http://www.nytimes.com/2016/09/11/opinion/sunday/before-you-spend-26000-on-weight-loss-surgery-do-this.html
Before You Spend $26,000 on Weight-Loss Surgery, Do This
By SARAH HALLBERG and OSAMA HAMDY SEPT. 10, 2016
Earlier this year, the Food and Drug
Administration approved a new weight-loss
procedure in which a thin tube, implanted in the
stomach, ejects food from the body before all the calories can be absorbed.
Some have called it "medically sanctioned
bulimia," and it is the latest in a desperate
search for new ways to stem the rising tides of
obesity and Type 2 diabetes. Roughly one-third of
adult Americans are now obese; two-thirds are
overweight; and diabetes afflicts some 29
million. Another 86 million Americans have a
condition called pre-diabetes. None of the
proposed solutions have made a dent in these epidemics.
Recently, 45 international medical and scientific
societies, including the American Diabetes
Association, called for bariatric surgery to
become a standard option for diabetes treatment.
The procedure, until now seen as a last resort,
involves stapling, binding or removing part of
the stomach to help people shed weight. It costs
$11,500 to $26,000, which many insurance plans
won't pay and which doesn't include the costs of
office visits for maintenance or postoperative
complications. And up to 17 percent of patients
will have complications, which can include
nutrient deficiencies, infections and intestinal blockages.
It is nonsensical that we're expected to
prescribe these techniques to our patients while
the medical guidelines don't include another
better, safer and far cheaper method: a diet low in carbohydrates.
Once a fad diet, the safety and efficacy of the
low-carb diet have now been verified in more than
40 clinical trials on thousands of subjects.
Given that the government projects that one in
three Americans (and one in two of those of
Hispanic origin) will be given a diagnosis of
diabetes by 2050, it's time to give this diet a closer look.
When someone has diabetes, he can no longer
produce sufficient insulin to process glucose
(sugar) in the blood. To lower glucose levels,
diabetics need to increase insulin, either by
taking medication that increases their own
endogenous production or by injecting insulin
directly. A patient with diabetes can be on four
or five different medications to control blood
glucose, with an annual price tag of thousands of dollars.
Yet there's another, more effective way to lower
glucose levels: Eat less of it.
Glucose is the breakdown product of
carbohydrates, which are found principally in
wheat, rice, corn, potatoes, fruit and sugars.
Restricting these foods keeps blood glucose low.
Moreover, replacing those carbohydrates with
healthy protein and fats, the most naturally
satiating of foods, often eliminates hunger.
People can lose weight without starving themselves, or even counting calories.
Most doctors — and the diabetes associations —
portray diabetes as an incurable disease,
presaging a steady decline that may include
kidney failure, amputations and blindness, as
well as life-threatening heart attacks and
stroke. Yet the literature on low-carbohydrate
intervention for diabetes tells another story.
For instance, a two-week study of 10 obese
patients with Type 2 diabetes found that their
glucose levels normalized and insulin sensitivity
was improved by 75 percent after they went on a low-carb diet.
At our obesity clinics, we've seen hundreds of
patients who, after cutting down on
carbohydrates, lose weight and get off their
medications. One patient in his 50s was a brick
worker so impaired by diabetes that he had
retired from his job. He came to see one of us
last winter, 100 pounds overweight and panicking.
He'd been taking insulin prescribed by a doctor
who said he would need to take it for the rest of
his life. Yet even with insurance coverage, his
drugs cost hundreds of dollars a month, which he
knew he couldn't afford, any more than he could bariatric surgery.
Instead, we advised him to stop eating most of
his meals out of boxes packed with processed
flour and grains, replacing them with meat, eggs,
nuts and even butter. Within five months, his
blood-sugar levels had normalized, and he was
back to working part-time. Today, he no longer needs to take insulin.
Another patient, in her 60s, had been suffering
from Type 2 diabetes for 12 years. She lost 35
pounds in a year on a low-carb diet, and was able
to stop taking her three medications, which
included more than 100 units of insulin daily.
One small trial found that 44 percent of low-carb
dieters were able to stop taking one or more
diabetes medications after only a few months,
compared with 11 percent of a control group
following a moderate-carb, lower-fat,
calorie-restricted diet. A similarly small trial
reported those numbers as 31 percent versus 0
percent. And in these as well as another, larger,
trial, hemoglobin A1C, which is the primary
marker for a diabetes diagnosis, improved
significantly more on the low-carb diet than on a
low-fat or low-calorie diet. Of course, the
results are dependent on patients' ability to
adhere to low-carb diets, which is why some
studies have shown that the positive effects weaken over time.
A low-carbohydrate diet was in fact standard
treatment for diabetes throughout most of the
20th century, when the condition was recognized
as one in which "the normal utilization of
carbohydrate is impaired," according to a 1923
medical text. When pharmaceutical insulin became
available in 1922, the advice changed, allowing
moderate amounts of carbohydrates in the diet.
Yet in the late 1970s, several organizations,
including the Department of Agriculture and the
diabetes association, began recommending a
high-carb, low-fat diet, in line with the then
growing (yet now refuted) concern that dietary
fat causes coronary artery disease. That advice
has continued for people with diabetes despite
more than a dozen peer-reviewed clinical trials
over the past 15 years showing that a diet low in
carbohydrates is more effective than one low in
fat for reducing both blood sugar and most cardiovascular risk factors.
The diabetes association has yet to acknowledge
this sizable body of scientific evidence. Its
current guidelines find "no conclusive evidence"
to recommend a specific carbohydrate limit. The
organization even tells people with diabetes to
maintain carbohydrate consumption, so that
patients on insulin don't see their blood sugar
fall too low. That condition, known as
hypoglycemia, is indeed dangerous, yet it can
better be avoided by restricting carbs and
eliminating the need for excess insulin in the
first place. Encouraging patients with diabetes
to eat a high-carb diet is effectively a
prescription for ensuring a lifelong dependence on medication.
At the annual diabetes association convention in
New Orleans this summer, there wasn't a single
prominent reference to low-carb treatment among
the hundreds of lectures and posters publicizing
cutting-edge research. Instead, we saw scores of
presentations on expensive medications for blood
sugar, obesity and liver problems, as well as new
medical procedures, including that
stomach-draining system, temptingly named
AspireAssist, and another involving "mucosal
resurfacing" of the digestive tract by burning
the inside of the duodenum with a hot balloon.
We owe our patients with diabetes more than a
lifetime of insulin injections and risky surgical
procedures. To combat diabetes and spare a great
deal of suffering, as well as the $322 billion in
diabetes-related costs incurred by the nation
each year, doctors should follow a version of
that timeworn advice against doing unnecessary
harm — and counsel their patients to first, do low carbs.
_______
Sarah Hallberg is medical director of the weight
loss program at Indiana University Health Arnett,
adjunct professor at the school of medicine,
director of the Nutrition Coalition and medical
director of a start-up developing nutrition-based
medical interventions. Osama Hamdy is the medical
director of the obesity and inpatient diabetes
programs at the Joslin Diabetes Center at Harvard Medical School.
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