Advanced Mediterranean Diet

Nicholas Yphantides, M.D., wrote in a brief article January 5, 2009, at Diabetes Self-Management about his reduction to an ideal weight after starting at 467 pounds (212 kg) through diet and exercise.  The focus of the article is on the risks of bariatric surgery.

In my Advanced Mediterranean Diet book I write that women over 300 pounds and men over 350 pounds ” . . . infrequently have success with self-help methods . . .”  That’s still true.

Dr. Yphantides is one of the exceptions that give hope to others.

Steve Parker, M.D.

Nonsurgical approaches to relieve morbid obesity, such as drug therapy, low-calorie diets, exercise, and behavior modification have been disappointing.

Bariatric surgery for morbid obesity, on the other hand, has been effective more often and to a greater degree.  Hence, the ten-fold increase in bariatric procedures over the past decade.

The leading procedures these days are Roux-en-Y gastric bypass and laparascopic adjustable gastric banding.  Banding is being promoted as safer and potentially reversible compared to the time-honored gastric bypass.

Doctors in the Department of Medicine at the University of California, San Francisco, recently reviewed the scientific literature that compares the two procedures.  They found 14 comparative studies done between 2000 and 2007.  The studies followed patients for at least one year after surgery, monitoring for complications, amount of weight loss, adverse events, quality of life, and effects on obesity-related medical conditions.

Findings

• Loss of excess body weight (measured at one year) was greater for gastric bypass than for banding: average difference was 26%.  In other words, bypass patients lost 26% more weight.
• Bypass patients had greater resolution of obesity-related medical conditions: diabetes, high blood pressure, adverse cholesterol levels, and sleep apnea.
• Length of hospitalization and operating room time were shorter for gastric banding.
• Death rates were under 0.5% for both procedures.
• Complications around the time of surgery were higher for bypass than for banding - 9% versus 5%.
• Long-term need for additional related operations was lower after gastric bypass - 16% versus 24%.
• Patient satisfaction was greater for gastric bypass.

Discussion From the Study Authors

Previous research has shown that weight loss improves both social functioning and quality of life.  Carefully controlled studies have demonstrated between 25% and 60% reductions in all-cause, cardiovascular, and cancer mortality associated with significant weight loss.

There is a risk that commercial sponsorship of laparoscopic adjustable gastric banding may promote the use of these devices over Roux-en-Y gastric bypass, which has no commercial sponsor.

Until trials demonstrate the advantages of laparoscopic adjustable gastric banding in clearly defined subgroups of patients, Roux-en-Y gastric bypass should remain the bariatric procedure of choice in the United States.

My Comment

You can bet there will be heated debate about this study in the bariatric surgery community, with vigorous rebuttals from people heavily invested in the banding devices.  Even if you have no dog in the fight, you can still disagree with these results.  But have your facts ready.

Steve Parker, M.D.

Reference:  Tice, Jeffrey, et al.  Gastric Banding or Bypass?  A Systematic Review Comparing the Two Most Popular Bariatric Procedures.  American Journal of Medicine, 121 (2008):885-893.

My local newspaper, The East Valley Tribune, had an article yesterday headlined, “Study says gastric bypass surgery reduces cancer rates.”  Google found me an online version of the story from another source.  I assume the Canadian researchers issued a news release.

Researchers at McGill University followed 1,035 gastric bypass patients over five years or more, with 5,746 obese people serving as controls.  “Controls” means they did not have the surgery but were otherwise similar to the surgical group.  The bypass patients lost 67% of their excess weight, which is considered successful surgery.

Breast and colon cancers were reduced by 85% and 70%, respectively.  Obesity is associated with increased risk of breast and colon cancer, so some reduction would make sense intuitively.  You might guess that loss of excess weight by any method would reduce risk of developing breast or colon cancer.  You may or may not be right.  But cancer death reduction has been ”proven” for weight loss only via bariatric surgery, not other weight-loss methods.  Utah surgeons reported 60% lower risk of death from cancer after bariartric surgery (see reference below).

The Canadian researchers reported that skin cancer was reduced by 60%, which is surprising.  Obesity is not associated with skin cancer.  They also report a 50% reduction in non-Hodgkins lymphoma and 70% reduction in pancreatic cancer.  Those cancers have not consistently been associated with obesity in the past.  Furthermore, pancreatic cancer and non-Hodgkins lympoma are not common, and you wouldn’t expect many cases, if any, to occur in such a small sample size (6781 people).  I suspect the observed reductions in skin cancer, pancreatic cancer, and lymphoma are not valid and reproducible.  But who knows?  We need more details of the study, including the statistical analysis.

My point in bringing up this subject is to caution you that these results are preliminary.  I hope they are real, meaning reproducible and reliable.  Prior research from Utah tends to confirm the essential finding: bariatric surgery significantly reduces cancer rates.  The Canadians undoubtedly have submitted their report to one or more medical scientific journals for publication at a future date.  A major part of the publication process involves “peer review.”  The manuscript for publication will be reviewed by independent experts in the field who are in a position to judge whether the study was well-designed, valid, and reliable.  If not, the findings will not gain credibility among the medical/scientific community and will be ignored.  We may not see publication of the study details in a peer-reviewed journal for over a year.

Much hangs in the balance here: increased insurance coverage for the surgery, the volume of future gastric bypass operations, and people’s lives.  The odds of dying from a surgical complication are about one in 200.

Steve Parker, M.D., author of The Advanced Mediterranean Diet

Reference:  Adams, Ted, et al.  Long-Term Mortality after Gastric Bypass Surgery.  New England Journal of Medicine, 357 (2007): 753-761. 

An up-and-coming theory to explain type 2 diabetes suggests that abnormal lipid metabolism, not glucose/sugar metabolism, is the primary metabolic defect.  Roger H. Unger, M.D., writes about this in the March 12, 2008, issue of the Journal of the American Medical Association.

Early in the writing of this blog entry, I realized it is much too technical for most of my readers.  If you are not interested in physiology, you can quit reading now.  This may be the most boring blog of mine you have ever read.  I’m writing this to solidify my own understanding of a new theory.

I assure you my prose in The Advanced Mediterranean Diet is not nearly this technical.

Still with me?  We start with definitions and physiology.  Diabetes is defined by high blood glucose (sugar) levels.  The lipid family includes triglycerides (fats and oils), sterols (e.g., cholesterol), and phospholipids (e.g., lecithin, a major cell membrane component).  Fats are almost entirely composed of trigylcerides.  When fats are broken down, fatty acids are produced.  On the other hand, fatty acids can be joined together, along with glycerol, to form triglycerides.  Glycogen is a storage form of glucose in liver and muscle tissue.  Insulin is a protein hormone produced by pancreatic beta cells.  Insulin 1) lowers blood glucose levels by driving glucose into cells, 2) inhibits breakdown of glycogen into glucose, 3) inhibits formation of new glucose molecules by the body, 4) stimulates glycogen formation 5) promotes storage of triglycerides in fat cells (i.e., lipogenesis, fat accumulation), 6) promotes formation of fatty acids (triglyceride building blocks) by the liver, 7) inhibits breakdown of stored triglycerides, and 9) supports protein synthesis.  Fatty acids in muscle tissue block the uptake of glucose from the bloodstream by muscle cells.  Fatty acids in liver tissue impair the ability of insulin to suppress breakdown of glycogen into glucose, and impairs the ability of insulin to suppress production of new glucose molecules.  In other words, an “excessive fatty acid” environment in liver and muscle tissue promotes elevated glucose levels.

Got that?  [This is very difficult material.]  Now on to the lipocentric theory of type 2 diabetes.

Type 2 diabetes may be caused by:

1. Eating too many calories, leading to…
2. High insulin levels, leading to…
3. Stimulation of fat production, leading to…
4. Increased body fat, leading to…
5. Deposition of lipids in cells where they don’t belong (that is, not in fat cells), leading to…
6. Resistance to insulin’s effects on glucose metabolism, leading to…
7. Lipid accumulation in pancreatic beta cells, damaging them, leading to…
8. Elevated blood glucose levels, i.e., diabetes.

Perhaps the key to understanding this is to know that “insulin resistance” refers to insulin having less ability to suppress glucose production by the liver, or less ability of various tissues to soak up circulating glucose.  Insulin resistance thereby leads to elevated glucose levels.  But insulin’s effect of “producing fats” (lipogenesis) continues unabated.  Excessive fats, actually fatty acids, accumulate not only in fat cells, but also in liver cells, muscle cells, pancreatic beta cells, and others.  This lipid overload can damage those cells.

If this theory is correct, so what?

Steps #1 and 2 of the lipocentric theory involve excessive caloric intake and high circulating insulin levels, leading to problems down the road.  So overweight people should restrict calories and try to lose at least a modest amount of weight.  Particularly if already having type 2 diabetes or prone to it.

And what about people with type 2 diabetes who have insulin resistance and have poorly controlled glucose levels?  Most of these have high insulin levels already, contributing to a fat-producing state.  Adding more insulin, by injection, would not seem to make much sense.  The extra insulin would bring glucose levels down, but might also cause lipid overload with associated cellular damage.  Effective clinical strategies according to Dr. Unger would include 1) caloric restriction, which helps reduce weight, high insulin levels, and fat production, and 2) if #1 fails, add anti-diabetic drugs that reduce caloric intake (exenatide?), that reduce lipid overload (which drug?), or that do both.  Dr. Unger suggests consideration of bariatric surgery, for caloric restriction and cure of diabetes.

Compared with dietary fats and proteins, carbohydrates generally cause higher circulating insulin levels.  And type 2 diabetics taking insulin shots need higher doses for higher intakes of carbohydrate. So it makes sense to me to consider preferential reduction of carbohydrate intake if someone is going to reduce caloric intake.

Dr. Unger and I agree that reduction of excessive food intake and excess body fat is critically important for overweight people with type 2 diabetes.

Steve Parker, M.D., author of The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer     www.AdvancedMediterraneanDiet.com

References: Unger, Robert H.  Reinventing Type 2 Diabetes: Pathogenesis, Treatment, and Prevention.  Journal of the American Medical Association, 299 (2008): 1185-1187.

I live near Scottsdale, Arizona.  The residents of Scottsdale have a reputation as being more image-conscious than the average U.S. citizen.  Think breast implants, blonde hair dye, face-lifts, Jimmy Choo shoes.  I am seeing increasing advertisements for lipodissolve, also called mesotherapy, aimed at reduction of localized fat deposits.  As a weight-loss expert, I figured I better learn more about it.  Does it work?  Are there adverse effects?  Is it just a scam to separate fools from their money?

Mesotherapy involves injection of substances into the fat tissue under the skin, leading to dissolution of that fat deposit.  It apparently kills fat cells.  The technical term would be chemical lipolysis: dead fat cells break down.  The body eliminates the residue.  Mesotherapy has been available in Europe for awhile.

I found a recently published study by physicians who are familiar with this treatment, conducted in Italy.  Study participants were 40 women, aged 20 to 55.  Average body mass index was around 21-22, right in the middle of the healthy BMI range.  They were not overweight but apparently wanted to reduce fat deposits on their thighs.  The authors described “bilateral gynoid lipodystrophy.” In less genteel terms,  these women had saddlebags.

The goal of the study was to compare two different mesotherapy chemical treatments: 1) phosphatidylcholine/sodium deoxycholate, and 2) sodium deoxycholate alone.  Injection #1 is sold in Europe as “Lipostabil.” Each woman served as her own “control:” one upper thigh was injected with #1, the other thigh with #2.  The area of treatment was limited to 80 square centimetes per side.  Think of a square 3.5 inches or 9 cm per side.  (The area injected was not actually square; more likely an oval.)  There were about 80 injections per side, about 1 cm apart.  Four treatments like this were performed every 8 weeks.

Any side effects?  The injections were quite painful, but usually short-lived.  Stinging and burning sensation lasted for some hours after injecion in all women.  Also quite common were bruising, redness, swelling, and transient nodules under the skin.  Nausea/malaise occurred in 11%, and diarrhea/steatorrhea in 16%.  Chemical #2 caused more side effects and they were slower to clear up.  Despite these side effects, the authors deemed the treatments “completely safe in the short term.”

Did it work?

Yes.  Thirty-four of the 40 women showed overall reduction of local fat.  Three of the women (8%) had no improvement at all.  Average upper thigh circumference decreased by about 4 cm (1.5 inches), from 58.48 cm down to 54.70 cm.  Loss of fat tissue was confirmed with ultrasound.  There was no difference between the two different injections.  The authors considered this a moderate amount of localized fat loss.

A commentary was made at the end of the article by a physician who performs liposuction, Naomi Lawrence, M.D.:

…it is good study, but will mesotherapy replace liposuction?  It is difficult to support the contention that this procedure has less morbidity than tumescent liposuction.  It involves four sessions, spaced 8 weeks apart requiring 80 painful injections.  It is limited to an 80 square centimeter area.  The treated subcutis becomes erythematous, bruised, and pruritic and then develops tender nodules that last about 1 month.  The mean decrease in thigh circumference is modest, approximately 4 cm on average.  Call me a pessimist but I do not think I will retire my machine or cannulas just yet.

Also, not mentioned in the article is the duration of the modest effect.  It may not be permanent.

Steve Parker, M.D., author of The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer   www.AdvancedMediterraneanDiet.com

References:

Salti, G., et al.  Phosphatidylcholine and Sodium Deoxycholate in the Treatment of Localized Fat: A Double-Blind, Randomized Study.  Dermatologic Surgery, 34 (2008): 60-66.

Rittes, P.G.  The use of phosphatidylcholine for correction of localized fat deposits.  Aesthetic Plastic Surgery, 27 (2003): 315-8.  [I did not read this but you may want to.  -SP]

Rotunda, A.M. and Kolodney, M.S.  Mesotherapy and phosphatidylcholine: historical classification and review.  Dermatologic Surgery, 32 (2006): 465-80.  [I did not read this but you may want to.  -SP]

Gastric bypass is the most common bariatric surgery in the U.S.  The odds of dying from that procedure are roughly 1 in 200.  Thousands of people sign on the dotted line for it every year.  Why do they take that risk?

A recent study out of Sweden shows that people who undergo various bariatric surgeries reduce their risk of death over the next 11 years by 25%.

In the Swedesh Obese Subjects Study, 2010 subjects underwent bariatric surgery and 2037 received conventional treatment.  Overall mortality was recorded over the next 11 years.  Only three of the subjects were lost to follow-up (unknown whether alive or not).  The average body mass index (BMI) for all subjects was 41.

Out of the conventional treatment group, 126 died.  In the surgery group, only 101 died.  Average weight change in the conventional treatment group was up or down only 2%.  People in the surgery group were given one of three operations: gastric bypass, vertical-banded gastroplasty, or banding.  After 10 years, average weight loss of the groups was 25%, 16%, and 14%, respectively.

Over the course of 11 years, people in the surgery group had 25% less chance of dying when compared to the conventional treatment group.  The most common causes of death were heart attacks and cancer.

Even better results were found back in the U.S.  Researchers in Utah looked at mortality rates of 7925 patients who had undergone gastric bypass surgery between 1984 and 2002.  They compared death rates to a control group (also 7925 people) of obese people who applied for driver’s licenses.  Subjects were matched for sex, body mass index, and age.  Average BMI of the surgical group was 45.

Over the course of seven years, there were 321 deaths in the control group and 213 in the surgery group.  Deaths from any cause were reduced by 40% in the surgery group, compare to the control group.  Surgery patients had less death from cardiovascular disease, diabetes, and cancer.

Surgery is definitely a roll of the dice.  Now you know why people play the game.

Steve Parker, M.D., author of The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer   www.AdvancedMediterraneanDiet.com

References:

Sjostrom, Lars, et al.  Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects.  New England Journal of Medicine, 357 (2007):  741-752.

Adams, Ted, et al.  Long-Term Mortality after Gastric Bypass Surgery.  New England Journal of Medicine, 357 (2007): 753-761.