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Posts Tagged ‘obesity’

My first case this morning with another surgeon was cancelled – which was disappointing, but I still had a great day in the operating room with Dr.  Ham and Dr. Abril.  This time I was able to witness a bariatric surgery, so I could report back to all of you.

Dr. Ham (left) and Dr. Abril

I really enjoy their relaxed but detail oriented style – it makes for a very enjoyable case.  Today they performed a sleeve gastrectomy** so I am able to report – that they (Dr. Ham) oversewed the staple line (quite nicely, I might add).  If you’ve read any of the previous books, then you know that this is an important step to prevent suture line dehiscence leading to leakage of stomach contents into the abdomen (which can cause very serious complications.)  As I said – it’s an important step – but not one that every doctor I’ve witnessed always performed.   So I was a pleased as punch to see that these surgeons are as world-class and upstanding as everything I’d seen already suggested..

** as long time readers know, I am a devoted fan of the Roux-en-Y, but recent literature suggests that the sleeve gastrectomy is equally effective in the treatment of diabetes.. Of course – we’ll be watching the research for more information on this topic of debate. I hope further studies confirm these results since the sleeve gives patients just a little less of a drastic lifestyle change.. (still drastic but not shot glass sized drastic.)

Dr. Ham

They invited me to the show this evening – they are having several clowns (that are doctors, sort of Patch Adams types) on the show to talk about the health benefits of laughter.  Sounds like a lot of fun – but I thought I better catch up on my writing..

I’ll be back in the OR with Los Doctores again tomorrow..

Speaking of which – I wanted to pass along some information on the anesthesiologist for Dr. Molina’s cases since he did such a nice job with the conscious sedation yesterday.  (I’ve only watched him just yesterday – so I will need a few more encounters, but I wanted to mention Dr. Andres Garcia Gutierrez all the same.

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A full year after we reported it here (and several years after initially being reported in the literature), mainstream media has finally picked up the story about gastric bypass surgery for the definitive treatment of diabetes.   The story made all of the heavies; the Washington Post, the Wall Street Journal, and the Los Angeles Times.

Unfortunately, all of these outlets seem unaware of the existing literature in this area – these results while encouraging, are not surprising.  Similar results have been demonstrated in several other (but smaller) studies for the past ten years, which led to previous recommendations (last summer) for the adoption of gastric bypass surgery as a first-line treatment for diabetes in obese patients.

The publication of two new studies showing clear benefits for diabetics undergoing bariatric surgery has brought this news to the forefront.  In both of these studies, diabetic patients were able to stop taking oral glycemics and insulins after surgery within days..

As this front page story from the New York Times notes – these results do not apply to the more widely marketed ‘lap-band.’  This comes to no surprise to dedicated followers at Cartagena Surgery, who have been reading articles on this topic since our site’s inception in late 2010.

You heard it here first.  For more information on this topic, see our tab on Diabetes & Bariatrics under the ‘surgery’ header. We’ve included a small selection from our archives here.

Bariatric surgery headlines – August 2010

Gastric bypass surgery gets the international federation of diabetes approval.

Gastric bypass as treatment for diabetes

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Not as innocent as the Corn Refiners Association would have you believe.

In a courtroom in Los Angeles, a fierce battle is being pitched right now – one that affects almost every person in this nation..    It’s a lawsuit from the nation’s sugar producers accusing the corn industry of false advertising.. That’s right – it takes industry giants to take on those ridiculous, and mis-leading ads.

You know, those ads that ridicule consumers for their health concerns related to the use of high-fructose corn syrup?  (We’ve discussed these health concerns previously in a series of posts that you can see here  and here.)

Link to ad by Corn Industry

But, here (finally) is a response to those ads – that uses science, not fallacy to refute those claims.

At the same time, the Corn Refiners Association has filed a petition with the Food & Drug Administration to change the name of their product from ‘High-fructose corn syrup” to the more innocuous-sounding “Corn Sugar,” which is just another attempt to deceive the American public.

This move comes just as a new medical study links the consumption of a single daily soda with a 20% increase in heart attacks in men.  There’s a great article over at the Heart.org that summarizing these findings, which I have re-posted below for readers.  (the original study was published in Circulation).

Unfortunately, corn syrup in our everyday products in not usually so easy to identify.

A soda a day raises CHD risk by 20% – Lisa Nainggolan

March 12. 2012

Boston, MA – Sugary drinks are associated with an increased risk of coronary heart disease (CHD) as well as some adverse changes in lipids, inflammatory factors, and leptin, according to a new analysis of men participating in the Health Professionals Follow-up Study, reported by  Dr Lawrence de Koning (Children’s Hospital Boston, MA) and colleagues online March 12, 2012 in Circulation [1].

Even a moderate amount of sugary beverage consumption—we are talking about one can of soda every day—is associated with a significant 20% increased risk of heart disease even after adjusting for a wide range of cardiovascular risk factors,” senior author Dr Frank B Hu (Harvard School of Public Health, Boston, MA) told heartwire. “The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda, not only in the US but also increasing very rapidly in developing countries.”

The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda.

The researchers did not find an increased risk of CHD with artificially sweetened beverages in this analysis, however. “Diet soda has been shown to be associated with weight gain and metabolic diseases in previous studies, even though this hasn’t been substantiated in our study,” says Hu. “The problem with diet soda is its high-intensity sweet taste, which may condition people’s taste. It’s still an open question whether diet soda is an optimal alternative to regular soda; we need more data on this. ”

Hu says water is the best thing to drink, or coffee or tea. Fruit juice is “not a very good alternative, because of the high amount of sugar,” he adds, although if diluted with water, “it’s much better than a can of soda,” he notes.

And Hu says although the current results apply only to men, prior data from his group in women in the Nurses’ Health Study [from 2009] were comparable, “which really boosts the credibility of the findings.”

Inflammation could be a pathway for impact of soda upon CHD risk

Hu and colleagues explain that while much research has shown a link between the consumption of sugar-sweetened beverages and type 2 diabetes, few studies have looked at the association of these drinks with CHD.

Hence, they analyzed the associations of cumulatively averaged sugar-sweetened (eg, sodas) and artificially sweetened (eg, diet sodas) beverage intake with incident fatal and nonfatal CHD (MI) in 42 883 men in the Health Professionals Follow-up study. Beginning in 1986 and every two years until December 2008, participants answered questionnaires about diet and other health habits. A blood sample was provided midway through the study.

There were 3683 CHD cases over 22 years of follow-up. Those in the top quartile of sugar-sweetened-beverage intake had a 20% higher relative risk of CHD than those in the bottom quartile (RR 1.20; p for trend <0.001) after adjustment for age, smoking, physical activity, alcohol, multivitamins, family history, diet quality, energy intake, body-mass index, preenrollment weight change, and dieting.

Adjustment for self-reported high cholesterol, high triglycerides, high blood pressure, and diagnosed type 2 diabetes only slightly attenuated these associations, which suggests that drinking soda “may impact on CHD risk above and beyond traditional risk factors,” say the researchers.

Consumption of artificially sweetened drinks was not significantly associated with CHD (multivariate RR 1.02; p for trend=0.28).

Intake of sugar-sweetened drinks, but not artificially sweetened ones, was also significantly associated with increased triglycerides and several circulating inflammatory factors—including C-reactive protein, interleukin 6 (IL-6), and tumor-necrosis-factor receptor 1 (TNFr1)—as well as decreased HDL cholesterol, lipoprotein (a) (Lp[a]), and leptin (p<0.02).

“Inflammation is a key factor in the pathogenesis of cardiovascular disease and cardiometabolic disease and could represent an additional pathway by which sugar-sweetened beverages influence risk,” say Hu et al.

Cutting consumption of soda is one of easiest behaviors to change

Hu says that one of the major constituents of soda, high-fructose corn syrup, is subsidized in the US, making such drinks “ridiculously cheap” and helping explain why consumption is so high, particularly in lower socioeconomic groups.

Doctors should be advising people with heart disease or at risk to cut back on sugary beverages; it’s almost a no-brainer.

“Doctors should set an example for their patients first,” he stresses. “Then, for people who already have heart disease or who are at high risk, physicians should be advising them to cut back on sugary beverages; it’s almost a no-brainer, like recommending that they stop smoking and do more exercise. The consumption of sugary beverages is a relatively easy behavior to change.”

And although this particular study included mostly white subjects and there are few data on the risk of cardiovascular disease associated with the consumption of soda in people of other ethnicities, there are data on its effect on type 2 diabetes in these groups, he says.

“It has been shown for minority groups—such as African Americans and Asians—that they are more susceptible to the detrimental effects” of sugary drinks on diabetes incidence, he notes.

And if you think soft drinks are the only culprits containing high-fructose corn syrup – you’ll be surprised.  Livestrong has published a list of corn syrup containing products – and you’ll see with even a quick glance, that it’s everywhere, and in everything.

Another blog talking about the harm of Corn Syrup

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Ironically, just a few days ago we were talking about lung cancer and discrimination against patients with lung cancer in the post, The Pearl Ribbon.   Now a new article published in Physicians Money Digest,  suggests that one of the latest trends is discrimination against the obese.  As obese people can tell you – this discrimination has always existed in some form, and from all avenues in society including medicine.

However, this new trend consists of doctors avoiding accepting obese patients in their practice, mainly to avoid the increased workload related to obesity related complications.  That’s right – as discussed in the article by Laura Mortokowitz, which I have re-posted below -some doctors are avoiding caring for obese patients because they do not want to provide care to patients with higher risks of certain complications – diabetes, heart disease, etc.

As someone who works in heart surgery, I can see this issue from both sides.  As many of you know – I am sometimes disheartened by the sheer overwhelming volume of disease (due to diabetes) and the amount of suffering involved for my patients.  I am particularly distressed at times when I see the amount of preventable suffering, and damage my patients experience from not controlling their blood pressure, checking their glucose or taking their medications.  But my patients are already sick – that’s why the are seeing a heart surgeon.  So, I often mourn these lost opportunities to prevent disease (heart attacks, strokes etc.), and I can see how primary care providers, and other providers may feel emotional fatigue and frustration at times.

But, other the other hand –  not every obese person is a stroke or heart attack waiting to happen.  Many of these people can be helped – by education, counseling or even bariatric surgery.  If these people are aggressively followed and cared for, risk reduction can help prevent catastrophic complications – by managing medical conditions that may develop – with aggressive cholesterol control, blood pressure management, etc.

Lastly, medicine is not an exact science – while risks may be greatly increased in many obese people – it is not a guarantee.. Just as it’s a false assumption that all overweight people are sedentary (ie. ‘fat and lazy’), not all overweight people will develop any or all of the complications we’ve discussed before.   But it is guaranteed that these obese patients will suffer, if this trend continues and more and more doctors shun them.

But my door is always open.

By Laura Mortkowitz, Wednesday, November, 16th, 2011
A recent move by Florida ob-gyn physicians to begin turning away overweight patients on the grounds that they were too risky might be the beginning of a new trend. According to Michael Nusbaum, MD, FACS, the health reform bill’s Accountable Care Organizations essentially de-incentivize physicians from taking on morbidly obese patients.
As they stand now, ACOs look at quality measures and they base reimbursements on complications. Doctors already know that a high complication rate will mean less money, and obese patients are considered high-risk patients by definition.
“Under the current bill, the Accountable Care Organizations are looking strictly at outcome measures, so unless that changes I don’t see the perception by physicians changing toward who they’re going to want to treat and who they’re not going to treat,” says Nusbaum, the Medical Director at The Obesity Treatment Centers of New Jersey.
This new practice is not something that would have occurred in the past for two reasons: one, physicians might be reluctant to treat an obese patient, but it was rare to turn them away completely; and two, it was very rare to treat a morbidly obese patient a couple of decades ago.
However, over the last 10 years, the percentage of the population that is overweight has increased dramatically. Today, close to 70% of the population is at least overweight, according to data from the Centers for Disease Control and Prevention. Even more concerning, is the fact that pediatric obesity has tripled over the last 20 years.
“Is the health care system to take care of morbidly obese patients? I would argue that it’s not,” Nusbaum says. “Pretty clearly it’s not. The problem with the health care system is that it lacks infrastructure.”
Most machines and tables can only hold up to 350 pounds, and any patients that exceed that weight might not even be able to get treated at a hospital that doesn’t have the equipment to handle an obese patient. According to Nusbaum, it should be a requirement that hospitals are equipped to treat any morbidly obese patient.
“Nobody is even talking about it,” he says. “Everybody is afraid to even talk about this.”
And it doesn’t seem as if new health laws are encouraging to the treatment of obesity. Under the new health bill’s Essentials Benefit Package, bariatric surgery is not covered because morbid obesity is being considered a poor lifestyle choice. As a result, insurance companies “have become emboldened to say, ‘Well, we’re not going to cover it either,’” Nusbaum says.
In New Jersey, Blue Cross/Blue Shield has 14 insurance policies, and eight of them do not cover bariatric surgery at all.
“What you’re seeing happening is a change in attitude to bariatric surgery and in my opinion a discrimination against those people who have weight issues,” Nusbaum says.
However, there was a rather positive turn of events in Michigan, where bariatric surgery will be covered in 2012 after it was dropped for all of this year.
“They noticed that while they were making money in the short term — they were saving money — they were losing more money by not taking care of these patients,” Nusbaum says. “[The patients] were getting sicker. It was very short sighted.”

//

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As reported at Medpage – the latest Diabetes estimates were released by the International Diabetes Foundation (IDF) this week at the EASD (European Association for the Study of Diabetes) as the news was even grimmer than predicted just a few short months ago: Researchers now estimate 366 million people HAVE diabetes worldwide – greatly surpassing all previous estimates – causing 4.6 million deaths every year.

Leading physicians at this year’s conference continued to stress the importance of Early diagnosis and treatment of Diabetes to prevent serious complications (and death).  This is something we’ve talked about here at Cartagena Surgery – the need for early diagnosis, prompt treatment and aggressive risk reduction.

Preventing diabetes remains a key element of this strategy, but one which we are failiing miserably.  Simple dietary changes such as reducing the consumption of sugar-laden beverages appears to be impossible to implement as we are hopelessly entrenched in American diets (and Indian, Chinese and other nations – as they adopt our fast-food habits).

As many of my face-to-face patients already know, one of the best lines of defense is also one of the oldest in our arsenal of oral anti-glycemics.  For all of my patients who have heard my metformin spiel in person, feel free to skip ahead.  As we’ve discussed in lectures and presentations – Metformin, that simple drug from the 1970’s (one of my $4 faves) has so many side benefits – and the potential cancer benefits are encouraging.. [what’s not encouraging  – is the difficulty getting patients to take their medications regularly – even humble Metformin which is one of the safest, most effective – (clinically proven!) and cheapest diabetes drugs available.]

*as many readers and patients know – this is the one topic where even Cartagena Surgery gets overwhelmed at times.. There is just so much disease/ disability and suffering but it seems like no one is listening or cares enough about themselves to change their habits.**  Please – dear readers – prove me wrong, and write me letters to let me know how you are taking control of your diabetes and your health..

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If you remember, in my blogs about the health benefits of coffee (here, here and here) as well as a previous blog on the health risks related to sugary soft drinks, I promised to bring you more information about our favorite devil-in-disguise, Starbucks.  (I will give them credit for making this information easily accessible, even if it is tiny print.)

I call Starbucks this because on initial consideration..

Coffee: Good!      Big super-sized coffees: Even Better!  and look – a Regular black coffee, no cream, no sugar, any size (including their super-size Venti) is only FIVE calories..

Coffee loaded with cream and sugar:  Not so good.  (How bad is it – you ask? or you should be asking)

well once you start drinking their specialty drinks (and I must be the only person who drinks regular coffee anymore) – that’s when you get into trouble.. so knowing that everyone loves their super-sized coffees, I’ve skipped right to the “Venti” calorie counts..

Cafe Latte with skim milk: 170 calories

Cafe Latte with 2% milk:  240 calories and NINE grams of fat

Cafe Mocha (without whipped cream in these examples)

with nonfat-milk: 280 calories

with 2% milk: 340 calories and 10 grams of fat (that’s a reasonable sized salad with a vinaigrette dressing and maybe cheese or not-so-healthy add-ons)

Vanilla (or other flavored) Lattes:

with non-fat milk: 250 calories (all sugar)

with 2% milk: 320 calories and eight grams of fat

Even the ‘skinny’ lattes have 160 calories..

The specialty espressos are no better (in fact – some are worse, as you will see)

Carmel macchiato:

 with non-fat milk: 240 calories, one gram of fat

with 2% milk:  300 calories, 8 grams of fat

White chocolate mocha (without whipped cream – I think they were afraid of putting the whipped cream calorie counts on this brochure)

with non-fat milk: 450 calories and 7 grams of fat (that’s a decent meal’s worth of calories!!)

with 2% milk: 510 calories and fifteen grams of fat – for a ‘coffee’ !  (I think you can see here how a few of these coffees a week can certainly pile on the pounds.)

Now, if you think that’s no big deal – go on over to www.Fitday.com (and don’t lie to yourself about your exercise) and put in your information (they have free accounts) and figure out how much walking, jogging or aerobics you have to do to equal out that one coffee.. Hint: It’s a lot more than you’d think – or we wouldn’t be in this mess!

The other items on the menu (including the teas) are no better once you pile in the milks, sugars and other garbage.

What about coffee with soy milk?  Isn’t that supposed to be good for you?  Well, in theory, perhaps.. But actually, for some products, the fat and calorie counts for Starbucks products with soy milk go way, way up.

Cafe Latte with soy milk: 220 calories, 6 grams of fat

Cafe Mocha (no whipped cream) with soy milk: 320 calories, 8 grams of fat

Vanilla Latte with soy milk: 300 calories with 6 grams of fat

Carmel macchiato with soy milk: 280 calories with 6 grams of fat

White chocolate mocha: (no whipped cream): 490 calories, 12 grams of fat

all of this – for a little eye-opener in the morning – time to stick with the regular coffee!

In fairness – I am not picking on Starbucks, they are just the most popular.  Even the local 7 – 11 has a coffee flavored slushy drink that is packed full of sugar and calories.  Of course it’s delicious – but really, that’s besides the point.  Obesity and diabetes are just a mathematical formulation – and it seems many of us are failing the subject entirely.

The Lancet, a well reputed medical journal has just published a series on Obesity, and the numbers are frightening – researchers estimate that by 2030 – (really not that far away) over 165 million Americans will be obese.

The costs of this to society are enormous, and frankly staggering.  Bloomberg published a story estimated an additional 66 BILLION dollars PER year in obesity related costs.  That isn’t just a threat to our health as a nation, but our financial future.

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The American Journal of Cardiology just published a new meta-analysis (a study looking at a collection of other studies) that evaluates the effectiveness of bariatric surgery for cardiovascular risk reduction.  As we’ve discussed before, meta-analyses are often used to sort through large numbers of studies to look for trends and weed out aberrant results or poorly designed studies.  (This is particularly helpful when a poorly designed study gives conflicting results in comparison to the rest of the existing studies.) So, we are going to talk a bit more about the meta-analysis.

In this case, the authors started with 637 studies to evaluate, but ended up using the data from only 52 studies involving almost 17,000 patients.  The first step of a meta-analysis is to find every single study even remotely related to your topic. So the authors pulled out, printed and looked at every single study they could find talking about bariatric surgery.

Then the authors start eliminating studies that aren’t relevant to their topic because once you take a closer look; a lot of the studies initially gathered aren’t really related to your topic at all.  (For example: If the authors gathered all studies talking about Bariatric surgery outcomes – on closer examination – a study about the rate of depression in bariatric surgery patients wouldn’t have any information usable to evaluate cardiac risk in these patients.)  Otherwise it would be like comparing apples to oranges.

Once authors have narrowed the pool to studies that are only looking at relevant topics, with measurable results – the authors then examine the studies themselves.  The authors evaluate all aspects of the studies: what is the study design, what does it measure, (is it designed to measure what it is supposed to measure?), what are the results?  (were the results calculated correctly?)  what are the conclusions?  what are the limitations of the study?

Then the authors summarize all of the findings, and draw conclusions based on the results. (if 50 studies involving 16,900 people show one thing – and 2 studies involving 100 people show something completely different – the authors will discuss that.)

The strengths of meta-analyses are that they summarize all of the existing studies out there – and provide readers with fairly powerful results because they involve large numbers of people.

For researchers, meta-analyses are cheap – particularly in comparison to designing, conducting a large-scale study with hundreds or thousands of subjects.  A meta-analysis doesn’t require federal grants or institutional permissions.  It just requires a computer and journal access (along with a good knowledge of study design, statistics).

As you can imagine, the downside of meta-analyses is that they don’t generate NEW knowledge, since they are summaries of other studies.  Meta-analyses are also limited by the AMOUNT of data already published.  If few researchers have written about a topic, then a meta-analysis isn’t very effective or powerful.  (A meta-analysis on three studies involving only 25 total patients, for example).

Now that we’ve discussed the purpose and function of the meta-analysis, let’s discuss the results of Heneghan’s reported results.

Now, readers need to be very careful when reading blogs, and other articles like mine reporting results such as this – because this is filtered, third-hand information by the time it’s published on blogs, or newspaper articles.  (First source is the meta-analysis itself – which as we’ve discussed is actually a summary evaluation of other work).  Secondary is the Medscape article which summarizes and discusses the results of Heneghan’s study.

Now, that means that anything you read here is essentially third-hand information – if it’s based on the Medscape article.  That’s why we provide links to our sources here at Cartagena Surgery – so readers can read it all first-hand.  This is important because just like the children’s game of telephone, as information is passed from source to source, it is edited, filtered and subtly changed (for reasons of space, editorial preference etc.)

heneghan’s meta-analysis results showed significant reductions in weight, blood pressure, cholesterol and hemoglobinA1c (blood glucose levels) after bariatric surgery.  The Framingham risk score (a score developed based on the landmark Framingham study) which predicts the risk of cardiovascular events (heart attacks, strokes) also showed a significant reduction (which would be expected if all the risk factors such as hypertension were improved).

Framingham Risk Score Calculator

Now, a lot of readers might say, “Wait a minute – isn’t this self-evident?  If you lose weight – shouldn’t all of these things (glucose, blood pressure, cholesterol) improve?”

Yes .- logical reasoning suggests that they should – but in medicine we require hard data, in addition to logical reasoning (ie. A should lead to B versus a study with ten thouand patients proving A does lead to B.)

We need to be particularly careful when suggesting or assuming causality from treatments (surgery) for conditions.  A good example of this is liposuction.  Since liposuction involves the removal of subcutaneous fat – and may result a (a small amount) of weight loss – many consumers assumed that this limited weight loss conferred additional health benefits associated with traditional weight loss.  Wrong!

Sucking fat out of your behind (liposuction) will not lower your blood pressure, cholesterol, or blood pressure and does not replace the health benefits of weight loss or exercise.  I can hear readers snickering now – but that’s because of my phrasing.  For years – many people, some health care providers themselves thought that weight loss, any weight loss lead to the above mentioned health benefits, and that included liposuction related weight loss.  It took several studies to disprove this.  So, in medicine – nothing is obvious – until we prove it is obvious!  (Remember: much of what was “obvious” in 1950’s medicine – is now considered absurd.)

Original Research Article Citation:

Heneghan HD, et al “Effect of bariatric surgery on cardiovascular risk profile” Am J Cardiol 2011; DOI:10.1016/j.amjcard.2011.06.076.  (abstract only – article for purchase).

Medpage Summary Article:

Bankhead, C. (2011). Medical News: Bariatric Surgery gets high marks for CVD risk reduction. Medpage Today.

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