Yes, Virginia! Obesity Is A Disease

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

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

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

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

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

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

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

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

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

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

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

Coming Attractions

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

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

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

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

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

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

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

Those measures are:

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

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

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

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

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

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

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

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

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

The More The Merrier

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

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

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

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

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

The results?

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

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

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

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

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

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

from postercreate.com

WFPBD?

Photo by M Clock

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

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

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

And this one is not fictional.

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

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

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

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

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

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

Yikes. 

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

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

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

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

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

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

The Swiss Army Knife of Metabolic Lab Tests

From Amazon.com

Isn't it enjoyable to find an additional use for something that is already useful?

Examples that come to mind are the hanger that you 'reused' to aid in reception for your boom box when the antennae broke, the banana peel that goes into the compost pile to feed future plants rather than the garbage can, or the leftover driveway sealer bucket that can hold baseballs for BP for years to come.

At the risk of practicing zealotry (yes, I looked it up, and it is a word- ), I was looking into a few studies regarding C-Peptide, and I came across an interesting study published in the Canadian Medical Association Journal from earlier this year.

I know we have gone over a number of practical, actual and theoretical uses for the laboratory test C-Peptide in the Bariatric surgery circles in this blog.  We've discussed how it can identify and predict the severity of metabolic (Diabetic) disease, and how it can predict the potential effect that bariatric surgery can have on Diabetes and the chances of its remission.

This new study was news to me, and it dealt with C-Peptide levels and the risk of death among adults without diabetes mellitus.

I understand the measurement of C-Peptide as a surrogate level for endogenous insulin secretion, and therefore pancreatic islet cell function.  Not a far stretch to equate that level with either a high level (early diabetes) or a low level (once pancreatic function is in decline, implicating marked severity of diabetes -  essentially creating a type 1 out of a type 2 diabetic) and it's implication on death from Cardiovascular diseases.

But, that C-Peptide levels correlated in a direct way, in Non- Diabetic patients, with the risk of death... that caught my eye.

It seems that C-Peptide may potentially be considered a bioactive peptide in it's own right.

5902 participants aged 40 years and older with no Hx of Diabetes were evaluated in terms of their baseline C-Peptide levels.  The primary outcome was all-cause, cardiovascular-related and coronary artery disease mortality.

What's also interesting is that as C-Peptide rose there were significant and graded increases in mortality regardless of whether or not there were increases in the level of glycated hemoglobin and fasting glucose.

In essence, higher C-Peptide levels were associated with increased mortality among strata of glycated hemoglobin and fasting serum glucose, but also independent of those markers.  Now some of these patients may have been 'pre-diabetic', with their baseline C-Peptide being the only evidence of the impending disease process, resulting from cumulative diet, aging, genetics, and increasing weight.

Given the epidemic nature of Diabetes these days, that probably represents a good chunk of the results, but there is very likely something more involved.

However, generally speaking, the levels in the study were noted to be higher in those patients with a Hx of HTN, hypercholesterolemia, or MI; and among those with a higher BMI, and with higher levels of C-reactive protein, total cholesterol, serum insulin, glycated hemoglobin, and fasting serum glucose.  What else do you need for the toxic stew to end up with heart disease?

So, consider a C-peptide the next time you do those annual labs on that patient in for a followup.  It could provide yet another objective data point to set the stage for 'the talk' to get them thinking about the urgency and necessity of making some changes before it's too late.

Whether or not that means that Bariatric Surgery is in their future, the main thing is that in preventing death and disease, the Heart, Brain, and Pancreas are literally of vital importance.

Bariatric Beriberi (Not a new flavored juice for weight loss)

From Brucemhood.wordpress.com

Say that 3 times... bet you can if you try (Mr. Rogers flashback, anyone?).

                 Nicely done.

Beriberi, or classic Thiamin (B1) deficiency is not all that uncommon in Bariatric surgery circles.  And, that makes some sense, especially in post-Bypass patients, and yet we are finding it so as well for Sleeve Gastrectomy patients, as reported in the literature.  B1 acts in the body as a cofactor in several enzymes associated with CHO metabolsm and energy production.  It's effects are most noticeable in the cardiovascular and neurological organ systems.

Thiamin is preferentially absorbed in the duodenum, with decreasing absorption caudally along the small intestine in an intact GI tract.  Therefore, a Bypass certainly increases the risk of having an issue with Thiamin, as the procedure essentially re-routes nutrient exposure away from these areas of maximal absorption.

Literature reviews show that 'Bariatric Beriberi' is most common in the setting of protracted vomiting, typically within the first 2-3 mos after a Gastric Bypass.  It is purported to be brought on by rapid weight loss and dietary insufficiency, as well as lack of strict adherence to required vitamin regimens.

For post op vitamin regimens, as detailed earlier in this blog, we usually advise a MVI and B Complex, among others,  which along with a reasonably sound diet, should keep their Thiamin levels up to snuff, even with the varying degrees of malabsorption between the Bypass and the Sleeve patients.

And the risk of not being mindful of a patient with potential Thiamin deficiency and the need for IV fluid replacement?  They can exhibit signs and symptoms of Wernicke's Encephalopathy if given Dextrose in their IV fluid, with this coexistent micronutrient deficiency.  Manifestations of WE include ataxia, opthalmoplegia, nystagmus, and mental confusion.  In the worst case, it can be non-reversible, or even fatal.

We will always give a banana bag with MVI, 100 mg Thiamin, and even a Gram of Folate in our initial IV as to negate this risk when we admit a post op patient who fits this description.  As much as we educate our hospital staff, and the ER staff, we still cringe when we see an occasional patient with D5(name your flavor....) hanging as an initial IV in a sick patient that has been vomiting, and with poor PO intake.  For additional monitoring, we do include a B1 level on our post op labs that we check regularly in the post op setting.

You should see a copy of those labs we check as we CC you on the labs as much as possible.

No Term Limits for Obesity

From Bariatrictv.org

I was in attendance at the NYS Chapter of the ASMBS meeting in NYC last week, and we were fortunate to have Dr. Jaime Ponce, the president of the ASMBS, address our group about updates on many hot topics in the Bariatric surgery world.  He spoke of access to care with new health care laws starting to take effect,  and he made note of his busy week he had experienced with two politicians in succession making it known that they had undergone weight loss surgery recently.

The ASMBS sent out a press release last week regarding New York Congressman Tom Reed who underwent Bariatric Surgery recently, after he went public about it just last week.

As the press release states, Obesity knows no particular class of person.  It does not discriminate amongst the celebrity or common man.  And certainly, the associated comorbidities are just as destructive and quality of life diminishing each group.

What is a little different though, between a public and a non-public figure, is the attention that surgery like this gets when a public servant chooses to undergo a weight loss operation due to significant obesity and related diseases.

Such is also the case with the Buffalo Representative Mr. Reed.  He made the decision to have a Gastric Bypass earlier this year has left him 70 pounds lighter, and now Diabetes-free.

It is hoped with this increased focus on this particular case, in combination with potential legislative sensitivity to the issues of access to surgical care of obesity and Diabetes, so that advances could be manifest in this area as well.

So who do you think might be next?!