Saturday, December 29, 2012

Does bariatric surgery cure diabetes?

Bariatric surgery has been heavily promoted to treat Type 2 diabetes. Bariatric surgery is now being considered for those with less severe obesity, a body mass index (BMI) less than 35.

Surgery generates a lot of revenue for surgeons and the hospitals where they work. The Lap-Band System generates substantial revenue for its manufacturer. But just how effective is bariatric surgery for diabetes?

Does bariatric surgery cure diabetes? For the sake of clarity, let’s use the term "complete remission" instead of "cure".

The definition of complete remission of diabetes has been agreed upon to mean normal blood glucose measurements lasting at least a year without the need for medications.

It has been known for decades that weight loss dramatically improves glucose levels in persons with Type 2 Diabetes.

Modest weight loss of even 5% reduces the need for medication to treat the diabetes.

With weight loss, insulin works better and the pancreas can produce more insulin. 
The amount of weight lost appears to be the main reason for the improvement in glucose after weight loss surgery.

A recently published trial called STAMPEDE was conducted at the Cleveland Clinic. This trial received a lot of media coverage. You might know that the "clinic",  as it is known in Cleveland,  has an outstanding marketing department. 
The goal of STAMPEDE was to test whether bariatric surgery was better than “intensive medical therapy” to control blood glucose in obese adults with Type 2 Diabetes.

The average BMI was 36 before surgery. 
A third had a BMI less than 35.
And either sleeve-gastrectomy or gastric bypass surgery was performed.

The investigators started off with 150 patients and determined the likelihood of these patients getting to a Hemoglobin A1c of less than 6% after 12 months. Now, a HgbA1c of less than 6% is really good blood glucose control and is lower than our goal for most patients with Type 2 Diabetes.
Patients were randomly assigned to one of the surgical treatments or to the so called "intensive medical therapy".

This study had obvious flaws that most people fail to see.
The main flaw is calling the medical therapy “intensive medical therapy”. This "intensive" treatment was a visit to the clinic every 3 months. That’s a joke! 
That is not intensive therapy!

The intensive therapy in the 10, 000 person ACCORD trial which also targeted a Hemoglobin A1c below 6% meant a visit every 2 weeks for 4 months and then at least monthly. And at the visits treatment was really intensified.

In STAMPEDE, there was minimal increase in the use of medications despite this supposed "intensive" therapy.  
STAMPEDE appears to have been designed by the surgeons to show that surgery was better.  
Well,  it clearly suggested that surgery is better than minimal medical therapy.  

And in this Cleveland Clinic trial, among those who had surgery, 22% in the gastric bypass group were still on medication for their diabetes at 12 months. And that number was 49 % for those who had undergone a sleeve gastrectomy!
And a recent analysis of 357 patients with Type 2 Diabetes who had  a BMI less than 35  before surgery found that about 20% fail to go into remission after surgery.

And another large recent analysis  of over 4400 patients who underwent gastric bypass showed that about 32% failed to have a complete remission of their diabetes within 5 years. These people were not “cured” of their diabetes. And of those who did have a complete remission, about 35% saw their diabetes come back within the next 5 years.

Those persons most likely to have a complete remission were those before surgery who were not using  insulin and those who had  shorter duration of their diabetes. 
Another recent large study of diabetes remission among over 1100 patients showed that 38 % still had diabetes 6 years after gastric bypass surgery.

So taken together these studies tell us that about 40% or more adults still will have to deal with treatment of their diabetes despite having had bariatric surgery.

Bariatric surgery helps many patients in many ways but it  is no "cure all" for Type 2 Diabetes.

Every treatment for diabetes has its pros and cons. 
And that includes surgery which does not “cure” diabetes in a significant number of patients. 
Your Diabetes Endocrine Nutrition Group

Sunday, December 23, 2012

Will fish oil make your baby smarter?

Will fish oil make your baby smarter?

Women who are pregnant are often advised by their doctors to take fish oil supplements, especially DHA.
DHA is short for docosahexaenoic acid. DHA is one of the two main omega-3 fatty acids found in fish oil. The other is abbreviated EPA.

Many people believe  that if mom takes DHA during pregnancy the baby will be smarter or otherwise better off.

Is any of this true?

Various clinical trials tested the benefit of DHA during pregnancy.
Doses of DHA used in these trials ranged from 400-1100 milligrams daily.
All these studies were randomized, double-blind, placebo controlled clinical trials. 
And all studies showed no benefit in the child's cognitive development whether the children were tested at 18 months as was done in one large Australian study or at 6 1/2  years.   

A small trial in which fish oil supplements were given only during breastfeeding  suggested worse cognitive function when children were tested at 7 years.

Visual function requires good brain and nerve function. 
One study that assessed visual function  showed no benefit. 
Another published this year showed no benefit in either visual or auditory function. 

So is there anything good about taking DHA during pregnancy?

Well there might be some benefits on immune function. Maybe.
Allergic or atopic eczema appeared to be less in a trial that used a 900 mg of fish oil supplement containing 800 mg of DHA.
Another smaller study with a lower dose of DHA  failed to show less atopic eczema.
One study showed benefit only in the infant’s first year but not in the second year. This last trial suggested less likelihood of egg allergy in the infant's first year as well as less eczema.

One small study showed better infant sleep within 48 hours of birth in those infants of mothers who received the DHA supplement. 
But how about after 48 hours? Many parents would like to know the answer to that!

The symptoms of the common cold and some other symptoms seemed less in infants in one study in those mothers who had received DHA supplements. But those infants also had more vomiting.

So where does all this leave us?
The results of DHA and fish oil supplements in general during pregnancy are singularly unimpressive. 
Pregnant women should take folic acid supplements, avoid alcohol and tobacco and prepare a safe home for their baby. Avoiding cow's milk and cow's milk formula in the first 6 months of life is also important.

And here's one last smart move:  get a knowledgeable and caring pediatrician.

Sunday, December 9, 2012

Sex, Death and Fidelity

Sex, Death and Fidelity

Patients with diabetes often have heart disease.
Those who have had a heart attack may worry about having sex after they've recovered.
Will sexual activity give them another heart attack?
Can sex cause sudden death in a person at high risk for heart attack?

It is clear that regular physical activity reduces your risk of heart attack, technically known as myocardial infarction.

Sexual activity can be considered a form of mild to moderate physical activity. I discussed this in a previous post.

In 4 studies of adults, the majority of which were men in their 50s and 60s, those who had been sedentary, physically inactive, had a 3 fold increased risk of myocardial infarction during the time of sex as compared to when they were not engaged in sexual intercourse.

But for those physically active persons, the relative risk of myocardial infarction was only 1.2.

Overall, the so-called absolute risk of a myocardial infarction during sexual intercourse is quite low. Less than 1 % of all myocardial infarctions occur in close relation to sexual intercourse. And the chance of another myocardial infarction during sex is also very low in those who have had a previous myocardial infarction.

How about suddenly dying during sex?
Sudden death can occur during sex from a myocardial infarction or life threatening arrhythmia (heart irregularity) . Although the increases in heart rate and blood pressure during orgasm and sex are about the same in women as for men, about 90% of those who suddenly die during sex are men. 

Interesting isn’t it?

In 3 autopsy reports of thousands of persons who suffered sudden death, only 0.6% had sudden death related to sexual activity. That is only 6 out of every thousand who died suddenly.
So, in general, your chances of dying suddenly during sex are fairly low, especially if you are healthy with few risk factors for heart disease.

But here’s a key point.
About 75 percent of those sudden deaths during sex occurred with sex outside of marriage.

The lessons I take away from this are:
·      stay physically active,
·      remain faithful to your partner and
·      talk to your doctor about your sexual concerns. 

This statement from the American Heart Association has much more in the way of guidance and recommendations for patients and their doctors.

Take care and be well,
Your Diabetes Endocrine Nutrition Group