Am I Biased and Confused?
This post may suggest to you that I am biased, prejudiced, myopic and don’t know what the hell I’m talking about.
If any have come here to smokinchoices, surely it is obvious by now that I AM biased toward natural health and all the ways that it can be achieved; through nature’s uncompromised bounty – - which is to say – without, pesticides, genetically modified construct, but rather - ORGANIC from seed to food basket. Animal protein of whatever sort or type – ditto, the way nature intended such to dwell – all profit us enormously, imparting health and broad-spectrum nutrition to us. Of course, this means staying as far away from all GMO’s, unlabeled foods of any sort and taking up a friendly relationship with one’s kitchen and the magic which can emerge from the simplest of efforts.
Leave cans, boxes, concocted or preserved stuff for the landfills – that’s all they are good for (and they are not even good for that). Delete grains, dairy and any and all (especially HFCS) sugars; drink plenty of the best water you can provide to yourself and you’ll be home free.
Problem is, there are just to many millions of our species who aren’t getting the message. They come from families who haven’t a clue about which end is up; believe that government wouldn’t lie to us – - we have that pyramid thing which tells us what to eat. And when we get fatter and sicker, we go to our doctors who give us all these medicines. Yeah,. . . .how is that workin’ for us? Well, the sad news is – - IT AIN’T WORKIN’ . . . . I’ll have a comment at the end, mean while, see the following – this is why I am so disturbed today.
Weight-loss surgery beats drugs for diabetes
By Denise Grady THE NEW YORK TIMES
For some people with diabetes, surgery may be the best medicine.
Two studies have found that weight-loss operations worked much better than the standard treatments to control Type 2 diabetes in obese and overweight people. Those who had surgery to staple the stomach and reroute the small intestine were much more likely to have their diabetes go into complete remission, or to need less medicine, than people given the typical regimen of drugs, diet and exercise, the studies found. The surgery also helped many to lower their blood pressure and cholesterol.
The new studies, published online yesterday by The New England Journal of Medicine, are among the first to rigorously compare surgery and medicine as ways to control diabetes. Doctors have noticed for years that weight-loss operations, also called bariatric surgery, (see below) sometimes get rid of Type 2 diabetes.
Better treatments are desperately needed for Type 2 diabetes, experts say. In the United States, the number of diabetes cases has tripled in the past 30 years and now number more than 20 million, according to the Centers for Disease Control and Prevention. Most of the cases are Type 2. The disease also is becoming more common in much of the world, with devastating complications such as heart disease, blindness, amputations and kidney failure. Type 2 diabetes, which causes high blood sugar and is linked to obesity, often becomes harder to manage as it progresses. Type 1, far less common, involves the immune system and is not linked to obesity.
The studies are part of a push by surgeons and obesity experts to establish a role for the operations in treating diabetes, not just obesity. Many surgeons now call the operations “metabolic” surgery to emphasize that they can affect more than weight.
One of the new studies, conducted at the Catholic University in Rome, looked at two types of bariatric surgery and compared them with medical treatment. After two years, the surgical groups had complete remission rates of 75 percent and 95 percent; there were no remissions in patients who received medical treatment.
The second study, at the Cleveland Clinic, also compared two types of surgery with an intensive medical regimen. The remission rates one year after surgery were lower than in the Italian study — 42 percent and 37 percent — at least in part because the U.S. study used a stricter definition of remission. The intensive medical treatment led to remissions in 12 percent of patients.
Heather Britton, 53, a computer programmer who lives in Bay Village, Ohio, a suburb of Cleveland, participated in the Cleveland study, and for her, it seemed to come in the nick of time.
Britton had been diabetic for five or six years and was taking two diabetes drugs, but her blood sugar was out of control and so were her cholesterol, blood pressure and triglycerides. Diabetes runs in her family. Relatives have had strokes caused by the disease, and her mother died from complications of diabetes.
“I only saw one direction in my life,” Britton said. “I wasn’t able to control it. It was controlling me.”
She saw the study as a way to get expert help and didn’t care which treatment group she wound up in. Still, when she learned that she had been picked at random to have a type of surgery called gastric bypass, she was frightened.
“It was kind of a shock, but I embraced it,” she said.
She had the operation in January 2009. Within a few months, she was off medications for diabetes, cholesterol, blood pressure and triglycerides. By May, she had lost about 80 pounds. As many people do, she gained some weight back, about 13 or 14 pounds. But her health has remained good.
“I would do it again in a heartbeat,” she said. “It’s been a total blessing.”
There is of course, no question what my reaction to this slanted article might be. I am outraged.
Outraged that such a procedure is available – no of course not.
But outraged that the MEDICAL PROFESSION has continued to do the same ole, same ole INEFFECTIVE treatment decade after decade while they watched people worsen and die and not have the wisdom to see that what they were prescribing was NOT WORKING! They have seen this – they had to know. Yet they questioned not what they were doing and trying to understand what the body was doing and why. Can we assume that they just didn’t care? Maybe didn’t want to know? Because the profits are in all those meds and procedures . . . . . now we get to it. Now here is one more procedure and by golly, it seems to be working. By Golly, look at that. Hey things are going to get even better. The whole medical profession is coming out for it including the famed CLEVELAND CLINIC, BIG W O W !
Where have the accolades been for the physicians, nutritionists and others who have actually broken ground and developed fool-proof plans to get the job done – Honestly, with integrity so as NOT to harm the body or cut it up and prevent it from doing the job NATURE intended. Why must the medical profession always try to re-invent the wheel, when it obviously doesn’t really get how the wheel is “supposed” to work, and how effortlessly it can, when we allow it function by nourishing it with proper sustenance, fresh air and exercise. No body ever broke down for lack of chemicals (pharmaceuticals), but it does diminish for lack of sustainable, whole nourishing foods and too many toxic compounds and agri-garbage labelled as “food”.
Last year the FOOD MATTERS people gave us “Raw for 30 Days”. It worked. Thousands did it and got better. Now this year, it is “Hungry for Change” Being very well received. Many of the biggest names in the health industry have been espousing the natural approach for decades. Here at smokinchoices, it would be hard to isolate a small handful of individuals, because that’s all any of us talk about, are committed to – - all for the reason, that it works!
My heart goes out to all those thousands of people who turn to bariatric surgery to get the job done which their physicians were supposed to take care of but didn’t. I guess doctors cannot advise us because they just don’t know, nor do they want to know. It’s all too confusing for them. I get that. We all struggle too. Trouble is, medicine just gets in the way and often prevents us from getting what we really need.. . . . like someone who is actually trained in how the body manifests HEALTH. What it is supposed to look like, feel like – understands what it needs to survive. So they don’t know, but they also don’t want us to have access to those knowledgeable people they often call “quacks” because they DO profess to know. So they beat their patients over the head criticizing them for not losing weight and taking care of their body. Being sick, fat and ashamed and defeated – why wouldn’t people accept this insane procedure which carves up their inners into ways that anything can go wrong. Why wouldn’t they accept It? I say, because you’ll have a shortened life filled with obstacles that maybe you didn’t know you’d have.
Ergo, I made a little trip over to Wikipedia (always go online – information is out there, all kinds. Be informed) At the very least, take a look around. Each of us has choice. After all, it’s our life. Do it the way you think best. Jan)
From Wikipedia, the free encyclopedia
Bariatric surgery (weight-loss surgery) includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with an implanted medical device (gastric banding) or through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).
Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a reduction in mortality of 23% from 40%.However, a study in Veterans Affairs (VA) patients has found no survival benefit associated with bariatric surgery among older, severely obese people when compared with usual care, at least out to seven years.
The U.S. National Institutes of Health recommends bariatric surgery for obese people with a body mass index (BMI) of at least 40, and for people with BMI 35 and serious coexisting medical conditions such as diabetes. However, research is emerging that suggests bariatric surgery could be appropriate for those with a BMI of 35 to 40 with no comorbidities or a BMI of 30 to 35 with significant comorbidities.
A medical guideline by the American College of Physicians concluded
- “Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor–patient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gallbladder disease, and malabsorption.”
- “Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery.”
Recently the International Diabetes Federation issued a position statement in which “Under some circumstances people with a BMI 30–35 should be eligible for surgery” International Diabetes Federation position statement on Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes When determining eligibility for bariatric surgery for extremely obese patients, psychiatric screening is critical; it is also critical for determining postoperative success. In patients with a body mass index of 40 kg/m2 or greater, there is a 5-fold risk of depression, and half of bariatric surgery candidates are depressed.
Classification of surgical procedures
Procedures can be grouped in three main categories: Standard of care in the United States and most of the industrialized world in 2009 is for laparoscopic as opposed to open procedures. Future trends are attempting to achieve similar or better results via endoscopic procedures.
Predominantly malabsorptive procedures
Predominantly malabsorptive procedures, although they also reduce stomach size, these operations are based mainly on creating malabsorption.
Diagram of a biliopancreatic diversion.
This complex operation is termed biliopancreatic diversion (BPD) or the Scopinaro procedure. The original form of this procedure is now rarely performed because of problems with malnourishment. It has been replaced with a modification known as duodenal switch (BPD/DS). Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.
In around 2% of patients there is severe malabsorption and nutritional deficiency that requires restoration of the normal absorption. The malabsorptive effect of BPD is so potent that those who undergo the procedure must take vitamin and dietary minerals above and beyond that of the normal population. Without these supplements, there is risk of serious deficiency diseases such as anemia and osteoporosis.
Because gallstones are a common complication of the rapid weight loss following any type of bariatric surgery, some surgeons remove the gallbladder as a preventive measure during BPD. Others prefer to prescribe medications to reduce the risk of post-operative gallstones.
Far fewer surgeons perform BPD compared to other weight loss surgeries, in part because of the need for long-term nutritional follow-up and monitoring of BPD patients.
This procedure is no longer performed.
A trial study performed on rats involved placing a 10 cm long impermeable sleeve into the rat’s intestine to block absorption of food in the duodenum and upper jejunum. A study at Massachusetts General Hospital Weight Center and Gastrointestinal Unit found that rats who had the surgery ate 30% less food and lost 20% more weight than counterpart rats, while blood glucose levels returned to normal levels in all mice who had the surgery.
A study on humans was done in Chile using the same technique however the results were not conclusive and the device had issues with migration and slipping. A study recently done in the Netherlands found a decrease of 5.5 BMI points in 3 months with an endoluminal sleeve
Predominantly restrictive procedures
Procedures that are solely restrictive, act to reduce oral intake by limiting gastric volume, produces early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications.
Diagram of a vertical banded gastroplasty.
 Vertical banded gastroplasty
In the vertical banded gastroplasty, also called the Mason procedure or stomach stapling, a part of the stomach is permanently stapled to create a smaller pre-stomach pouch, which serves as the new stomach.
Diagram of an adjustable gastric banding.
Adjustable gastric band
The restriction of the stomach also can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation can be performed laparoscopically, and is commonly referred to as a “lap band“. Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. It is considered one of the safest procedures performed today with a mortality rate of 0.05%.
Sleeve gastrectomy, or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.
This combined approach has tremendously decreased the risk of weight loss surgery for specific groups of patients, even when the risk of the two surgeries is added. Most patients can expect to lose 30 to 50% of their excess body weight over a 6–12 month period with the sleeve gastrectomy alone. The timing of the second procedure will vary according to the degree of weight loss, typically 6 – 18 months.
- Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.
- Removes the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin), although the durability of this removal has yet to be confirmed.
- Dumping syndrome is less likely due to the preservation of the pylorus (although dumping can occur anytime stomach surgery takes place).
- Minimizes the chance of an ulcer occurring.
- By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced.
- Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2).
- Limited results appear promising as a single stage procedure for low BMI patients (BMI 35–45 kg/m2).
- Appealing option for people with existing anemia, Crohn’s disease, irritable bowel syndrome, and numerous other conditions that make them too high risk for intestinal bypass procedures.
Intragastric balloon (gastric balloon)
Intragastric balloon involves placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5–9 BMI over half a year.While not yet approved by the FDA the intragastric balloon is approved in Australia, Canada, Mexico, India and several European and South American countries. The intragastric balloon may be used prior to another bariatric surgery in order to assist the patient to reach a weight which is suitable for surgery, further it can also be used on several occasions if necessary.
Basically, the procedure can best be understood as a version of the more popular gastric sleeve or gastrectomy surgery where a sleeve is created by suturing rather than removing stomach tissue thus preserving its natural nutrient absorption capabilities. The procedure is producing some significant results that were published in a recent study in Bariatric Times and are based on post-operative outcomes for 66 patients (44 female) who had the gastric sleeve plication procedure between January 2007 and March 2010. Mean patient age was 34, with a mean BMI of 35. Follow-up visits for the assessment of safety and weight loss were scheduled at regular intervals in the postoperative period. No major complications were reported among the 66 patients. Weight loss outcomes are comparable to gastric bypass.
The study describes gastric sleeve plication (also referred to as gastric imbrication or laparoscopic greater curvature plication) as a restrictive technique that eliminates the complications associated with adjustable gastric banding and vertical sleeve gastrectomy—it does this by creating restriction without the use of implants and without gastric resection (cutting) and staples.
Mixed procedures apply both techniques simultaneously.
Roux-en-Y gastric bypass.
 Gastric bypass surgery
A common form of gastric bypass surgery is the Roux-en-Y gastric bypass. Here, a small stomach pouch is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration.
The gastric bypass had been the most commonly performed operation for weight loss in the United States, and approximately 140,000 gastric bypass procedures were performed in 2005, dwarfing the number of Lap-Band, duodenal switch and vertical banded gastroplasty procedures. The gastric bypass operation is considered the “gold standard” in the U.S.
A factor in the success of any bariatric surgery is strict post-surgical adherence to a healthier pattern of eating.
Diagram of a sleeve gastrectomy with duodenal switch.
Sleeve gastrectomy with duodenal switch
A variation of the biliopancreatic diversion includes a duodenal switch. The part of the stomach along its greater curve is resected. The stomach is “tubulized” with a residual volume of about 150 ml. This volume reduction provides the food intake restriction component of this operation. This type of gastric resection is anatomically and functionally irreversible. The stomach is then disconnected from the duodenum and connected to the distal part of the small intestine. The duodenum and the upper part of the small intestine are reattached to the rest at about 75–100 cm from the colon.
Implantable gastric stimulation
This procedure where a device similar to a heart pacemaker is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, is being studied in the USA. Electrical stimulation is thought to modify the activity of the enteric nervous system of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of bariatric surgery.
Eating after bariatric surgery
Immediately after bariatric surgery, the patient is restricted to a clear liquid diet, which includes foods such as clear broth, diluted fruit juices or sugar-free gelatin desserts. This diet is continued until the gastrointenstinal tract has recovered somewhat from the surgery. The next stage provides a blended or pureed sugar-free diet for at least two weeks. This may consist of skimmed milk, cream of wheat, a small pat of margarine, protein drinks, cream soup, pureed fruit and mashed potatoes with gravy.
Post-surgery, overeating is curbed because exceeding the capacity of the stomach causes nausea and vomiting. Diet restrictions after recovery from surgery depend in part on the type of surgery. Many patients will need to take a daily multivitamin pill for life to compensate for reduced absorption of essential nutrients. Because patients cannot eat a large quantity of food, physicians typically recommend a diet that is relatively high in protein and low in fats and alcohol.
It is very common, within the first month post-surgery, for a patient to undergo volume depletion and dehydration. Patients have difficulty drinking the appropriate amount of fluids as they adapt to their new gastric volume. Limitations on oral fluid intake, reduced calorie intake, and a higher incidence of vomiting and diarrhea are all factors that have a significant contribution to dehydration. In order to prevent fluid volume depletion and dehydration, a minimum of 48–64 fl oz should be consumed by repetitive small sips all day.
Effectiveness of surgery
In general, the malabsorptive procedures lead to more weight loss than the restrictive procedures however, have a higher risk profile. A meta-analysis from University of California, Los Angeles, reports the following weight loss at 36 months:
- Biliopancreatic diversion — 117 Lbs / 53 kg
- Roux-en-Y gastric bypass (RYGB) — 90 Lbs / 41 kg
- Open — 95 Lbs/ 43 kg
- Laparoscopic — 84 Lbs / 38 kg
- Vertical banded gastroplasty — 71 Lbs / 32 kg
More recent studies have demonstrated that the medium (3–8 years) and long term (> 10 years) weight loss results for RYGB and LAGB become very similar. However, the range of excess weight loss for LAGB patients (25% to 80%) is much broader than that of RYGB patients (50% to 70%). Data (beyond 5 years) for sleeve gastrectomy indicates weight loss statistics similar to RYGB.
Reduced mortality and morbidity
Several recent studies report decrease in mortality and severity of medical conditions after bariatric surgery.But long term effects are not clear. In the Swedish prospective matched controlled trial, patients with a body mass index (BMI) of 34 or more for men and 38 or more for women underwent various types of bariatric surgery and were followed for an average of 11 years. Surgery patients had a 23.7% reduction in mortality (5.0% vs. 6.3% control, adjusted hazard ratio 0.71). This means 75 patients must be treated to avoid one death after 11 years (number needed to treat is 77).
In a Utah retrospective cohort study that followed patients for an average of 7 years after various types of gastric bypass, surgery patients had 0.4% mortality while control patients had 0.6% mortality.] Death rates were lower in the gastric bypass patients for all diseases combined, as well as for diabetes, heart disease and cancer. Deaths from accident and suicide were 58% higher in the surgery group.
A randomized, controlled trial in Australia compared laparoscopic adjustable gastric banding (“lap banding”) with non-surgical therapy in 80 moderately obese adults (BMI 30–35). At 2 years, the surgically-treated group lost more weight (21.6% of initial weight vs. 5.5%) and had statistically significant improvement in blood pressure, measures of diabetic control, and high-density lipoprotein cholesterol. Post surgical complications included 1 patient with an infected surgical site, 4 with lap band malpositioning requiring laparoscopic revision, and 1 patient with cholecystitis. In the non-surgical group, 12 patients declined or did not tolerate orlistat or diet restrictions, and 4 patients developed acute cholecystitis.
Bariatric surgery in older patients has also been a topic of debate, centered on concerns for safety in this population. One study of elderly patients undergoing laparoscopic bariatric surgery at Mount Sinai Medical Center, however, reported 0% conversion to open surgery, 0% 30-day mortality, 7.3% complication rate, and average hospital stay of 2.8 days.Post operative mortality from 0.1–2 %.
Given the remarkable rate of diabetes remission with bariatric surgery, there is considerable interest in offering this intervention to type 2 diabetes patients with a BMI of <35 kg/m2. Until high-quality, controlled trials are completed, appropriateness criteria (based on age, BMI, and the severity of eight obesity-related comorbidities) may be used to guide the careful selection of diabetes patients who may potentially benefit from bariatric surgery.
Laparoscopic bariatric surgery requires a hospital stay of only one or two days. Short-term complications from laparoscopic adjustable gastric banding are reported to be lower than laparoscopic Roux-en-Y surgery, and complications from laparoscopic Roux-en-Y surgery are lower than conventional (open) Roux-en-Y surgery.
Complications from weight loss surgery are frequent. A study of insurance claims of 2522 who had undergone bariatric surgery showed 21.9% complications during the initial hospital stay and a total of 40% risk of complications in the subsequent six months. This was more common in those over 40 and led to an increased health care expenditure. Common problems were gastric dumping syndrome in about 20% (bloating and diarrhea after eating, necessitating small meals or medication), leaks at the surgical site (12%), incisional hernia (7%), infections (6%) and pneumonia (4%). Mortality was 0.2%. As the rate of complications appears to be reduced when the procedure is performed by an experienced surgeon, guidelines recommend that surgery be performed in dedicated or experienced units.
Metabolic bone disease manifesting as osteopenia and secondary hyperparathyroidism have been reported after Roux-en-Y gastric bypass surgery due to reduced calcium absorption. The highest concentration of calcium transporters is in the duodenum. Since the ingested food will not pass through the duodenum after a bypass procedure, calcium levels in the blood may decrease, causing secondary hyperparathyroidism, increase in bone turnover, and a decrease in bone mass. Increased risk of fracture has also been linked to bariatric surgery.
Rapid weight loss after obesity surgery can contribute to the development of gallstones as well by increasing the lithogenicity of bile. Adverse effects on the kidneys have been studied. Hyperoxaluria that can potentially lead to oxalate nephropathy and irreversible renal failure is the most significant abnormality seen on urine chemistry studies.Rhabdomyolysis leading to acute kidney injury, and impaired renal handling of acid and base has been reported after bypass surgery.
Nutritional derangements due to deficiencies of micronutrients like iron, vitamin B12, fat soluble vitamins, thiamine, and folate are especially common after malabsorptive bariatric procedures. Seizures due to hyperinsulinemic hypoglycemia have been reported. Inappropriate insulin secretion secondary to islet cell hyperplasia, called pancreatic nesidioblastosis, might explain this syndrome.
(I have deliberately deleted all the reference numbers relating to the analysis made in this article. If you want this, please go to Wikipedia – its easy to do, hey, I did it! Jan)