An Ounce of Prevention...

From NCDHHS.gov

Good old Ben.

Essentially always true, this adage holds even more weight (pun intended) in light of an article that a friend brought to my attention recently regarding T2DM  and the metabolic effects of Bariatric surgery.

The superlative and far-reaching benefits of bariatric / metabolic surgery for patients with Diabetes and obesity are quite well known.  I have wondered for some time if this can translate into a prevention of sorts for these high risk patients, and if so, how could it be studied and presented in a way that was believable and evidence-based.

The article is actually not a newly published study, but rather from an article published in the NEJM in August of 2012, by a group of physicians that prospectively reviewed the Swedish Obesity Study data,  looking for evidence of a preventative effect on the development of T2DM in Bariatric Surgery patients vs. obese matched controls who were treated with 'usual care'.

The authors found that bariatric surgery appeared to be markedly more efficient than usual care (diet, weight loss, and medicines) in the prevention of T2DM in obese persons.

Some more nitty gritty bullet points:

*  Whereby both patient groups (surgery vs. usual care) had no evidence of T2DM at the start of the study (no reported DM meds, FBG <110, Random BG if measured <126), the bariatric surgery group developed Diabetes in 110 of the patients studies vs. 392 participants in the control group.

*  The disparity in the  rate of developing T2DM are even more noteworthy when it is noted that the surgery group had a significantly higher BMI and additional comorbidities vs. the non-surgical group.

*  The mix of surgical procedures was based on what would be a percentage mix that would not be seen in this current era: Banding (19%), Vertical Banded Gastroplasty (69%), and Gastric Bypass (12%).  Our current mix for cases is likely in the 60% Bypass / and near 40% for Sleeves, with a few percentage points for Bands. VBG's are not currently done all that often to my knowledge, but the procedure does involve gastric stapling and division, and therefore did confer some metabolic benefit.

*  Running the numbers, the authors calculated a 78% reduction in the long term incidence of T2DM in obese patients.

*  Among those patients who fit the definition of Impaired fasting glucose, bariatric surgery reduced the risk by 87%, and T2DM did not develop in 10 of 13 patients that underwent bariatric surgery.  This effect was twice as large as observed with lifestyle interventions in moderately obese, prediabetic persons.

*  This last point is probably the best takeaway action step that certainly mirrors other such information that is at the heart of this blog's purpose as a whole:

"Type 2 Diabetes is a progressive disease, and the ability to produce insulin declines with time.

  Improvement of insulin sensitivity by means of weight loss may not be enough 

to induce the remission of diabetes if the destruction of beta cells is advanced, 

and the diabetes remission rate is 

inversely related to the duration of diabetes at the time of bariatric surgery.  

...this suggests that the disturbances of  glucose metabolism might be treated early, even before T2DM is diagnosed."

I will let you read between the lines as far a that action step - one I suspect you have heard here many times before.

Thinfluence Book Report

Finally! Done reading and ready to do the report.

I do feel like I am back in 5th grade (shout out to Mr. Mandarano!), when these types of assignments were much more commonplace. Even the phrase "book report" sends me down memory lane.

So, as for my overall impression on the book: I am surprised. Yes, happily surprised!

I am surprised at my reaction to this well-written book, and the lack of what I expected to be a bias against personal responsibility in a book about one's personal health, more specifically in the emotionally-charged area of weight and obesity.

As I stated before I started reading the book, I was hoping that the book wasn't going to dismiss a large chunk of the responsibility from the person who was looking to deal with their weight issue, but I was skeptical that that may have been the case.  Maybe it's this era of acceptance for diminished personal responsibility that lowered my expectations? actually   I digress...

I actually got a much different feeling from reading the book.  Yes, there was the detailed descriptions about many of the 'outside' factors that directly or indirectly contribute to weight, or at least the environment in a way that is obesogenic. Some of these were commonsense, and some were uniquely thought-provoking as to their cause and effect.

Take for instance, the disparity (evidence-based / studied) surrounding the fact that even though one's battle against obesity / weight issues is a highly individualized and personal matter( and very reinforced and dictated to by societal norms), patients actually do much better hitting their goals when engaged in group dynamics on may levels.

Whether it is a regularly meeting exercise group, a workplace weight challenge, a group benefit walk, or another group of people with a focus on weight and health, or even social media groups, studies did show that the rate of weight loss and healthy goal achievement was much in participants in those groups than in solo efforts.

And, taking that same approach to many similar levels of "influence" in our personal environment, based on the "Circles of Influence" graph depicted below, the book thoroughly described each one in light of their effect on a person's decisions and actions.

Photo by M Clock

The circle graph represents many different areas of influence, with the matters that we have the most direct control over in the center (Inner Self) of the concentric circles, and as we go further out from the center, less direct personal control (Environment and Societal Factors).

Reviewed and described as far as their effect and influence, were the areas of the Inner Factors, Relationships (family, friends, and work associates), the food and media "diet", and Policy factors of local to national laws and regulations.

Each chapter also had a final section that had an interactive action plan and a quiz to encourage the reader to put in place real change based on the information that was provided in the chapter. Pretty practical steps and input, I thought, without being patronizing.  Real examples were also provided of actual patients at Harvard, and how they realized their own results and attained heir heath / weight goals based on the chapter's content.

And, last but not least, and also studied in an evidence-based format, was the fact that people as individuals can have an impact on others and their pursuit of a healthier lifestyle.

The authors further encouraged people to realize more control over the areas that can variably be controlled, acknowledging less capability to do so as the circle graph extends away from the individual.  They also urged all those in search of  healthier weight and lifestyle to be a force for good for others, and in the foreseeable future, the US could be a much healthier place in the process.

Thinfluence? A Book Report

photo by M Clock

Okay, time to change it up a bit.

This post will be brief, and serve as an introduction to a new book I picked up at the library the other day.

"Thinfluence" caught my eye in the recently released section.  The cover defines the term as "the powerful and surprising effect family, work, and environment have on weight".

Written by two physicians that work at Harvard, and with the addition of evidence-based information and perspective, I thought it might be worth the read.  My bias against significantly relieving a patient's responsibilities with obesity, comorbidities,  and decreasing quality of life from self-care and purposeful attentiveness are well reinforced.  I am interested as to how well the cover-style marketing of this book, and it's "It's not really all your fault" initial message will stand up to my experience with patients, human nature and my day in day out interaction with the psyche of the patients we serve.

So, it is with some acknowledged bias that I start this book.  As often is the case, I at least  hope to gain some nuggets of evidence-based wisdom as to how patients can recognize and take advantage of their environment, perhaps in new and effective ways, and even be an influence, as the book details on its back cover, for others undergoing similar weight and health issues.

Sounds benign enough - right?

And, for the record, I don't think I am a totally half empty kind of guy... just a realist that may appear that way from time to time.

Trust but verify...

See what I mean?  Only now on page 6 and I've got to see how they qualify this....

More information on my 'book report' soon.

Genitourinary Issues with Obesity

Seeing patients in the office last week, I heard one patient excitedly say that she had an unexpected improvement in her 'health' despite just being only 1 month post op from her surgery.

She described her prior 'normal' habits of urinary stress incontinence with straining, exercise, lifting groceries, or laughing / coughing / sneezing.  She admitted an average of 5-7 times per week the utter embarrassment of such events, as well as the ever-present anticipatory dread, that such events could occur at the most inopportune of times.

She was down in weight only 30# from her start weight (pre op), yet recounted a diminution in events now only 1-2 x per month now.  Talk about quality-of-life improvement.  This was a woman in her early 50s, obviously was morbidly obese, and the mom of 2 prior NSVDs.

As luck would have it, I just so happened to come across a study reported recently that was done at the University of California San Francisco School of Medicine, by Dr. Leslee Subak, professor of obstetrics, gynecology, and reproductive sciences there.

She led a team that looked at the rates of incontinence in a specific bariatric surgery patient population, and the resolution of those urinary tract symptoms in that same group.

She found that nearly 50% of the women in her study group, namely 775 of 1500, reported episodes of urinary incontinence at least 1 time per week preoperatively.

71% of those patients had Gastric Bypass, the remainder had Gastric Banding.

Demographically, the average age was 46 y/o, most were caucasian, and most lost at least 30% of their body weight by one year and maintained that through 3 years from their surgery date.

The findings from the completed annual questionnaires?

 From an average of 11 instances of incontinence per week, the frequency dropped to only 4 per week at two and three years post-surgery. Further, the remission rate — less than 1 weekly episode over the past 3 months — was about 61 percent after 3 years. And 25 percent of the women had had no episodes in the previous 3 months, they reported at 3-year post-surgery.

Obesity and stress incontinence certainly do have a causal relationship.  Not only can the long term pressure on the pelvic floor cause muscular and sphincteric laxity and dyscoordination, the effects of often comorbid Diabetes can further complicate the issue by adding neuromuscular dysfunction.

While incontinence is not one of the major players in the comorbidity strata, especially in terms of insurance reimbursement for surgery approval with a BMI of the 35 - 40 range patient, I am sure if you asked a patient how much negative lifestyle impact it has, you might be a little surprised. (Especially if you do not 'know' about the entity personally.)

So, there you go: Another reported / studied benefit of weight loss surgery, something to be mindful of, or mention to a patient when considering someone who would be a good candidate for surgery.  

It's not too hard to remember the BIG benefits of mortality reduction and improvements in HTN, DM2, Lipids, and DJD / joint pain, as well as OSA improvements among others - disease processes all mentioned numerous times throughout the history of this Blog.

And, despite no one likely ever dying directly of incontinence, that doesn't mean that a patient with that affliction hasn't wished at one or more times they had - when that inopportune moment struck...

From Flickr.com

It's The DIet, Stupid

From Musingsofahousewife.com

Remember when "It's the economy, stupid" helped get bill Clinton elected in 1992?

I had a ah-hah moment recently of a similar nature, during a discussion with one of our surgeons about striking differences in post op glucose control, despite two seemingly similar patients. 

Both had Bariatric / metabolic procedures - one had a Sleeve, the other a Bypass.

Both had longstanding histories of DM2,  both had slightly advanced ages (late 50s, early 60's), and both ended up OFF insulin post op; Patient A in the hospital, and Patient B within days of coming home, despite requiring it (as a new medicine to her regimen, needed to control her sugar from perioperatively in the 300s, to mid 100s by POD 2) immediately post op.

Patient A I expected to follow a similar course as with Patient B, namely needing aggressive Novolg scale, initially on a Q2 hr basis, to asses his new insulin needs, with a goal to maintain BGs in the 150s or lower, especially given his preop  Lantus maintenance dose of 144 units (Yes, that's one hundred forty four), last dosed the night before surgery. 

By the way, Patient B came to the day surgery area, an hour before surgery at 110, and with a most recent A1C of 6.2.  And, with his preop 60# weight loss (about double of what was 'required' as his 10% to get to the OR), he was actually off 3 of his other antidiabetic meds, and with a slightly reduced dose of Lantus to boot. Pretty good control heading into his surgery.

Not so similarly, Patient A was the epitome of poor control. She was someone who probably needed insulin long before surgery day, but was reluctant to start it, to say the least.  She was hopeful that the 5-10% weight loss and low calorie diet preop would help her, and she was assumptive that post op she would be fine.

I wasn't so sure, when I saw she arrived at the day surgery unit just 1.5 hr preop at 302 for her BG.  She had stopped her Glucophage 1000 BID about 6 weeks earlier due to slight LFT elevation, aware of her NASH diagnosis (Cirrhotic changes from steatosis, on our intraop liver Bx) as her PCP was following apparently both and didn't want to insult her liver potentially further.

In any event, her most recent A1C before surgery was 12.2, certainly out of control, and for some time. 

She (Patient B) however, was the one that really ended up surprising me.

For both patients, and for that fact any T2 Diabetic patient that has surgery, after a Sleeve or Bypass, due to their beneficial metabolic effects, there are many significant metabolic changes occurring very rapidly, often within the first few hours after surgery, that can make control of BGs post op most challenging at times.

Each patient is a little (or a lot) different, but there are a number of trends we keep in mind for post op monitoring and insulin orders, and we let the patients perioperatively declare themselves as one of 3 general types of post op Diabetics. 

#1 is the patient we do Q 6 hr fingersticks on, have a scale ready, and they don't require much if any insulin coverage.

#2 is the patient we start out the same way, and ends up needing a little insulin, which the patient generally reacts to appropriately in reducing their BGs. We usually send them home after a typical 2 night stay off any further DM meds / their pre op maintenance DM meds, and have them monitor BGs at home, with the goal to keep BGs in the 140-160 range or less.  This hands-off approach prevents potentially overdoing it (with resultant hypoglycemia) with PO or injectable meds while the metabolic changes of improved insulin sensitivity,  advancing diet (still very minimal CHO), and decreasing post operative stress is theoretically diminishing. Those 3 factors make you think of a decreased need for meds anyway. Should they then have spikes in BG or a few readings over 180's, etc. they call their PCP for further management before we see them at a  standard 1 week post op visit.

#3 is the wildcard. These patients are usually under not-so-optimal control preop, and are on multiple meds, often with crazy amounts of insulin (both rapid acting and basal) required; sometimes they even have a pump with total doses of insulin easily in the 200 plus unit range.  We have seen a few of these patients on U500 insulin (5x the potency of standard insulin) as well to minimize the volume needed to control the BGs.

You know you have one of these patients when you monitor their BGS in the PACU just out of surgery, and their BG is already in the 200s, especially if they were closer to euglycemic as they went into surgery.  Another not so subtle tip-off is when the aggressive Novolog scale does nothing (BG substantially rises) when checked about 2 hrs after administered.

These patients will often require a number of 'catch up' rapid-acting doses to get back on top of BGs, the dose dependent upon how they react to the doses being given, which usually approximately the dose that would be given in the outlined 'aggressive' scale.

This is when you start thinking about needing a basal dose of a peakless, once daily insulin (Lantus or Levmir) that evening, to give you some help with some background coverage.  I usually start with a dose in the 0.3 - 0.5 units per KG dosage, and expect to possibly start to see its effect within 6-9 hrs, as far as maintaining BGs and lessening the need for the 'catch up' short-acting doses.  If the patient is already on a basal insulin preop, usually we look at 1/2 to 1/3 of that dose to start.

So, back to Patient B. SHe followed the #3 pathway pretty well, and required 3-4 catch up Novolog dosings Q2 h to get her sugars to the mid 100s, started Lantus close to 40 units, and she did well the following day, with less and less Q6 hr scale requirement.  

Interesting enough, she refused the Lantus when she went home, and reports now (I saw her last week) that her BGs are in the 120s and less at home. Well, I'll be....

Anyway, back to what led to this whole discussion, and the picture at the top of the page.

I suspect her "glucotoxicity" of such poor preoperative control, and longstanding at that, created a post op situation that, even with the rapid immediate BG-beneficial effects from the surgery (as essentially declared to be adequate enough to control her BGs off all meds a week post op) was a significant factor in making her look like she would need at least some short term help from exogenous insulin.

What was the other factor?

Diet.

Yes, a very low CHO diet (especially immediately post op), and the limited quantity that could be eaten due to her restrictive procedure, a sort of 'forced' behavior modification. It provided the consistent background of a fixed amount of calories IN, and likely gave the pancreas a fighting chance to keep the BGs controlled.

Which led myself, and the surgeon I was discussing this with, to think:

"How often does this happen in the real world of Diabetes treatment, that we are acting as if the meds aren't adequate, when they cannot possibly overcome maladaptive diets of poor quality and excess amount, in addition to little to no regular exercise?"

I am not in Primary Care anymore, but I think I know the answer to that one.

Age Limits vs. Term Limits, part 2

So when is "old" too old?

As in so many other areas in medicine, this has a relative answer.

Relative risk of age needs to be viewed in terms of potential benefit, as is also the case with younger morbidly obese patients that undergo surgery.  As most now (as opposed to a number of years ago) are in agreement that Bariatric surgery is not solely a "cosmetic procedure" to reduce body mass and "improve" a patient's appearance, the potential for significant health benefit is always in the equation.

Obstructive Sleep Apnea, Diabetes, Hyperlipidemia, HTN, symptomatic / activity- limiting weight bearing OA, and other comorbidities have been shown to substantially improve with surgery and its attendant weight loss.  Advancing age has not been shown to consistently diminish the potential benefits from surgery.

Also keep in mind a patient's genetic risks / predispositions, as well as the potential for increased risk of malignancies with age and decreasing quality of life, on the continuum of time,  as a further characterization of what life may be like if the condition of excess (and likely increasing weight) over continued time is allowed to persist. As the saying goes, there aren't too many significantly overweight people in nursing homes, in their 80s and beyond, these days.

There certainly is a generally agreed upon increased risk as the aging process continues, with the added effects of time and comorbid conditions,  under admittedly variable control (lipids, glyco, BP, etc.), which I think we are quicker to add up than the potential benefits of surgery in a patient of increased age.

Patients are cleared all the time for other types of surgery in their 70s and beyond.  The workup for such a patient is understandably more detailed to qualify end organ status, to assess perioperative risk, as well as to establish whether or not the patient is as optimized as they can be prior to elective surgery.

Our guidelines state that anyone over age 50 sees cardiology preop for potential further evaluation, in order to obtain clearance before surgery.  All patients, regardless of age,  have an EKG in the office as part of their preop workup and data base establishment. Anyone with DM2 of 5-10 years duration, and on insulin, and/or under poor diabetic control should see caridology as well,  given their risk for silent cardiac events.  Most patients are also cleared by their PCP prior to surgery as well just before the time of their procedure.

How do the insurance companies deal with this issue?  Most are in agreement that anyone over the age of 65-70 requires a peer to peer discussion (Insurance Company Medical Director to Surgeon) .  In our experience, the patient usually gets through that review,  as long as our workup is intact, they have been cleared by Cardiology have had adequate diagnostic testing, and stand to experience significant health benefits from surgery and weight loss (from comorbidty reduction / resolution).

to further put it in perspective, and I think I have mentioned it before, but it is worth restating here. (hint: NEJM 2007)

The risks of surgery / anesthesia do slowly increase with advancing age.  However, when you can show the substantial health benefits in the comorbidites listed above, with improved quality of life, and significant disease-associated mortality reduction, (actually greater than Coronary Artery Bypass Grafting) and you have an interested patient of increased age questioning whether Bariatric Surgery is right for them, it pays substantial dividends to be in-the-know!

Exhibit K: Age Limits vs. Term Limits (Part 1)

From Finra.org

Age can be limiting factor for many things, both via legal mandate, or by the progressive experience of bodily function diminishing or lost.

The opposite may also be true of aging, such as with the accumulation of wisdom, a valuable asset that increases in proportion to age.

(I would venture a guess that the negative effects of advancing age are easier to tabulate than the positive when it comes to aging, but that's just a guess.)

Furthermore, certain events in life occur at an arbitrarily set time and circumstance, as depicted in the image on the right.

Other, often more subtle effects of the aging process, occur progressively and can have just as a defining outcome when it comes to bodily function, physiology, cognition, and physical function. Frequently the additive effects of time can be unforgiving based on genetics, behavior and preexisting medical conditions.

Now, how about  Term Limits for a politician? I suspect that would bring about some well-needed change....

Where am I going with this? Good Question.

Another "Exhibit" whereby I describe a clinical presentation of an actual patient, and some real-time results, illustrating a new wrinkle in the daily care of our Bariatric patients.

In this presentation, from a patient I saw in the office last week, we will see the effect of surgery in a patient of moderately advanced age.  Interesting enough, I had a conversation about this very subject with a local Cardiologist who wanted to refer a patient to us, but was concerned that the patient in question was in her 60s.

Well, check this out.


Demographics:  73 y/o WF

Start Weight:  238   BMI 42

Date of Surgery:  1/28/14

DM2 History:  Longstanding h/o Diabetes, albeit "borderline", and on no anti-diabetic medicines. Her Glyco on our initial labs showed 6.5. She was concerned about the long term effects of her Diabetes, and whether or not it would lead to medicines and/or Insulin, or rapidly deteriorating health.

Other comorbidites were HTN (on 3 medicines), Hyperlipidemia (on a statin), and OA pain to her lower extremity joints, GERD on a PPI,  as well as Hypovitaminosis D.

Current DM2 and Post op Changes:  I saw her recently at her 6 mos post op check and she was 'Beaming' on the outside, but it came from the inside.  She said she felt wonderful with her new weight of 159, BMI of 28, and had a new found energy and zest for life.  Her BP meds were reduced to just one, and her BGs had been stable since surgery, to the point that she rarely checked them anymore.  She was incorporating a new level of exercise to her life, and her ADLs were getting easier and more enjoyable with much less OA pain.  She had taken to her new post op Bariatric diet, and was exploring new foods and optimizing her dietary intake calorically for protein and limited CHO.

Wow. Not a bad body of work for 6 mos post op.

Take Home Points: The more I have thought about this part of this Case Report, I have a number of related points that will make this THP section a little long to read.  I intend to neaten it up a bit by making this a Part 1 of 2 to go into these issues in a little more detail.

Additional related points of discussion I need to review revolve around the idea of risk vs. benefit in this population of more advanced age, and our standards as far as preop workup.  I want to briefly mention the position of most insurance companies when it comes to age and bariatric Surgery. And a few other salient points. So look out for that in Part 2 coming very soon!

In any event, in conclusion for this part, there seems to be no limited 'Term Limit' on the ability of the human body to bounce back from the effects of increasing weight-related comorbidity even with advancing age.

I believe I characterize our group's feeling well, by stating that age is a relative factor, and not an absolute factor, in considering the overall fitness / risk for surgery, especially in light the potential gains (as described here) that can knowingly be appreciated in the context of that relative surgical risk.

I would assume that Orthopedic Surgeons (total joints) and Cardiothoracic Surgeons (CABG, Valve Replacements, etc.) do the same, yet are met with far less less scrutiny than Bariatric Surgeons are, seemingly in the same regard. Is that fair?

Part 2 coming up next......

Witch Procedure is Best

From Fangirlsarewe.com

I might be a little bit predictable, but I often do start out these posts with a play on words.

So I really did mean 'Witch' in this case :)  Kind of-

We had this discussion in the office just a few days ago, and we all though it might be a good idea to get the word out on procedure choice and some of the pitfalls we have experienced lately.

But first a story about my neighbor.  No she didn't have weight loss surgery.  But she did closely resemble the "Wicked Witch of the West" - but in appearance only.  She was a very nice lady and a long time great neighbor.

I remember when I was a little kid , and after watching the Wizard of Oz I mentioned it to my Mom and I was surprised at her abrupt and negative reaction when I compared the two of them.

I think she thought I meant how she acted..not how she looked like her.  Seeing this picture again only reinforces what I first thought.  It still is true! I wonder what my Mom would say if I mentioned it to her again?  Might take that walk down memory lane this weekend...

Anyways - Which Bariatric procedure for which patient?

As I said, we had a discussion in the office about this very topic recently.

Historically, the patient comes in to the office with a general idea of which procedure they are intending on having (Band, Bypass or Sleeve), and when the Surgeon meets with them, they review the patient's history and fill in any gaps in the patient's knowledge about the other procedures, how they work, and complications - and they work together to decide on their surgical procedure, "tool" if you will.

The issues that started the discussion recently, was that a new patient met the Surgeon for the first time with a very limited view on surgical options, based on one of their Physician's recommendations about either which one they had to have (and be cleared for), or limited the patient by which surgery they couldn't have.

Both Physicians in question were long time providers of care to their respective patients, and the Surgeon, new to them, had a hard time fully discussing both risks and benefits, as well as real world implications of their limited choice of one procedure over another one.

There now certainly is more information and experience out there with all health care providers, due to the explosion of cases of Bariatric Surgery in the general population.  And there certainly are many "grey area"subtleties, and nuiances that exist among the different procedures that we do, especially as taken in context with an individual patient's presentation and needs / comorbidites, age, mobility, etc..

Although there still is not hard and fast data that steers us easily and unequivocally to match up a certain patient demographic and medical characteristics to guarantee 'success' with a specific procedure type for a specific patient, there are some general time-proven principles that we can experientially apply to patients that we see in the office before surgery. The patient's Surgeon usually speaks to that over two visits pre op, and those discussions have real merit and potential consequence.

Unfortunately, every now and then, a well-meaning PCP or specialist will short-circuit that discussion with a previous discussion that can close the mind of a patient and lead them to suboptimal results down the road.

However, don't get me wrong -  the patient, generally in discussion with his or her Surgeon, arrives at a decision for surgery, and the patient's final desire for procedure type is always what is done.

 I just know that recently, one of our Surgeons felt a bit shut out of the benefits of a full discussion about what procedure may be best for a couple of patients, seemingly due to the directive from their PCP or specialist who had a bias about what procedure to have done, and it was very difficult to change that patient's mind because of it.

Frustrating, but we do the best we can do.

So, keep those referrals coming, but try and leave open the final discussion about which procedure for which patient mainly between the Surgeon  and their new patient.

Thanks!

Stampede III: Standing the Test of Time

From Moondancefilmfestival.com

Readers of this Blog are quite familiar with the ongoing results of the Stampede trial.  This is a trial following 150 obese patients with uncontrolled DM2 who were randomized to either have Intensive Medical Therapy (IMT) alone, or IMT and either Roux-en-Y Gastric Bypass or Sleeve Gastrectomy.

Previously published data, inclusive of 2 years of data,  demonstrated substantial improvement in DM2 in the IMT plus bariatric surgery group.

Great, but will it stand the test of time?

Now that the study is 3 years old, new data is available.

Exciting as the results are for improved blood sugar control and secondary end points (weight, antidiabetic med usage, quality of life measures), they more represent a continuation in effect than anything new.

Some highlights of the study to review and update the data:

1.  Mean age of the group was 48 y/o, 68% were women

2.  Mean baseline A1C was 9.3

3.  Mean baseline BMI was 36

4.  At 3 years:
 
     *Endpoint of A1C of 6.0% or less was achieved in 5% of the IMT group, as opposed to 38% of the Bypass + IMT group, and 24% of the Sleeve group

     *Use of meds for DM2, including insulin, was lower in the surgical groups than the IMT group alone

     *Patients in the surgical groups had a greater mean percentage reduction in their baseline weight- with 24% reduction in the Bypass group, and 21% in the Sleeve group, vs. only 4% in the medically treated group

     *Quality of life measures were greater for the surgical groups than the medical group

     *No major late surgical complications were reported

Now how does this new "boring" clinical trial update compare with your non-surgical obese diabetic patients' experiences and quality of life lately?

Probably boring is not the word to describe that...

What's worse for your Liver: Fat or Acohol?

from Leanbodylaunchpad.com

Fat?

Or Alcohol?

Which is more hepatotoxic?

Kind of a trick question.

In an article entitled "Obesity Trumps Alcohol in Liver Damage" (Oops, gave it away), in terms of liver-related morbidity and mortality, it seems that obesity was even more dangerous than alcohol consumption.

The study involved 100,000 women in London. The author and his team studied the interaction between BMI and alcohol consumption for 'liver related events', in women middle aged and older.

'Liver-related events' (illness or death related to alcoholic liver disease, NASH, cirrhosis, or decompensation of cirrhosis) were measured, and calibrated for those who were both heavy drinkers or not, and those with a BMI of less than or greater than 30.

Clearly, as expected, for those that drank heavily, the risk of liver events increased irrespective of BMI.

The other findings were a little more surprising, when obesity gets into the mix.

In heavy drinkers that were overweight (BMI <30), the event rate was notably higher than those who drank heavily but were not overweight.

Events were also higher in patients who were overweight, but did not drink heavily. The combined risk was additive.

An effect described as "super additive" was noted with obesity and heavy drinking.

There was a difference between overweight drinkers and obese drinkers, in that more damage was demonstrated with increasing weight. More event were tallied in the obese group (BMI >30) that drank heavily, vs. the dame rate of alcohol ingestion and "just" overweight status.

Interestingly, this study has more public health implications than you might think for the UK and Europe.

Europe has the heaviest alcohol consumption in the world, and consequently alcohol consumption is the third leading cause of death and illness there, only after tobacco and hypertension.

Men and Women are Different...

From Inclusionmagazine.com

Quite a lead title for this post, don't you think?

This could go a number of very interesting ways, but for the purpose of this Blog post, I am going to center on their differences in terms of their participation and results of efforts and treatments for obesity.

I think I have stated before that women far outnumber men in our bariatric surgical practice, by at least a 3:1 margin if not more; it may in fact we may be closer to 80% for female patients in our practice.

I recently saw a post in Fairfield County's (Connecticut) bariatric surgery blog that highlighted a few of the reasons.  Good post.

We all know men and women are different animals, and the same is true in respect to their proclivity to seek treatment, and what kind of treatment for obesity.

Why are our bariatric surgical practices so female-dominant?

While being overweight is not a female or male predominant situation (or disease as recently noted by the AMA), however, according to 2012 US data, it does favor males at nearly 70% of their adult group, vs. females at nearly 60% of their group.  That's a huge group of people that are overweight and obese in the US, and while both sexes have this affliction, how they react to their illness / poor health (female description?) or their challenge (male description?) is  markedly different.  And that, in a nutshell, is probably the main contributor to whether or not a male or female seeks out surgical care for their obesity.

As far as medical treatment as a whole, it is well known that females are much more likely to seek care for health-related matters, whereas men tend to under utilize the health care system more commonly.  Studies have shown that men tend to put off a surgical option for weight loss until they had a significant weight-related health problem that effected their daily functioning. The writer of the blog post from Fairfield correlates this with the parallel of not asking for directions until it's very late in the journey, and how that has always been a stereotype of men from women (before the advent of GPS assistance) :) .

Studies also reveal that men often have a bit more success with weight loss efforts on their own, in terms of utilizing diet and exercise to get to a weight goal.  Men do have more lean body mass (Testosterone = muscle mass),  and can build muscle easier to aid in more 'rapid' metabolic changes, with a similar level of exercise vs. what women experience from their efforts.

So, I guess if you have had a degree of success with lifestyle changes in the past, you can probably justify not considering that definitive surgical option, and delay it until you can just buckle down and give it another shot.

Not as easy as it sounds, but if it works (this time), go for it, for sure.  If you don't need / want the surgical option, and you are successful losing weight and improving health and reducing your comorbidities, admittedly that is the best way.  Waiting years to start this process, or letting your medical issues slowly get out of hand, with irreversible damage from them, can border on irresponsible. Spoken like a true procrastinating male.

And back to those women that make up the majority of our surgical weight loss practice, and likely the vast majority of clients of non-surgical weight loss businesses in the country, persistence does have its rewards.  According to the ASMBS, their data shows that in the battle of the sexes for weight loss averages after bariatric surgery, women tend to lose more weight than their male counterparts, by 10% more.

"So there..." I can hear a female voice saying those words right now...

Bariatric Surgery for Type 1 Diabetics?

It Really Isn't Always This Clear-cut!  From loldiabetes.com

Why Not??

A recent report may make you think twice.

As you know, the vast majority of Diabetics in the US are of the ever-blossoming Type 2 variety, especially in adolescents, but there are a fair number of overweight / obese Type 1 diabetics out there too.

If you are of the same generation of health care education and training as myself (does "Blue Boaters / Pink Puffers" mean anything to you?), then you will harken back to the fact that most, if not all, type 1 Diabetics are skinny, usually younger, ketosis-prone, etc.

As you have likely experienced in real practice, however, especially in the past few decades, there are also the 'hybrid-like' Type 1s. They tend to be obese, or have a later onset in diagnosis (Type 1 1/2), yet still have marked insulinopenia, and likely have an autoimmune process at root cause for their disease process, thereby primarily destroying their Islet cells as their pathophysiologic insult.

I have reviewed one such patient earlier in this Blog, a true Type 1 that was overweight when she came to see us. She had a Sleeve and did very well, with dramatically reduced insulin needs, improved glucose control, and much improved sense of well-being and lifestyle.

A recently reported small study, published in the letters to the editor in Diabetes Care, described some interesting findings.

In the 10 patients retrospectively studied, all were type 1 Diabetics, as proven by the presence of Auto Islet Cell antibodies, absence of C-Peptide, and/or documented history of Ketoacidosis. All patients were followed postoperatively in terms of changes in weight, A1C, insulin requirements, lipid panels, and blood pressure. The patients surgically underwent a mix of Bands and Sleeves, but most had Gastric Bypass surgery.

At mean follow-up at 36 mos, BMI was reduced by 27% on average, and had a mean BMI of 41.6 at the time of surgery. Nine of the patients at 36 mos had experienced a 60% loss in their weight.

A1C levels dropped from 10.0% to 8.9%. Average LDL cholesterol dropped by 23.0 mg/dl, HDL increased by 10.8 mg/dl, and triglycerides dropped by 30. Mg/dl- all significant changes.

Hypertension resolved or improved in 5 of the 7 patients who had the diagnosis preoperatively, and albuminuria resolved in 1 of the 2 patients that had microalbuminuria.

Dr, Brethauer, the lead investigator for this report, stated that “The findings of this study, the largest case series of its kind to date (!-my emphasis), indicate that bariatric surgery leads to a remarkable and sustained weight loss in severely obese patients with type 1 DM, and results in significant improvement in their glycemic status and comorbid conditions.”

Obviously, type 1 and type 2 diabetics are two different animals, for the most part, due to their presentation, pathophysiology, genetics, and treatment. Where crossover exists in their clinical status, i.e. for type 1’s that are significantly overweight, and share then likely share the A1C, lipid, and BP elevations, keep in mind the proven benefit from the ‘remarkable and sustained’ weight loss, and likely some additional metabolic benefit, similar to that seen with the more garden-variety overweight type 2’s that we much more commonly see.

All in all, we all know the pathophysiologic consequence manifested by all uncontrolled diabetics that will occur, sooner or later. Time is not on their side if they consistently do not get to the goals of BP control, A1C, and lipid levels. 

 This may be 'the other' tool to consider when the time is right.

Remember to take your Bile Acids before you go to bed, Dear.

From NPR.org

Bile Acids?

For Metabolic Diseases, like Diabetes?

Maybe this ad from the 1940's wasn't to far off - touting the health benefit of bile-like ingredients.

And maybe someday taking a bile acid pill will be a pleasant reality for those suffering from T2DM, thanks to a recent "breakthrough" finding from Sahlgrenska Academy in Sweden, and the University of Cincinnati.

As reported in the Journal Nature recently, in a study just concluded, found that metabolic surgery-induced (in this case Vertical Sleeve Gastrectomy) elevation in bile acids in the blood, was the principal effect that causes such a rapid improvement in obesity-related Diabetes.

Not only is this interesting and exciting news unto itself, but it may shed some new light on an area that could be developed in the future as a pharmacological intervention, without surgery, to positively effect Diabetes.

The research led to pinpoint a receptor, named FXR, that is directly involved in bile acid signaling.
The study showed that signaling through FXR is essential for the metabolic effects of surgery to be achieved.

This was demonstrated by performing the equivalent of a Vertical Sleeve Gastrectomy on two sets of mice: those with the FXR receptor, and those who genetically were altered to not have the receptor.  The researchers observed that the operation produced weight loss and improved glucose metabolism in the mice with the FXR receptor, yet no effect n the mice that lacked FXR.

The study also showed that VSG produced changes in gut microflora, and that may or may not be working in concert with the FXR receptor to drive the beneficial metabolic results.  More study is needed to investigate those relationships.

"Can't I Just Take A Pill For That?"

From surgerywithoutmedicalinsurance.com

Admittedly, it would be nice.  To have a Bariatric surgical  procedure, with the weight loss and the metabolic benefits of the procedure, without the hassle and potential risk of the surgery itself.  None of the associated surgical and anesthetic risks. Just the benefits. Like the frosting without the cake, right?

So, are we yet to the point yet that medical therapy, in today's advanced age of interventions, non-surgical treatments and pharmacotherapy, that we can duplicate the wide-ranging effects that Bariatric Surgery can provide?

I have spent some time reviewing an article in the International Journal of Obesity, from 2014, that sets out to illuminate us on such a question.

In "Can medical therapy mimic the clinical efficacy or physiological effects of bariatric surgery?" the authors from London, England make their case, and describe where we are as of now. 

Certainly we have come a long way in new medical (Non-surgical) interventions and pharmacotherapy, as we have also come a long way in our understanding of the significance of the benefit and some (but not all) of the physiologic mechanisms of how / why bariatric surgery works.

But, as the article concludes, we are not totally there yet.  Closer than we ever have been to purely medical treatments, yes, but not all there yet.

And, as I have said many times in this blog, surgery is not for everyone.  For most obese patients, with their obesity and their comorbidities, weight loss is weight loss, and in a perfect world if they can lose a substantial amount of weight, and keep it off, we are still talking apples and apples (or pears in the morbidly obese world).

But, in the real world, there aren't many that are very successful with non-surgical weight loss, especially in the context of keeping it off.

And there aren't many that see the long term benefit of weight loss, either to degree or duration, to make a longstanding difference in their comorbidites, their quality of life, or to their longevity of life.

However, that being said, as the article details, there have been many 'new' developments that help us to inch closer to mimicking what a Bypass, Band or Sleeve can do, for example. Here are a few of the developments.

* T2DM benefit after surgery seems to come from improved beta cell function and reduced insulin resistance, as well as a change in gut nutrient sensing.  As the search for how bariatric surgery seems to work physiologically, it has opened new potential metabolic targets for medical therapy to effect.  Both a change in diet amount / portion, calories, and makeup of the diet have been studied to carry about a similar effect.  New T2DM agents, such as GLP-1 agonists and DPP-4 inhibitors and SGLT-2 inhibitors have a new role in the step care approach to T2DM.

*Lifestyle modification for weight loss begins with caloric intake restriction. In a perfect world, it is certainly aided by appetite reduction, as occurs at least temporarily with bariatric surgical procedures, and is reinforced longer term by the restrictive element of the surgical 'tool' that is created through the patient's Sleeve, Bypass or Band.  Medically, newer agents such as Qsymia, in addition to conscious lifestyle modifications, may offer a somewhat similar effect. Further studied dietary makeup, both for calorie amount (?1000-1200) as well as composition (Low glycemic, high protein, high fiber) may offer additional benefit in conjunction with the above. 

*Furthermore, Devices that are now available are also in play.  An endoscopically-placed duodenal-jejunal bypass liner, is a potentially less invasive treatment that aims to recreate the 'bypass' of the duodenal-jejunal region as occcurs in the Gastric Bypass surgically.  Studies have shown that this is a powerful part of the rerouting of the ingested nutrients that changes how the body, and the GI tract specifically, handles the ingested nutrients, and seems to greatly benefit how blood sugar is regulated. The experience with this approach is very early, and has had some complications, in so far as the need for explantation by 6-12 mos, some reports of bleeding, obstruction, abdominal pain, vomiting, etc. Gastric stimulators and intragastric balloons are other devices also in trials at a very early stage in their usage. Results remain to be seen.

So, yes, we have come a long way in our understanding of how and why surgery works so well for obesity and especially it's associated metabolic disease.  We are closer now than we have ever been to maximizing those medical therapeutics and procedures that may avoid surgery, but retain some of the benefits that surgery has shown to exact.

But, in summary, we are still a very long way away, I think, from being able to believably say that a pill, or a device, or a lifestyle change (or a combination of all of these) can mimic the established effects that bariatric surgery can produce for obesity and it's attendant comorbid disease states.

And so my job at this time is still somewhat secure, at least from the fate that has take the cardiac surgery subspecialty by storm over the past 10+ years. In somewhat of a similar phenomenon of scale that is potentially prposed here, with the advent of endovascular techniques (PCI - Percutaneous Coronary Interventions), the rate of CABG  for CAD decreased per hospital caseload by 28% from 2001-2008 in one study, whereby the rates of PCI stayed about the same over that time.

I guess in the area of medicine, and surgery specifically, the more things change, the more they stay the same...

What Happened?

From maniacworld.com

Into every life a little rain must fall.

Frequent music lyrics from a number of artists.  And, apropos for a patient who came in for a post op visit last week.

In the course of an unusually predictable day, I had a patient that I had seen a number of times in the past, and was in the office for her post op Sleeve Gastrectomy visit, closing in on 1 year post surgery.

She had a pre op history of HTN, OSA, Asthma, T2DM, and Depression.  Her start weight was 249 with a BMI of 45.5.

One of her ongoing issues from previous visits was the scarcity of her weight loss, and resultantly, the lack of significant positive change in her comorbidities .  At her visit last week, she had lost only a few pounds more than previous visits, had a history of a few pounds up and down in past visits, and her weight loss total, (including her 15# loss preoperatively) stood at a net of 0. 

That is, she was back to her pre operative weight.


How can that happen?


This issue, and this patient example, fortunately is not a common finding.  It is actually quite rare for a patient within their first year to lose very little, or actually start to gain at some time, already working against their expected mounting weight loss after their surgery.

As you can imagine, is is usually a neon red flag that something is up.

We had interactive, ongoing discussions from her previous visits, and the lack of her post op weight loss did have a cause.  She was going through some very rough times psychologically, with depression and having binge eating issues in response.  Some of the stress was likely brought on by her surgery, at least indirectly, but she also had new and significant stressors at home to deal with.

She fully admitted her issues, and her awareness about it's impact on the lack of success thus far from her surgery.  She was embarrassed and saddened about it, but was actively engaged in counseling and was slowly on the road to getting better in the mental health area.

A few key points.

Interesting, how most patients have a degree of "automatic" weight loss after surgery, most seeing the expected 60-80% loss of excess weight loss within that first year, but on occasion they do not.  Of those that do not, there are some practical prognostic signs can give us a tip off that something is up.

The amount of weight loss at post op visits varies widely, patient to patient.  There is no 'normal' so to speak, but lack of meaningful weight loss at earlier visits post op (1 mos, 3 mos, 6 mos), or weight gain often requires us to delve more into the history to see if there is a behavioral or dietary issue.

Specific and detailed questioning about portion sizes, junk food / empty calories, lack of protein, snacking, etc. may yield some clues.  A thorough exercise / activity review also is needed.

This being said, I also have a low threshold to call a patient out on a self-reported glowing history of bariatric lifestyle adherence, when it's in the face of fair to poor weight loss.

In the case of this patient, fairly superficial questioning allowed her to explain her psych issues, diet issues, and her understanding about the interaction between those factors and her lack of weight loss. Somewhat refreshing, actually, as I have had patients in the past with admittedly less obvious lack of weight loss, who have a hard time admitting to any correlative behavioral issues that may be at cause.

I did bring back this patient more frequently than our usual Q3 mos visits, in an effort to try and stay in touch with her, offer encouragement, and review proper lifestyle changes that were needed for better weight loss.

Sometimes you can only do what you can do.

We will continue to work with her, and support her as we can, and hopefully get her on track to realize some of the benefits she anticipated from her referral to us in the first place. Both for the weight and comorbidity benefit.

The honeymoon phase of 12 mos after the surgery is now nearly gone, but there still is hope if she can start to consistently use her 'tool' of her Sleeve the proper way long term.

I Can See Your Halo

Nature or nurture?

When it comes to obesity, the answer is Yes.

Both.

So, if those two factors undeniably contribute to obesity, might the opposite be true?

That is, could weight loss from surgery, and efforts at lifestyle change make a difference on all the members of a family? That is, a "Halo effect"?

That topic was studied in a 2011 report from researchers at the Stanford University of Medicine, as published in the Archives of Surgery journal.

The article notes that obesity is in essence a familial disease, and the study looked at the potential for healthy behavior transmission as enhanced by family relationships.  They specifically looked at the change in weight, and healthy behaviors of adult family members and children of patients that underwent Gastric Bypass.

Eighty-five participants were studied, broken down as 35 patients, 35 adult family members, and 15 children <18 years old.

The results showed some interesting findings.

Before the operation on the family member, 60% of adult family members were overweight, as were 73% of the children of those patients.  At 12 mos post surgery, significant weight loss was achieved in the obese adult family members, from an average of 234 to 226 lbs. The obese children showed a trend to have a lower body mass index than expected for their growth curve (31.2 expected vs. 29.6 observed).

As far as behavior, family members increased their daily activity levels, and demonstrated improved eating habits with less uncontrollable eating, emotional eating, and alcohol consumption. They noted that lifestyle changes can be socially contagious.

It is also mentioned that each of the family members in the study were required to accompany their family member-patient, when they went for their pre- and post-operative clinical visits, where they received dietary and lifestyle counseling.  Those sessions emphasized a high-protein, high-fiber, low sugar diet and small, frequent  meals.  Further discussed were goal setting for daily exercise, a good night's sleep, alcohol moderation, and minimizing time in front of the TV.

"Can you imagine if every one of these bariatric patients were an ambassador for good health? You would have a huge, grassroots movement with bariatric surgery providing a vehicle for healthy change for patient and family alike", Dr. Morton said, one of the authors of the study.  Obesity is a family disease and bariatric surgery sets the table for future, healthy family meals." The total number of bariatric cases worldwide in 2011 was reported to be over 340,000.

The authors also concluded that bariatric surgery programs should also encourage family members to be a part of support groups and office visits to not only provide support for healthy changes taking place after surgery, but also potentially for their own health benefit, directly.

Keep this in mind in your Family Practice, when you see a patient considering weight loss surgery. There may be more potentially at stake for the associated members of the family as well.

And keep an eye out for the halo effect.  Patients I see often make mention of it in their post-operative office visits. They should get some credit for that as well!

From Reddit.com

A Body Recontouring Primer, Part 2

So, after the ins and outs of the most basic, and essential recountouring procedure for our weight loss patients, and the differences in Abdominplasty and Panniculectomy, (and the attendant insurance games to be played) now we turn to finish up this topic with a few areas of concern.

These remaining procedures / anatomical locations, are almost always purely cosmetic, and therefore NOT covered by insurance.  Of the three - Breasts, Thighs, and Upper Arms-  on occasion, Breast work may be covered by a patient's insurance carrier.  Let's start there.

Breast recontouring is very often highly desired after massive weight loss.  While the abdominal area is almost universally effected by massive weight loss, the breasts (for females) are a close second, and a close second as well in their list of potential body image issues after surgery.

Depending on the degree of weight loss, and on the degree (or lack thereof-) of breast / glandular tissue in an individual patient's breasts, very significant ptosis often occurs with massive weight loss. This often creates a cosmetic concern for a patient, but can also lead to functional issues of intertrigo, rashes, and having challenges with finding a special bra that can fit their new shape and size comfortably.

On the occasion where breast size remains large, and is associated disproportionately with the rest of the upper body habitus, and also in the setting of supportive signs and symptoms of back pain and shoulder divots, I have heard of an occiasional case here and there that may be covered.  The procedure performed is usually a bilateral reductive mammoplasty or mastopexy, and/or may involve implants if needed (which may not be covered).

As far as the upper arms (Brachioplasty) and the thighs (Thigh lift), these are somewhat lesser desired, as some but not all patients have significant issues in these anatomical areas post op. Both are always cosmetic cases and not covered by insurance, but may be an individual patient's main concern and they may be willing to pay for it out of their pocket or on a payment plan set up with the Plastic Surgeon.

Both procedures involve taking a triangle of excess skin off along the long axis of the extremity, with the apex situated distally.  Patients are often willing to 'trade a scar' for the benefit of "tightening up" of the skin in those areas, but the scarring can be at least moderate at times, yet is confined to the inner portion of the arms and the legs, and fairly easy to conceal. Most are very happy with their results.

Of additional note, for Plastic Surgeons that have an interest in the area of body recontouring after massive weight loss, and most these days do, patients and their surgeons can negotiate to an extent on prices and procedures that aren't covered by insurance, or mix and match procedures to fit the desired services and a patients financial status.  The surgeries can be done at one time, or over a couple of procedures, sometimes in an office setting or in the hospital. It pays to have a few Plastic Surgeons in whom you trust their work and their personality / relatability to your patients, to refer your patients to.

I have attached a link to the American Society of Plastic Surgeons for a nice Before and After gallery of recontouring procedures for you to see.

Patients often feel their weight loss mission is well on their way to 'completed' once they lose their weight, keep it off for a year or two, and have some of their 'excess skin' removed to improve their self image. They often feel that by having their body recontouring done, it can put them on a fresh start to their new life mentally and physically.

I do want to say though, taking in to account this Blog post and the previous one as well, most patients do not have recontouring surgery done after weight loss.

Most are not that concerned afterward, or are willing to have some mild to moderate body / skin issues as a trade off for their substantialy improved new health, new abilities, reduced medicines, and toleration of ADL's and beyond.

Those post op patients that do not have surgery easily represents the majority of the patients I see... but for those who have skin and anatomical needs after surgery, there is hope out there, you just need to know where and how to find it!

"What can I do about all this extra skin?" A Body Recontouring Primer

Just returned from a nice and warm week to Florida to catch some Spring Training baseball and some Vitamin D and Vitamin C (as in Citrus).  Great week.

Got to thinking about the next topic for this Blog. When I thought of writing on excess skin removal, and body recontouring, I had to look back to see if I had already covered it.  Looks like  really haven't thus far, and yet it's one of those often recurring questions we get from both patients and providers alike, and a great post-op topic to get into.

As I said, one of the most common questions / concerns patients have at sometime along their massive weight loss journey is again in regard to body image.  It may have been at least somewhat of a psychological issue pre op, and now paradoxically can resurface post op in a different light.

Massive weight loss resulting from bariatric surgery can be both exciting and anxiety producing. While patients are essentially universally pleased with their resultant weight loss, new problems of sagging skin, or markedly absent regions of their previous anatomy ("...where did my butt and breasts go?") do get them on edge and frustrated.  Most I see do admit, though, that they would generally trade the weight loss and its attendant health benefits for their new found body makeup and shape.

So, what is there that can be done?  This is well within the domain of the Plastic Surgeon, and the increasingly popular field of Body Recontouring after massive weight loss, usually associated with weight loss surgery.

As may be expected, and it can be argued that it truly is a medical problem, and it results from a procedure that was medically necessary (and approved by the insurance company), playing the "excess skin insurance game" to see what can be covered is a fairly complicated process.  It certainly is not automatic. Much less complicated are the excellent results that patients obtain after the surgery, whether they self-pay or are able to have it covered by their insurance company. Let's see if I can cover this in a way to at least let you in on the process, so you are aware what we and the patient often goes through, and may need from us (you and me) on their way to have their plastic surgery done.

The most common desire our patients have after successful weight loss surgery has to do with their abdominal pannus, or panniculus.  This redundant drape of skin is the result of the 'overstretching' of the abdominal wall skin from prolonged obesity and increased sub cutaneous tissue.  Their may or may not be associated striae, as is seen post pregnancy, and the extent of the excess skin may further extend posteriorly, bilaterally, around to the flanks, depending on the amount of weight lost, as well as the degree of skin elasticity and compliance.  It is well known that persons of color do tend to have better collagen and elasticity, and may show comparatively less redundancy and disfigurement after massive weight loss.  Age is also inversely proportional to elasticity and compliance of the skin, and certainly smoking as well as other disease states and medicines can accelerate skin changes negatively systemically with associated massive weight loss.

In broad terms, a Panniculectomy may be covered by insurance, whereas an Abdomioplasty (Panniculectomy with muscular / fascial tightenting, possibly with some Liposuction for added contouring) is essentially never covered.

The good side of the issue is that if insurance covers it, that's great.  It is a mostly functional procedure, and will go a long way to get rid of the associated recurrent skin fold rash (intertrigo, bacterial +/- fungal), and the cosmetic issues of what to do with the bunch of skin near the belt line that is difficult to hide.  Patients say that the extra abdominal skin acts as a constant reminder of the patient's previous body habitus that they frustratingly still cannot change. Patients are usually very happy with their results, and for the most part tell me, "I'm not looking to get into a bikini at the beach, I just can't get rid of this big wad of extra skin". The weight from the extra skin can go 7-15# or more  depending on the amount that is resected, and whether or not a circumferential (Belt Lipectomy) approach is necessary.

The down side to the insurance issue is that it frequently is not covered by the patient's insurance carrier.

This often stems from their view that the procedure is essentially a cosmetic procedure, and not medically necessary.  Each insurance company has a slightly different view, and it's often difficult from our side of the equation to know how to best play the game in order to try and get it approved. We rely on the Plastic Surgeons and their staff to guide the patient through this as able.  Often at an initial consult, based on the exam, the history, and the known quirks of an individual patient's insurance company, a Plastic Surgeon may advise the patient outright that it won't be covered.

Other instances may require more information and documentation to get it covered.  Usually, the patient must be 15-18 months plus post surgery, in order to be at or near their reasonable goal weight, and demonstrating both weight stability as well as sound nutrition and normal lab work and nutritional parameters (protein, CBC, vitamin levels, Fe, etc.).  They must also be  non-smoking, as this semi-cosmetic procedure is elective, and concomitant smoking greatly increases the risk of unwanted wound complications and healing issues, as well as increasedpulmonary and DVT risks.

The documentation required is often a retrospective look the weight loss history, abdominal skin fold rashes, their treatments, and their recurrences.  This can be from a PCP and/or us at the bariatric surgery office.  As is often the case, the more documentation the better.

We have also found that sending our patients to different Plastic Surgeons in our area can yield different results.  Some Plastic Surgeons participate more easily with certain insurance types, and some honestly have more of an interest in doing the legwork to get the patient to surgery and get the procedure done than others do.  I can understand that the process with some patient's insurance companies is cumbersome, and can demand a lot of effort.   And then the aspect that the extra effort is for a case that may not pay very well, and take their time away from cosmetic specialty cases that may be reimbursed at a better rate for less burden on the staff.  This may just not be a desirable trade off for a busy Plastics practice.

However, as far as the patient goes, a brief investment of time on our part (or yours) to document some needed history for the patient, and get it to the insurance company in an effort to get a panniculectomy reimbursed, they are very appreciative.

So, for part 2 a little more about body recontouring in respect to Breasts, Axillae, and Thighs to complete the primer.