Wednesday, June 18, 2014

The Nutrition Debate #219: “Surgery Tops Usual Care in Obese Diabetics…”

The phrase “usual care” caught my attention in this otherwise unsurprising (I’ll explain) headline. These days the bariatric surgery business in on the rise, and self-serving articles like this one are all too common in the best peer-reviewed scientific journals. I found this one in an article by Marlene Busko in Medscape Medical news who was reporting on the June 11th special diabetes-themed issue of the Journal of the American Medical Association (JAMA), timed to coincide with the American Diabetes Association (ADA) 2014 Scientific Sessions which started in San Francisco last Friday.

“Usual care” is a “term of art” and so commonly used that Busko saw no need to describe it. It is certainly defined in the study itself or by reference in the practice guidelines of bariatric surgery physicians, but I will not bother now. That’s not what this study was about. This was about promoting bariatric surgery as the preferred course of action for the treatment of obese diabetics. For the record, the findings on the bariatric surgery option were from this 15-year Swedish Obese Subjects (SOS) study by Lars Sjöström, MD, et. al., at Sahlgrenska University Hospital in Gothenburg, Sweden.

The Medscape piece also quotes Anne Cappola, MD (Perelman School of Medicine at the University of Pennsylvania), a co-author of an accompanying editorial and a JAMA associate editor. Dr Cappola says, the study findings “validate the expectations of bariatric-surgery-associated weight loss and provide concrete numbers to cite.” Perfunctorily, she adds, “Diet and lifestyle measures will always be the cornerstone of diabetes therapy, but bariatric surgery is an option for patients who are unable to lose sufficient weight with diet and exercise and who are willing to accept the risk of bariatric surgery and comply with the lifestyle changes required after bariatric surgery” [emphasis mine].

So, let’s see what we’re being told here: 1) “Usual care,” whatever that is, usually doesn’t work, for many if not most obese diabetics; “Diet and lifestyle measures” (exercise, d’ya think?), as counseled by physicians who treat obese diabetics, are the cornerstone of diabetes therapy. “Usual care,” it would seem, are these “diet and lifestyle measures” (and counseling, of course). And when such measures fail over the long term to result in “sufficient” weight loss, the patient will then be counseled to consider the option of bariatric surgery. That is, if the patient is “willing to accept the risk of bariatric surgery and comply with the lifestyle changes required after bariatric surgery.

Okay, let’s review: “Usual care,” as currently defined by the standards of medical practice, is such a hopeless cause as to be forlorn. And, of course, the failure to achieve sufficient weight loss with “usual care” is laid on the patient, who was obviously “non-compliant” with the diet and lifestyle measures the physician had “prescribed.” So, surgery to the rescue! The doctor takes charge again, providing the patient is “willing to accept the risk of bariatric surgery and comply with the lifestyle changes required after bariatric surgery.” Risk? Wanna know more about the risks of bariatric surgery? Look here:

Note that many other surgeries have higher mortality rates, but they are performed on people who are quite ill.

And the “lifestyle changes” after bariatric surgery? What are those? Liquid meals only for weeks or months after surgery? Thereafter, only very small meals at frequent intervals because the stomach is no longer a large expandable storage pouch. And if you happen to eat more than your greatly reduced stomach capacity: nausea, projectile vomiting, “dumping,” etc.

Another point to bear in mind: These “lifestyle changes” are now life-long requirements. In contrast, the “lifestyle changes” of a low-carb “diet and exercise” program are volitional. You get a “holiday” from them now and then, if you want it, and the major downside is guilt (and a temporary weight gain or loss of blood sugar control). After bariatric surgery, you had better not try to take a break from your regimen; you will pay dearly for it. As a consequence of accepting the risk of bariatric surgery, you must comply with the lifestyle changes required after bariatric surgery. You are no longer “the master of your fate;” you are no longer “the captain of your soul.”
Of course, none of these consequences are necessary. You do not need to opt for bariatric surgery. You simply need to opt for a diet that works to achieve “sufficient” weight loss. Admittedly, it is also a lifetime requirement, if you want to maintain the weight you have lost (and all the other improved health markers) for the remainder of your lifetime – a lifetime that’s likely to last longer as well. My regular readers know, of course, that I personally adhere to a low-carb lifestyle. I don’t exercise. I don’t enjoy it. You can, if you like it, wait until you’ve lost 50 or 100 pounds (or more) to start an exercise program. You’ll enjoy it more and reduce your risk of injury when it isn’t so much work to lug around that extra weight. You could start off (as I did) on a Very Low Carb program (Atkins @ 20g/d or Bernstein @ 30g/d) to get a jump start.


  1. I talked to a friend of mine last night who is diabetic and has been in a stroke rehab facility for a few months. She said there are a good number of diabetics there. She has been pushing them to provide appropriate food for these people, not the very high carb stuff they're getting. The only thing they do is offer artificial sweeteners and non-sugar syrup for the pancakes. Sometimes you just have to wonder what's up with the medical world when their solutions defy even common sense.

    1. It is a sad commentary indeed on the medical communities ignorance; Or to be fair, maybe it's that if they don't follow Medicare and Medicaid guidelines, they will risk reimbursement or even sanction. I don't know how to figure it.

      You will be interested in the column I am publishing tomorrow morning: "Eat Protein to Lower Stroke Risk"

  2. Bariatric surgery is a good option to go for when we get higher concern that we arent able to control diet

    1. Thanks for commenting, John. But I'm unclear about what you mean "we aren't able to control diet." After surgery (and I don't mean immediately after), aren't you required, i.e. forced, by the smaller capacity of your stomach, to control your diet? That is, eat very small portions, more frequently than say 3 times a day? Isn't that "controlling your diet"? And, if you agree, wouldn't you rather have the ability to control your diet by your own volition than by being forced by a physical limitation that is no longer within your control?

      Personally, I couldn't be talked into giving up my free will, but I understand that it works for some people. I came to grips with my carbohydrate intolerance when I discovered (at my doctor's suggestion) at eating Very Low Carb was a very good way to lose weight permanently (and improve my diabetes and lipid health at the same time). That's why I am such a fierce advocate for carb restriction as an alternative to food restriction (as required by bariatric surgery).

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