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.

Goooooooaaaaaalllllll! Part 2

And now for the punch line, although this really is no joke-

In fact, we had a clinical meeting at the office just the other day to discuss the weight goal issue itself, as well as reinforcing the complex and delicate nature of assigning the "Goal Weight", and reinforced what it means to the patient as well as to our own staff here at the Bariatric Center.

So brace yourself, here it comes.

Let's organize it this way - the 'What it is, What it was, and What it shall be' classification.

What It Is

*  Not just a number.  There's so much more involved, some of it actual, and some of it artificially associated by the patient, trying to recapture what life was like when they were "that weight".  I guess it's the same as your 70 year old Dad wearing the same style of clothes he did back in his glory days of the Air Force, connecting with his days of old.

*  Based on a "Healthy Weight", as stamped out in concrete fashion by the BMI wheels, and the Insurance tables that delineate a certain weight for a certain height, related to actuarial data.  This certainly does not tell the whole story.

*  A Big Deal.  This cannot be overstated. (Just ask your patient) Having surgery is a big deal unto itself.  Having surgery for being overweight is just as much a big deal, if not bigger.  "What if it doesn't work, like all the other weight loss things I've done didn't work?" Also. "What if it does work, what will my life be like then?" The self-talk can be numbing or fear-inspiring for these folks.


What It Was

*  Again, the association between weight and a "feeling" of how it used to be when I was at that weight.  For me, a personal example is how 80's music takes me down my own memory lane... And for me, not a bad time of my life, but I don't really want to get back there to those now glorified days of early adulthood.  Although I'll take the hair back, that I lost somewhere along the line.

*  In another sense, misleading is a often a better way of a patient's rigidity to get back to a certain weight.  It is not uncommon to have a patient discouraged or even a bit depressed despite having getting to their goal after surgery, only to not "feel" the way they thought it would fell at that weight.


What it Shall Be

*  Reasonable.  I look for a weight around a BMI of 27-30 based on start weight, how much they have to lose, and their age.  I adjust to a higher BMI for more advanced age (above 60 let's say), as well as accept a higher BMI dependent upon how much they have to lose.  For example, a patient who starts out with a weight of 450 and a BMI in the 60s will not be expected to get to a BMI of the same range because the BMI wheel (and insurance company tables of ideal weight) 'requires' the patient to get to a BMI of 24.99 or less the be healthy.

*  Relatively dependent upon procedure and when it was done. Sleeves and Bypasses enable most patients to lose the majority of their weight over a 9-12 mos time frame.  For Bands, they can get to a similar end result, but generally over an 18-24 mos period or more.  Additionally, for most patients, there is a limit to what they can reasonably lose.  Expecting that 450 pound patient to lose 250 pounds is likely not all that reasonable, although not impossible, especially in the 9-12 mos after surgery.  Most Bypass patients, for example, can lose around 200+ pounds, but this is not hard and fast.  Weight loss after that first year can continue in the right behavioral setting, but happens at a much slower rate.  Duodenal switch patients, however,  tend to lose more weight as it is a much more malabsorptive surgery, but we do not offer that surgery at this time, and my experience with it is very limited.

*  Centered on becoming more healthy based on the many benefits of weight loss.  Isn't that the ultimate goal of surgery and weight loss in the first place?  Many categories, some difficult to measure,  summate to embody "Health" for our patients.

Here are some of the questions we ask to get a handle on this measure.  Some answers resonate to certain patients more than others.  What comorbidities are improved or gone, associated medicines reduced or not needing to be refilled? What activities can you now comfortably participate in that you only dreamed of before?  What are others saying about your new appearance, your new clothes, your new attitude?  More importantly, how do you  feel about yourself with more control over your weight and your health?

The sometimes unexpected benefit to patients, and providers, (who thoughtfully take stock of these parameters) is that there are some very unexpected scenic vistas along the way to the the top of the mountain, the end goal if you will, that a patient dreams of reaching.  It doesn't take arriving at a "goal weight" to appreciate very substantial gains in Quality of Life in most of the above markers of health. Studies routinely bear that out.

We as Health Care Providers just have to remember that. We need to remind them of where they are on their journey, help them set a reasonable goal weight, not further burden them, and get out of their way as they journey on the trail to the top.

Photo by M Clock

Goooooooaaaaaalllllll!

Although I love sports, I am honestly not a big fan of soccer. I am more of baseball guy.

I am a fan of goals, though. Not just in the sporting sense, but as a futuristic concrete stretch to encourage effort and measure performance.

In the weight loss surgery world, a weight goal sounds simple enough, but commonly has a lot of emotion and coupled baggage associated with it.

"Why do you think that is your goal weight?"I will often ask...  Here's what I often hear in response

   * "That was the weight I got married, before we had our 2 kids"

   * "That's the weight I think I need to get into my old clothes that are a size 5"

   * "I think that weight will be good, because that will be 100 pounds less than I am now"

   * "If I can just get under 200 I will be happy"

   * "I need to get to that weight because my Doctor told me that to be healthy I need to be a BMI of 25 at the most"

 "I don't know, what weight do you think I should be?" they often ask.

Conflicting information from well meaning sources, including the patient themselves, can lead to unneeded frustration and angst.  And, the 'goal' they are pursuing may be nowhere close to what is reasonable and necessary.  In fact, it's often less than what they are working toward.

Given that the fact this topic is a very important to clarify for us and for you as PCPs, I think it best to keep you all on the edge of your seats for a couple more days and give a complete answer to this multifaceted response in a part 2, to follow...

How do you typically respond to the 'goal weight' question, whether it's a surgical weight loss patient, or a non-surgical weight loss patient?

The answer may surprise you.

Photo by M Clock