Given this bias, it's worth looking closely at two new studies presented at the recent Annual Meeting of the American Society for Metabolic and Bariatric Surgery
First off, you need to understand that this convention is not an objective scientific gathering. It's the annual trade group meeting of the surgeons who profit--to the tune of $20,000 or more per surgery--from doing WLS.
The organization's membership is open to any licensed surgeon who has performed 25 weight loss surgeries. Associate membership is open to just about any medical professional willing to pay the membership fee. This group does not certify WLS surgeons. It does not even insist that the surgeons who join the organization prove that their patients survived the surgery or had good outcomes.
The mission of this WLS trade group is simple: to promote WLS and to provide "research" that will motivate insurers and Medicare to pay for ever more surgeries.
With that in mind, let's look at the studies presented at this latest conference because they are being reported in publications targeting endocrinologists and family doctors as showing that "Data confirms long-term effects of bariatric surgery on Type 2 diabetes."
I do not have access to the actual report, but there is a lengthy summary of it which appeared in the newsletter, Endocrine Today, which gives enough information to help us evaluate what the study really found.
The report begins by quoting a Dr. Christine Ren, identified only as an "associate professor of surgery at New York University School of Medicine," who says,
“This is a strong message to physicians and endocrinologists that gastric banding should be very seriously considered in the morbidly obese diabetic population because it offers the best chance to have better control or remission of their diabetes long-term [emphasis mine].Unmentioned in the report is the fact that Dr. Ren advertises herself publicly, on a web site with the URL "Thin for life" as "the Leading Surgeon for lap band surgery in the U.S." So she is hardly an objective source of endocrinological advice.
Dr. Ren's study gathered preoperative data on 95 patients (mean age, 49.3) who underwent laparoscopic adjustable gastric banding between 2002 and 2004. Five-year follow-up data were collected beginning in 2008.
She states, "At the five-year follow-up, mean BMI decreased from 46.3 to 35.0 — a mean value of 48.3% excess weight-loss."
As Dr. Ren explained it, “There was a sustained benefit — about 40% of patients had complete remission in their diabetes"
Complete remission sounds wonderful doesn't it? But what does "remission" really mean? Well, it turns out to mean this: "Mean fasting glucose decreased from 146 mg/dL preoperatively to 118.5 mg/dL at five years; mean HbA1c decreased from 7.53% to 6.58% (P<.001). "
I don't know about you, but I can get much better numbers than that without having my stomach permanently altered. I did it for seven years only by cutting way down on carbohydrates. Hundreds of my readers do this too.
But I would not consider a fasting blood sugar of 118.5 mg/dl (6.6 mmol/L) "complete remission." Nor would I consider an A1c of 6.58% nondiabetic.
And I'm not alone in this. The ultra-conservative ADA recently updated their position statements to define an A1c over 6.5% as diagnostic of diabetes.
The reason given by the ADA experts for choosing 6.5% as the diagnostic cutoff is that the incidence of retinopathy starts to rise significantly when A1c goes over 6.5%, though if you look at the data the ADA experts cite in their report, the incidence of retinopathy actually starts to rise when A1c goes over 6.0%. I urge all of you to read the ADA Position linking A1c to Diabetes diagnosis.
We all know that retinopathy is a relatively late diabetic complication. The ADA continues to use the presence of retinopathy as a diagnostic indicator for Diabetes, but since Retinopathy develops years after sudden onset diabetes (Type 1) that criterion makes as much sense as diagnosing AIDS by waiting until people develop brain lesions.
Other data suggest that heart disease incidence rises dramatically when A1c goes over 6.0% and that of neuropathy and kidney disease probably do too--as they begin to rise when post-meal blood sugars reach the pre-diabetic range.
Dr. Ren goes on to say,
"about 40% of patients had complete remission in their diabetes. This was confirmed with normal fasting blood sugar, normal HbA1c and they were completely off all medications including insulin,” Ren said. “In addition, there were another 40% of patients who had improvements in diabetes as shown by a decrease in their medication, improvements in fasting blood glucose control and improvements in HbA1c.” Diabetes was resolved in 43% of patients, for a total improvement/resolution rate of 83%.If we define "complete remission" of diabetes as achieving A1c under 7% and FBG under 125 mg/dl, my guess is that a lot more than 43% of us have "resolved" our diabetes with much less invasive approaches. Even if we define a diabetes cure as meaning we achieve truly "normal" blood sugars--i.e. FBG under 100 mg/dl and post-meal numbers under 140 mg/dl at two hours after eating, most of my long term readers may be surprised to discover they have long been are "cured" of their diabetes.
A second study presented at the WLS trade show looked at long term outcomes of the even more dangerous Roux-en-Y gastric bypass surgery, where a large portion of the stomach is permanent amputated. Its findings also make it clear that the diabetes "cure" through WLS is completely illusory.
This study reports,
Complete resolution was achieved in 157 patients who also had a decrease in mean BMI from 50.2 before surgery to 31.3 after surgery. Forty-three percent of these patients subsequently had type 2 diabetes recurrence and associated weight gain [emphasis mine].The chief researcher in this study is quoted as saying, "“When looking at the insulin-controlled diabetic patients, 80% had resolution at some point, but recurred in 72%."
So let's get this straight. Amputating a large part of people's stomach resulted in a transient resolution" of diabetes, that did not last for almost half of them. Only 8% of those who were already diabetic enough to need insulin ended up better off than before they had the surgery.
How much more modest this data is than the results that were all over the media from other studies that claimed diabetes immediately went away in people who had WLS, "Like magic" and did not mention that this finding was based on blood sugar results a few weeks after surgery when the patients were not able to eat any carbs!
If we define "remissions" as dropping FBG or A1c just below Diagnostic Criteria for diabetes, a moderately low carb diet will achieve a higher rate of "remission" with the same or better long term statistics. And it will do so without risking the patients' life or condemning them to life-long nutritional problems.
The drug, Byetta, has been found to achieve similar weight loss and blood sugar improvements in about 1/3 of those who take it, without risking life or malnutrition either.
What leaves me gasping with shock is this: the death rate of these surgeries runs quite high. You can read about the latest metastudy that came up with the statistics, HERE.
No oral drug could ever be approved or sold to the public that killed 13 out of every thousand people who took it. But surgeries are not regulated. So surgeons have been performing WLS for decades even when they knew the death rate from this surgery was as high as 3 in every hundred.
Reading between the lines, this latest study was run in a cherry-picked fashion as i "The data was accrued from participants in the ASMBS Bariatric Surgery Centers of Excellence program." The criteria for being a part of that program is undoubtedly a low mortality rate. So this statistic does not tell you what the death rate among average patients and doctors might be. The numbers I have seen elsewhere range from 1-3%.
Other studies have found the death rate from WLS much higher in some populations and found--more importantly--that it rises when the surgery is performed by doctors with little experience or skill. Since you have no way of knowing how skilled your surgeon may be, as doctors cover for each other and do not let word of their colleague's incompetence or drug addiction or alcoholism to become public, you have no way of knowing what your doctor's personal kill rate might be when you sign up for surgery.
But even those who do not die of the surgery--and some of those whose diabetes "goes into remission" are at high risk of serious nutrition deficiencies after WLS. This is because altering the stomach often destroys the ability to absorb important minerals. This nutritional deficiency syndrome is so severe that a recent Mayo Clinic study found that people who have had WLS have twice the risk of fractures as the normal population. (Read about that study HERE.)
Many people who have had the surgery must go to the hospital periodically for intravenous mineral supplementation without which they can die.
IF your doctor suggests that WLS is a quick way to eliminate your diabetes, remember that he learned this "Fact" from the studies that looked at blood sugar a few weeks or months after the surgery when the stomach is so tiny people cannot eat enough carbohydrates to see elevated blood sugars.
Remember too that the studies show that people with diabetes who need insulin probably won't see an improvement, because if your beta cells are dead, the surgery is not going to be able to fix them.
All WLS does to "reverse diabetes" is make significant carb restriction non-negotiable. Eat enough carbs to raise your blood sugar, early on after the surgery, and you'll vomit it all back up. There isn't room in your tiny stomach pouch for enough food to raise your blood sugar.
Over time the pouch stretches and your blood sugar will go right back up as you eat more food. You didn't reverse anything. You simply lowered your blood sugar by making it impossible to eat carbs.
You can cut way back on carbs without surgery. Byetta can give you non-surgical stomach-valve closure which makes it very hard to eat anything but does not risk fatal infection, opening of stomach wounds, scarring that keeps you from absorbing nutrients or any of the other, horrible complications of WLS.
Metformin can cut way down on hunger and when combined with a carb restricted diet can also give you blood sugars at least as good as what these surgeries produce, and possibly better.
But don't expect to hear this from the media. The WLS surgeons have unleashed a formidable PR machine. They make their claims on TV unchallenged. They promote their surgeries with highly questionable research conducted by doctors who profit personally from the growth of the WLS patient base.
And tragically, they kill people who might otherwise have lived long and productive lives. You can read about many people's experience with WLS including stories of several tragic surgical deaths in this discussion posted on the Low Carb Friends discussion board:
Considering Lap Band Anything I Should Know?