Finally a commentator has had the guts to attack the bariatric surgery myth (see below).
We have been arguing for years that these operations to reduce stomach size in various ways cannot possibly have any physiological effect on caloric intake and that their effect is purely psychological. “I have been anesthetized, I have scars on my stomach and I have been told that I can’t eat as much as before”. Some sort of vague threat is implied. If they eat too much they will get abdominal pain, nausea or vomiting. But patients eventually figure out that they can indeed eat as much as before without pain or nauseas and the weight is regained. The reason is that the esophagus is the smallest part of the GI tract. It is impossible to make any part further along smaller than the esophagus or food will back up in the esophagus and cause aspiration of food into the lungs which can be fatal. So, whatever will go down the esophagus will go through the stomach no matter how small it is made as long as it is bigger than the esophagus and from there right into the small bowel where it is rapidly broken down by the digestive enzymes.
The only type of bariatric surgery that makes physiological sense is bypass of the small intestine to cause malabsorption, a much bigger and more hazardous procedure with many side effects.
In the era before antibiotic treatment of ulcers, many gastrectomies were done to reduce stomach acid production and patient did not lose weight dramatically. Why? Because they were not told they had to eat less.
Here is a typical instruction to patients undergoing bariatric surgery (http://www.obesitysurgery.ca/faq.php ). Note that the patient MUST be “committed to your new lifestyle.”
Q: How much weight will I lose?
A: Studies show that most LAP-BAND patients successfully lose between one-half and two-thirds of their excess weight. Results vary due to numerous factors. You need to be committed to your new lifestyle and eating habits. We expect that your weight loss will be gradual (2 – 3 pounds per week). Twelve to 18 months after the operation, the rate of weight loss usually slows down. Losing weight too fast creates health risks and can lead to a number of problems. The goal is to have a weight loss that prevents, improves, or resolves the health problems connected with severe obesity.
“She should be required to make a commitment to an appropriate postoperative regimen of diet, exercise, and medical and surgical follow-up care.”
So why can’t obese patients commit to a new lifestyle WITHOUT the surgery? What is really effective, the surgery or the post-op diet and exercise. The only way to tell is to do a SHAM-OPERATED RANDOMIZED CONTROLLED TRIAL. Obese patients wanting surgery are randomly assigned to one group has some form of bariatric surgery or another group that is anesthetized, the same incisions made bowel is manipulated but no bypass or stapling is done. The post-op care team is blinded to the type of surgery and both groups get the same post op attention. Only after such a trial can we know if the effects of surgery are physiological of psychological, if bariatric surgery is just not another form of psychic surgery.
But there are a number of obesity “experts” who promote bariatric surgery as the ultimate answer to the obesity epidemic. One of these is Arya M. Sharma, MD, FRCPC, Professor of Medicine, Canada Research Chair for Cardiovascular Obesity Research & Management, McMaster University (http://www.cardio.on.ca/obesity) who is paid handsomely from taxpayer dollars and drug companies to promote the myth of bariatric surgery and various drugs for obesity. He refuses to even entertain the thought of doing a randomized, sham-controlled trial of bariatric surgery before spending billions of taxpayer dollars on the procedures with no proven benefit in a controlled trial.
Here is Dr. Sharma. “I think that much can be derived from careful objective observational studies, and indeed the majority of our knowledge in medical practice comes from empirical observation and NOT from controlled trials (the field of cardiology being the exception – this may be largely, because the field of cardiology lends itself best to such studies). These are far more difficult in other areas of medical practice, especially when dealing with long-term outcomes in low-risk populations. While providing the best possible care, we need to ensure that we do not degrade our patients to the level of laboratory animals just to prove a point that is reasonably obvious and biologically plausible based on what we already know. When you have no Class A evidence the right thing to do is to base your decisions on Class B or even Class C evidence, rather than do nothing. I come back to the point about checks and balances that need to be in place, but I also say that the time to act is now – the clock is ticking…..”
The same has been said about every treatment in the history of medicine; unethical not to do it, improved surgical techniques, can’t do a randomized trial, can’t wait for randomized trials, obviously effective, calculated benefit based on case controlled studies, Medicare pays for it, etc. If we continued to subscribe to the intuitive approach we would still be using blood-letting for pneumonia. Any treatment for any disease (other than hormone deficiency) must be subject to rigorous scientific investigation. Patients are NOT treated like “laboratory animals.” There are very detailed ethical guidelines about conducting controlled trials. Many “obvious and biologically plausible” treatments have turned out to be useless or harmful when subjected to controlled trial. Modern medicine like to pride itself on practicing evidence-based medicine. But when it comes to deeply held beliefs in the power of a treatment, particularly when it is good for one’s bank account, the search for evidence becomes less imperative.
Dr. David D’Alessio of the University of Cincinnati says, bariatric surgery is “kind of the Wild West…huge demand, no regulation [and] patients are willing to do whatever it takes to get it.”
It is a mystery to me why the populace insists that its government scrutinize new drugs in great detail and insist on years of testing before they are licensed but any surgeon can come up with a superficially attractive operation and he and his colleagues can perform thousands of them at great expense in money and possibly lives before anyone gets around to doing an experiment to prove that the operation’s benefits outweigh its risks or have some benefit over medical treatment. See my blog on angioplasty for a classic example of billions of dollars spent on a procedure with no benefit. The latest surgical scam is the “liberation” treatment for multiple sclerosis upon which billions of dollars will be spent for a totally unproven, scientifically absurd procedure. Perhaps surgeons are the modern high-tech shamans. Surgery still maintains an aura of supernatural healing; evil spirits are being extirpated. To subject surgical procedures to controlled trials disturbs faith in its magical powers.
Will making the stomach smaller cure this women? The chocolate-coated ice cream bar will melt in the esophagus and pass through any orifice larger than a the diameter of a pin and pass rapidly through a gastic pouch no matter how small. The only cure for this women in mastering her food addiction. See my photo essay on food addiction.
July, 26, 2006
Taxpayers the losers in weight-loss surgery funding
OTTAWA — ‘I n one form or another, the corset has swaddled women since Cleopatra laced herself breathless for Caesar. Medieval women used leather and wood plates to flatten bulges. In Shakespearean times, 13 inches — no more, no less — was deemed the proper circumference of a feminine waist. And 18th century ladies cinched themselves to the point of frequent fainting. The 1890s produced the hourglass silhouette made famous by [actress and singer] Lillian Russell. If modern fashion has its way, the stage joke of a husband lacing his wife’s corset will repeat itself endlessly in connubial bedrooms across the country.” – Life magazine 1948.
For centuries, women handled fat the old-fashioned way. They hid it. More precisely, they shaped it to a particular aesthetic form. Corsets served strictly architectural purposes. Throughout the Victorian era, corsets used vertical steel rods to keep the female figure rigidly aligned with the blueprint, though the use of whalebone continued into the 20th century. These rods were appropriately called stays, defined by Oxford as “appliances used to hold up part of a structure.” Corsets worked and they were cheap. Eatons listed an economy corset in its 1901 catalogue at 28 cents.
With lightweight plastic stays, as Life magazine’s postwar essay suggests, corsets became modern appliances. With further refinements, they remained (along with girdles) essential woman’s wear well into the 1960s when they were rendered obsolete, first by fashion and now, finally, by surgeons with vacuum pumps.
Men used corsets, too, both for aesthetic deception and for medical reasons (wounded by gunshot in 1968, Andy Warhol wore a corset every day for the last 20 years of his life). But corsets primarily shaped the lives of women, just as cosmetic surgery now primarily shapes the lives of women. Casual tummy surgery is probably preferable to corsets — people who have experienced neither really can’t say. But the public policy issue here isn’t the change in fashion.
It’s the difficulty in distinguishing cosmetic alteration from medical procedure — and in determining who pays.
Start with the soaring use of weight reduction surgery in the U.S. These operations range from minimalist procedures (say 10 pounds) to heavy-duty surgery (say 50 pounds or more). On the one hand, cosmetic surgeons insist they do shapes, not weights. But who determines real motives — doctor or client? Since it’s now the client who pays for most of these procedures, the distinction is mostly moot. On the other hand, weight-loss operations performed on the “morbidly obese” — any person 100 pounds or more overweight — are deemed medically necessary. Eighty seven per cent of these patients are women.
In the early 1990s, U.S. doctors performed 16,000 of these bariatric (meaning weight) operations a year. In 2004, they performed more than 100,000. This year, they will perform 200,000. Obesity is, after all, ballooning. And doctors now perform these operations on adolescents. The cost averages $30,000 (U.S.) per operation. Perform it 100,000 times and you have an invoice for $3-billion.
This is an interesting calculation because there are more than 100,000 people in Ontario alone who qualify, by medical definition, for this operation — perhaps 150,000. Last year, the Ontario Health Insurance Plan paid $15-million (Canadian) to send a mere 600 of them to the States for this surgery at an average cost of $25,000. In a study released Monday, however, the U.S. government reported that four bariatric operations in 10 result in serious complications within six months — driving the cost in these cases as high as $65,000 (U.S.).
But, ominous as these costs appear, no one should think that the provinces will be able to restrict medicare access to weight-loss surgery for long. Now that governments are paying for the removal of fat from people who are “morbidly obese,” it’s only a matter of time before they extend coverage. People 90 pounds overweight will want coverage, then people 80 pounds overweight.
Restrictions will finally be deemed discriminatory — violations, no doubt, of the Charter of Rights and Freedoms. Self-indulgent people who eat too much and exercise too little will inevitably come to regard shape and weight as entitlements.
Weight-loss surgery is a dubious proposition. In one Canadian study, Dr. Raj S. Padwal at the University of Alberta Hospital in Edmonton found that bariatric patients shed between 35 and 60 per cent of their baseline weight in these operations — and, 10 years later, may maintain a loss of only 16 per cent. This simply means that a 300-pound person will become — in the long run — a 255 pound person, almost as fat as when he or she started. This person could achieve the same result by losing 4.5 pounds a year.
Fifty per cent of Canadians are now deemed overweight. Depending on your perspective, this means either 17 million people or 17 million patients. What to do with them? A few years back, Dr. Kenneth Walker, the Canadian medical columnist, facetiously suggested the use of force — that fat people be locked up in prison camps until they lose weight. In the end, though, there’s only one responsible option. Self-government. And, perhaps, corsets.