Is Surgery the Magic Bullet Against Obesity?

by Lou Schuler on Apr 21, 2008 9:24 AM EDT in News

I had no idea, until I saw this report on 60 Minutes last night, that gastric-bypass surgery causes immediate remission of type 2 diabetes, stops sleep apnea, and may even reduce the incidence of obesity-related cancer.

The report makes a pretty strong argument for all those benefits, which kick in even before the main effect of the surgery, which is dramatic (and more or less sustained) weight loss.

Something else I didn't know:

A big reason the operation works is because it seems to suppress appetite. "If you listen to your patients, they come back and they say, 'Doctor, you put the fire out,'" Hutcher says. ...

Paul Delios of Saugus, Mass. has lost 90 pounds. He owns a doughnut shop with his siblings, but he's able to resist the cravings. "Before I'd have cravings for everything. Now I really don't," he told Stahl.

For most patients the cravings really do disappear. One theory is that's because the operation suppresses the levels of a stomach hormone called "grelin" that activates the sensation of hunger.

The most startling information, though, concerned diabetes:

Studies confirm that about 80 percent of diabetics go into complete remission following the operation. Obesity is considered one of the major causes of type 2 diabetes, but here's something odd: when you have the gastric bypass operation, your diabetes goes away long before you lose the weight. ...

This spontaneous remission puzzled Italian surgeon Francesco Rubino, now at New York Presbyterian Weill Cornell Medical Center. "We wanted to know what is making diabetes remit. We thought it could have been something to do with the small bowel," Dr. Rubino says.

So he began performing the bypass on diabetic rats, and realized that when he disconnected the top of the small intestine, an area called the duodenum, the diabetes disappeared. Then, he reversed the operation. When he reattached it, the diabetes came back.

This was a pivotal discovery. By merely blocking food from traveling through the duodenum, Rubino sent diabetes into remission, proving the effect was independent from weight loss. This meant diabetes could essentially be removed with a scalpel.

Dr. Rubino argues that the surgery, which he now performs on humans with type 2 diabetes, is safe and effective. 60 Minutes notes that it's not legal in the U.S., since our regulations only allow bariatric surgery for people who're morbidly obese. Naturally, 60 Minutes argues that those guidelines -- written 19 years ago, long before anyone knew about the surgery's potential benefit for diabetics -- should be reversed.

Which brings me to the big question I have about all this: Just because we can reverse obesity-related disorders with a surgery, should we? One doctor, himself a successful bariatric-surgery patient, says he now is much more likely to recommend it for overweight patients:

The bypass operation costs an average of $25,000 and insurance companies don't always cover it; and despite the gains in safety, most doctors still consider the operation an option of last resort. That is no longer the case for Dr. Miller's patients.

"I look at 'em now and I'm handing out my surgeon's card right when I see 'em. I'm not waiting for the last resort now," Dr. Miller says, who lost 120 pounds after the surgery.

"Do you think most doctors are where you are?" Stahl asks.

"Probably not," he says. "They haven't walked the walk."

On the one hand, the surgery is more refined now, with less risk to patients. The death rate, according to 60 Minutes, has gone from 1 in 100 patients to 1 in 1,000. More surgeons have more cumulative experience with the operation than ever before. On the whole, the odds of the surgery improving the lives of patients seems to far outweigh the potential risks, assuming at this point that the only people getting the surgery are the ones who want it. (We may someday get to the point where people who don't want it are pressured into it, but I think that's still pretty far down the road.)

But, to use a financial-industry term, I wonder if making bariatric surgery too easy to get presents a risk of moral hazard. Here's the Wikipedia definition of the term:

Moral hazard is the prospect that a party insulated from risk may behave differently from the way it would behave if it were fully exposed to the risk. Moral hazard arises because an individual or institution does not bear the full consequences of its actions, and therefore has a tendency to act less carefully than it otherwise would, leaving another party to bear some responsibility for the consequences of those actions.

When the subprime-mortgage crisis hit, there was a lot of talk of moral hazard. If people on both ends of the crisis - lenders and borrowers -- can get relief from the bad choices they made, what message does that send? Here's Wikipedia again:

A moral hazard arises if lending institutions believe that they can make risky loans that will pay handsomely if the investment turns out well but they will not have to fully pay for losses if the investment turns out badly. Taxpayers, depositors, other creditors have often had to shoulder at least part of the burden of risky financial decisions made by lending institutions.

A moral hazard can also occur with borrowers. Borrowers may not act prudently (in the view of the lender) when they invest or spend funds recklessly. For example, credit card companies often limit the amount borrowers can spend using their cards, because without such limits those borrowers may spend borrowed funds recklessly, leading to default.

It's easy to apply that to obesity: If you know that surgery can reverse the impact of bad choices you've made in your diet and lifestyle, what's your incentive to change those behaviors? One of the surgery patients interviewed in the 60 Minutes story said he used to be "addicted to food." After the surgery he was not only cured of that addiction, he also became more active.

Which is great for him, but what message does it send to others? What if there was a surgery that cured alcoholism, for example? Would someone struggling with drinking problems have any incentive to change his behavior? Or would he get the message that he can keep on drinking, and if it becomes too problematic he can simply get an operation that turns him into a teetotaler overnight?

The libertarian in me wants people who want the surgery to be able to get it with as few roadblocks as possible. The part of me that's inherently skeptical about miracle cures wants to keep the gastric-bypass bandwagon in the slow lane. The part of me that's a realist acknowledges that nobody really chooses to be obese, that there's a powerful genetic component to obesity, and that modern life encourages overconsumption of everything, including food. Finally, the part of me that's a fitness professional wants people to have every incentive to exercise, eat a clean diet, and manage their lifestyle for maximum health and longevity.

I have no idea which of those four arguments should win. Thoughts?

Monday blog meat

This is a different topic, but it kind of touches on the periphery of the "moral hazard" argument: A new study shows that cancer survivors in Canada don't get enough exercise and are often obese. The flip side is that chemotherapy screws with your metabolism and energy levels in a huge way, and I think the last thing we should do is judge cancer survivors by their activity levels or weight on the scale.
On the lighter side, here's a spring-related fitness topic: how to stay in shape by gardening. I'm not ready to abandon the weight room, but I notice I get leaner in the summer when I'm trying to take care of an increasingly unruly lawn.

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60 minutes

Did you notice that although everyone lost weight most of the people on 60 minutes were still overweight or obese?

Looking at the amount of neck fat I doubt that they all had cured sleep apnea. Only one man, the youngest looked fit. He was overweight/obese all his life but he adopted an active lifestyle after the surgery.

In fact he looked good- most of the others did not I still think physical activity has to be promoted despite the surgery. I really don't understand the angle on reduced cancer either.

If most people after surgery stay overweight or obese how does the cancer risk get reduced?- assuming the risk is there in the first place. One other question if the stomach holds only four ounces how can you get essential nutrients?

Personally I've been overweight/obese most of my life and I think the failing of most weight loss regimes is that they fail to recognize that it's much harder for someone who has always been overweight to lose and maintain their weight then it is for someone to maintain fitness or go back to a fit state after letting themselves slip.

I think I've found the right combination of activity and diet and I've seen steady results for the last four months. I was in my best shape in my 20s very active but still overweight. Thankfully I'm not diabetic. I don't want to judge people who have surgery but I think other means have to be promoted.

One complaint I have about fitness professionals and others who have never been fat is that they simply have no conception of how hard it is for a fat person (since childhood) to bring down their weight. They have to work twice as hard than someone who is already fit.

But if one opts for surgery physical activity after the fact has to be promoted. If not I bet that these people will still be effected by issues of health especially those effecting mobility in later life.

by finecrowd on Apr 21, 2008 11:14 AM EDT 0 recs

More power to you

Congratulations on working hard to be helthy even though you have to work twice as hard.

In my case the surgery worked to "reset" my body to a healthy weight and level of fitness. I still have to work pretty hard to keep fit - but now a setback like biceps tendonitis (my most recent sports-related injury) won't undo everything I've worked for the last year. Good luck and keep fit!

by Marisette on Apr 23, 2008 12:59 PM EDT up 0 recs

not condemming

I'm not condemming surgury heck I may have to do it myself if i see no way out (besides I'm chicken) and I'm glad you exercise but it seemed like most of the 8 or 9 people in the 60 minutes piece were both still obese and out of shape- except for one man.

by finecrowd on Apr 24, 2008 12:07 PM EDT up 0 recs

On the fence

I'm really on the fence on this. The surgery without a lifestyle change isn't going to be effective. I've seen it personally with a couple of associates, they had the surgery lost a bunch of weight but slowly put a big chunk back on. On the other hand having been obese most of my life I can understand the battle to get the weight off and importantly keep it off. I don't plan on surgery even though I am probably an ideal candidate but I can certainly see the appeal.

A couple questions

Are there any studies out there comparing active overweight/obese people to inactive people of any size ?
Has anyone looked at why overweight/obese people seem to have a harder time keeping the weight off ? For example I have noticed if during the week I have a slip up and over eat my weight loss will stall for several days despite my cumulative calorie count being down for the week.

by slevan on Apr 21, 2008 2:55 PM EDT 0 recs

I agree on 2

I have the same problem as you mention in your second question. It's just easier to stay on caloric track now that I've had the gastric bypass.

by Marisette on Apr 23, 2008 1:01 PM EDT up 0 recs

diabetes and bariatric surgery

When I lost c30 lbs of fat 5 years ago, I assumed I would not get diabetes. Two sessions of retinopathy changed my mind, I have type 2 controlled with diet, exercise, and now insulin. My opposition to bariatric surgery was that if you had to control your eating as much as you do afterwards, why not control it now. Part of the answer is that if disconnecting the duodendum not only stops appetite, and also controls glucose misfunction then it is in fact curative. And weigh that against the figure I have read (not confirmed) that the average diabetic cost in the US is $35,000 a year. The figure seems incredibly high, but a single amputation and the ensuing costs could probably hit a millions dollars. Anyway I shall follow this and if in a few years they still are recommending it, I would be tempted to have it done. RobLL

ps - I have lost almost all my extra weight, maybe 5-10 lbs to ideal weight.

by Rob on Apr 21, 2008 3:13 PM EDT 0 recs

The diabetic connection has been known for years

The diabetic connection to Gastric Bypass has been known for years. I would suggest that you check gastric bypass message boards or go to some support meetings in your area to learn more - often the surgeon will be present and answer questions. This subject often comes up in support meetings and even 6 years ago the surgeons were already remarking on the speed with which diabetes was clearing up in their patients. Not that I'm suggesting the surgery for you (you wouldn't qualify with a BMI under 35 with diabetes, or under 40 without it), but if you are interested in following the subject that's where you can start to find out more.

by Marisette on Apr 23, 2008 1:05 PM EDT up 0 recs

uh, what?

Yeah, it's much better for people to lose their eyesight, limbs, and life expectancy to diabetes after suffering the "moral" failing of coming down with the disease than it is for them to have the option of surgery. I've known a number of people with type 2 diabetes who were way, way to small to qualify for bariatric surgery in this country (as are most of Dr. Rubino's patients, from what you report), including athletes. Should they also be condemned to all the horrifying side effects of their disease, or is it only the fat diabetics who deserve to suffer?

In any case, it's not like bariatric surgery is an "easy out". If you've ever spoken with people who've had the surgery, the successful patients who are thriving years after surgery are working their asses off...and they still risk osteoporosis, B12 deficiency, iron deficiency, repeated surgeries, and probably other effects we'll only discover as the oldest successful patients continue to age.

by kimuchi on Apr 22, 2008 5:09 AM EDT 0 recs

I don't think anyone deserves to suffer

That's why I'm conflicted about all this. But I also understand some of the risks involved in the surgery, and I'm loathe to view it as a magic bullet. It may be "simple" from an outside point of view, but I know it's complicated for the person whose digestive system is getting rearranged.

I've known three women who had the surgery. One was morbidly obese, the size of two normal-size adults, at least. Richard Simmons used to get on the phone and cry with her. We only worked together a short time, but from what coworkers told me, she had serious issues, both before and after the surgery.

Another fell into the category of "pleasantly plump," a really terrific coworker who happened to be overweight and inactive. I've mentioned her before, either on this blog or the old one. After the surgery, she tried working out for the first time. It was a completely new sensation to her. She told me she'd never considered herself someone who could be active.

That one offhand comment really changed the way I look at exercise. Lots of people don't do it because, for reasons I can't pretend to understand, they don't feel like they can. I'd be a fraud as a fitness advocate if I didn't acknowledge that self-efficacy is a huge obstacle for a lot of people.

The third was healthy and active but stocky. She'd had four or five kids, and the weight just wasn't coming off with diet and exercise. So she took the risk and had the surgery. It was largely a vanity thing, but let me tell you, it worked. Post-surgery, she was really lean and svelte. She may have been in the "mildly obese" category pre-surgery, but afterwards, you'd never have guessed she was ever overweight.

by Lou Schuler on Apr 22, 2008 6:23 AM EDT up 0 recs

Here's What

My heart goes out to anyone who has eaten themselves into a corner. The problem is, if surgery becomes the front line solution we will disempower people to change the very habits that got them there in the forst place.

Whilst for some, it may be too late and this is the only option, for many it's a way out that in offers it's own problems. "osteoporosis, B12 deficiency, iron deficiency, repeated surgeries..." Is that really such a great solution.

More importantly, what kind on message are we sending younger generations faced with spiralling obesity rates and the associated conditions that go along with it. "Don't worry guys we can fix it with surgery"? Better to tackle the roots of the problem otherwise we will always be treating not curing.

by Rannoch on Apr 22, 2008 6:00 AM EDT 0 recs

eating themselves into a corner

See this is the problem- This appears to be the kind of attitude that shows a lack of comprehension of being fat. You make it sound like a choice? As adults you can make more conscious choices but what if your childhood weight makes it twice as difficult? (Snowball effect, yo yo dieting. things we don't know)

You should be asking how the person got there. Were they thin in their 20s? Or did they pack on the pounds since childhood? Were they encouraged to eat well and be physically active as children by their parents? What indeed did eating well mean to your parents? My parents are older grew up during a time when abundance of food was a marker of success before that malnutrition was the problem.

The solution is much more difficult for someone who grew up fat so maybe surgury is the answer- for some it defiantly is.

The complexity of obesity demands more research and a more learned approach.

by finecrowd on Apr 24, 2008 12:28 PM EDT up 0 recs

bariatric surgery

Yoicks - read Jenny

http://diabetesupdate.blogspot.com/

I had no idea of the subsequent (ie, ten year) excess death rate. On the other hand, whatever is happening to the diabetes is fascinating. But no meat ax solution, this will require a lot more information and finesse.

by Rob on Apr 22, 2008 2:56 PM EDT 0 recs

Holy shit!

Rob, thanks for that link. I hope everyone reads it.

The part about malnutrition killing bariatric-surgery patients years after the operation, while speculative, is still scary enough to make me a lot more pessimistic about this whole process.

by Lou Schuler on Apr 23, 2008 7:43 AM EDT up 0 recs

Awww, so many statistics

I just went to my five year checkup with my bariatric surgeon where I complained that my appetite was back with a vengeance. (My weight loss total shrunk from 110 # lost to 100 # lost, but I still look pretty good.) He said, "the problems that got you overweight in the first place, whether systemic or emotional or a combination, will be something you have to deal with until you die." He told me to up my exercise from four 1.5 hour sessions (hard-core rowing and weights) a week to five, and focus on high protein, low carb eating. All stuff that you support and all stuff I did before and while I became overweight. Don't assume that someone who is morbidly obese just hasn't tried to do the right things, nor that those who opt for surgery can avoid doing them.

As a 1986 cancer & chemotherapy survivor, at the same time that high-fructose corn syrup started being used as "food", perhaps that muddies the statistics. I'm not sure what caused it (cancer or morbid obesity), but I did the right things all my life and I'm glad somebody was non-judgmental about helping me recover from it (cancer or morbid obesity, you pick).

Anyway, some other points. I followed the link and am not impressed. You have to compare that sample with a similar sample of population that did not have the surgery. I found a study that did that before I had my GBP in 2003 - and the deaths of the control group were more frequent and frightening.

If you follow the doctor's orders and take the recommended supplements, starvation and malnutrition is unlikely. I probably take no more supplements than most health buffs and my latest bloodwork showed that I was fine. I also get that checked yearly at my surgeons insistence. I can eat "normal" meals now (I wish I still had no appetite), and I religiously monitor everything that goes in my mouth because I tend to gain weight after just one day of eating, say 500 extra calories. (On my frame it doesn't take 3500, apparently).

This surgery has cured or abated many of my health problems and enabled me to enjoy my life as a normal-sized person - saving me from dealing with society's moralizing against my "obvious" faults. I would do it again in a heartbeat - and I would tell anyone considering it to do a ton of research and self-searching, and to start living the required life-style now.

by Marisette on Apr 23, 2008 12:50 PM EDT 0 recs

Appreciate the balanced discussion here

I want you to know I signed up with a user account just so that I could comment on this post!

When I got to the "moral hazard" part I was ready to be outraged and angry. Obesity is not a moral issue, and I don't think any studies have shown that guilt or fear are effective deterrents or cures. Unfortunately, diet and exercise aren't sure-fire cures either. I can't imagine any person "choosing" to be fat, and suffering all that entails, because they believe they can fix it with surgery whenever they want to. I think I can speak on this issue on behalf of anyone who is fat: We ALL want to fix it - we're not waiting for some miracle surgery!

So I was really impressed with the balanced view in your summary, and the Four Questions, all points worth considering. And I was even more impressed that not a single commenter on this post so far invoked the "you don't need surgery you just need to stop stuffing your fat face" advice. That attitude is so abhorrent to me, and it is so prevalent on fitness websites of all kinds, that I've essentially stopped reading any but a very few.

The reality of my life is that I HAVE made the lifestyle changes: I do eat well; I do exercise; I pursue increasing fitness as an important goal in my life. I consider this to be the single most significant change I've ever made in my life and I'm very happy about it. However, those changes do not result in weight loss for me - not an uncommon experience - and it is beyond frustrating to look to experts for guidance and receive ridicule and accusations in return. I think we are at the beginning of important breakthroughs in our understanding of obesity and its causes, but we're not going to get there if the prevalent attitude remains one of superstition, blaming, and prejudice.

I want to congratulate you and your readers for examining this issue in a balanced way and without ugly remarks. I want to second the remark by one of the commenters: "it's much harder for someone who has always been overweight to lose and maintain their weight." I really do believe that's true. My evidence is anecdotal, but boy there's a LOT of it! As long as we insist on believing that obesity is always a person's "fault" and due to their lack of responsibility or willpower, we will never find out if perhaps this is true, and find ways to deal with it.

by Marla on Apr 23, 2008 2:20 PM EDT 0 recs