Every week, it seems, we are bombarded with a new article declaring the magical, curative qualities of gastric bypass surgery. These articles make it seem like gastric bypass is the simplest, most sensible way of managing diabetes -- and gosh darn it -- everyone ought to pursue it so we can put a stop to this overwhelming epidemic that's going to just take over America, and murder us all. (Please note I am being sarcastic here.)
I admit I don't have all the answers -- if I did, I'd have long ago found a cure for all of us, and retired to my white castle atop a hill, facing the ocean. But what I can tell you is that I have a lot of questions and skepticism. And so should you.
Whenever there are articles like this, I look for red flags:
- Is the article edited properly? It might seem like a simple thing, but honestly, if someone in a professional, journalistic setting, doesn't care enough to edit their articles for grammar, spelling, content, and accuracy, they certainly might not care about outright lying to you to get some readership.
- Is the article unusually chipper or eager to present this as an 'all around' solution to a problem? Does it present ALL sides of the debate? Does it present ALL alternatives?
- Does the article portray accurate medical conclusions, information, and accurate explanations, or does it confuse the public about its target audience?
- Does the article present accurate, statistical data, as has been reported by other research outlets, and scientific journals?
- Is the study funded by third parties with deep pockets, and deep interests in the outcome of said study?
Taking all these questions into account, let's look at this week's gastric bypass article (which I have linked to above.)
Red Flag #1
The article starts off by telling us about Cristina Iaboni (a woman who was selected as a test subject for gastric bypass in leaner patients), and offers this description of her situation:
"Cristina Iaboni had the dubious distinction of being not quite obese enough. For all the pounds on her 5'5" frame, she did not meet the criteria for bariatric surgery to help control her type-2 diabetes.
Yet six years of medications and attempts at healthy living had failed to rein in her blood glucose, leaving Iaboni terrified that she was on course to have her kidneys fail "and my feet cut off" -- common consequences of uncontrolled diabetes."Right off the bat, I'm kind of concerned about the quality of medical care Mrs. Iaboni may have received. Did her medical team question everything that needed to be questioned? Was she on insulin? When I read "6 years of medications," it literally screams at me that they kept her on every oral medication combination out there, and did NOT put her on insulin, like they should have. What kind of 'healthy living' changes did she attempt to make? Was she she still consuming a high carbohydrate diet, and just substituted her carbs for wheat, and whole grains? Did she even know how to carb count? Did her doctor ever test her for antibodies, and is she a LADA, instead? While the article declares she's 'cured,' I have the strong feeling this woman might rebound down the road.
Red Flag #2
Follow this logic statement with me: "If smoking triggers lung cancer, than smoking cessation should cure cancer."
Oh, it doesn't work that way, you say? Once you have it, you're stuck with it? Oh. Then why do some media and some 'researchers' assume that if obesity triggers diabetes (in those who are genetically predisposed, mind you), that losing weight should cure the diabetes?
The simple answer is "I don't know." The complex answer is "Because they probably have something to sell you."
Certainly, one can assume smoking cessation helps better manage cancer -- I am sure. One will be healthier, and respond better to treatments, and will have a stronger immune system... But one cannot say one is suddenly cured of the cancer. (Even when one is in remission.) Diabetes and weight loss are much the same: weight loss merely makes one healthier, and be able to respond better to treatments (ie, be more insulin sensitive, use less insulin and medications, sometimes none, etc.) These are only ways of tightly controlling diabetes, though, and slowing down it's progression. The absence of medicine is NOT an absence of illness. In this case, it is the strict diabetic patient's regimen that is the patient's medicine. The pancreas has damage, and this damage is irreversible, thus far. It is not, suddenly, magically healed.
Interestingly, this article seems ready to admit (though hesitantly so) that gastric bypass -- since people seemed to be 'magically' better just days after surgery -- proves that a diabetic 'cure' is NOT about weight control, or weight loss. However, here is where the red flag comes in: they are NOT willing to admit that the extreme dietary restrictions a patient must submit to (caloric and, consequently, carbohydrate level restrictions), post op, will play a role and immediately make less glucose available to the patient, and therefore, less high blood glucose issues. Now, normally, a patient who chose to control diabetes with diet and exercise would take a bit longer to achieve euglycemia (or normal blood glucose levels) when consuming a diet lower in carbohydrates and eating 'normal' amounts of food -- but they don't get a head start. A pre-op gastric bypass patient has to be on a type of fast with limited food and liquid intake, so they're already starting out with less available glucose in their system for a couple of days. Yes, they are going to have great numbers in just a few days. Barring other variables, yes, it's that simple, sometimes. I don't think this is rocket science.
Quite frankly, a patient could just go on the restricted diet, and skip the surgery, and achieve similar results... And not that long ago, some of these 'researchers' were practically claiming this same argument: A 'very low calorie diet' could cure type 2 diabetes.
This article though, quickly sidesteps the discussion and dismisses it without much more than an acknowledgement.
Red Flag #3
The idea that type 2 diabetes begins in the gut is not a new one. It has been, however, a seldom reported one.
More commonly, you see articles speculatively linking the bacteria most known for leading to peptic ulcers (h. pylori), to endocrine disorders (as well as diabetes), and these have been quietly making the rounds since at least 2009, maybe even earlier. There's even an interesting study dating back to 1999, and involving children with type 1 diabetes, insulin requirements, and the presence of h. pylori. The most recent finding came this month, and it involves h. pylori and it's impact on A1C.
The underlying message is clear: bacteria, and inflammation, alter the body's ability to process glucose -- whether in the stomach, or in the gut.
But are the researchers missing the obvious clues? They mention that 'in the past,' patients with peptic ulcers who had surgeries altering their stomachs, and gut connection, 'cured' their diabetes. Or did they just achieve better control of their diabetes because a.) they were now having to, forcefully, eat far less, and b.) the surgery removed chronic inflammation from bacterial infection (which would have dramatically raised blood glucose levels)?
Other articles, and research, have pointed to a bacterial imbalance in the gut as a trigger to an imbalance in processing glucose, and development of type 2 diabetes, but they do NOT suggest surgery for 'curing' the disease. In fact, they suggest a more preventative method -- receiving gut microbiota transplantation. This seems to me like the less invasive, less dangerous, less costly and time consuming, way to go when it comes to researching a cure. Why are we not investing in this? Why is there such a PUSH for getting this dangerous surgery?
The attempts to also connect this surgery to a potential 'cure' or reversal of type 1 diabetes seem a bit far fetched, and improbable to me, and make me question if this researcher has a proper understanding of the etiology of type 1(a) diabetes -- and that it isn't just an insulin insufficiency scenario. I'm pretty sure people need insulin to live, and for many various metabolic functions, and just 'bypassing' a gut mechanism isn't going to make a person insulin independent. I'd like to see more than just three sentences in a poorly edited FOX news article, on the matter.
Red Flag #4
These articles always seem to exaggerate diabetes incidence numbers. This one is no exception. It claims that 8.3% of the world's population has diabetes, and that 11.3% of Americans, have it. Honestly, I don't know where the 11.3% figure came from, with these folks -- but according to the most recent data (released January 26, 2011 -- and not the 2010 date these folks claim) released by the American Diabetes Association, only 8.3% of Americans have diabetes -- and this includes all types, and the undiagnosed.
Similarly, these folks make these grandiose claims for the 'remission' rates of Roux-en-Y to be 80-85%, and to be incredibly superior to other forms of gastric surgery. But major studies DON'T show that.
"New research reports that no procedure for weight loss surgery is any better at treating diabetes than another. The study, presented May 7 at the International Congress of Endocrinology/European Congress of Endocrinology in Florence, Italy, uses a large ongoing study to show that improvements to diabetes in patients undergoing such surgery is likely to be due to the degree of weight loss itself rather than the type of procedure." (http://www.sciencedaily.com/releases/2012/05/120507102225.htm)And here's a more startling fact...
"Weight loss surgery is not a cure for type 2 diabetes, but it can improve blood sugar control, according to a new study published in the British Journal of Surgery. Whereas some previous studies have claimed that up to 80 per cent of diabetes patients have been cured following gastric bypass surgery, researchers at Imperial College London found that only 41 per cent of patients achieve remission using more stringent criteria." [emphasis added by me] (http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_4-1-2012-13-32-26)And that's the ticket here, isn't it? What kind of criteria are these folks using to claim someone is cured? What are their A1Cs, now, and what are their average blood glucose numbers like? I've had folks tell me "I have an A1C in the 6.5% range, so I no longer have diabetes." But wait a minute? That's the number used to diagnosed diabetes to begin with!
Hey, but you no longer need medicine (for now, anyway), so you must be cured, right? It sounds so pretty... It sounds like such a good sell.
And because it sounds like such a good sell... I give you:
Red Flag #5
"The cost of the bypass surgery is covered by a grant from Covidien Plc, which makes laparoscopic instruments and surgical staplers."Oh, so let me see... the people who profit the most from this surgery are the ones funding a study to tell me how awesome this surgery is, how high a success rate it has (even though it is absolutely not supported by independent studies), and how I will just be so cured.
Hmmmmmmmm. Let me think about that. Fox guarding the hen house much? This reminds me of last year, when the ADA published a study done by the Australian Dairy Association, claiming that milk consumption lowered risk of diabetes.
Of course you're going to tell me it's awesome! You want me to buy more of it, and you want me to fall in love with it. You need to make money, too, like everyone else! It's MARKETING.
The problem comes when the money making interests muddle the big picture, and really go against the best interests of the INFORMED patient.
What am I trying to get at, with this blog post?
Should you avoid gastric bypass? Is it a dangerous alternative?
These are questions you must weigh for yourself... but what I would like to see is for patients to be able to weigh the TRUTH against the hype. NO ONE should promise that surgery will be a success, that it will heal and cure diabetes, or that it will be complication free; but, instead, they must help guide the patient to a point where they can soberly weigh their current health risks against the surgery's very real risks and potential failures. It is easier to accept the roll of the dice when we know that risks are possibilities -- and when we aren't lead to believe that this is just a simple, routine procedure, that will fix our woes forever.
More importantly -- the type of lifestyle changes required by these surgeries are far more demanding than say, pursuing a low carbohydrate regimen (like Berstein's Diabetes Solution, or Atkins), or even raw dieting. If a patient fails at these, or simpler life style changes -- when their life is not at stake -- what makes them feel they could do okay with the dietary demands of such a surgery? Because they got 'two weeks' of psychological counseling pre-op? Disordered eating, and compulsion, take years of counseling to improve (much more to 'fix')!
Additionally, studies have shown that after some time, people's diabetic symptoms may return, and some folks even regain weight and end up pursuing additional gastric surgeries. I am not entirely sure that the costs of surgery, with it's attendant complications, are worth my getting a 'free pass' for a few more years; especially, when I can just give myself that free pass with a more calorie restricted, low carbohydrate diet.
And I don't know about you... but I just like eating food in portions larger than a peanut.