The $60.9 Billion Dollar Question

In the year 2010, the marketdata for the US Weight Loss and Diet Control Market that year was up 1% to $60.9 Billion Dollars. 

In the last completed year of reported data, that number includes the 'frugal dieter' segment of the market (diet websites, OTC pills, meal replacements, diet books), Commercial weight loss chains, Diet drugs by Rx, and the ever-present medical weight loss programs.  The biggest segment to grow during that year was the 'do-it-yourself' weight loss crowd from the 'frugal' heading.

Probably not much of a surprise to you on multiple levels, but the fact this industry exists at all, and continues to grow, is multifactorial as well.  But at its most fundamental level, it is essentially predicated on the fact, the belief, that we have some degree of control over our weight.  All but the most despondent of those looking to lose a few pounds would likely agree. 

But how much control do we really have?  And what, exactly, is it that we have control over?

In some ways it's more than you might expect.

As far as the microenvironmental  influences that have been studied and shown to have a direct impact on our metabolism, weight, and energy balance, these 6 do bear watching:

   *Sleep Health
   *Types of Nutrients
   *Eating Schedules
   *Physical activity
   *Drugs and Medications
   *Local Stressors

Let's start with sleep health.  From a 2008 study in the Journal of Sleep, it has been suggested that short sleep may lead to obesity through the activation of hormonal responses leading to an increase in appetite and caloric intake. Short sleep is associated to reciprocal changes in leptin and ghrelin. This in turn would likely increase appetite and contribute to the development of obesity.

Also, as discussed in a previous blog post on OSA, disrupted sleep quality from OSA (which commonly accompanies obesity) can set up a 'chicken and egg' scenario.  Disrupted quality of sleep can lead to increased weight, which can lead to further poor REM sleep, and worsen obesity..and round and round it goes, in a downward spiral.

Bottom Line:  Pay attention to sleep quality and quantity.  Get a sleep study if in doubt, and review and appropriately reinforce healthy sleeping habits as a way to help regulate metabolism and weight.

Nutrient Type, and not just nutrient amount (calories) also deserves a closer look.  In the previous post having to do with nutrient signaling, this is an exciting area that's currently under close investigation.  It's not enough just to rely on the old "calories in, energy (calories) burned" equation as the only hard and fast rule as the basis for weight gain, loss, or maintenance.  For better or for worse, it really is much more complicated than that.

It is being revealed that the nutrients themselves are to be looked at in a different way than just a summation of calories.  Different foods, and the individual building blocks of those special foods, have amazing effects.  The recent Mediterranean diet news from the NEJM study regarding vastly improved primary prevention of cardiovascular events for those on that diet was very telling.

Not only did that study show significant cardiovascular benefit in the test group with that diet, but those patients did so without showing any real weight loss on the diet. It also showed that certain fats have a real benefit for cardiovascular health, vs. the American attempts at weight loss, as often attempted via a very low fat diet.

Bottom Line:  A fat is not a fat is not a fat. For example, Sat fat vs Monosat fat vs Trans fat are not all metabolically equal.  And therefore avoidance of all fats makes caloric sense as one tries to control weight, but at what health expense?   I am sure there are more of these stories to come from the nutrient world in the near future that will definitely require further dissection.

More to come on the "control list" next post....

Surgical Polypharmacy



Photo by M Clock

Polypharmacy isn't usually a good thing.

The very term connotes severe or resistant disease processes, or even worse, possibly some type of negligence on the part of the prescriber(s) of those medicines as to the true necessity of each one for its intended purpose, etc.

What if the polypharmacy was a good thing?  How about a 'super drug' that could effect a broad range of similar conditions, and be effective via a mechanism of action that was multimodal?

I know, you probably saw it coming, but Bariatric Surgery is such a "drug". It really helps to think of it that way, or even describe it that way to a patient.

And as we have been discussing, the metabolic surgeries (notably Sleeves and Bypasses) do have powerful metabolic effects, by targeting many different sites to achieve that benefit.

Take Diabetes for example.  What medicine can you utilize as monotherapy that will effect body weight, food intake / portions, energy expenditure, insulin sensitivity, Glucose tolerance, and insulin secretion?

That's right, there is none.

Both Sleeve Gastrectomy and Gastric Bypass effect all of these parameters through their GI manipulation as a means to their metabolic effects.

Again, keep that in mind as you reach for that Rx pad to increase a medicine, add insulin, or consider an Endo referral for your overweight Diabetic patient.  Maybe it's time to initiate 'The Talk' about trading some medicines off for a surgical referral for weight loss surgery!

Ready, SET, Go.....

Are you Ready?

Get Set for another interesting proposal. It's the idea of "Set Points".

The above picture I took from our workbooks.  The image depicts the wide variety of "Zones of Opportunity" in the setting of natural variation of the population.  I know, I know.  If I was to stop there, I would get a failing grade describing this as an essay response to actually detail the above concept.

But wait, there's more.  No, there's no Ginsu knives...

The above graph of sorts shows just how much an individual (represented by a single stripe of color from blue to red, representing the range of potential effect) may respond to an intervention, in this case, to Bariatric Surgery.

They may do as well as the blue response (lower BMI), or as poor as the red area of the stripe (higher BMI).  Some individuals have a wide range of possibility or opportunity, and some have a much smaller window.  When they studied rats, they noticed that there was a genetic predisposition that was very strongly linked to the degree of response an intervention was to exert.

It does go without saying, environment (and behavior!) has a significant say in the short term and long term results as well, but there is much more to it than just behavior alone. These limitations are referred to as set points.  Bariatric surgery, especially Bypass and Sleeve Gastrectomy, have been shown to positively effect set points, in a way that not only makes the body think it should be reset to a lower BMI, but it will in turn defend it at that point as well.

The researchers made the analogy to Blood Pressure and Cholesterol, in which set points there are "reset" with the use of medicines in a way to reduce risk of disease, or treat a disease state.

Interestingly enough, again in their rat studies, they showed that the set points that were artificially high (likely based on diet and genetic influences), but can be temporarily reset to a lower level by a traditional diet and exercise program and a loss of let's say 10% of excess weight.  They did see, however, that an exaggerated weight loss under durress, say 80-100# in a patient of 300#, done again with non-surgical means, caused a significant rebound effect and reset the set point back to where it was originally, or in some cases even higher than before the diet and lifestyle changes were undertaken!

 This is a process that in other circles has been dubbed "metabolic adaptation", and has been seen and studied in participants after their "Biggest Loser" appearances.  Some participants on the show tend to regain significant amounts of weight within weeks of being home.

The benefit we see from Bariatric Surgery is different.  We will discuss in the next installment, how it acts a "Super Drug" in exerting its numerous weight and metabolic effects.

This is a place where 'polypharmacy' is a good thing!

Food As A Hormone?

Interesting notion, one that we reviewed at the recent Metabolic and Applied Research conference.  Dr. Randy Seeley reviewed this advanced idea, partially back by research, partially by what he has observed in the laboratory.

He wrote about it (same name as the title of this blog) in the most recent edition of the Journal of Science.

The idea is very thought-provoking, and makes you rethink of food not as macronutrients alone (fats, protein, sugars), but rather on a deeper level.  To understand the full effect of diet upon the human organism, we need to look at how the micronutrients derived from certain foods act on cellular level. That's totally different, and an even farther cry from counting food as a sum aggregate of 'calories', implying that's what matters the most.

Unfortunately, that also comes from our not-so-outdated view that weight loss results most fundamentally from a reduction in calories, independent of where those calories (don't) come from.

The article cites the Amino Acid Leucine, which is not made in the human body, and needs to be ingested from food.  Leucine has been found to trigger pathways in the brain that controls appetite, and reduces body weight.  Leucine can be found in soy, brown rice, chicken egg yolk, and some cuts of beef as well as cow's milk.

To further the notion proposed of food as a physiologically active cocktail, Seeley suspects there is a complex interaction of how the micronutrients derived from certain foods act at the cellular level. It leads Dr. Seeley to question the broad focus on the negative effects of high fat, and highly processed carbohydrate-rich diets.  More specifically, where does the blame lie in the current diet of most Americans, and somewhat more importantly, how do you maximize the beneficial effects of positive 'signaling' from micronutrients, and increase our intake of those.  Positive benefits may be in the form of improved weight loss or control, or even disease amelioration or prevention.

I was intrigued enough by the notion of this proposition, that I stayed after the lecture to ask Dr. Seeley the $1,000,000 question.

"So, what foods are the best ones to eat, to get the most benefit from the signaling that you discussed?"

"I am not exactly sure, honestly," he replied.  "A lot more research needs to be done, but you can count on the basics that we do now know: Whole foods, focusing on fruits and vegetables, and limitation of highly processed foods," items that are stripped of many beneficial aspects including fiber, bran, and phytonutrients that we don't even fully understand yet.  Some processed foods also have additives that include chemicals, antibiotics, pharmacologic agents, etc.

Dr. Lee Kaplan, a researcher - Internist from Harvard, who also presented at the conference added this take away quip.

"My test, if the patient asks about what a 'Whole Food' is?  If it rots on its own, don't let it.  If it doesn't rot on its own, don't eat too much of it."


Up next- what the researchers proposed as the real mechanism of success of Bariatric surgery, specifically Bypass and Sleeve, that is surprisingly farther from dietary and lifestyle behavior than most of us would have suspected... and the studied consequences of manipulating this aspect too far from a non-surgical standpoint.

Weight, Surgery and Disease: We're not in Kansas anymore, Toto

Historic Photo by M Clock

So we are back.

And, not to be too dramatic, I think at least I am changed.

We were exposed to some new thoughts, backed up by convincing studies, with the information really challenging to the Bariatric status quo. Information that needs to be somehow matriculated. Maybe I can start with you, and the PCP perspective, and then we can someday get it to the patient level in a way that's meaningful and accurate.

So, on the slate to be discussed in more detail in this Blog:

*Our description of our surgeries, especially the Bypass, the Gold Standard, as less "Restrictive and Malabsorptive", and much more a metabolic surgery with its effects exerted on multiple levels physiologically, and stil second to none as far as any similar effects from lifestyle alone, and remaining out of current pharmacologic reach.

*Our understanding of 'set points' for weight and what can effect it, both in the positive and the negatives sense.  Once the set point is established, or re-established, the body will defend it- again for better or worse, depending on the situation.

*The net result of weight maintenance, as a sum dynamic effect of environment, activity, and diet.  On the side of weight loss or maintenance, genetics actually play the biggest role, but the other aspects can be altered or 'optimized' to a certain effect, but the genetics have the upper hand in determining weight and metabolism and how your body reacts to the above factors.

*How Diabetes, one of the greatest success stories in the Gastric Bypass world, actually is impacted by the surgeries (not all is known yet...), and how the next realm of major impact to be discussed may in fact be Cancer, as certain types seem to be well below the expected rate in the post-Bypass population.

*The idea of food as a hormone, insofar as the concept that the constitution of food is as, or likely much more important, to weight and health and metabolism, than mere quantification of calories in a diet.  There has been proven, although still probably in its infantile stages, complicated signaling that occurs both in positive and negative side from the types of food we eat, and it is much more impactful than just the amount (calories) that we eat.

*And lastly, but likely not 'leastly', expected rates of weight "recidivism"(regain) which may more likely represent normal physiologic weight gain, rather than 'failing' in the post op period.  From what I heard last weekend, the concept of expecting a patient to remain stable and unchanging at their 'goal weight' is unreasonable, unfair, and does not take into account normal physiologic aging, and its effects on metabolism and weight.

I am sure there may be more, but those are my initial topics / goals to be discussed soon in more detail. As you can see from above, I did take notes, and I intend to use them!  I am sure as I review them, even more will come out.

I will get to work soon!

Good and Plenty

We decided to stay a bit longer in Florida after the MARS conference and watch some Spring Training baseball.

In our travels we came across many visual reminders that we were in a special and unique place, at a particularly wonderful time of year.

Trucks loaded with visible and overflowing oranges and grapefruit; mile after mile of citrus groves in the middle of the state; tomatoes and farm stands with fresh tomatoes and strawberries. And all this with 70-80 degree temps and sunshine with plenty to spare.

Kind of made me think about the MARS conference. There were many new and interesting ideas put forth, all with specific data and scientific experimentation to back them. The results?

You will see, as I organize a few of the ideas soon that are the most impactful to the way we think and practice in Bariatrics. Proper diets, weight set points, and surgery results that are a good part independent of behavior- (blasphemy!)
will be a few of the topics coming up.

For now, though, it will be some more fun in the sun, watching some baseball and working on storing up some fruit and vegetable servings for when I get back home.

M.A.R.S. By Way of Orlando

From the Orlando Hyatt Website

Work, work, work.....

Looking forward to a conference end of this week in Orlando.  Ethicon Endo Surgery is sponsoring a meeting regarding newly studied  metabolic issues and Bariatric Surgery.

The Metabolic Applied Research Strategy (M.A.R.S.) initiative was mentioned earlier in the "Myth" entries in this blog.

From the Ethicon MARS website:

 "MARS represents a comprehensive approach to developing an understanding of the mechanisms that drive the significant improvements in health associated with metabolic and bariatric surgery.

Primarily leveraging preclinical models of these surgeries, the approach of MARS is to systematically deconstruct these procedures to understand how they work. This improved understanding provides insights into predictors of procedure outcomes and allows for the rapid and efficient testing of new treatment concepts in the preclinical setting.

Successful therapies and predictors of success are then validated through clinical trials as we seek to improve existing therapies, as well as invent new therapies for patients suffering from obesity and metabolic diseases."

Stay tuned...  More information to follow

P.S.  On a related note, during rounds today, it was nice to see a patient who was post op day 1, 62 years old, 10 years of Diabetes type 2, with sugars in the 150-160 range less than 24 hours after her Bypass, only on prn insulin scale... And her insulin pump sitting on her bedside stand, turned off, neglected.  Not needed, and not wanted.

In the words of the B-52s: Good, Good Stuff.

#fulldisclosure

From http://www.123rf.com

If this was a Twitter feed, I might try and see if that hash tag could get any worldwide attention.  I am not "on" Twitter, but I have been looking into it more recently (#fledglingnovice).

I saw some posts and twitter feeds recently on the subject of a 2/20/13 online JAMA Surgery article regarding the cost effectiveness of Gastric Bypass on health care costs for obese individuals over a 6 year period.

In "Impact of Health Care Costs of Obese Persons, A 6 Year Follow up of Surgical and Comparison Cohorts Using Health Plan Data", over 29,000 obese patients were followed for up to 6 years, and their health care costs were monitored.  Half the group were surgical patients, and the other half were medically managed.  The results implied that there was no real health care cost savings realized over that time, which refuted the well-accepted findings of a previous study in 2011 demonstrating the converse.

As we are always quick to do, especially when a result doesn't jibe with what you expect to see, looking more in depth at the study does point out some flaws that need to be taken into consideration.  And, in further #fulldisclosure, I have personally not read the full article to gather these points, just reporting and commenting on them from some authorities that have reflected on the article,  its research methodology, and its relative impact as a whole.

The patients studied were mostly Veteran males, average age 50 and above.  As a contrast to our experiences, in our high volume center's office,  the demographic we serve has an average age around 35,  and 80-20 favoring females.  I am not sure what the national demographics are for Bariatric Surgery as a whole, but I'd be surprised if this studied group was closely representative in their age, gender, and degree of overall health,  as they embarked on weight loss surgery.

The surgery patients were followed from 2000-2006, and their caseload is significantly more laden with open Bypass as opposed to laparoscopic cases, the latter of which is much more commonplace and safer in the present day.  for example, nearly all of our 700 cases last year were laparoscopic, and the average length of stay was 2 days or less.  Therefore, The laparoscopic approach to surgery would decrease length of stay after surgery, as well as decrease the likelihood of some post op complications, such as ventral hernias, which results in readmission or further surgery and therefore increased cost over the studied 6 year period.

Cost is the only studied measure as an index created by the authors, an Obesity Propensity Score, yet there is no measure or index for a 'benefit score'.  I realize that is beyond the scope of this article, but not having a cost vs benefit discussion as far as the insurance reimbursement for weight loss surgery makes the argument against surgery based on cost alone, and practically incomplete.

Furthermore, as a takeaway point, Dr. Robin Blackstone from the ASMBS stated that this study may actually argue for further studies regarding earlier intervention for obese patients, so as to shift the cost effectiveness curve  to a more measure, as earlier intervention could positively effect comorbidities dramatically from a monetary and resolution standpoint.

And finally, there was a mention in one article I read about the study that stated the actual results of their 6 year followup was lacking, as data for followup dropped off for most patients at much shorter that the 6 years, the time when the curve should favor benefit and reduced cost owing to the procedure. We keep track longitudinally in our office of all patients who are seen, as is required by our Centers of Excellence standards.  We, as most high volume center, have found it difficult to get follow up for a long period of time after surgery, base on a number of factors, so it is labor intensive and understandable.

All that glitters is not Gold, for those who have issues with Bariatric surgery, and are staunch against it.  I understand that position on weight loss surgery to a degree, but looking into the results of this most recent study, in association with our experiences at our Bariatric Care Center, shows that further studies need to be done.  Isn't that the result of most studies? :)

Variations On A Theme

Photo by M Clock

This Chilean study caught my eye the other day, from the  February 2013 Obesity Surgery Journal.

It essentially mimics a report in Diabetes Care from 2012 noting similar results, as well as a Stanford study that led to an ASMBS news release in 2011 after it was presented at a national meeting.

The Chilean study showed the results of a group of 31 patients who were Diabetic and underwent Laparoscopic Gastric Bypass for their diabetes.  It also placed the surgical treatment fairly in context with other medical treatments for Diabetes.

Interestingly, the twist in all these reports is the fact that all the patients had a BMI between 30 and 35. As you are aware, those patients would not be approved for surgery in the US, yet still had significant / uncontrolled diabetes, as demonstrated average duration of disease at 5.8 years, and average preoperative BGs were 152 +\-70, and average HGBA1C was 7.7+\-2.1.  No mention of C Peptide results though, which would have been nice to see.

The results of surgery confirmed what we already know from the effects of Gastric Bypass on obese patients and their metabolic disease from the higher more traditional BMI groupings.  The implications from surgical treatment in this group are significant on a number of levels.

Notably, only one complication was reported in the study, a case of hematoperitoneum (post op bleeding) which caused a return to the OR, but no long term effects. At 36 mos average BMI decreased to 24.7. All patients showed evidence of greatly improved glycemic control, with 29/31 (94%) meeting the criteria for remission of their Diabetic disease.

Furthermore, the article also mentions other more commonplace standard, medical treatments for Diabetes, often treatment regimens that do not provide adequate long term control of the disease, let alone remission, and are not free from potential side effects.

Non-surgical treatments are not completely benign, unto themselves:
 
   *  Lifestyle Change - Difficult to do, and hard to maintain to impact disease state and reduce risk of complications long term

   *  Thiazolidinediones - Reported increased risk of fractures, heart failure

   *   GLP-1 Analogs - not evaluated in long term studies as of this time; possibility of acute pancreatitis, medullary thyroid cancer

   *   Inhibitors of dipeptidyl peptidase-4 - not studied long term trials for safety / efficacy

So, while not earth-shattering information, these studies do underscore a couple of points that have been recurrent concepts on this Blog.

Earlier  Referral for Surgery is Better, whether in the context of the existing BMI categories we have through NIH guidelines for referral, or in the sense of earlier in the disease process, or now even earlier in the BMI range, currently for research purposes only in the US, which may induce a change in the future to insurance coverage of Bariatric Surgery at a lower weight.  Earlier surgery = earlier benefit = greater long term benefit.

Surgery is Safe and Effective Treatment for Diabetes, as borne out of many studies, and the bang-for -the-buck is very worthwhile.  Surgically-induced effects on Diabetes cannot be matched by medical treatment as we currently know it.  Period.

Traditional Medical (Non-Surgical) Treatment for Diabetes is not Perfect, it has its flaws, side effects, and inherent lack of efficacy.  I don't think we honestly put that in the equation of medical vs surgical treatment,  risk - benefit ratio enough.

So, maybe we are on the eve of a change to the Clinical Guidelines statement from the American Diabetes Association "Standards of Medical Care in Diabetes".  Published in 2009, it recommends surgical treatment for patients with poorly controlled Diabetes and a BMI of 35 or greater, and below 35 under research protocols.

Identifying those patients that qualify currently for surgery with Diabetes, and there are more and more every day, and consistently offering them a surgical option as part of your treatment plan is a great place to start.