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.