April 24, 2012 in Features

While effective, surgery is last option

Bariatric procedures can be painful and require post-op dedication
By The Spokesman-Review
 

Two bariatric-surgery studies published last month supported what many doctors and patients already knew: Weight-loss surgery works better than medicine alone to put type 2 diabetes in remission, or at least to lessen the need for medicine.

But while the results weren’t shocking, the studies were unique in that they were randomized and controlled – the “holy grail of research,” said Dr. Mathew Rawlins, who performs bariatric surgeries at the Rockwood Surgical Group and Weight Loss Surgery Center in Spokane.

Some patients were assigned to go through drug treatment alone; some received drug therapy and bariatric surgery. The studies were published March 26 in the New England Journal of Medicine.

“There’s nothing like a randomized, controlled trial to really convince the skeptics,” Rawlins said.

Another unique aspect: One of the two studies included patients with relatively low BMIs. Body mass index is a number calculated from your weight and height that indicates body “fatness.”

Bariatric surgery has in the past been mostly reserved for people with BMIs of 40 or higher, or 35 if the person has type 2 diabetes or another obesity-related illness. But one of the new diabetes studies included type 2 diabetes patients with BMIs as low as 27. That might be a woman who’s 5-foot-7 and 170 pounds or a 6-foot man who weighs 200 pounds – overweight, but not considered obese.

The results are “starting to suggest that (surgery) may work in thinner type 2 diabetics as well,” Rawlins said.

That’s because the operations used in the studies didn’t just lead to weight loss – already known to treat type 2 diabetes – but also changed the way patients metabolized sugars and fats.

‘Tidal wave’ of prediabetics

But here’s what the studies didn’t cover: Life is no picnic with a stomach pouch the size of an egg and a rerouted intestine – what you get with a Roux-en-Y gastric bypass, the type of bariatric surgery found to be most effective against type 2 diabetes.

“Surgery is the very last treatment on the tier,” said Megan Vulcan, an advanced registered-nurse practitioner who works with bariatric patients at Rockwood.

That’s why diabetes educators are so keen on catching patients with prediabetes – before it turns into diabetes.

There are a lot of prediabetics to catch. In 2009, more than 28,800 adults in Spokane County had been diagnosed with diabetes, according to the Centers for Disease Control and Prevention. That was 8 percent of the population.

Three times that many people are considered prediabetic – their blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes.

“It’s a tidal wave coming, this prediabetic crowd that’s out there,” said Ted Duncan, executive director of the American Diabetes Association’s office in Spokane.

People with prediabetes can stave off type 2 diabetes by exercising and changing their diets, said Lisa Randall, clinical coordinator for the Diabetes Education Center at CHER, or Community Health Education and Resources, in Spokane.

Nurses and dietitians at the Diabetes Education Center teach patients how to change their lives to stave off diabetes, or, if they have it, to try to control it using exercise and diet – along with glucose monitoring and insulin therapy.

“We try to get people to eat less processed food and more whole foods – and less quantity,” Randall said.

Symptoms of prediabetes and diabetes are insidious, Randall said. Fatigue is a major one, but many sufferers mistakenly believe they’re growing more tired simply because they’re aging.

‘They have to do the work’

About 55 percent of the roughly 200 patients a year who undergo bariatric surgery at Rockwood have diabetes, said Rawlins, the surgeon. Others suffer from high blood pressure or heart disease, joint or muscle pain, sleep apnea or other health problems related to obesity.

The operation itself may be the easiest part.

Insurance companies impose their own requirements before they’ll cover bariatric surgery, such as consultations with dietitians or that patients meet pre-surgery weight-loss targets to demonstrate that they can follow a diet and exercise plan – key to post-surgery weight loss.

The Rockwood center requires that patients have worked for at least five years with their primary physician to lose weight.

As part of the Rockwood center’s pre-surgery process, Vulcan said, she looks for evidence that patients can change their behavior, that they’re making efforts to exercise and eat better.

She gives them work to do between visits such as practicing reading food labels to glean nutritional information; gradually cutting down on pop consumption; or trying new exercises.

“We don’t want to give them things that are overwhelming, that are socially embarrassing, that are uncomfortable,” Vulcan said.

Patients receive a mental-health screening, too, and some must go to regular therapy sessions.

After surgery, patients are limited to small food portions eaten several times throughout the day. Some foods will make them sick. And they have to plan carefully to eat the nutrients they need.

Rockwood schedules follow-up visits that will continue for the rest of patients’ lives.

Vulcan said the annual visits and weigh-ins let her discuss diet and exercise plans with patients and provide a measure of accountability.

“Most of the annual visits are very happy,” Vulcan said. “But there are some where they’re falling off the program, and they’re struggling.”

While it is uncomfortable to overeat when you have such a small stomach, it’s possible, Vulcan said.

When her patients regain weight, she said, it’s usually because they’ve been drinking high-calorie beverages and grazing.

“They have this whole team that are supporting them, but they have to do the work when they get home,” Vulcan said.

Some people take a couple of years to change their diets or exercise habits before surgery can happen, Rawlins said. And some find that those changes are enough – they drop the weight, improve their health and don’t need surgery after all.

“Those are the cases I’m most proud of,” he said.

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