The Weighty Cost of Diabetes

By Chuck Dinerstein — October 7, 2019

Two new studies, one surgical, the other medical come to similar conclusions - significant weight loss alters the course of Type 2 diabetes.

In the first study, 867 40 to 69-year-old, patients with new-onset diabetes were randomized into treatment or control groups. Seven hundred thirty had both their weights and HbA1c measured initially and at five years and represented the study group. It was predominately Caucasian (97%), male (61%), and with a BMI of about 34. At the end of 5-years, 30% of patients who lost 10% or more of their body were in remission from diabetes. And the incidence of remission followed the degree of weight loss – the kind of dose-response to treatment that suggests underlying physiologic changes.

The researchers considered several associated behavioral changes, smoking cessation, less alcohol or caloric intake, fewer fats, more exercise, you know the litany. But with the exception of a small improvement with diminished alcohol intake, none of those changes made a difference – it was solely that drop in weight.

"These findings suggest that remission is achievable without intensive lifestyle interventions or extreme calorie restrictions."

Of course, the study has some fine print. First, while a weight loss of this magnitude during the five years achieved this result for some patients, it was more effective earlier in the course of the disease. The more important caveat and one many of us know first-hand, losing that amount of weight and keeping it off is far easier said than done. And that brings us to the second study.

When is a "bug" a feature?

One of the most frequently performed operations in the mid-20th century was a host of procedures for treating peptic ulcers, stomach ulcers. They have been substantially entirely supplanted by medications like ranitidine (Zantac currently under recall). But even though all those different operations on the stomach "cured" the ulcers, many had an adverse side effect, significant weight loss. Innovative surgeons turned that adverse effect, that operative "bug" into an operative benefit with the introduction of bariatric surgery – alterations of the GI tract meant to reduce a patient's weight.

There are several operations categorized as bariatric surgery, some designed to diminish the size of the stomach, increasing the onset of satiety and reducing caloric intake; others that re-arrange the GI tract to reduce capacity and alter metabolism. All are associated with significant weight reduction and have been offered to patients who are significantly obese. A new study looks at how patients, with Type 2 diabetes, undergoing bariatric procedures fare for adverse cardiovascular outcomes – the usual concerns of heart attacks, strokes, and other problems.

Roughly 2300 patients undergoing bariatric surgery and with a history of Type 2 diabetes were followed for approximately four years and compared with control patients who did not undergo bariatric surgery. An inspection of the two groups suggests that the control patients were at best "similar" rather than the same, so the effect size I am reporting should be taken with a grain of salt.

These patients were far more overweight at a BMI of 40 or higher than the previous study. The surgical group had more dyslipidemia and hypertension; the control group more smokers and blacks.

The cumulative incidence of all-cause mortality, coronary artery disease, heart failure, cerebrovascular disease (strokes) atrial fibrillation, and nephropathy (kidney disease) were all reduced over the 8-year follow up for the surgical patients as compared to the controls.




But for me, the critical finding is the profound and long-standing weight loss from the surgery, as depicted on the right. These patients not only had remission from diabetes but significant reductions in the need for medications for both hypertension and dyslipidemia.

"We speculate that the lower rate of MACE after metabolic surgery observed in this study may be related to substantial and sustained weight loss with subsequent improvement in metabolic, structural, hemodynamic, and neurohormonal abnormalities."

The surgery is not a free ride, as with all procedures, there can and were complications; 0.7 % of patients died within 90 days of surgery (for open-heart surgery that percentage is about 3.7%). Five percent needed open surgical revision, while 16% had revisions of their operation by more non-invasive means. The authors are not suggesting that bariatric surgery be the primary treatment.
What I think is clear is that in well-motivated patients, a 10% weight loss can "reverse" Type 2 diabetes and show significant improvements in many associated cardiovascular diseases. And weight loss, whether or not assisted by bariatric surgery, had a more substantial impact on adverse cardiovascular outcomes than the new generation of medications for diabetes advertised with an "added cardiovascular benefit." The signal from the studies is strong; at least for me, losing a significant amount of your "over" weight is strong medicine.

Source: Behaviour change, weight loss and remission of Type 2 diabetes: a community‐based prospective cohort study Diabetic Medicine DOI:10.1111/dme.14122 and Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Type 2 Diabetes and Obesity JAMA DOI: 10.1001/jama.2019.14231
 

Tags: 

type 2 diabetes

bariatric surgery

weight loss

 

Is the 'Impossible Burger' Safe?

By Chuck Dinerstein — August 12, 2019

Having jumped all the appropriate FDA hurdles to ensure safety, the Impossible Burger in its uncooked form is coming to supermarket shelves this fall. That has not silenced its critics who now consider the Impossible Burger “unhealthy” and continue to raise concerns.

What is actually in an Impossible Burger?

The top five ingredients begin with water, soy protein that replaced an earlier version made from wheat protein (perhaps a nod to the gluten-free crowd), coconut oil now reduced with sunflower oil to reduce saturated fats, and natural flavors. It also contains methylcellulose, not to worry, it is a plant-based binder creating the right mouthfeel, and of course, heme or soy leghemoglobin. This last ingredient is tasty, a feat of genetic engineering and the one ingredient getting the evil eye of safety concerns.

From a nutritional lens, the complaint is that Impossible Burgers have too much fat and salt. In comparison to equal size (roughly 4 ounces) and equal caloric lean beef hamburger, it has 1 gram more fat, 9 grams of carbohydrate, and 16% rather than beef’s 1% of our “daily value” of salt. It also contains 10 grams less protein, but three gms of fiber. But none of this is surprising; you are eating a plant, not a cow. And all the variations of protein, carbs, fiber, and like the percentages you would find in the oft-cited plant-based diet. As for fat and salt, the increased fat is 1.5% of the recommended daily amount, and the salt can be easily managed by most individual's kidneys who have been doing it far longer than the USDA.

The Impossible Burger also contains a number of vitamins some of which are needed when strictly following a plant-based diet. The most important, and controversial, is the iron found in that genetically engineered soy leghemoglobin..........To Read More....

Training a New Breed of Surgeons: Internists

By Chuck Dinerstein — July 5, 2019

One way to reduce healthcare costs, especially on the medical side of the equation has been to increase the utilization of mid-level or advanced care practitioners, e.g., nurse practitioners and physician assistants. There are similar but more nuanced shifts in the same direction in surgery, restricted to performing the “less critical” components of surgical care. A new study looks at whether physicians, not trained as surgeons, can provide reasonable, “non-inferior,” surgical care for those critical components............To Read More....

Opioid Deaths Are Not Solely a Medical Issue

By Chuck Dinerstein — July 9, 2019

Pop quiz! What is the cause of our opioid epidemic?

A. Doctors prescribe too many opioids.
B. The government insisted doctors control pain better
C. Big Pharma created addictive drugs and lied to us
D. Free trade policy

Pencils down, time is up. While variations in the first three responses all may have some culpability, how many of you put down that last choice? A new study in Population Health suggests that our free trade policy did play a role.

Let’s first address how opioid overdoses and free trade may be related. Free trade shifts the manufacture of goods to the cheapest supplier, the Dollar Store, Walmart, and Amazon are built upon that economic principle. But for the country that cannot compete on price, and that would be us in many instances, trade-related job loss closes factories, eliminates middle-class jobs, and as it turns out disproportionately impacts those regions on the US most burdened by opioids’ disruption. The displaced workers, often less-educated, have only short term unemployment benefits for what has become a long term problem. There is also evidence that one way to make ends meet, is to apply for disability benefits; benefits that require a medical examination and are associated with a greater likelihood of being prescribed opioids...........To Read More...

Mick Jagger's 'Start Me Up' Choice in Valve Surgery

By Chuck Dinerstein — April 3, 2019  Mick may be 75, but he seems to have chosen some cutting-edge care. While Mr. Jagger’s privacy concerning his upcoming surgery prevents us from knowing exactly what is planned I am going to make an assumption [1], that he is undergoing replacement of his aortic valve in a minimally invasive procedure. Let’s break it down.

The aortic valve separates the left ventricle from the aorta; it is the valve that separates the chamber of the heart pumping blood into our main artery. The ventricle provides most of the force to carry the blood throughout our body; the valve opens and closes in synchrony with the contraction to make the effort efficient. In aortic stenosis, the valve is narrowed, not opening fully and more rarely not closing fully as well. The inability to open fully makes it more difficult for the left ventricle to pump out the blood making the heart work harder.

As a result of this obstruction blood backs up into the lungs where it may cause shortness of breath; or less blood will be pumped out and reduce the amount of blood getting to the brain, causing dizziness; or in some instances the increased work the heart must do in conjunction with blockages in the coronary (heart) arteries may cause chest pain. In the case of the aortic valve remaining open, aortic regurgitation, the inefficiency of the heart to pump blood out results in similar symptoms. In the presence of these symptoms, it is time to replace the valve.........To Read More....

My Take -  I keep being amazed at the non-invasive advancements being made in medicine. But I think the real story is he didn't have this done in Britain with their "free health care". He came to the U.S. instead.

Amazing!

Can you "Feel the Bern"?

Science and Environmental Litigation

By Chuck Dinerstein — August 21, 2018 @ American Council on Science and Health

The judiciary frequently acts in its role as a counterbalance to executive and legislative action and non-action. A new article in Nature Climate Change finds patterns of climate change litigation identified in the Sabin Center for Climate Change database, a part of Columbia’s School of Law. As it turns out, there are some instructive patterns, and we begin to see the role of Science – with a capital S.

The Who and Why of Litigation

Who files these cases? - Environmental non-government organizations were the largest plaintiff, initiating 42% of cases, industry followed at 30%, with city, state and federal government involved in about 11%.  The Sabin database contained 838 cases from 1990 to 2016.

• 46% dealt with atmospheric environmental issues especially coal-fired power plants
• 8.5% dealt with energy efficiency or renewables
• 4% addressed water quality
• 8% raised concerns about biodiversity

The courts were asked to address the reduction in greenhouse gases, to assess responsibility for environmental impacts and as a way to change both corporate behavior and public debate (the latter presumably through policy).

For those interested in keeping some form of score, in those cases involving atmospheric environmental issues, the courts more often sided with the “anti-regulators.” On the other hand, “pro-regulatory” litigants won more often when the cases involved issues of energy. And whether it was an NGO or an industrial group acting as plaintiff, they were generally less successful than the defendants. The authors felt that this might reflect both weaker cases and the courts more often deferring to the judgment of state officials.

The Who and the Where

To file a court case, the plaintiff must have “standing,” a legal term that establishes that the plaintiff has suffered some injury [1] or that there is a causal relationship between the defendant’s actions and those injuries. In establishing standing, NGOs often found that collaborating with local stakeholders was helpful. If the NGO could not demonstrate “their” injury, then an alliance with a local community group who had suffered injury got them a seat at the plaintiff’s table. These collaborations were not limited to the NGOs; industrial litigants found that joining forces with other large business within the sector with also in their interest. The authors suggest that these collaborations helped to demonstrate a larger group of concerned citizens, helped to mask disagreements among the stakeholders and in some cases gain otherwise unavailable legitimacy.

The where of litigation is referred to as venue - the jurisdiction in which the case is heard. The plaintiff’s goal is to identify the most favorable court for hearing their case. Delaware is home to many corporations because its corporate laws frequently favor their concerns, which has resulted to more corporate litigation in that state which in turn creates a large body of case law to serve as precedence. California is a more favored venue when statutory concerns are pivotal, because of their strict environmental rulings and the case laws that have flowed from those decision. And in both instances, prior case law often provides a sense of how the courts may act.

The role of science

Unsurprisingly, both NGOs and industry felt that scientific evidence was an essential factor in the court’s ruling. Equally unsurprising was that the litigants offered differing evidence and used it in differing ways. The “pro-regulatory” litigants, the NGOs, used their scientific evidence to establish a causal link between the defendants and the injury. This could serve two purposes, first to warrant their standing before the court and then to substantiate the environmental effects causing the injury.  The “anti-regulatory” litigants also found the same two uses; using the “dismal science” of economics to demonstrate their economic injury, and the environmental science to refute the claims of the plaintiffs.

The researchers did not review the court transcripts, so what science and how it was presented remains unknown, but from studying the Court’s written judgments they found that scientific evidence was cited in roughly half the cases; it made no difference whether it was for or against regulation.

So what can we conclude? Everyone brings their own “scientific evidence” to the table; that their evidence differs is not a flaw in the scientific method, it is a feature. Scientific theory and evidence represent are a best current approximation, and there is always an unknown element. So our evidence will differ, only time and further replication will push us towards the “right” answer. As the authors write:

“The results turn on factors such as the roles courts think are appropriate for the judiciary in influencing important environmental, social and economic policy questions, how they react to scientific evidence that relates to climate change presented before agencies or during civil trials and what remedies they are willing to impose.”

The question we need to ask is whether a courtroom is the best venue for that discussion. The courts act on these matters because the other branches of the government are unable or unwilling to have this discussion; I think that those other branches are as able as the courts so that just leaves unwilling.

[1] Injury does not have to be physical, it can be emotional or anything that reflects a form of damage.

Source: Strategies in and outcomes of climate change litigation in the United States Nature Climate Change DOI: 10.1038/s41558-018-0240-8