I saw the AP version of this article yesterday*, and I was immediately struck by what was missing. Sad to say, the Times version isn’t any better:
Weight-loss surgery works much better than standard medical therapy as a treatment for Type 2 diabetes in obese people, the first study to compare the two approaches has found.
The study, of 60 patients, showed that 73 percent of those who had surgery had complete remissions of diabetes, meaning all signs of the disease went away. By contrast, the remission rate was only 13 percent in those given conventional treatment, which included intensive counseling on diet and exercise for weight loss, and, when needed, diabetes medicines like insulin, metformin and other drugs.
The study was done in Australia, on patients who had had lap-band surgery (more popular there than gastric bypass). Lap-band surgery involves putting a band around the stomach to create a small pouch rather than removing parts of the stomach and intestine. In theory, it’s less invasive and risky than gastric bypass, and reversible. In reality, it carries a number of risks, such as erosion of the stomach (rendering the procedure irreversible) and death.
In the study, the surgery worked better because patients who had it lost much more weight than the medically treated group did — 20.7 percent versus 1.7 percent of their body weight, on average. Type 2 diabetes is usually brought on by obesity, and patients can often lessen the severity of the disease, or even get rid of it entirely, by losing about 10 percent of their body weight. Though many people can lose that much weight, few can keep it off without surgery. (Type 1 diabetes, a much less common form of the disease, involves the immune system and is not linked to obesity.)
What’s interesting about this bit is that the AP article mentioned that the diabetes often went into remission within days of the surgery.** Which tells me that maybe the effects are due not to weight loss itself but to some other factor. One not mentioned in the article, perhaps. What could it be? From wikipedia:
The patient may be prescribed a liquid-only diet, followed by mushy foods and then solids. This is prescribed for a varied length of time and each surgeon and manufacturer varies. Some may find that before their first fill that they are still able to eat fairly large portions. This is not surprising since before the fill there is little or no restriction and this is why a proper post-op diet and a good after-care plan is essential to success. Many health practitioners make the first adjustment between 6 – 8 weeks post operatively to allow the stomach time to heal.
IOW, someone who’s had lap-band surgery may show improvement in their diabetes symptoms within days of surgery not because they’ve lost sufficient weight to make a difference, but because they’re on an enforced liquid diet, and probably can’t have the kinds of sugary or fatty foods that can aggravate diabetes. Patients who have lap band surgery can, once they heal, go on to eat a fairly wide variety of foods in small amounts. As for gastric bypass patients? (AP):
Gastric bypass is even more effective against diabetes, achieving remission in a matter of days or a month, said Dr. David Cummings, who wrote an accompanying editorial in the journal but was not involved in the study.
Yeah. And yet somehow the AP article, like the Times article, mentions this without also mentioning what gastric-bypass patients face after surgery. From the Mayo Clinic:
You won’t be allowed to eat for one to three days after the surgery so that your stomach can heal. Then, you’ll follow a specific progression of your diet for about 12 weeks. The progression begins with liquids only, proceeds to pureed and soft foods, and finally to regular foods.
With your stomach pouch reduced to the size of a walnut, you’ll need to eat very small meals during the day. In the first six months after surgery, eating too much or too fast may cause vomiting or an intense pain under your breastbone. The amount you can eat gradually increases, but you won’t be able to return to your old eating habits.
Should you try to return to your old eating habits, your body will let you know in no uncertain terms that it’s not going for that:
* Eat small amounts. Just after surgery, your stomach holds only about 1 ounce of food. Though your stomach stretches over time to hold more food, by the end of three months, you may be able to eat 1 to 1 1/2 cups of food with each meal. Eating too much food not only adds more calories than you need but also may cause pain, nausea and vomiting. Make sure you eat only the recommended amounts and stop eating before you feel full.
* Eat and drink slowly. Eating or drinking too quickly may cause dumping syndrome — when foods and liquids enter your small intestine rapidly and in larger amounts than normal, causing nausea, vomiting, diarrhea, dizziness and sweating. To prevent dumping syndrome, choose foods and liquids low in fat and sugar, eat and drink slowly, and wait 30 minutes before or after each meal to drink liquids. Take at least 30 minutes to eat your meals and 30 to 60 minutes to drink 1 cup of liquid. Avoid foods high in fat and sugar, such as regular soda, candy and candy bars, and ice cream.
* Chew food thoroughly. The new opening that leads from your stomach into your intestine is very small, and larger pieces of food can block the opening. Blockages prevent food from leaving your stomach and could cause vomiting, nausea and abdominal pain. Take small bites of food and chew them to a pureed consistency before swallowing. If you can’t chew the food thoroughly, don’t swallow it.
* Drink liquids between meals. Drinking liquids with your meals can cause pain, nausea and vomiting as well as dumping syndrome. Also, drinking too much liquid at or around mealtime can leave you feeling overly full and prevent you from eating enough nutrient-rich foods. Expect to drink at least 6 to 8 cups (48 to 64 ounces) of fluids a day to prevent dehydration.
* Try new foods one at a time. After surgery, certain foods may cause nausea, pain, vomiting or may block the opening of the stomach. The ability to tolerate foods varies from person to person. Try one new food at a time and chew thoroughly before swallowing. If a food causes discomfort, don’t eat it. As time passes, you may be able to eat this food. Foods and liquids that commonly cause discomfort include meat, bread, pasta, rice, raw vegetables, milk and carbonated beverages. Food textures not tolerated well include dry, sticky or stringy foods.
* Take recommended vitamin and mineral supplements. After surgery, your body has difficulty absorbing certain nutrients because most of your stomach and part of your small intestine are bypassed. To prevent a vitamin or mineral deficiency, take vitamin and mineral supplements regularly. These generally include a multivitamin-multimineral, calcium, iron, vitamin B-12 and vitamin D. Talk to your health care provider about recommended vitamin and mineral supplements following gastric bypass surgery.
There are some chilling quotes from a couple of the different articles on this. From the Times article:
The study and an editorial about it are being published Wednesday in The Journal of the American Medical Association.
The editorial, by doctors not involved in the study, said, “The insights already beginning to be gained by studying surgical interventions for diabetes may be the most profound since the discovery of insulin.”
A researcher who is not a surgeon and was not part of the research, Dr. Rudolph L. Leibel, co-director of the Naomi Berrie Diabetes Center at Columbia University Medical Center, said the study was important because it showed that a minimally invasive type of surgery could reverse diabetes.
“At this point,” Dr. Leibel said, “maybe we should be more accepting or responsive to the idea of surgical intervention for reducing or prevention of diabetes and its complications.” …
Based on guidelines created by the National Institutes of Health in 1991, weight-loss surgery is generally only recommended for people whose B.M.I. is 40 or more, unless they also have Type 2 diabetes, in which case a B.M.I. of 35 is the cutoff. In this study, 13 people, or 22 percent, had a B.M.I. under 35.
Medicare covers weight-loss surgery according to the institutes’ rules, but many private insurers refuse to cover the surgery at all, said Dr. Philip Schauer, director of the bariatric and metabolic institute at the Cleveland Clinic. He said his center had to turn away three or four patients for every one accepted because insurers would not pay.
On average in the United States, banding costs $17,000 and the other bariatric operations $25,000.
Dr. Schauer said that the B.M.I. cutoffs did not make sense medically and that the study “blows away this arbitrary barrier.” He said that the cutoffs should be lowered, so that a patient with diabetes and a B.M.I. of 34.9 would not be considered ineligible, as is now the case.
Dr. Francesco Rubino, director of the metabolic surgery program at NewYork-Presbyterian/Weill Cornell Medical Center, also said that the criteria for the surgery should be changed so that it could be offered to diabetes patients early enough to reverse the disease.
Or, you know, we might reform healthcare so people could get into treatment and prevention earlier (perhaps even when they’re thin or average-weight and beginning to show signs of pre-diabetic conditions) instead of cutting them up after they’ve already become diabetic.
From a HealthDay version:
Still, the surgery is extremely expensive and carries risks. However, the findings show promise for people with diabetes who need alternative ways to shed pounds, said study author John Dixon, a obesity researcher at Monash University in Melbourne, Australia.
“It doesn’t seem to matter how you lose it,” Dixon said. “This particular study shows that it’s the weight loss that has the effect.”
Sure, you may die, you may vomit, your stomach might be perforated, and your hair might fall out, but you’ll have lost the weight and that’s all that’s important! (To his credit, Dixon acknowledges that it’s not easy to lose weight via traditional methods, particularly for diabetics — and that that is due in part to the medication they’re on. So, vicious cycle — you develop insulin resistance, you start taking medication that won’t let you lose weight, and because you can’t lose weight, you start getting pushed into surgery).
And yet, does he, or the other editorial writers, really deserve credit for pushing the surgery? From the Times:
Dr. Dixon has received research grants and speakers’ fees from the company that makes the gastric bands, Allergan Health, and the company paid for the study through a grant to the university. But his report said the company had no influence on the design of the study, the data or their report.
The editorial writers said they had accepted travel grants from Allergan and other companies to attend a conference on diabetes surgery in Rome.
No influence. Right.
*I was gearing up to write about it, but I’m fighting off something that feels flulike.
** Whoops. As Vox pointed out, the article actually says that it went into remission within two years of the lap band surgery, but within days of gastric bypass. I blame the flu.
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