Search Results for "why i support bariatric surgery"
Time Course of Incretin Responsiveness to Bariatric Surgery
A rapidly accumulating body of evidence supports the profound impact of bariatric surgery on patients with type 2 diabetes, often resulting in complete resolution of this condition. Two of the key mechanisms by which bariatric surgery improves glucose control are related to weight loss and to changes in the secretion of gut hormones that influence metabolism. The later may explain why, especially in patients undergoing gastric bypass, type 2 diabetes can markedly improve within days of undergoing surgery, well before patients lose a significant amount of weight. A paper by Mousumi Bose and colleagues from Columbia University, published in the Journal of Diabetes suggests that both mechanisms follow different timelines and may therefore independently contribute to improvements in glucose control after gastric bypass surgery. The researchers studied 11 severely obese women with type 2 diabetes before and 1, 6, and 12 months after gastric bypass surgery; 8 non-diabetic severely obese women were used as controls. Measurements included insulin levels in response to oral glucose and to an isoglycemic intravenous challenge, C-peptide, proinsulin, amylin, glucagon, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide-1 (GLP-1) levels and the incretin effect on insulin secretion. While the improvements in fasting glucose and insulin was associated with weight loss up to 12 months, the blunted incretin effects improved at 1 month, but remained unchanged with further weight loss at 6 and 12 months. The same pattern was observed with the initially blunted incretin (GLP-1 and GIP) levels, early phase insulin secretion, and other parameters of beta-cell function (amylin, proinsulin/insulin), which improved rapidly at 1 month but remained unchanged thereafter. The data support the notion that while the rapid improvement seen in glucose metabolism after bypass surgery may be largely determined by a rapid improvement in the secretion and action of gut hormones, the overall longer-term improvement in glucose control may be more likely determined by the ultimate magnitude of weight loss. Clinicians should note that because of the different mechanisms involved in the metabolic changes seen after bariatric surgery, both the time course and magnitude of changes in individual patients may be quite variable and in some cases hard to predict. Whether or not these findings will eventually guide the specific use of certain types of operations for patients with type 2 diabetes remains to be seen. AMS Duchesnay, Quebec You can now also follow me and post your comments on Facebook Bose M, Teixeira J, Olivan… Read More »
Why in Obesity Treatment Averages Are Not Good Enough
One of the topics that I have often thought about (especially in light of our seeming inability to develop zero-risk obesity drugs) is the problem of averages. Our entire medical philosophy of “evidence-based” medicine seems built on the “Gaussian” assumption that averages can reflect the true benefit (or risk) of a drug, when in real life (or medical practice) there is no such thing as the truly average patient. Clearly, a drug that works in most cases may be entirely ineffective (or have rare but serious adverse effects) in a given patient. Similarly, a drug that is ineffective for most patients can potentially work miracles in a small set of individuals. For those of you who like analogies, imagine wanting to treat every case of fever with penicillin. Yes, if you run your study during an epidemic of streptococcal infections, more people with fevers may respond than during other times. But even then you will need large numbers to cut through the “noise”, as many fevers will spontaneously resolve or continue unabated unto death (which is why we need a “control” group). Chances are, we may well find that treating all fevers with penicillin is not much better that placebo and we will likely nicely demonstrate that simply taking penicillin for fever has unacceptable individual risks (including deaths from anaphylactic shock). Clearly, penicillin should not be on the market given its potential for “abuse” by anyone who has a fever. But as we take a closer look at the data we may find that while penicillin is not a great drug for everyone who comes down with a fever, there may be a subset of patients (strangely those who appear to have bacterial infections), in which penicillin does seem to sometimes work. Yes, some of these patients may also have severe anaphylactic responses, but on “average”, people with fever due to bacterial infections do seem to get better faster than people with other causes of fever. As we look even more closely at the data it seems that even among those with bacterial infections not everyone is “average” – fever patients affected with a certain type of bacteria (interestingly those who stain positively with a certain dye) seem to respond well (albeit still with occasional anaphylactic responses), while those infected by non-staining bacteria (and even some of those that stain positive) seem entirely unresponsive. You can see where I am… Read More »
Psychological Assessment and Management of Bariatric Surgical Patients: What and Why?
All current guidelines highlight the need for mental health assessments in individuals considering bariatric surgery. But what exactly should be assessed, how important is mental health as a predictor of outcomes and what is the risk for exacerbation of mental health problems after surgery (remember: bariatric surgery has been reported to substantially increase the risk of suicides and accidental deaths). These questions are now addressed in a review paper by Charles Pull from the Centre de Recherche Public de la Santé, Luxembourg, just published in Current Opinions in Psychiatry. The review summarizes findings from previous review articles and new research findings published between August 2006 and August 2009. According to Pull’s review, although the value of psychopathological factors for predicting weight loss and mental health after surgery remains controversial, the presence of psychopathology should be taken into account both in the presurgical and postsurgical management of patients undergoing bariatric surgery. Not only is morbid obesity associated with higher rates of psychopathology, including depression, anxiety, eating disorders, abnormal personality traits and personality disorders, there is also clear evidence for poorer postsurgery outcome in individuals with significant presurgery psychopathology (although mental health may improve in a significant number of patients after surgery). There is a clear need for more substantial information with regard to reliable psychological predictors of weight loss and mental health after surgery. Importantly, Pull concludes, “whatever the predictive value of psychopathology prior to surgery, it is essential to detect patients in need of psychiatric and/or psychological support after surgery”. I could not agree more. AMS Sapporo, Japan
Year-End Roundup, May 2011
As 2011 approaches its end, I thought I’d take the opportunity to remind readers of some of my favourite posts of the past year: Why I Support Bariatric Surgery (5-part series starts here) Why Bariatric Surgery Can Fail (5-part series starts here) Why It Is So Hard To Maintain a Reduced Body Weight The 4 M’s of Obesity Assessment and Management 10 Game-Changing Rules For Obesity Management Happy Holidays! AMS You can now also follow me and post your comments on Facebook
Is There A Role For Dietitians In Obesity Management?
Over the past 30 years, I have actively been involved in nutrition research – conducting numerous carefully controlled dietary studies ranging from the impact of electrolytes on blood pressure and renal function, to the impact of micro and macronutrients on insulin resistance and metabolism, to the role of genetic factors in response to nutrient intake. In all of this, dietitians have always been key players in my research team helping with the design and execution of these studies. In my clinical work, I have regularly depended on the tremendous expertise of dietitians in the care of my patients with hypertension, chronic kidney disease, dyslipidemia, and type 2 diabetes – in virtually all of these conditions, dietitians have helped my patients on a wide range of treatments ranging from medications to chronic hemodialysis improve their diets, thereby significantly improving control of their underlying diseases or averting complications. I have practiced medicine long enough to remember the days of prescribing low-salt diets before the modern era of anti-hypertensive medications, dietary lipid management before the introduction of statins, and worrying about glycosuria well-before most people considered type 2 diabetes to be an actual “disease” and not just a “risk factor” of questionable significance that happens to old people. Thus, it is with a bit of wonder that I sense an increasing reluctance of some dietitians (at least in Canada) to fully embrace the important role that they could play in obesity management. At times, in recent conversations, I was surprised (and concerned) that more than a few (younger?) dietitians are not only uncomfortable with addressing obesity in their clients, they are in fact ambivilant (if not frankly hostile) to the very idea that obesity is a disease or that dietary interventions to support weight loss have a role to play in obesity management. This, of course does not apply to the many excellent and skilled dietitians working in the many bariatric centres and obesity clinics, without who many of the successful outcomes in medical and surgical treatment of this chronic disease would hardly be possible. Rather, ambivalence towards nutritional obesity management appears to emanate from folks who clearly do not (yet) have a sound understanding of the complex psycho-neurobiology of obesity or the mode of action and effectiveness of evidence-based obesity treatments that include medications and surgery. Indeed, I cannot but wonder about these dietitians’ qualifications to actually contribute to the care of… Read More »
