the Weight of a Nation: the obesity epidemic

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).

Lifestyle Modification after Bariatric Surgery

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.

Bariatric Surgery: latest headines

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.)

International Diabetes Federation supports Bariatric Surgery for treatment of Diabetes

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.