January 13, 2010

Reckless Recommendation for WLS By Those Who Profit From it--And the ADA

During the holiday season another disturbing diabetes news story was released to the medical press without attracting much notice. That probably didn't bother those who planted it because their target audience isn't you, it's your family doctor.

The group releasing the news is an organization of surgeons who perform weight loss surgery (WLS) What they're promoting is the idea that WLS is a cure for diabetes. They did this by holding a convention filled with surgeons who earn a great deal of money every time they perform this particular surgery and representatives of the American Diabetes Association, a group that has never failed to endorse any product or service that has the potential to earn high profits for those who prey on people with diabetes. This convention released an impressive-sounding "Consensus Statement" designed to make busy family doctors think that world health authorities and experts have carefully analyzed bushels of research and concluded that WLS is a wonderful new cure for diabetes.

You can read about this convention and the Consensus Statement:

The Diabetes Surgery Summit Consensus Conference: Recommendations for the Evaluation and Use of Gastrointestinal Surgery to Treat Type 2 Diabetes Mellitus.
Rubino, Francesco. Annals of Surgery. 19 November 2009
doi: 10.1097/SLA.0b013e3181be34e7

You'll find a bit more detail here:

Diabetes In Control: World Summit on Bariatric Surgery Defines New Guidelines.

Soon you will be hearing from your family doctor that you could be "cured" of diabetes simply by undergoing a routine $20,000 operation. If you don't sign up, your diabetes is obviously your own fault. I have already heard from people who were given just that message by their doctors.

The most disturbing thing about the consensus statement is the horrifying suggestion, based on ZERO peer reviewed research--that WLS--obesity surgery--should be given to people with a BMI as low as 30, which is a much lower BMI than any used as a cutpoint in the recommendations of any experts in organizations who don't provide surgery. But this group of bariatric surgeons is obviously rubbing its hands in glee at the thought of the millions of new customers it's self-serving recommendation will bring in and their recommendations are very high on hype and almost entirely without grounding in hard science.

The position statement recommends weight loss surgery for women who are slightly overweight. For someone 5'3" the recommendation would kick in when they weigh only 170 lbs.

I happen to be 5'3" woman who once weighed that amount. I weigh 138 now, thanks entirely to cutting way down on the carbs in my diet and the addition of carefully chosen safe drugs to my daily regimen.

But the pitch these surgeons make is that WLS isn't just for weight loss. Oh, no. It "cures" diabetes. In fact, the science (what little there is, and there isn't much of good quality) shows WLSdoesn't do anything of the kind. What WLS does is lower A1c. It does that by severely limiting how much food you can eat and, more to the point, it makes people vomit violently when they eat a lot of carbohydrate so that it imposes a low carb diet on them, like it or not.

But before you get excited about the idea that WLS is a cure, it turns out, these surgeries don't even give people truly normal blood sugars. You can read about this in an earlier blog post HERE. The study cited in that post makes it clear that the dramatic claims that diabetes has been "cured" refer only to the blood sugars taken a month or two after surgery when people can barely eat. By five years later the average A1c is 6.58% and 17% of those who had the surgery see no improvement at all.

Almost twelve years after diagnosis my A1c is a lot better than the 6.58% that the loudest proponents of WLS claim as their 5 year surgery result. My highest A1c in the last 5 years was 6.0. My average is 5.7%. All from cutting back on carbs and finding the right, safe, drugs to control my blood sugar. No need for risky surgery.

Yes, my drugs do cost something: Metformin is a generic that is about $120 a year. My insulin cartridges cost $444. Total cost: $564. The cost of WLS runs about $20,000, assuming you don't have complications that will require more expensive surgery and hospitalization, as many people do. So the cost benefit to me of WLS would take 35 years to kick in--assuming WLS worked as well as meds and the low carb diet to prevent complications, which given how high the A1c is at five years in the patients whose surgeons are among the biggest boosters of WLS as a "Cure" for diabetes, is unlikely.

The tragedy is that it does NOT take dangerous surgery to achieve dramatic drops in blood sugar. You might have learned about this on the day you were diagnosed, had the ADA not put all its energy into terrifying doctors and the public about the "dangers" of the low carb diet and pushing a blood sugar boosting diet full of pasta, oatmeal, "healthy" whole grains, and high carb fruits like the banana.

Though a decade of research has come up with not a scintilla of evidence that that low carb diet does anything but improve blood sugar and cardiovascular markers and lower the incidence of diabetic complications, the ADA is now ready to recommend expensive life-threatening surgeries about which little is known though that little shows that the safety of WLS is far worse than the most extreme low carb diet.

In fact, there is very little high quality research about the long term effects of weight loss surgery. Most studies only involve a very few individuals followed for a short time, or, often in the case of diabetes "cures" of rodents. But what human research there is comes up with disturbing findings.

Weight loss surgery, it turns out, is dangerous. To know just how dangerous it is you have to remember that it is standard practice when evaluating the outcome of a surgery to report on the patient's status six weeks after the surgery. After that, most patients are "lost to follow up."

So when you read the statistics about deaths associated with WLS, the percentages given usually describe usually only those deaths that occurred during the first few weeks after the surgery. You do not hear about the complications--or deaths--that take place two, five and ten years after the surgery.

Here's a good example of a study that has been interpreted to show that WLS is safe: Mortality After Bariatric Surgery: Analysis of 13,871 Morbidly Obese Patients From a National Registry
Morino, Mario. Annals of Surgery. December 2007, Volume 246, Issue 6, pp 1002-1009. doi: 10.1097/SLA.0b013e31815c404e

Like most, it only only tracks deaths that occurred within the first 60 days. Even then, in this group of patients, .25% died people within two months. That's 25 for each 10,000 people who had the surgery. Drugs that can be shown to have killed that many people are taken off the market--viz Rezulin, Bextra, etc.

But if you accept that it was worth killing 25 people so that thousands can lose weight and have their diabetes "cured", you might want to look at another very similar study that expanded the time horizon. You can read about it in my previous blog post HERE

This study analyzed registry statistics collected in Pennsylvania and it too found modest death rate. "Only" .9% of patients died within 30 days, slightly less than one in a hundred, though for the families of that one in a hundred, the death was a horrible, unexpected tragedy.

But there were a lot more families left to mourn because the death toll rose dramatically as the group was followed longer. One year after surgery, 2.1% of the group had died. (Twenty-one out of every thousand.) By two years, 2.9% (Twenty-nine out of a thousand). Then things got worse. Three years after they had had the surgery, 3.7% were dead. By four years, 4.8% and by five years, 6.4%. That's slightly more than one out of every seventeen dead.

And yet the ADA's leaders, who have railed about the "dangers" of the low carb diet, stand by when these surgeons suggest that people whose weight is only slightly above normal should be subjecting themselves to a surgery this dangerous to attain an A1c (if they live) of 6.7.

The reason that the death rate increases as time goes by is that people who have had these surgeries are prone to develop problems as the years go by that often require more surgery. The stomach stretches and incisions burst. Bands get embedded in tissue or infected. Some people develop so much scarring in their intestinal tract they can no longer absorb nutrients and starve to death. Some develop profound anorexia, due to the destruction of part of the gut that secretes the hormones that regulate brain hormone centers and they literally starve themselves to death--often blaming themselves for what they think are psychologicla problems because no one explains to them that the brain hunger regulatory system depends on gut hormones.

Would a drug that killed 6.4% of those who took it over five years ever get approved? Of course not. But surgeries don't have to be approved. The FDA does not examine surgeries. No one does. Surgeons are free to do any surgery they can get paid for and the only limit on them is how likely they are to get sued by unhappy survivors of their victims.


If you are a person with diabetes with a BMI near 30, here is a list of safe alternatives to weight loss surgery.

1. Follow the technique described here: How to Get Your Blood Sugar Under Control. This simple, moderate approach works extremely well. I hear from people all over the world who have tried it and report that their A1cs have plummeted from as high as 13% down to the 5% range. Try it for two months before you let someone amputate portions of your stomach. This techniques will give most people much better results, over time, than the surgery.

2. Byetta. If you can't control your eating, Byetta may help a lot. One out of three people respond well to it, and when they do, they find that they can easily cut way back on their food and that their blood sugar improves greatly. I know two people who have lost over 100 lbs each on Byetta and several who have lost 30-50 lbs. All have seen better blood sugars. Best of all, if you don't do well on Byetta, all you have to do is stop taking it and any problems it has caused will reverse.

3. Insulin. If your blood sugars can't be controlled by cutting carbs, surgery probably won't fix it, because if your beta cells are dead, messing with your digestive tract won't do much. According to Dr. Ren, who is cited in the blog post linked above, about 17% of those who undergo gastric surgery for diabetes experience no improvement. And of course, that number excludes those who die of the surgery whose diabetes became tragically irrelevant. Insulin, prescribed by a doctor whose staff is willing to work with you to set the dose correctly, will normalize your blood sugar, especially if you cut way down on your carb intake so that the insulin doesn't have as much work to do.

None of thse is a "cure" but neither, according to the blood sugar statistics released by the most enthusiastic proponents of WLS, is the surgery.



Scott said...

It is morally reprehensible for any medical organization to recommend such radical surgery to patients at the BMI levels you note (although some morbidly obese patients can benefit), and to make such a crass recommendation in the absence of peer-reviewed studies is even worse. I also question the ADA's motives here; they are not fulfilling any of the organization's core objectives by endorsing such strategy. My only guess is that dollars might be involved-somewhere!sli

Bob Fenton said...

Whoa, everyone is going ga-ga over the artificial pancreas and many bloggers are giving it their full attention. It is still way off in the future and is getting a full measure of hype.

And when something as serious as this is and going on now takes place - only one blogger steps forward to alert the rest of us. Something is wrong with our sense of values here.

It appears that some bloggers are only interested in feel good issues and are willing to promote hype (on issues greater than five years in the future - if not a lot longer) instead of doing some investigative work and reporting on serious issues that could harm many more people.


Susanne said...

I have personally known three people who have had WLS (2 of which were only moderately obese and not severely). All have had repeated corrective surgeries afterwards, all of them suffer from digestion and absorbtion problems, all are in poor health now, years after the original surgery. All of them regret having the surgery.

Sure there are success stories, I'm sure. However, the risk of harm is so great it seems obvious the surgery should be 'saved' for the morbidly obese, and not required as a treatment for diabetes, especially when there are far safer and cheaper alternatives (like Jenny points out).

Boz said...

Neither my gp or endo docs recommend bariatric surgery for anything but life and death situations, like disease or morbid obesity. They both said there is no cure, only a lowering of symptoms. Having now lived with 2 partners that had the surgery, no thanks. In my estimation, it's just better to push away from the buffet than have your innerds rearranged.

Jenny, thanks for throwing some more light on this weird science.

Anna said...

I see ads for WLS all the time in my local San Diego newspaper. The "before" pictures always show someone only moderately obese, never morbidly obese. In recent months I've been driving frequently to the northern Los Angeles region and along the way I've identified "WLS billboard zones" in Orange County and Los Angeles County, always near major medical centers. WLS is clearly big business, but not necessarily good medicine.

Bill Fabrey said...

Excellent blog. The ADA has been acting suspiciously for years. Scott is right. Follow the money trail...

I have known people who had WLS who died from it, not always right away. I've known an equal number who regained the lost weight within three years, plus their digestion is now shot. And I've known nobody who benefited in the long run. That doesn't mean that nobody has ever benefited. I just said that I did not know anyone who has.

Fat gets blamed for everything. I believe in a HAES philosophy--Health at Every Size.

Diabetes is a nasty disease, but it can usually be controlled, even in a person with a high BMI. Weight-loss diets, on the other hand, only works for 5% of those who try it, in the long run.

Bill Fabrey
Council on Size & Weight Discrimination
Mt. Marion, NY, USA