Monday, April 8, 2013

Surgery Diet without Surgery?

When a person who has been defined as morbidly obese has been unable to lose weight via conventional methods he or she might turn to weight loss surgery.  If the person has Type 2 diabetes he/she might elect to have Gastric Bypass Surgery as the rapid weight loss after this surgery often results in a rapid normalization of blood glucose levels (and some people are able to remove oral diabetic agents and insulin from their regimen).  The diet one has to follow when one is post Gastric Bypass, however, is very strict as one hopefully wants to avoid vomiting and/or diarrhea from eating too much period or too much of the "wrong" thing, and wants to avoid the expanding of the pouch so you wind up gaining the weight back.  Since the diet is so strict, some scientists have been doing studies to attempt to determine whether it's just the diet or other factors associated with the surgery that help blood glucose levels (Of particular interest to me is the research being done on alteration of absorption as it pertains to gut microbes.

Such was the reasoning behind this small study that was done at UT Southwestern, and it indicated that the diet itself has quite a bit to do with the reduction in blood glucose levels.  One of the obvious limitations of this study is it's small sample size, but I'm not going to spend this post critiquing the study; instead I am going to complain about the inaccurate reporting of the diet in this particular news post.  The only description of this "strict" diet was this:
"During each of these observations, which lasted for 10 days, the volunteers consumed less than 2,000 calories total each day - the customary diet for gastric bypass surgery patients."

Well, yes they did consume fewer calories.  But let me tell you what else you have to do, particularly in that first six months post surgery.  You have to make sure that you get your daily requirement of protein in so your body can heal, so your protein source is eaten first.  Your portions are measured out carefully before you even sit down to eat.  If you have no room for your starch, you don't eat it, unless you want to have nausea and vomiting.  You make sure that you chew each bite 25-30 times and make your meal last 20-30 or longer so you can let the salivary enzymes and chewing action aid in digestion so you don't have nausea and vomiting.  You don't eat anything that is deep fried because you will have (guess what) nausea and vomiting.  You don't have anything with added sugar, because that will give you nausea, heart palpitations, and diarrhea.  You don't have any caffeine or alcohol because that will irritate the stomach pouch and you will either be having heart palpitations (caffeine) or be intoxicated (alcohol) because of the rapid absorption.  So, if you are one of those people who don't find nausea/vomiting/diarrhea as part of your list of top ten fun things to do, you have some pretty good incentive to eat less period and severely limit your carbohydrate, hence the falling blood glucose levels.  On the slightly less scary side, when someone's carbohydrate intake (and intake period) is that restricted after surgery the person might go into ketosis which supresses the appetite (that's why breath strips on the pre-surgery shopping list I give to patients).

So the point that I hopefully made in the above paragraph was that saying that they merely just ate less than 2000 calories per day is a gross misrepresentation of what a person has to go through post surgery and the "added incentives" they have for actually sticking with the diet.  The potential complications/risks are also why gastric bypass surgery is still seen as a "last resort" for a lot of obese individuals (and why people need to go into it as informed as possible, and have a variety of evaluations by a variety of health care professionals); on the flip side, it is also why some individuals have the surgery because they feel like they need that extra incentive to stay on the plan (it certainly isn't the "easy way out" that some people think it is.  And why Dr. Lingvay made this comment:
"Unfortunately, such a restrictive diet is nearly impossible to adhere to long-term in the absence of bariatric surgery. We found that the success of bariatric surgery is mediated through its ability to control food intake, which in turn has a beneficial effect on diabetes."

I'm sure of you are wondering if there isn't a "half-way" point for your self or a love one who has both type 2 diabetes and has had difficulty losing weight.  I would say if  you could find a to engage in the eating habits listed above MOST of the time (e.g. measuring your portions, eating protein first, only eating a little starch at the end of the meal if you are still actually hungry, etc), then you might be able to accomplish your goals without surgery.  In other words, if you would put as much work into your diet as a post surgery person does, a lot could be accomplished even without the negative feedback.  There are some people who elect to have the surgery as they still are not able to lose to their goal weight, or because they want the "negative feedback," but that is a decision between that person and their physician.   (Keep in mind too that I am talking about people whose weight is causing a health crisis, not someone who just needs to lose a few pounds.  Someone who needs to lose a lot less weight [and maybe isn't diabetic] might be able to get away with making much more gradual changes and still lose weight).

Take home message--Losing weight and controlling your blood glucose levels takes hard work and is a major lifestyle change if you want to keep that weight off; said changes go way beyond the reduction of calories.

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