastric bypass news

A frank talk about Diabetes: part one

American Hospitals get into the act: Bariatric Surgery

More Gastric Bypass News!

International Diabetes Federation supports Bariatric Surgery for treatment of Diabetes

Gastric banding versus gastric bypass: Easy?

Diabetes as a surgical disease

More news on Bariatric Surgery & Diabetes