Tuesday, September 24, 2019

Retrospective #219: “Surgery Tops Usual Care in Obese Diabetics”

Not a surprising result but the term “usual care” caught my attention in this otherwise unsurprising Medscape Medical News piece in a special diabetes-themed issue of the Journal of the American Medical Association, timed to coincide with an annual American Diabetes Association (ADA) Scientific Session. These days the bariatric surgery business in on the rise, and self-serving articles like this one are all too common, even in peer-reviewed scientific journals.
“Usual care” is a “term of art” so commonly used that the Medscape reviewer did not define it. It was defined in the study itself and, I’m sure, in the practice guidelines of bariatric surgeons. Besides, this study was not about “usual care.” It was about promoting bariatric surgery as the preferred course of action for the treatment of obese diabetics.
Medscape quotes a JAMA editor who was also co-author of an accompanying editorial: “The study findings validate the expectations [LOL] of bariatric-surgery-associated weight loss and provide concrete numbers to cite.” She added, perfunctorily, “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” [all my emphases].
So, let’s see what we’re being told here: 1) “Usual care” usually doesn’t work, for most obese diabetics; The “usual” “diet and lifestyle measures,” a “balanced, low-fat diet and exercise,” as counseled by physicians who treat obese diabetics, are the “cornerstones of diabetes therapy.” And when this “usual care” is prescribed, and followed by the patient, with the resulting “insufficient” 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. Thanks a lot! Maybe a change before surgery should be thought about.
Okay, let’s review again: “Usual care,” as currently defined by the standards of medical practice, is such a hopeless cause as to be forlorn. And, of course, your failure to achieve sufficient weight loss with “usual care” is laid on YOU, the patient, who was obviously “non-compliant” with the diet and lifestyle measures your 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.” Is this what you want?
And the “lifestyle changes” after bariatric surgery? 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 eat more than your greatly reduced stomach capacity: nausea, projectile vomiting, even dumping, i.e., where food gets “dumped directly from your stomach pouch into your small intestine without being digested.” Think about that!
Another point to bear in mind: These “lifestyle changes” are now life-long REQUIREMENTS, not options. In contrast, the “lifestyle changes” of a low-carb “diet and exercise” program are volitional. If you want to, you can take a “holiday” from them now and then, and the major downside is a temporary weight gain or loss of blood sugar control, and guilt. 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, permanently.  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 will likely be longer if you do.
My regular readers know, of course, that I personally adhere to a Very Low Carb lifestyle. And I don’t exercise. I don’t enjoy it. You can, if you like it, or you can wait until you’ve lost 50 or 100 pounds 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 (as I did) on a Very Low Carb regimen (20g/d), or you could just go Low Carb, at 50 or 100 or even 200g/d.

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