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

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