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Benefits (?) of bariatric surgery (WLS)

July 11, 2012
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There were three articles in my MedPage Today update on Monday that I’m finding highly questionable: “Weight-Loss Surgery Works in IBD Patients,” “Bariatric Tx May Stave Off Diabetic Kidney Problems,” and “Obese Diabetics May Benefit from Early Bariatric Tx.”

Let’s take these one at a time, shall we?

Weight-Loss Surgery Works in IBD Patients

Now, I have a problem with that, seeing that some of the complications of WLS are diarrhea, constipation, and bowel blockages (all symptoms of inflammatory bowel disease (IBD). The other problem I have with this “study” is its size: between July of 1999 and May of 2012, researchers studied 3,002 patients who had WLS and only came up with 17 who had some form of IBD.You would think that with 12.5 years of WLS patients, they could have found more than 17 patients with some form of IBD to give this “study” more authority.

The other problem is the lack of follow-up. Nowhere could I find anything that said how long these patients were followed by their surgeons/doctors to see if their IBD continued to be improved, in remission, or whatever. That seems to be the main problem with WLS in general — lack of follow-up for more than six months to a year in most cases. What is needed is a follow-up of five years or more so that the true scope of success, failure, and complications are known for all WLS before it’s prescribed as a “cure” for every ailment suffered by even moderately fat people.

Bariatric Tx May Stave Off Diabetic Kidney Problems

This is another one that had a very small sample size — 52 patients who had five years of follow-up. An overview of WLS and diabetes provided by the Obesity Action Coalition (PDF) says that 15% of bariatric surgery patients have type 2 diabetes. Another study claims there were 1,025 morbidly obese people who had Roux-en-Y (RNY), and 15% of them were T2Ds, which includes 153 people.

If this is a representative sample, then only about one-third of the RNY people who had T2D before surgery had follow-up of at least five years. And I’m betting those who didn’t have T2D and had any type of WLS, didn’t have that (I’d say they had less than two years of follow-up). Why are they not doing more follow-up on WLS patients?

According to the results of the few who do manage to get more than sux months to a year of follow-up, WLS is the greatest thing since sliced bread (/sarcasm). It seems to me that if WLS is so great, and cures so many ills for so many fat people, they should be doing follow-up studies on every patient for at least five years so they can shout their awesome results from the rooftops.

That would convince more people to have WLS, turn more fat people into thin people, cure more illnesses than all the antibiotics and safe water initiatives ever have, and make the WLSurgeons tons of money (yeah, right, when pigs fucking fly).

Obese Diabetics May Benefit from Early Bariatric Tx

I think I’ve covered this one before, and I’m getting tired of beating a dead horse. Now they’re saying that if you have type 2 diabetes, you should have WLS as soon after you get the diagnosis as possible because the longer you have T2D, the worse your chances of staying in remission are.

Patients with a disease duration of 5 years or longer had almost a four-fold higher likelihood of diabetes recurrence as compared with patients who had diabetes for a briefer period before surgery.
Diabetes duration was the only clinical or demographic factor associated with recurrence, Yessica Ramos, MD, reported here at ENDO 2012.

So why are doctors still telling patients that WLS will “cure” their type 2 diabetes?

Multiple studies have shown that many obese patients have disease remission or substantial improvement after bariatric surgery. Earlier this year, investigators at the Cleveland Clinic in Ohio reported that medical therapy plus bariatric surgery controlled diabetes better than medical therapy alone.
A few weeks later, investigators in Rome showed that 75% to 95% of obese diabetic patients had disease remission at 2 years after bariatric surgery versus no patients treated with intensive medical therapy.

I wonder what they consider “disease remission”? Does that mean patients no longer have to take any type of oral medication to control their blood glucose and can eat whatever they want without having to worry about their blood glucose spiking or going low? Because I know of one person who has type 2 diabetes, had WLS, his T2D is in remission, he takes no meds at all, but he still tests his blood glucose several times a day, watches what he eats like a hawk, counts carbs, etc. to make sure that his blood glucose stays in the normal range. He belongs to one of the diabetes lists I joined, and several people on the list have had WLS, hoping to duplicate his results (hasn’t happened).

Most studies to date have provided little information about the frequency and timing of diabetes recurrence after bariatric surgery. To address that issue, Ramos and colleagues reviewed records of all patients who underwent Roux-en-Y gastric bypass from January 2000 to December 2007.
From all records, investigators identified patients who had type 2 diabetes prior to surgery and had a least 3 years of continuous follow-up. The search yielded 72 patients, who formed the basis for the analysis.

Again, in seven years of records of WLS patients, all they could find was 72 patients who had type 2 diabetes prior to surgery and had at least three years of continuous follow-up? WTF is wrong with this picture? Again, I’m asking WhyTF are researchers not following up with their patients for more than six months, a year, 18 months? Are they afraid of what they’ll find if they do follow subjects for longer than that? If they are so afraid of what they’ll find, then maybe they should be a lot more scrupulous about whose digestive systems they choose to mutilate.

Following surgery, 66 of 72 (91.6%) of the patients achieved diabetes remission at some time during follow-up, and the remaining six had persistent diabetes throughout follow-up. The highest remission rate was 83.3% and occurred 12 months after surgery.

Subsequently, 14 of the 66 (21.2%) patients had diabetes recurrence. Five of the 14 patients had recurrence within 2 years, followed by three each at years 3, 4, and 5.

Researchers sought to explain the failure of these 14 subjects.

Examination of pre- and postoperative variables proved to be mostly uninformative about potential explanations for recurrence. Preoperative BMI, fasting blood glucose, HbA1c, or homeostatic model assessment (a measure of insulin resistance and beta-cell function) predicted recurrence.

Patients who remained in remission had a larger initial decrease in weight and had a lower weight throughout follow-up compared with patients who had diabetes recurrence. However, between-group differences never achieved statistical significance, Ramos said.

It looks like what they’re saying is that if you can lose a large amount of weight right away, and keep most of it off, the chances of successfully remaining in “remission” are better. The main problem with that is that there hasn’t been enough long-term follow-up to really know how successful WLS is at maintaining that weight loss — either the initial amount, or even most of it. If the experiences of our WLS group are anything to go by, I’d say the success rate is abysmal.

Only preoperative diabetes duration had predictive value for recurrence, resulting in an odds ratio of 1.26 for trend with increasing disease duration. In the subset of patients with diabetes duration of 5 years or longer, the OR for recurrence jumped to 3.8.

One plausible explanation for the diabetes recurrence is greater beta-cell depletion among patients with longer-duration disease, said Alvin Powers, MD, of Vanderilt University in Nashville, Tenn., who moderated a press briefing where Ramos presented her findings. A larger volume of long-term data is needed to confirm the findings and identify factors associated with an increased risk of recurrence after bariatric surgery, he added.

The only way they’re going to get a larger volume of long-term data is to require surgeons to do at least 5 years of follow-up with each and every WLS patient they have. The odds of that happening aren’t good, because that follow-up takes time away from performing those surgeries. Plus, the follow-up would show how many people end up with life-altering complications, how many people don’t manage to maintain their weight loss, how many people end up as fat as they were before surgery (or fatter), and how many people would never do this again. None of that information is good for the WLS industry (but they’re all good for fat people).

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10 Comments leave one →
  1. July 11, 2012 11:20 am

    There’s something bizarre about that OAC information sheet you mentioned. It cites a study with 1,025 morbidly obese subjects, but the citation leads to this PDF of a study from 1995, which included 608 morbidly obese patients. Also, on followup, half of the subjects weren’t reviewed in a clinic, but over the phone. There were also some really interesting findings in this study, such as “Mental health evaluations revealed marked overall improvement in mood and mental health indicators during the first 2 years after surgery. These gains, however, eroded by the 3rd year, with a return to their previous mood status, perhaps because some of their personal dreams in terms ofmates or socioeconomic success were unrealized.”

    Most shocking is that 9 people (1.5%) died within 30 days of the surgery, while 34 (around 5%) died within five years.

    Regarding glucose intolerance goes, of the 298 diabetic and glucose-intolerant people they followed (they don’t say for how long, as far as I can tell), 271 (91%) have maintained normal glucose levels, while 121 of 146 (83%) diabetic subjects have done so. The rest continue to be diabetic.

    All this makes me curious what the real study they meant to cite actually said.

    Peace,
    Shannon

  2. Pattie M. permalink
    July 11, 2012 11:50 am

    I have to wonder about these conclusions, while I am no expert, I have seen day to day life of several WLS patients some as long as 10+ yrs out. Bottom line in my experience has been within 10 yrs, much of the weight lost is once again regained. All of those I personally know have some sort of IBS symptoms that are not dependent on the amount of food they eat, these range from vomiting to diarrhea.

    Not only are these people not followed by the surgeons, one has to wonder how good their medical follow up is. What I mean by medical is their primary care physicians. I know how good my ileostomy follow up is… almost non existent. There is no follow up to nutritional status…etc.

    As far as the T2D goes, I really have to wonder if this isn’t more due to the reasons they developed it in the first place. Not everyone with T2D develops it as a result of their weight. In my case I developed it at 35, 2ndary to PCOD and genetics. While my primary care insists if I lose “x” percentage of weight, it will improve my T2D…. WRONG! It is what it is. now add to this the fact that I have lupus… this adds another dimension.. my body attacks itself. My conclusion is that my pancrease has been irrepairably damaged, no amount of weight loss is going to change that.

    Physicians fail to really follow patients post op/post diagnosis for a variety of reasons. Most will have you believe that this is always somehow the fault of the patients or patient non compliance. Surgeons seem to feel(based on my own experience) that once a patient is recovered from the procedure, nothing else needs doing and their job is done. This is pure and utter bullshit.

    I agree there needs to be much more follow up. I do have to say though.. that just because glucose control improves short term… it’s likely T2D will return… insulin resistance is insulin resistance no matter how much you weigh. I really think this result will be temporary for the majority and that in some point in time, it will return.

  3. July 11, 2012 12:22 pm

    Well I went into my gastric bypass with mild anemia, normal blood sugars and abnormally low good and bad lipids and normal blood pressure. But because I was fat, that was eventually going to get me right?(dripping sarcasm)
    I now have reactive hypoglycemia, still low lipids, pulmonary HYPOtension, almost 2 years after my gastric bypass has been reversed. My complications prior to my reversal were many and I’ve talked about them before, if I feel better I’ll write more..
    Shannon, the OAC is an organization that’s mission to help the obese is by “eradicating” them from their Obesity. Meaning they are fighting to have weight loss surgery covered standard as a form of health care. I didn’t know how much you knew about them…
    Can’t write or read much today. My blood sugar is low and I have trouble absorbing meds and nutrients, not as bad as when I was intact. I’m still not “normal” and I never will be again. Good Blog, Mariellen, I apologize I didn’t do it justice, my brain is just fried right now.. Hugs..

  4. Janet permalink
    July 11, 2012 1:07 pm

    So this is why my internal doctor wants me to have the WLS….I was diagnosed with Type 2 a year ago in June and I’ve been on diamicron for that time. I lost some weight but then gained some back (not happy about it but I don’t think I look or feel different), so she told me to consider it. I don’t like surgery, in fact I’m terrified and I don’t feel i need this (for the record, I’m still under 300 pounds and I feel pretty great as all my other numbers are really good and my A1C is lower than it was when I was diagnosed – though it did go up a few points in a 6 month span). I told her no. I’m going to continue to tell her no. I think WLS should be for extreme cases and only if it’s the only answer to regaining better health. I do know one woman who is Diabetic and did the surgery and now she’s “cured”, but she was also diabetic for years and insulin dependant (I’m not on insulin and don’t plan on it). This seems like a scam on the part of doctors.

    • vesta44 permalink
      July 11, 2012 1:35 pm

      Janet – My husband has had type 2 diabetes for 18 years now (both his parents had it, as do 4 of his 6 brothers). He managed to control it fairly well with diet and exercise for about 15 years, but finally had to go on insulin 3 years ago. It’s not that big a deal to have to use insulin, especially if it means keeping your blood glucose under control and not having to deal with complications like nerve damage, eye problems, etc. Insulin is just another tool to be used when the time comes, unlike WLS, which is a tool that no one should have to use except as a last resort when everything else has been tried and it’s all quit working (and in the case of type 2 diabetes, I haven’t seen it happen that all the medications available quit working if they’re used correctly and one watches their diet with regards to carbs).

      • Janet permalink
        July 11, 2012 1:48 pm

        Thanks for the reply Vesta. And Yeah, I know that insulin is a tool but I’ve been scared into believing that if you are on it, you will die soon. No kidding!

  5. fatology101 permalink
    July 11, 2012 3:11 pm

    I had a lap band in 2005 and it has given me problems. When I eat, the food gets stuck. Doesnt matter what type and I never know when it will happen. I now have IBS and thanks to you all, I understand why. My lap band was put in wrong. I never lost an ounce with it. I will have it taken out as soon as I can get the money. My husband hates it and cant wait for me to have it removed. I cant eat in public because of the IBS and if I do get food stuck I have to go into the bathroom and stick my finger in my throat to force it up. Nice isnt it. Im just glad I didnt die from it. I should have known better because food doesnt make us fat. But I had hope this was the answer. I have changed my beliefs since then, for sure. I didnt have diabetes then but after getting ‘older’ I started showing signs and my count was going up. Im on meds and it is controlled for now. Isnt it amazing what people believe when it comes to all of this. Even doctors. What a shame.

  6. July 11, 2012 6:50 pm

    … all symptoms of irritable bowel syndrome (IBD)…

    Just as a quick thing: IBD is actually “inflammatory bowel disease,” and it’s a separate diagnosis from irritable bowel syndrome. Though they can produce outwardly similar GI symptoms (cramping, gas, diarrhea, etc.), IBDs are inflammatory autoimmune disorders that can also include symptoms like intestinal ulcerations, internal bleeding, and anemia.

    That said, I have Crohn’s, and quite frankly, the idea of undergoing any kind of surgery that might decrease my ability to absorb nutrients while increasing my possibility for GI discomfort and complications effing scares the shit out of me.

    • July 11, 2012 8:09 pm

      My bad! I proofread this. I’ll correct it later. Thanks for the tip Tori!

      Peace,
      Shannon

  7. July 12, 2012 5:50 am

    I find it hard to see anything WLS cures, all it does is damage. So these WLS advocators are just trying to find ways to sell a useless product. It’s just a sign that since fat people are one of the last groups it’s openly acceptable to hate, they’re also the last acceptable group it is seen as okay to medically experiment on for their health.

    I suggest if any doctor suggests WLS to you look them square in the eyes and say, “First do no harm!” then walk out. WLS is unethical and years from now, the people who promoted it will be seen for their unethical ways by everyone.

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