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Does Bariatric Surgery Reset The Setpoint?

As readers are well aware, the crux of the obesity problem is that the body tends to defend it’s highest body weight. This is why anytime you try to lose weight, the complex neuroendocrine kick in to try to “sabotage” your efforts and seemingly won’t rest till the weight is regained. So why does bariatric surgery work? Why do people who undergo bariatric surgery not simply eat back the extra calories required regain all of the weight they lost in the first year after surgery? One of the notions is that the surgery itself makes it hard to overeat (restriction) or works by interfering with digestion (malabsorption) – but there is now increasing evidence that neither of these mechanisms appear to be the real reason surgery is so successful. Now, a study by Zheng Hao and colleagues from Baton Rouge, LA, published in OBESITY, provides evidence to support the idea that gastric bypass surgery may produce favourable long-term outcomes by reprogramming the way that they body regulates its weight. The studies (performed in mice), show that after Roux-en-Y gastric bypass surgery, the animals begin to regulate body weight at a level that is lower than before surgery. What was most surprising in these experiments, was that mice which were starved down to a rather low weight before surgery, actually regained weight after surgery (albeit to a weight that is still well below where they would have been before the experiment) and that this weight gain was mainly due to an increase in lean-body mass. This response is very different from animals (or humans) regaining weight after dietary caloric restriction, where most of the weight gain is due to an increase in fat mass. Thus, it seems that the neuroendocrine alterations that happen with surgery, trigger mechanisms that appear to defend against a higher level of body fat, while remaining sensitive to the defense of lean mass. How exactly this works remains unclear but the hope is that by better understanding the molecular and physiological mechanisms underlying this reprogramming we may be able to develop medications that will mimic the effects of surgery. @DrSharma Edmonton, AB


Mental Health Issues In Patients Seeking Bariatric Surgery

There is no doubt that bariatric surgery is currently the most effective long-term treatment for severe obesity, however, there is also some evidence to suggest that patients seeking bariatric surgery (or for that matter any kind of weight loss) are more likely to have accompanying mental issues that individuals with obesity who don’t and that such issues may affect the outcomes of surgery. Now, a paper by Aaron Dawes and colleagues from Los Angeles, CA, published in JAMA presents a meta-analysis of mental health conditions among patients seeking and undergoing bariatric surgery. They identified 68 publications meeting inclusion criteria: 59 reporting the prevalence of preoperative mental health conditions (65,363 patients) and 27 reporting associations between preoperative mental health conditions and postoperative outcomes (50,182 patients). Among patients seeking and undergoing bariatric surgery, the most common mental health conditions, each affecting about one-in-five patients were depression and binge eating disorder. However, neither condition was consistently associated with differences in post-surgical weight outcomes. Nor was there a consistent relationship between other mental health conditions including PTSD or bipolar disease and post-surgical outcomes. Interestingly, bariatric surgery was consistently associated with a significant decrease in the prevalence and/or severity of depressive symptoms. So what do these findings mean for clinical practice? As the authors note, “Guidelines from the American Society for Metabolic and Bariatric Surgery and the Department of Veterans Affairs/Department of Defense recommend routine preoperative health assessments, including a review of patients’ mental health conditions. Other groups advocate for a more comprehensive, preoperative mental health examination in addition to the general evaluation currently performed by medical and surgical teams. The results of our study do not defend or rebut such a recommendation.” So why are these data not clearer than they should be? Here is what the authors have to offer: “Much of the difficulty in determining the effectiveness of preoperative mental health screening is due to the limitations of current screening strategies, which use a variety of scales and focus on mental health diagnoses rather than psychosocial factors. Previous reviews have suggested that self-esteem, mental image, cognitive function, temperament, support networks, and socioeconomic stability play major roles in determining outcomes after bariatric surgery. Future studies would benefit from including these characteristics as well as having clear eligibility criteria, standardized instruments, regular measurement intervals, and transparency with respect to time-specific follow-up rates. By addressing these methodological issues, future work can help to identify the… Read More »


Why Metabolic Surgery Cannot Be A Population Solution To the Obesity Problem

Ludicrous as the thought that any form of surgery could be even remotely considered a possible solution to a problem that affects billions of people around the world may seem, the metabolic surgery literature continues to suggest that it may. There is no doubt that bariatric (or metabolic) surgery is highly effective in reducing body weight and putting diabetes into remission, at least compared to any existing behavioural or medical treatment. Be this as it may, a commentary by Robin Blackstone, published in JAMA Surgery in response to a paper by Chih-Cheng Hsu and colleagues showing favourable 5-year outcomes in surgical treated patients with type 2 diabetes with BMI lower than 35, makes some salient points. “Should metabolic surgery be more widely adopted? The barriers are significant. Cost of the procedure, complications, lack of surgical manpower, poor access to financially supported care, the problems of weight regain, and clinician and payer bias against surgery limit application as a population solution. These barriers are unlikely to change and may be magnified in very large populations.” No one can argue with this assessment. Nor can anyone argue with the statement that what we really need is “…disruptive innovation that can be widely applied to the population at risk, is inexpensive to administer, and can be repeated as necessary. The pace of this work needs to be accelerated with increased funding and collaboration.” Although “Our collective response has neither the scope nor the scale to stem or reverse the tide of this disease. Access to all modalities of treatment should be expanded, keeping our collective fingers in the dike to salvage people in this generation.” This would of course  require an astronomical hike in funding for the search of innovative and disruptive treatments for obesity – funding that may need to approach the cost dimensions of a manned mission to Mars. Whether or not there is any political will to do this, given the stigma and discrimination that people living with obesity experience on all fronts, remains rather unlikely at best. @DrSharma Edmonton, AB


Bariatric Care: Only For The Brave of Heart?

Last week, I discussed in considerable detail the finding of the APPLES study, a prospective 24-month parallel group study comparing weight-loss and health outcomes in wait-listed as well as medically and surgically managed severely obese patients seen in a tertiary care publicly funded bariatric program. While the surgically treated subjects did as well as might one may expect from the published literature (albeit with rather disappointing results in patients undergoing gastric banding), so did the non-surgically managed patients. Indeed, the rather modest degree of weight loss at 24 months (~2.8%) is virtually identical to what has been reported at 24 months in randomised controlled trials and other prospective studies, conducted in research settings. A glass-half-full view of these findings would suggest that clinically significant weight loss at 24 months be achieved in a publicly funded bariatric program (which takes all comers and is generally accessible to patients, who in other systems may not have access to such treatments). On the other hand, a glass-half-empty view of these findings would suggest that our current behavioural treatments for obesity are dismally inadequate and, despite the dedication of considerable resources, barely scrape the surface of providing the help that these patients need. If nothing else, this latter view speaks to the sad reality of this condition in terms of its formidable resistance to behavioural treatment. Indeed, I cannot help but be reminded of the rather dismal state of hypertension management before the advent of modern pharmacotherapy. Older colleagues may recall that not so long ago (less than 50 years!), medicine had little to offer patients with high blood pressure short of drastic sodium restriction, ganglion blockers and surgical sympathectomies (funnily enough, renal denervation for hypertension is currently undergoing a renaissance). Prior to the discovery of safe and effective blood-pressure lowering drugs, many patients with hypertension rapidly progressed to having strokes, heart attacks and kidney failure. Younger practitioners may have forgotten, but “malignant hypertension”, was once a common medical problem, killed thousands of patients in their mid-fifies – a situation that is now virtually non-existant. A similar story could be told for lipid management, where, before the advent of modern lipid-lowering medications, despite best dietary efforts, thousands of middle-aged patients would succumb to heart attacks from their elevated cholesterols. As previously for patients with high blood pressure and high cholesterol, there today remains a severe and urgent therapeutic gap for our obese patients. The… Read More »


Why We Need Medications For Obesity

Regular readers will know of my support for bariatric surgery. Despite all caveats (discussed in previous posts), it remains the most effective (and perhaps only feasible) option for many struggling with severe obesity. However, even under the best circumstances, surgery is not a realistic option to deal with an epidemic that affects millions of individuals. Even with 10,000 surgeries a year, it would only take about 100 years to operate on every eligible patient in Canada, who is severely obese today. This is neither feasible nor affordable. Thus, numbers dictate that overweight and obesity will require treatments that can be taken by millions. To use an analogy: if there were no pharmacological treatments for hypertension or diabetes and the only treatment was an operation, most people would still be dying of heart disease and other complications that are now perfectly preventable and treatable because we have a large armamentum of anti-hypertensive and anti-diabetic medications. Yes, people could perhaps do more to prevent getting hypertension and diabetes in the first place – we know that healthy diets and regular exercise go a long way in preventing both conditions – but even if we can adopt prevention measures that miraculously cut the incidence of these conditions in half – we are still left with millions who will have hypertension and diabetes. If we had no drugs, some of these folks may get some relief by reducing their salt intake or following a strict diet – but we know that in real-life, these interventions are neither realistic nor powerful – without anti-hypertensive and anti-diabetic medications we would certainly not have seen the recent remarkable (over 50%) reduction in cardiovascular diseases – we are seeing far fewer strokes and heart attacks than ever before despite an increasingly overweight and obese populations, an increased prevalence of risk factors (except perhaps smoking) and an aging population. The only reasonable explanation for this decline is the widespread use of highly effective and “proven” medical treatments for these conditions. While it is impossible for 10s of millions of people to be operated upon, there is nothing to stop 10s of millions of people taking a tablet or two everyday if it helps lower their blood pressure or control their blood glucose. These medications were not discovered or tested overnight. It took decades of medical research and innovation to develop the wide range of anti-hypertensive and anti-diabetic medications we… Read More »