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.