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5 Years Later: Surgery Still Beats Conventional Treatment for Type 2 Diabetes

sharma-obesity-surgery2Readers will recall previous posts on the STAMPEDE trial, an ongoing trial of 150 patients who had type 2 diabetes and a BMI of 27 to 43 who were randomly assigned to receive intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy.

Now the 5 year results of this trial have been published in the New England Journal of Medicine.

Of the 150 patients who underwent randomization, 1 patient in the medical-therapy group died during the 5-year follow-up period (from myocardial infarction during year 4) and 1 patient in the sleeve-gastrectomy group had a stroke; 134 of the remaining 149 patients (90%) completed 5 years of follow-up. One patient in the medical-therapy group, underwent gastric bypass during year 3, owing to failure of the medical treatment. One patient in the sleeve-gastrectomy group underwent gastric bypass during year 4 for the treatment of a gastric fistula.

At 5 years, the criterion for the primary end point (Hba1c <6% without the use of anti-diabetic mediations) was met by 2 of 38 patients (5%) who received medical therapy alone, as compared with 14 of 49 patients (29%) who underwent gastric bypass and 11 of 47 patients (23%) who underwent sleeve gastrectomy.

At 5 years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (−23%, −19%, and −5% in the gastric-bypass, sleeve-gastrectomy, and medical-therapy groups, respectively), triglyceride level (−40%, −29%, and −8%), high-density lipoprotein cholesterol level (32%, 30%, and 7%), use of insulin (−35%, −34%, and −13%), and quality-of-life measures.

Excessive weight gain was observed in 19% of the patients in the medical-therapy group and in no patients in either surgical group.

No major late surgical complications were reported except for the one reoperation mentioned above.

From these findings the author conclude that,

“…bariatric surgery was superior to intensive medical therapy in terms of glycemic control, weight reduction, medication reduction, improvement in lipid levels, and quality of life. Patients who underwent gastric bypass or sleeve gastrectomy were significantly more likely to achieve and maintain a glycated hemoglobin level of 6.0% or less, with or without medications, than were those who received intensive medical therapy alone…The surgically treated patients had superior glycemic control throughout the 5-year period while also using fewer diabetes medications, including insulin. More than 88% of the surgical patients had glycemic control that was considered to be very good to acceptable (average glycated hemoglobin level of 7.0%), without the use of insulin. A majority of the surgical patients who achieved a glycated hemoglobin level of 6.0% or less reached that target without the use of diabetes medications, whereas none of the patients in the medical-therapy group reached that target without the use of diabetes medications.”

No doubt this study supports the notion of long-term benefits of bariatric surgery (even in people with BMI in the 27-34 range) compared to intensive medical treatment alone. Clearly, this should be a treatment that may be considered for patients with type 2 diabetes, who struggle with glycemic control.

@DrSharma
Edmonton, AB

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Doctors Do Not Know Much About Obesity Because They Are Not Expected To

sharma-obesity-medical-students1Despite recognition of obesity by the American Medical Association as a chronic medical disease not unlike hypertension or diabetes, do not expect doctors in the US to know much about it.

If you’re wondering why, the answer is rather simple.

According to a paper by Robert Kushner and colleagues published in the journal Teaching And Learning In Medicine, competencies in obesity prevention, assessment, and treatment are apparently not really required, at least not based on the questions that young doctors can expect to be asked in licensing exams.

The researchers examined the coverage and distribution of obesity-related items on the three step United States Medical Licensing Examination (USMLE), which every practicing US physician (irrespective of the specialty or discipline) has to pass to qualify for licensing.

Although the USMLE question panel did include over 80o multiple-choice items containing obesity-related keywords, 58% of these items were represented by only 4 of 17 organ systems, and 80% of coded items were represented by only 6 of the 107 American Board of Obesity Medicine subdomains.

While the majority of obesity-coded items pertained to the diagnosis and management of obesity-related comorbid conditions, they did not directly address the prevention, diagnosis, or management of obesity itself.

In medicine (as in any other discipline), students focus on topics that they can expect to encounter in their exams – clearly, diagnosing obesity and managing it, is not one of them.

Although this analysis was performed in the US, I would be surprised if any licensing body in the world actually requires of medical graduates to have a good working knowledge of preventing, diagnosing, and managing obesity (rather than just the related comorbidities).
Till this changes, people living with obesity should not be surprised to encounter physicians who may know less about obesity, its causes, and treatments than they might expect.
@DrSharma
Edmonton, AB
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We Desperately Need Scalable Treatments For Obesity

NN Benefits White Paper CoverObesity, defined as the presence of abnormal or excess body fat that impairs health, currently affects 100s of millions of people worldwide.

Although “weight-loss” is a booming global multi-billion dollar business, we desperately lack effective long-term treatments for this chronic disease – the vast majority of people who fall prey to the natural supplement, diet, and fitness industry will on occasion manage to lose weight – but few will keep it off.

Thus, there is little evidence that the majority (or even just a significant proportion) of people trying to lose weight with help of the “commercial weight loss industry” will experience long-term health benefits.

When it comes to evidence-based treatments, there is ample evidence that behavioural interventions can help patients achieve and sustain important health benefits, but the magnitude of sustainable weight loss is modest (3-5% of initial weight at best).

Furthermore, although one may think that “behavioural” or “lifestyle” interventions are cost-effective, this is by no means the case. Successful behaviour change requires significant intervention by trained health professionals, a limited and expensive resource to which most patients will never have access. Moreover, there is ample evidence showing maintenance of long-term behaviour change requires significant on-going resources in terms of follow-up visits – thus adding to the cost.

This severely limits the scalability of behavioural treatments for obesity.

If for example, every Canadian with obesity (around 7,000,000) met with a registered dietitian just twice a year on an ongoing basis (which is probably far less than required to sustain ongoing behaviour change), the Canadian Health Care system would need to provide 14,000,000 dietitian consultations for obesity alone.

Given that there are currently fewer than 10,000 registered dietitians in Canada, each dietitian would need to do 14,000 consultations for obesity annually (~ 70 consultations per day) or look after approximately 7,000 clients living with obesity each year. Even if some of these consultations were not done by dietitians but by less-qualified health professionals, it is easy to see how this approach is simply not scalable to the size of the problem.

A similar calculation can be easily made for clinical psychologists or exercise physiologists.

Thus, behavioural interventions for obesity, delivered by trained and licensed  healthcare professionals are simply not a scalable (or cost-effective) option.

At the other extreme, we now have considerable long-term data supporting the morbidity, mortality, and quality of life benefits of bariatric surgery. However, bariatric surgery is also not scalable to the magnitude of the problem

There are currently well over 1,500,000 Canadians living with obesity that is severe enough to warrant the costs and risks of surgery. However, at the current pace of 10,000 surgeries a year (a number that is unlikely to dramatically increase in the near future), it would take over 150 years to operate every Canadian with severe obesity alive today.

This is where we have to look at how Canada has made significant strides in managing the millions of Canadians living with other chronic diseases?

How are we managing the over 5,000,000 Canadians living with hypertension?

How are we managing the over 2.5 million Canadians living with diabetes?

How are we managing the over 1.5 million Canadians living with heart disease?

The answer to all is – with the help of prescription medications.

There are now millions of Canadians who benefit from their daily dose of blood pressure-, glucose-, and cholesterol-lowering medications. The lives saved by the use of these medications in Canada alone is in the 10s of thousands each year.

So, if millions of Canadians take medications for other chronic diseases (clearly a scalable approach), where are the medications for obesity?

Sadly, there are currently only two prescription medications available to Canadians (neither scalable, one due to cost the other due to unacceptable side effects).

So what would it take to find treatments for obesity that are scalable to the magnitude of the problem?

More on that in tomorrow’s post.

@DrSharma
Edmonton, Ab

 

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Does Gastric Bypass Surgery Change Body Weight Set Point?

sharma-obesity-surgery3The Holy Grail of obesity treatment is to find a way to revere the resetting of the body weight set point from the highest achieved body weight to something that is lower.

Unfortunately, all current treatments fail to “cure” obesity, as they fail to reset the set point to what would be considered “normal weight”. This makes ongoing treatment (be it behavioural, medical, or surgical) inevitable.

For all we know, any attempt at creating and sustaining weight loss regularly activates complex neurohormonal responses that serve to promote weight regain.

The only treatment, which may prove to be an exception is bariatric surgery (although this also only works as long as the surgery is in place – reverse the surgery, and the weight comes back).

Now, a paper by Hans Rudi Berthoud and colleagues, published in the International Journal of Obesity takes an in depth look at if and how gastric bypass surgery changes the body weight set point.

The paper reviews the data in support of the notion that surgery physiologically reprograms the body weight defense mechanism.

Thus, behavioural studies in animal models have shown that the defended body weight is indeed lowered after RYGB and sleeve gastrectomy.

For example, after surgeries, rodents return to their preferred lower body weight if over- or underfed for a period of time, and the ability to drastically increase food intake during the anabolic phase strongly argues against the physical restriction hypothesis.

Furthermore, these authors have also demonstrated that the defense of fat mass is less efficient (whereas defense of lean mass remains intact) after surgery.

However, as they point out,

“…the underlying mechanisms remain obscure. Although the mechanism involves central leptin and melanocortin signaling pathways, other peripheral signals such as gut hormones and their neural effector pathways likely contribute.”

Trying to elucidate the exact underlying mechanisms will hopefully not just improve our understanding of how bariatric surgery works, but also hopefully ultimately lead to the development of novel medical treatments that specifically target the body weight set point and its defence.

@DrSharma
Monterrey, Mexico

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Is Obstructive Sleep Apnea A Barrier to Weight Loss?

sleep-apneaObstructive sleep apnea is a common issue in individuals with excess weight.

Given that untreated sleep apnea negatively affects restorative sleep, which in turn affects both metabolism and appetite, it may well be that sleep apnea is an important barrier to weight loss.

This is exactly what is suggested in a recent study by Whited and colleagues, published in Health Psychology.

The researchers conducted a secondary analysis of a 12 month randomized trial comparing 2 weight loss interventions consisting of dietary counseling for adults with obesity and metabolic syndrome.

Subjects who screened positive for high risk of sleep apnea using the STOP questionnaire (about 50% of the 175 participants), lost less weight (1.2% vs. 4.2%) and were less likely to lose 5% or greater (24% vs. 75%) than participants without risk for sleep apnea.

Thus, the authors conclude that,

“…an OSA screening indicating high risk identifies individuals who will struggle to lose weight when participating in a weight loss intervention, despite equal attendance at treatment sessions and study assessments. Findings of this study suggest that OSA is a significant barrier to weight loss.”

Whether or not treating sleep apnea makes weight loss any easier, the authors have this to offer:

“Although we found that participants reporting current OSA treatment had greater weight loss (6.5% vs. 0.6%), the small sample of individuals receiving OSA treatment (n = 24) precluded statistical comparison.”

Clearly,

“OSA screening as a standard component of weight loss interventions has a high potential for usefulness, as identified individuals can be targeted for more intense or comprehensive treatment. The benefits of OSA treatment as a standard part of weight loss interventions among individuals with obesity and metabolic syndrome has yet to be determined, and future research must include examination of adherence to both OSA and weight loss intervention components.”

@DrSharma
Copenhagen, DK

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