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A Report from the Bariatric Trenches

The American Society of Bariatric Physicians recently invited me to speak at their continuing medical education (CME) conference on obesity in Seattle. They got my name from Stephen Barrett of Quackwatch and asked if I could speak about questionable weight loss treatments like HGH, MIC (methionine, inositol and choline), and the HCG Diet. I seized the opportunity to discuss how to evaluate any medical claim, with examples from alternative medicine as well as from weight loss. My title was “Questionable Evidence for Questionable Treatments.” I talked about some of the things that can go wrong in clinical trials and why simply finding reports of positive randomized controlled trials (RCT) is not enough. I advocated rigorously science-based medicine and recommended the SBM website.

Several people came up afterwards to express their thanks and their agreement, but some of the questions from the audience were rather hostile. One man said he was a military doctor and he was using and teaching acupuncture (which I had criticized as a bad example of “tooth fairy science” in my talk). I asked for his opinion of battlefield acupuncture and he just said “No comment.” A couple of people thought science wasn’t enough and thought it was okay to prescribe questionable treatments when there was no proven effective treatment. I responded that I had no objection as long as the patient was told the facts and not given the false impression that the questionable treatment had been tested and shown to work.

I was glad for the chance to meet some of the ASBP members. I had never met a bariatric physician and was interested to learn about their practices and philosophies. I had never really thought about the fact that most obese patients had associated diseases like hypertension and diabetes, so their overall management could be very complex. I attended the whole obesity course: some of what I heard was educational, some of it was questionable, and some of it was frankly disturbing.

The first speaker was Gary Taubes, author of Good Calories, Bad Calories. I had read his book and agreed with his evaluation of the dietary fat hypothesis, but I was not entirely convinced that he had enough clinically significant evidence to justify replacing it with the carbohydrate hypothesis. In this talk, based on his forthcoming book, he focused on the history of the case against sugar. It was refreshing to hear him say that

Until demonstrated otherwise, high fructose corn syrup is just another form of sugar.

A researcher, John Baxter, MD, discussed new drugs based on thyroid hormone that attempt to separate its beneficial effects on atherosclerosis and obesity from its harmful side effects. Interesting, but still in a very preliminary research stage. He went on to complain about the impediments to approving new drugs. In his opinion, the studies the FDA requires are intended to look for risks rather than benefits. He defended the “file drawer” practice, saying that his group did not publish negative trials that didn’t get the results they wanted (perhaps because the experimental design was flawed), since that would “pollute the literature” (?!).

Dr. Vernon Neppe spoke on nutritional supplementation and biopsychosocial issues. He said that supplements are drugs, they may be dangerous, manufacturing controls are poor, evidence is lacking, pharmacology is complex, interactions are common, there is evidence favoring vitamin D and fish oil supplements but questions remain, and generally food is better than pills. And he addressed the “natural” fallacy by pointing out that snake venom was natural. I was impressed by his common sense and was amazed by his alphabet soup of credentials: I don’t remember ever seeing anyone with more initials after his name. He listed 14 titles: MD, PhD, FRSSAf, DFAPA, DSPE, BN&NP, FRCPC, DABPN, FFPsych, MMed, DPsM, MB, BCh. I only know what the first two mean.

Dr. Kendall Gerdes spoke on food allergy and food addiction, a talk deserving a post just for itself. I’ll cover it next week.

Dr. Robert Lerman recommended omega-3 supplementation for bariatric patients because of its anti-inflammatory, insulin sensitizing, CVD risk-reducing effects and other potential benefits. He made a good theoretical case, but didn’t have any real evidence showing clinical benefit. He cited one study that reported higher maximum weight losses with fish and fish oil supplements than with placebo but did not report the average weight loss or the statistical significance. Without that information, I thought it was too meaningless to bother mentioning.

Dr. Barbara Schneidman reported on hot button issues for state medical boards. Some boards have restricted the use of “weight loss enhancers” to patients with a BMI over 30, and have prohibited using Schedule II drugs for the purposes of weight loss. Audience members thought this was unwise, that doctors should have the freedom to prescribe according to their own clinical judgment.

Jeffrey Bland, PhD spoke on “Beyond the Dogma of the Calorie.” Maybe it’s not that excess calories cause obesity which then causes diabetes, but rather that some underlying mechanism causes both obesity and diabetes. He pointed out that after bariatric surgery the blood glucose and lipid levels fall faster than the weight. He blames an interaction between genetics and the environment that he thinks involves “Larmarckian” inheritance (that’s his synonym for epigenetics). He implicates the gut microbiome as both causing and resulting from obesity. Some of the slides he didn’t get to (but that were included in the syllabus) covered resveratrol and claimed that specific dietary phytochemicals play a role in obesity and metabolic diseases. For what it’s worth, Dr. Bland is featured on Quackwatch. He has been in trouble with the FTC and the FDA for making unsubstantiated claims about supplements sold by his companies. He believes in detoxification and is a notorious promoter of naturopathy.

There were informative talks about managing childhood obesity and about pre- and post-op care for bariatric surgery. A talk on the Mediterranean diet covered a number of evidence-based health benefits, but did not explain why the speaker advocates a “modified” Mediterranean diet supplemented with protein powder, chromium, lipoic acid, and cinnamon.

The ASBP recently issued an official policy statement that HCG does not work for weight loss and that the HCG diet is not recommended. The last speaker on the program challenged the ASBP’s position. He claimed that the “con” studies were flawed, that more studies are needed, and that meanwhile HCG should only be used by physicians with special training and expertise (like him). One of his slides said “It is OK to use a placebo;” he added the caveat “as long as it works.” That statement can be criticized both on the basis of the meaning of the word “placebo” and on the consensus of medical ethicists that using placebos is unethical.

There was a room full of commercial booths. I was amazed at all the innovative ways companies had devised to profit from obesity. Most of them were giving away free samples of foods and supplements. (“You’re too fat, so let us sell you food”?) One product was a calcium citrate/vitamin D supplement disguised as a chocolate candy, with added calories. Is that a good idea? One salesman told me his products were classified as “medical foods” that were covered under a special FDA regulation. The FDA apparently doesn’t agree. They warned Dr. Bland that his similar products did not fit their regulatory definition of medical foods

…because the diseases and conditions described in the product labels do not have distinct nutritional requirements and because the products do not have any unique impact on the dietary management of those diseases and conditions beyond that which could be achieved by modification of the normal diet alone.

More next week.

Posted in: Herbs & Supplements, Nutrition, Science and Medicine

Leave a Comment (16) ↓

16 thoughts on “A Report from the Bariatric Trenches

  1. daijiyobu says:

    Bland may be ‘the’ biggest promoter of ‘functional medicine.’

    As if medicine ignores physiology!

    Which always seems to require expensive [profitable?] and irregular [dubious?] diagnostic testing and coincidentally, supplementation.

    Metagenics? [Here's a cease and desist from 1996, http://www.ftc.gov/os/1996/10/d9267idc.htm ].

    Ironically, the company was called “Ethical Nutrients.”

    What’s funny is that Wikipedia defines metagenics as “the creation of something which creates.”

    Therein, functional medicine is very creative [fictional?].

    -r.c.

  2. anoopbal says:

    Most people want to hear something ground breaking or new when they attend conferences. They don’t want to hear the same old thing in the textbooks. So I guess the organizers invite these people who has something controversial or interesting to say. This is a typical conference

    If you think about it, they can easily find who is science-based and who is not before inviting. That is if they have any idea about science based or evidence based approach.

    And I don’t think any of the obesity researchers agree with Gary Taubes. He is another researcher caught in the confirmation bias. In the recent years, there has been number of RCT studies looking at low carb diets and sytematic reviews which shows NO advantage of low carb diets over high carb diets. But he still maintains his opinion based on some anecdotal evidence and “logic” and how his” Mom said this” and quoting studies from 1960′s . He might be right about cause of obesity being so complex but his carb hypothesis is just wrong.

  3. Jojo says:

    ‘One of his slides said “It is OK to use a placebo;” he added the caveat “as long as it works.”’

    It’s only OK to use as long as it works. But, you don’t know if it will work until you actually use it, right? To me that means that you couldn’t know if it’s OK to use until after you have already used it.

    It’s interesting to me that people who advocate the use of placebo don’t seem to consider how patients feel on the subject. In addition to the ethical issue of offering a treatment that has no shown benefit, there is also a matter of trust that needs to be considered. How many patients will trust a doctor if they realize that their doctor has prescribed a useless procedure?

    I complained about breast pain to a gyn. He explained that I had fibrocystic breast disease and told me to take a certain dose of vitamin E. I spent months taking vitamin E (paid for out of pocket) and nothing improved. I eventually ended up switching to a different under wire bra and the problem resolved. Not only did he suggest a treatment that cost money and didn’t help, he also dismissed a real problem and by offering up a generic diagnosis and unproven treatment, I spent several months not even trying to figure out what was causing the problem. Needless to say, I stopped seeing him and did not recommend him to firends either.

  4. Interesting article. My sister recently had weight loss surgery, which I was apprehensive about, but she seems to be happy with the results thus far.

    Just a quick idea, in the article a definition of the HCG diet and a good link might be helpful to readers who aren’t familiar with all the different weight loss trends (like me.)

  5. Do you think we are going to see a Bland Diet marketed in the future…

  6. daijiyobu says:

    Here’s a bland diet,

    per “foods that are soft, lightly spiced, and low in fiber”

    http://www.healthsquare.com/mc/fgmc2019.htm !

    But, it’s apparently not a Bland diet:

    no exotic, expensive tests and supplements

    touted as accurately diagnostic and actually therapeutic.

    -r.c.

  7. PeterHansen says:

    Dr. Hall:

    You might be interested in my recent experience. I filed a complaint with the Colorado Board of Medical Examiners on a physician prescribing HCG for weight loss. In Colorado, HCG is listed in the anabolic steroid list.

    Surprisingly, their letter of admonition to this physician was for his lack of work up for the patients complaint of chest pain, and was silent on the HCG issue. I asked the board for clarification on the HCG issue.

    Their reply: The regulation forbids the use of HCG for weight gain, but not for weight loss.

    Peter Hansen M.D.

  8. anoopbal says:

    If I am right, for people with morbid obesity bariatric surgery is the only effective treatment. The reason why it works is not really clear.

    Here is an article about weight loss : http://www.exercisebiology.com/index.php/site/articles/weight_loss_goals_how_to_set_realistic_weight_loss_goals/

  9. anoopbal says:

    And I just saw the Vaccine war on PBS and thought it was very well done. Here is the link to the full video:

    http://www.pbs.org/wgbh/pages/frontline/vaccines/view/?utm_campaign=viewpage&utm_medium=toparea&utm_source=toparea

    Hopefully someone can link it in the reference section.

  10. zed says:

    in 2007 my Wife had a vagotomy in a study to see if it would work for weight loss ( http://www.washingtonpost.com/wp-dyn/content/article/2007/07/02/AR2007070201063.html ) while it worked well for the first 18 months or so, she developed major stomach problems including gastric stasis which the Doctors decided to correct with Roux en-Y gastric bypass surgery, this helped, but she still has problems with pain and blood pressure/heart rate whenever she eats.

    Any weight loss surgery should be undergone with extreme caution and all possible risks should be told to the patient before any decision is made.

  11. weing says:

    Harriet,
    What was the take on diabetes at the conference? I’ve heard some claim that bariatric surgery is a cure for diabetes. When I spoke with endocrinologists about it they were livid. They look upon the post bariatric surgery patient as having diet controlled diabetes.

  12. David_Brown says:

    Dr. Hall,

    I’m concerned that excessive omega-6 is seldom openly discussed in relation to obesity and associated chronic inflammatory conditions. http://wholehealthsource.blogspot.com/2010/04/do-seed-oils-cause-multi-generational.html

    I have experience with long term excessive omega-6 intake and it’s not fun. http://theconsciouslife.com/omega-6-friend-or-foe.htm

  13. Harriet Hall says:

    weing,

    I was intrigued by what they said about the effects of bariatric surgery on diabetes and other obesity-associated diseases. The blood sugar comes down promptly after surgery, before a significant amount of weight is lost. The surgery does “cure” diabetes in the sense that the patient may no longer have elevated blood sugars and may no longer need anti-diabetic medications. But then, the surgery drastically limits the amount of food intake. If the patient could have controlled food intake in the same way without surgery, I would guess that the effect on diabetes would be the same, but I don’t think that’s ever been tested.

    Bariatric surgery is very drastic and there are all kinds of complications. Patients require lifelong vitamins and other supplements to prevent malnutrition. One thing I hadn’t realized before the conference was that patients who have had the surgery can’t take some medications that require an intact digestive system for proper absorption. Nevertheless, there is clear evidence that surgery prolongs life and reduces the complications from obesity.

  14. Harriet Hall says:

    David_Brown,

    I think omega-6 is openly discussed. I’m constantly getting the message “omega-3 good, omega-6 bad.”

    There is a lot of evidence for increasing omega-3, but not so much evidence for decreasing omega-6. It would be an interesting area for research.

  15. The Blind Watchmaker says:

    Dr. Bland’s statement about diabetes improving faster than weight after bariatric surgery is correct, but his explanation of this phenomenon is not.

    Evidence suggests that…”the intestine is itself involved in the immediate regulation of carbohydrate homoeostasis. In humans, the rapid improvement in carbohydrate homoeostasis observed after bypass surgery is secondary to an increase in insulin sensitivity rather than an increase in insulin secretion, which occurs later.”
    http://www.ncbi.nlm.nih.gov/pubmed/20152734

    After gastric bypass increases the secretion of GLP-1 in the distal small intestine, which stimulates insulin secretion and inhibits glucagon. This likely results in an initial fall in diabetes parameterrs.
    http://www.ncbi.nlm.nih.gov/pubmed/20152734

  16. Chris_C says:

    I actually did see one study that found that rats being fed high-fructose corn syrup gained more weight than rats being fed an equivalent amount of sugar. In addition, their weight gain was more focused in the abdominal fat pad.

    here’s the link:
    http://www.princeton.edu/main/news/archive/S26/91/22K07/

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