Yes, Virginia! Obesity Is A Disease

As you may have heard this week, Obesity has been formally classified as a disease by the AMA.  A big deal in some ways, not so much a revelation in other ways.

In the strict terms of a disease-state, certainly Obesity qualifies.  In fact, it has already been formally recognized so by a number of health organizations previously, including the NIH (National Institutes of Health), the SSA (Social Security Administration), and the Center for Medicare and Medicaid Services.  Now the AMA has added their name to the list.

“Similar to many other medical conditions, obesity is a complex, multifactorial chronic disease, requiring a multidisciplinary treatment approach. This approach must encompass the best standards of care, both in terms of the treatments chosen, and the care coordination and clinical environment in which they are delivered. Because of the complex nature of obesity and its variety of impacts on both physical and mental health, effective treatment requires the coordinated services of providers from several disciplines and professions (both physician and non-physician) within both of these treatment areas,” said AACE President Dr. Mechanick. “Adoption of this policy position by the AMA will help advocates in the obesity community address a number of key hurdles to individuals receiving critical medically necessary obesity treatment services.”

The hope is that with this new AMA-endorsed designation, patient access to proven treatments will become aligned with insurance coverage policy.  It may also put an emphasis on developing, or reinforcing, new treatment and prevention strategies, and additional resources to accelerate the compliation of that data.

Obesity is a complex condition with numerous casuses and manifestations.  It is attached to enormous social stigma and discrimination, causes poor quality of life, poor health, and accelerates premature mortality.

The additional take home message that we, as health care providers, need to keep in mind is responsibility.  It can be a fine line to walk, but despite there being a number of genetic, and even environmental factors (to a degree) that are beyond the control of the individual, we cannot disempower patients with such an emphasis on "Disease" to the point of encouraging fatalistic despair or helplessness.

Having patients "give up" and not even try to do what they can to control and reverse their overweight status is truly "the easy way out", as opposed to numerous patients that report receiving that same comment to us from their friends and family after successful bariatric surgery.

Similar in some ways to Alcoholism, the designation of the disease state certainly applies, but can tempt an effected individual to resign themselves to the fact that they have no power to do anything about their condition as a victim in the grand scheme when they acknowledge their current state of health.

The idea that the genes load the gun, and the environment pulls the trigger is still a good way of thinking about it, but must also take into account that there is a great deal of potential trigger-preventing behavior that can be actualized to have a profound impact on a patient's life in many aspects.

Optimally, caught early enough, and with due lifestyle diligence and persistence, the need for a Bariatric Surgery referral would not be necessary.  However, when treatment is needed in those who repeatedly fail lifestyle intervention, and/or have deteriortating lifestyle quality (and likely reduced quantity) from burgeoning commorbidities, there is a certain time and a place for bariatric / metabolic surgery. 

Finally, I think that noone would argue that bariatric surgery is the end-all, be-all for Obesity as a diease state.  There abviously is no preventative aspect to what we do in terms of forestalling the development of increasing body weight in the first place, but that shouldn't diminish its role in the treatment of advanced obesity and comorbidites, especially when another reasonable alternative doesn't exist.

Coming Attractions

Here's something coming to a 'theater' near you.

Something we have been working on for a while, now with a renewed interest.  A new look at an issue in a different and detailed way.

That issue is the post op (perioperative) management of blood sugars in patients immediately after Bypass or Sleeve. 

My Question:  Is there a way to more precisely predict the precise degree of perioperative physiologic response of improved endogenous-glycemic control after bypass or sleeve?

The query is self-initiated when I write for insulin in the post operative orders.  Typically we see a marked improvement with 8-12 hours after surgery (even in the face of expected stress response to surgery), but where they settle out prior to discharge (usually a 1 day stay for Sleeves, a 2 day stay for Bypasses) can change subtly, but profoundly.

The interim product of enhanced glycemic control can mean the difference between going home on no PO meds, dramatically lessening the amount of basal insulin that was required preoperatively, or even getting off a pump and going with a reduced amount of basal insulin to satisfy the new insulin needs.

The clinical parameters of who will respond to surgery in the first place, and to what degree are in essence the same places we look for expected response metabolically just out of surgery.

Those measures are:

* Age of the patient? - The older the patient, generally >55, leads to possibly less pancreatic reserve, and with increasing age the more possibly pronounced the effect.

*Duration of Diabetes? - After 5 - 10 years of a timely diagnosis, again, possibly less reserve, increasingly likely the longer the duration of the disease.

*Degree of control? - As reflected by a glycohemoglobin of 7 or higher. Poorly controlled DM2 is increasingly toxic over time to the pancreas, but only reflects the prior 3 mos of averaged control, implying the higher the number the more unfavorable the control. The cause of this is as varied as poor adherence to lifestyle / diet / meds, to even possibly maxed out medical therapeutic options in the face of increasing weight and insulin resistance, becoming a true dead end street.

* Insulin-requiring? If they come to us already on insulin, this is an important indicator of preexistent pancreatic embarrassment, with more to come unless reversed.  Often, prescribing needed insulin leads to hunger, which leads to more weight, which leads to more insulin resistance, which leads to increasing insulin doses, leading to increasing hunger, then increased weight..... (That quip about the definition of insanity comes to mind-)

* C Peptide level?  Last in this list, but definitely not least.  As stated many times earlier in this blog, it appears more and more that this test, a surrogate for functioning pancreatic mass / effect, can fairly neatly wrap up the sometimes vague effects of all the other factors above, combined.  If what we are looking for in summation of this clinical markers is the end result of damage to the pancreas through a number of related insults, then the current secretory ability of the pancreas, as reflected in this blood test, "should" allow us to look at the C Peptide as an index to the here and now of pancreatic function.

Then, taking it one step further, the for the 'Coming Attraction', we may then be able to take that information, and apply some algorithm of the interaction of that reserve to the effects of surgery, and come up with a more precise model and prediction of the acute effect of surgery, in terms of expected insulin / medication needs.

The quotes around "should" are intentional. As in life, it seems like the more you know, the more you actually don't know.  (As long as you know that, you should be OK) We are probably just starting to scratch the surface of this and related issues, but I believe we are on to something here more than esoterica.

Logic doesn't always win the day, but it's a good place to start!

For the next post, I will detail a recent case of post op insulin needs in a patient who came to surgery on a pump with U500 insulin and 5 different basal settings.  I think you will be as impressed as he is with his new simple Rx protocol.

The More The Merrier

Yet another study this week, somewhat publicized in the lay press, from JAMA, regarding the surgical treatment of Diabetes.

All of this attention is indeed a good thing, for the issues of Bariatric Surgery and metabolic disease. And despite there always being some subtle, or not so subtle, bone to pick with the study itself or an implied bias of some sort, I still feel that this is kind of like adolescents.  Any attention is good, sometimes no matter whether it is good or not so good.

This latest study is mostly of the beneficial type, as far as I can see.  In Roux-en-Y gastric Bypass vs Medical Management for the Control of Type 2 Diabetes, Hypertension, and Hyperlipidemia, in the most recent JAMA publication, Gastric Bypass was compared with intensive medical management on a number of parameters.  The goal was to achieve control of comorbid risk factors.

Centered in Taiwan and the US at 4 teaching hospitals, 120 patients were studied, with half of them being assigned Bypass after the entire group had lifestyle-intensive medical management for all of their comorbid conditions.

Outcomes and measures were a composite goal of glyco less than 7%, LDL less than 100 mg/dl, and systolic BP less than 130 mm Hg.  You will recognize these as the "triple endpoint" as recommended by the ADA for DM 2 treatment.

The results?

At 12 months, 49% (28 pts) of the patients in the Gastric Bypass group met their endpoint goal, whereas only 19 % (11 pts) of the lifestyle-medical management group did.  Both groups had improvement in their blood pressure and lipid levels, but the difference was much more striking in the blood sugar realm comparatively.  Weight loss was not surprisingly superior in the Bypass group (26% change in body weight) vs. the non-surgical group (8% change).

Complications were higher in the surgically treated group with 'nuisance' adverse events (nutritional, stricture, ulcer, bleeding, bowel obstruction), as well as major event of one patient with a number of post op events including an anoxic injury.  Not so nuisance there.

The associated editorial in the same issue of JAMA discussed the rate and type of complications in the surgical group that needs to be considered along with the offsetting improvement in the 3 parameters as outlined, even with the noted and significant Diabetes benefit.  Long term safety in terms of continued issues of duration of those effects from complications will need to appropriately weighed out against the known effects of generally increasing weight and deteriorating goals of care in terms of BP, Lipids, and glucose control in the common Diabetic patient that is not on intensive treatment of any type.  As I have said numerous times before, we all know where that road takes us, it's just a matter of when.  Cost was also raised, as it commonly is, and rightly so.  This is hard to accurately quantitate as well, as a cost benefit of 'quality of life is essentially immeasurable.

However, I do agree that quantifying what we are getting ourselves into from a surgical perspective is important to look at in the big picture of a realistic view of 'getting to goal' with non-surgical intensive lifestyle-medical management as it stands today.

In a very non-scientific way, with all of the medical vs. surgical cards accurately on the table, I would take the bet that surgery not only has it's place, but can achieve the ADA goals of care more consistently than the non-surgical treatment, especially when the patient who stands the most from it is selected in a timely manner.

Maybe someday this will all be hammered out, but the attention now is always good, as this is what continues to move the debate forward to a usable and practical best practice in the near future.

from postercreate.com

WFPBD?

Photo by M Clock

In this world of invasive acronyms, I just had to throw that one at you.

I have been reading a book entitled "Whole" by  T. Colin Campbell, PhD, the Jacob Gould Schurman Professor Emeritus of Nutritional Biochemistry at Cornell University.  The book deals with the highly emotional subject of dietary practices and mortality in the U.S.  I offer that any new or revised discussion about diets and death, especially when it involves some objective data, is bound to be potentially fiery and polarized.

Add some money and politics, a hint of backroom deals and subjective scientific interests, cancer, death and disease as an unintended outcome, and you have a great recipe for a good book.

And this one is not fictional.

The book is about the Whole Food Plant-Based Diet (WFPBD).  Dr. Campbell  has been studying nutrition and the benefits of this dietary approach for quite a while.  He has seen the emerging repercussions of our Western diet, one that  relies heavily on processed foods as well as a large proportion of calories derived from animal products (dairy) /protein. 

His data shows much less disease (Diabetes, Heart Disease and Cancer) in animal studies with a diet limited (20% or less of the day's caloric content) in animal protein (Casein) vs a diet high in Casein (80% of daily caloric intake). 

These studies reproduced earlier Indian studies on the same subject, and were also in agreement with population-based studies in a China study by Dr. Campbell as well.

In the China Study, from the China-Cornell-Oxford Project, they looked at 65 counties in China in terms of mortality rates of Cancer and chronic disease, and correlated that with  dietary surveys and labwork in those same counties.  The dates of the study spanned from the mid 1970's to the early 80's.

What they found was that counties with a high animal-based foods intake, had a markedly higher death rate from "Western diseases" (DM, CAD, Ca), than counties that had a predominantly plant-based dietary intake. The populations and counties studied were chosen due to their demographics,  that favored communities that tended to stay in their location and had similar regional dietary practices and genetics.

So, the conclusion of the study, as detailed in the book "The China Study" was that eat a plant-based / vegan diet (avoiding animal-based products such as pork, beef, poultry, eggs, fish, eggs, cheese and milk) as well as avoid refined CHO and processed foods, can escape, reduce, or reverse the development of chronic diseases.

Yikes. 

Worth taking note of?  Just another "fad" diet?   A drive-by study that details what to do, and then a few months later another study is revealed that refutes it entirely?

I don't know, but this seems to be legit.  Not in a "do-it-or-die" sense per se, but in a common sense, getting back to a levelheaded means of  proper nutrition in a 'real food' sense.  Yet, I guess you could argue that meat is real food, and it certainly is.  But maybe not so good for you as afr as your body might be concerned.

But what if the emphasis on fast and cheap for our food in America is leading to our current health epidemics?  I think there would be broad agreement in the notion that our current state of "food" is a far stretch nutritionally from what a whole food diet could provide.

Dr. Campbell also goes on to detail in his book "Whole" the demise of useful nutritional information, in his opinion, from the idea that the benefit from isolated nutrients (Calcium, Acai, Iron, Fish oil) as studied in a vacuum leads to distortion of those benefits and marginalizes the upside of whole foods that contain those essential nutrients.  He terms that way of studying nutrition as Reductionism.

There is really so much we don't know about the exponentially complex nature of how our bodies handle whole foods, but it makes sense to keep it "Whole", and not fall prey to "Reductionism" in terms of nutritional information and thought, as well as 'fast and cheap' for our food at the expense of decent nutrition.  Food should 'taste good', but also 'be good' (nutritionally) for you as well.

I am not nearly done reading this 300+ page hardcover book yet, but I will certainly press on...