Wednesday, July 18, 2012

How a third of gastric surgery patients put ALL the weight back on

More evidence of the futility of the war on "obesity"

Seventeen firefighters and ambulance staff were needed to carry a 40st woman from her home to an ambulance in Croydon, it was reported last week.  At one point, it was thought a window would need to be removed to get the woman out. And a firefighter later told reporters: ‘We are finding we are getting more of these calls.’

Another day in overweight Britain, where one in four adults is now officially obese. The cost to the NHS of treating diabetes — often triggered by excess weight — is a staggering £1.5 million an hour, while experts warn our children may be the first generation to die at an earlier age than their parents.

In the ten years since bariatric (weight loss) surgery was first recommended as a last resort for obesity by government watchdog NICE, the number of operations has increased tenfold.

Eight thousand procedures were carried out in England alone on the NHS last year, most of them either a gastric band — in which a silicone band is fitted around the stomach to make it smaller — or a gastric bypass, where a small pouch is created at the top of the stomach and connected to the small intestine, bypassing the rest of the stomach and bowel.

The aim is to reduce appetite and speed up feelings of fullness — to transform the patient from someone who eats too much into one who simply cannot. Results are often impressive, especially the first post-op months, as the weight falls off.

Surgery can also dramatically reduce the risk of health problems such as heart disease, high blood pressure and type 2 diabetes.

Each operation costs the NHS £3,000 to £10,000, but a study by the Office of Health Economics in 2010 reported that it pays for itself within a year in reduced prescriptions and GP time, and benefit payments.

As obesity rates continue to rise — by 2050 it’s expected that half of all British adults will be clinically obese — many experts are keen to see more people offered surgery.

In April this year, Scottish doctors warned that unless more gastric operations are performed, the costs of treating diabetes and its complications will ‘bankrupt’ the NHS. But now evidence is emerging that this very modern approach to losing weight may not be the panacea it was hoped to be.

A worrying proportion of patients fail to keep the weight off long term, largely because although their stomachs have physically shrunk their addiction to food remains.

In fact, 63 per cent of patients put weight back on within two years of their operation, according to one Brazilian study of 782 patients. Meanwhile, a German review of studies on weight-loss surgery found 30 per cent of patients regained their lost weight between 18 and 36 months.

As a result, growing numbers of patients are requesting a second operation. In a Dutch study of patients who’d had gastric banding, a third needed the operation redone after five years and half after ten years.

‘You must realise this is not the final answer most of the time,’ lead researcher Dr Edo Aarts says.
Most hospitals in the UK now carry out gastric bypasses rather than banding, as these have been shown to be more effective long term.

‘A percentage of patients will not do well,’ says Guy Slater, a bariatric surgeon at St Richard’s Hospital in Chichester. ‘And it’s very hard to predict, because there are so many physiological and psychological variables involved.

‘That’s one of the problems with this type of surgery — and also what makes it so different from any other.’

When weight-loss surgery fails it is not only extremely distressing for the patient, but means they are still at risk of all the health problems linked with obesity, such as joint damage, diabetes, heart disease and stroke.

‘They can become a burden to the NHS again, because either they have revision surgery or need procedures like knee ops because they are overweight again,’ says Jane Ogden, professor of health psychology at the University of Surrey. ‘Weight-loss surgery is cost effective but only if it works.’

Meanwhile, results for a second operation are poor, with a higher risk of complications and death, says Mr Slater, who also practises privately for Streamline Surgical, agrees. ‘I try to avoid it at all costs. I’m always much more nervous doing it the second time than the first time.’

So what’s going wrong?

Crucial to the success of bariatric surgery is that the patient is mentally prepared for the vigorous diet plan they’ll need to stick to for the rest of their lives. Their stomach will only cope with small side-dish size portions.

However, it is possible to stretch the newly reduced stomach by eating a little more each time. So experts agree patients need psychological screening before surgery, to ensure they have the willpower to resist the old temptations. And then, if necessary, they will need aftercare with dietitians and specialists to keep them on track.

‘In the first year, or two years, after the surgery, you feel like you’re walking on air. But three or four years on is a very different thing,’ says Bianca Scollen, of the support group Weight Loss Surgery Info (she herself had surgery eight years ago).

‘In a way, losing the weight is the easy part, it’s changing your lifestyle and keeping it off that’s hard.’
Some people find the sight of their new, slimmer shape is enough to keep them motivated, but for others it’s not so easy.

‘Hunger isn’t just a biological process — it can be about feeling fed up and wanting comfort, or feeling bored,’ says Professor Ogden. ‘Unless patients have changed their attitude towards food, they end up cheating — grazing, or drinking lots of water so their stomach can manage more food.’

Guy Slater agrees. ‘We get rid of the physical hunger, but some people have an emotional hunger that is less easy to get rid of,’ he says.

Under NICE guidelines, NHS patients must receive a psychological assessment before being approved for surgery, as well as regular aftercare appointments. But provision is patchy, because of waiting times for psychologists on the NHS.

‘All our patients have a psychological assessment, and we turn down around one in eight of them, because we don’t feel they’re ready for it,’ says Mr Slater. ‘But this doesn’t always happen elsewhere.

‘We try to spot the people who are going to need the psychological support after their operation and try to get their GP to put a programme in place, but it’s very difficult with funding.’ It’s also vital that patients are properly prepared for the realities of life after surgery. Most patients will be left with large folds of excess skin that’s vulnerable to infection.

Some suffer depression as a result of the dramatic transformation to their body and the effect it has on their relationships, lifestyle and sense of identity.

Another risk is ‘transfer addiction’ — where, denied food, patients develop other dependencies, such as gambling and alcohol.

The NHS will only offer the surgery to those with a Body Mass Index (BMI) of 40 or above (or 35 and above if you also have a serious health condition such as type 2 diabetes or high blood pressure).

An estimated one million Britons qualify on the basis of their BMI but as a result of  growing NHS waiting lists more people are going private.

One company, BMI Healthcare, has seen a 20 per cent year-on-year increase in requests.
But private providers don’t have to provide any psychological support and, often, patients are just given the option to pay extra for it.

Some providers also don’t offer sufficient aftercare, vital to protect against weight regain and, because of the risk of complications such as infections, vomiting, gastric bands that slip or leak and intestinal blockages.

The number of negligence claims against independent bariatric surgeons doubled in the two years between 2008 and 2010, according to the Medical Defence Union, the doctors’ insurers.

Common complaints included failure to obtain consent from the patient about the risks involved.
Bariatric surgery is often seen as the easy solution to a growing problem — but it won’t work unless the patient changes their mind, as well as their body.


Diabetes drug costing just 2p could beat prostate cancer by shrinking tumours

Sounds hopeful

A diabetes drug costing as  little as 2p a tablet could offer a major breakthrough in the treatment of prostate cancer.

Research has shown that the medicine, called metformin, causes tumours to shrink by slowing the rate at which cancerous cells grow.

If the results are confirmed in bigger  trials, it raises the possibility that men could be given the cheap, readily available drug as soon as they are diagnosed.

Nearly 40,000 cases of prostate cancer are diagnosed every year in the UK and 10,000 men die from it – the equivalent of more than one an hour.

The risks of developing a tumour increase with age, and there is a strong genetic element to the disease.

Metformin is widely used on the NHS to treat patients with type 2 diabetes.

But recent studies highlighting the drug’s effects against a variety of tumours have generated considerable excitement among cancer researchers looking for  powerful new treatments.

Last year, scientists discovered  it could slash the risk of ovarian cancer by around 40 per cent.

And Cancer Research UK is currently funding a major five-year study, involving early 5,000 British women with breast cancer, to see if the drug will stop the disease returning and boost survival rates.

Other research teams around the world are investigating metformin’s powers against skin, lung and pancreatic cancer, with promising early results.

In the latest breakthrough, doctors at the Princess Margaret Hospital in Toronto, Canada, tested the drug on 22 men after they noticed that it stunted prostate cancer cell growth in laboratory experiments.

All of the men had been diagnosed with tumours and were due to undergo surgery to have their prostates removed.

For six weeks before their operation, each one took 500mg of metformin three times a day, during which time researchers measured the rate at which the tumour cells multiplied.

The results, presented at the recent American Association for Cancer Research annual meeting in Chicago, showed malignant cells grew at a significantly slower rate once the men were put on the drug, suggesting metformin might be able to keep tumours under control.

The findings support a 2009 study which found that men taking metformin every day to control their diabetes were up to 44 per cent less likely to develop prostate cancer.

Dr Anthony Joshua, a cancer specialist who carried out the latest study, said: ‘We compared what the prostate cancer looked like when  it was first diagnosed to what it looked like when it was removed.

‘And although these are preliminary results, it appeared to reduce the growth rate of prostate cancer in a proportion of men.’

Metformin works by reducing the amount of glucose produced by  the liver and helping cells mop up sugar that is circulating in the bloodstream, preventing damage from excessive blood sugar levels.

At about £30 per patient per year – or just 6p to 8p a day – it could be a highly cost-effective way to tackle prostate tumours.

Eleanor Barrie, Cancer Research UK’s senior science information officer, said: ‘Larger trials will tell us more in the next few years.’


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