Diabetes can be 'Cured'!

Type 2 Diabetes is "CURED" in 24% of patients who have bariatric surgery.  

These patients  have maintained a Hb A1c below 6, a fasting glucose of less than 100 for more than 5 years while being off all diabetic medications. In short, These patients no longer have any evidence of diabetes!

This amazing news was reported in the Surgery News of the American College of Surgeons Surgery in July 2013 by Dr. Brethauer from the Cleveland Clinic. He reported on long term follow up of 217 patients who had had bariatric surgery after years of struggling with obesity and type 2 diabetes.

Another 26% of patients were greatly improved off diabetic medicines but dis not meet the more stringent requirements of the first group of patients.

A total of 56% of patients where not on any diabetic medications 6 years ofter their operation.

Which patients did best?

1). Patients who had a gastric bypass operation (instead of a gastric band or gastric sleeve).

2). Patients who had diabetes for less than 5 years prior to surgery.

3). Patients who lost most weight after surgery.

Dr, Brethauer's conclusion: "Bariatric surgery can a significant and sustainable remission of type 2 diabetes and other metabolic risk factors in obese patients and should be considered early in the course of the disease."

I wholeheartedly agree. If you are diagnosed with diabetes your next plan should be to get rid of it as soon as possible. If you are like 90% of diabetics and are at least 50 to 75 lbs overweight you meet criteria for surgery and can often 'cure' the disease before it gets worse! Decide you will not put up with it and contact your bariatric surgeon today. What are you waiting for?

If you are one of the very many people that have their diabetes resolved or improved after bariatric surgery please spread the word of your amazing result and to as many people as possible and help me change our country's understanding. Type 2 diabetes is not inevitable but preventable, treatable and often curable.  Join me. We have our work cut out for us so let's get to it.  

Current Thinking Oppresses Patients with Diabetes

I am angry with how we think of diabetes.  In fact, I am so angry could scream! Type 2 Diabetes is a monster devouring legs, portions of brains, kidneys, eyes and even people’s very lives every day.

This week I lost another family member that had suffered with Type 2 Diabetes for many years. Two of my immediate family members continue to suffer with diabetes. It is all so unnecessary and it is because our country and our world has the wrong idea about diabetes. We are thinking wrongly and we will not be able to change our world until we change our thinking.

We believe the projections that 30% of our adult population will have type 2 diabetes by year 2030. We accept this as inevitable because the obesity rates are so high!

This is ridiculous. This is unacceptable. We only accept this because we are thinking  wrongly.

We do not have to accept this present paradigm. We know that 90% of Type 2 diabetes is related to obesity. Nearly everyone who reaches a BMI of 40, (for instance, five foot five with a weight of 240 lbs.), will develop type 2 diabetes in time. Some have already developed type 2 diabetes even at a lower weight of a BMI of 35.

For patients with weight high enough to meet criteria for bariatric surgery, sustained weight loss without surgery is very unlikely and therefore dieting and behavior modification is not a solution to this dilemma.  In fact, less than 5% of these people will be able to lose significant amount of weight and keep it off long term without surgery. Diabetic medications decrease blood sugar but the glocose is often forced into fat cells increasing weight over time and making diabetes more dificult to manage. It is a viscious cycle of failure and frustration.

However we know that type 2 diabetes can be prevented by the long term weight reduction that occurs after bariatric surgery. Further, we know that most patients that have had type 2 diabetes for 10 years or less will have no evidence of diabetes after having bariatric surgery and be off most if not all of their diabetic medications.

We need to stop thinking inevitable and start thinking what is possible.

I am no Martin Luther King, Jr. but I also have a dream.

I have a dream that as a society we decide that obesity that reaches a BMI of 40 is unacceptable and a person that finds himself or herself in this situation should have bariatric surgery to prevent type 2 diabetes if they have not developed this disease already.

I have a dream that as a society we will decide that people with type 2 diabetes with a BMI of 35 need bariatric surgery to treat and hopefully resolve their type 2 diabetes.

I have a dream that thousands of amputations, strokes, patients with kidney failure, blindness and premature death will be avoided as we get angry and say we will not accept the death, destruction and suffering any more when we have the medical know how to prevent and treat this monster we call type 2 diabetes.

I am really angry. Our present way of thinking is wrong and dangerous.  Some medical professionals are slowly waking up to the need for some of their patients to have bariatric surgery to prevent or treat this awful disease but we cannot wait. The pace is too slow. Too many are at risk.

Just like breast cancer. If you have breast cancer it is unacceptable not to have surgery and other treatment for that disease. You can choose not to be treated but as a society we believe it is inappropriate. I am not talking about forcing anyone but we need to bring this problem out into the open and take a stand. Obesity is a killer and it is inappropriate not to seriously consider bariatric surgery if a person reaches a certain level of obesity. Why? Because we know the devastation resulting from diseases such as type 2 diabetes and other obesity related medical problems.

We must demand a change in thinking now! Too many lives depend on it.

Will you join me in this righteous anger? Our society needs to change, our insurance companies must change, our government agencies need to change and our medical professionals must change. But this will not happen if you and I do not demand it.

No more amputations.

No more diabetes related strokes.

No more diabetes related heart attacks.

No more dialysis from diabetic kidney failure.

No more blindness from diabetic retinopathy.

No more premature deaths from diabetes.

Are you fed up with diabetes like I am?  Maybe you are so angry you could scream too. Do you have family members suffering from this dreaded disease?  Are you one that suffers from diabetes or at risk for this disease? Type 2 Diabetes indeed is a monster devouring legs, portions of brains, kidneys, eyes and even people’s very lives every day.

We must change our thinking and the thinking of others. Pick up your sword with me and together let us strike blow after blow to fell this terrible dragon and warn others of this danger. Let us dream together of a day when diabetes is viewed by everyone as a preventable and treatable disease. It does not take millions. Only a few good men and women of passion and commitment willing to be filled with righteous anger to slay this deadly monster once and for all.

Are you willing to join me in exploring ways to change the way our culture thinks of diabetes? If so please comment or email me to tell me why you are angry with how we think of diabetes and how this disease has affected you or your family members.

Reflux after a Gastric Sleeve Operation

Most patients do not have problems with reflux after a gastric sleeve operation but reflux can be bothersome for some.  Symptoms of gastroesophageal reflux include heartburn or reflux of gastric contents into the throat or mouth especially when lying down.

When a patient that has a gastric sleeve swallows food , the food travels down the esophagus past the high pressure zone called the Lower Esophageal Sphincter ( LES) at the lower end of esophagus and enters into new stomach call the gastric sleeve. The outlet of this new stomach is constricted by the circular muscle called the pylorus and food and/or drink stays in the stomach for a time and is released only very slowly. The slow release of gastric contents means food remaining in the sleeve may be under higher pressure is able to reflux up into the esophagus and even up into the mouth as the pressure in the gastric sleeve becomes higher than the pressure of the LES.

Patients that are high risk for gastroesophageal reflux after a gastric sleeve operation are those that have symptoms even before surgery. In fact, patients with severe gastroesophageal reflux with pre-cancerous changes in the esophagus called Barrett's esophagus should probably select a gastric bypass instead of a gastric sleeve operation since a gastric bypass is a much more effective way to treat severe reflux.

In my practice, if a patient needs to take medication called a Proton Pump Inhibitor, (Protonix, Previcid, Nexium) every day to control reflux I consider them to have moderate to severe reflux. These symptoms are frequently associated with a hiatal hernia since the opening in the diaphragm where the esophagus enters into the abdomen is often larger than normal allowing the upper part of the stomach to slide up into the chest. In this case if the patient prefers to have a gastric sleeve instead of a gastric bypass I will plan to add an additional component to their gastric sleeve operation by approximating the diaphragmatic muscles behind the esophagus with sutures narrowing the diaphragmatic opening for the esophagus called the hiatus making reflux much less likely. Of course since I use the da Vinci surgical robot this additional step becomes much easier. 

For those patients having reflux symptoms after a gastric sleeve operation I would suggest the following:

1). For mild occasional symptoms - use Pepcid complete or equivalent when symptoms occur. The antacid will neutralize the acid and the Pepcid will decrease the amount of acid the gastric sleeve is making.

2). For more persistant reflux take a Proton Pump Inhibitor as mentioned above each day.

3). Other suggestions include avoiding eating late into the evening, avoid spicy foods and sleep on more than one pillow if possible.

The good news is that the symptoms often improve after the patient loses significant weight and the medications may be able to be discontinued a few months after surgery.

Iron Deficiency After Bariatric Surgery

We need iron to stay healthy. 

Usually the amount of iron we ingest in our diet is enough to keep up with our needs.

The iron we ingest as food is absorbed very efficiently by the first part of our small intestine.

However, gastric bypass patients have reduced ability to absorb iron since the first part of the small intestine is bypassed along with much of the stomach.

Anemia, or decreased red blood cells, may be the result of not absorbing enough iron. Persons who are anemic often look pale and feel tired. If the anemia is severe the heart rate may increase to compensate for too few red blood cells to transport oxygen to the body. In some situations this increased heart rate can be dangerous.

Persons who are anemic often crave ice and eat ice frequently.

To prevent iron deficiency anemia we suggest a gastric bypass patient consider iron supplementation taken by mouth.

To check if someone has an iron deficiency anemia doctors check a ferritin level as a blood test. If this is low we know the person has low iron storage and iron deficiency is likely to be the cause of their anemia and we will place them on daily iron supplementation.

This supplement should be Ferrous Fumarate or Ferrous Glucanate since the usual form of iron supplementation, Ferrous Sulfate, will not be absorbed well since it needs acid to make the iron available for absorption and the new small gastric pouch formed at the time of the gastric bypass makes very little acid, Ferrous Sulfate is likely to pass out in the stool without being absorbed.

You any need to remind your family doctor about this since he or she are so used to writing for Ferrous Sulfate and may forget you need a different form of Iron.

Menstruating women are a particular risk for anemia since they may have difficulty keeping up with their monthly blood loss. In this situation a woman with iron deficiency anemia will be referred to her gynecologist for intervention like hormonal therapy, endometrial ablation or even hysterectomy. 

If these interventions are not acceptable she may need to be seen by a hematologist for periotic intravenous iron infusions.

Of course a thorough evaluation is often in order. This may require a colonoscopy since patients with a history of obesity have a higher risk of colon polyps and colon cancer.

Avoiding Constipation after Bariatric Surgery

Patients often complain of constipation after bariatric surgery. Constipation can happen a few weeks after surgery or complaints may continue for months or even years. 

Why do people often have constipation following bariatric surgery? This symptom is usually the result of too little fiber in the diet following bariatric surgery.

After a gastric bypass, gastric sleeve or even a gastric band, patients are asked to take liquids for several weeks and slowly transition through puree to soft and eventually to regular foods. However, often these foods are low in fiber. Also since portion sizes are smaller less total fiber is consumed.

The solution?

1)     Fiber – 25 grams every day. If you are consistent your stools should be softer and more regular in 2 weeks.

2)     Choose soluble fiber that dissolves in water and is tasteless such as Benefiber or another soluble fiber product suggested by your pharmacist.

3)     Avoid gooey fiber products (such as Metamucil) or tablets (such as Fibercon) since they may be difficult to pass through the modified stomach.

4)     Make sure sugar or other calories are not added to your fiber product. You do not want the extra calories.

5)     Take the supplemental fiber every day whether you feel you need it that day or not. This is a long term solution not a quick fix.

6)     Taper to smaller amounts of supplemental fiber slowly as your regular diet includes more fiber.

7)     Stool softeners may help but you need enough fiber to make sure you have stool to soften.

Other suggestions:

1)     Avoid narcotic pain meds where possible as all narcotics slow bowel function and cause constipation.

2)     Discuss adding fish oil to your medicines with your doctor. Fish oil may improve your cholesterol and help constipation as well.

3)     For temporary and rapid relief I would suggest as much Miralax as needed. Other products such as Milk of Magnesia can provide relief as well.

Being proactive by taking enough supplemental fiber soon after surgery can help you avoid this problem altogether!

Doing Great Six Years After Bariatric Surgery

I recently received this note from Joanna Baker who had her gastric bypass 6 years ago. She she has some great words of wisdom and encouragement. Here is what she wrote:


Dr. Myers,

Now

Before

I just was having one of those times of reflection, counting my blessings, and you and your program are near the top of my list. I am so grateful at your dedication to good medicine, safe practices, and stellar patient outcomes.

I can't believe that it's been 6 years since I started this journey with you! My six-year surgery anniversary is in September, and my BMI is still 25 (down from 45).

My best advice for those considering or just having had weight-loss surgery--allow the surgery and recovery to give you the precious gift of the time and physiologically forced discipline you need to recover from dependence on sugar.

Patients who are considering or who have just had weight-loss surgery, especially bypass, no doubt understand the need to avoid sugar, particularly processed sugar, and particularly in the absence of fiber (which is why I'm so grateful for fiber-rich fruits)!

Don't ever go back! Don't dabble. Don't toe dangle. Read labels. Try not to consume anything with more than 5 grams of sugar per serving. There it is. The rules I live by.

Do I miss sugar? No! (Though I'm sure results will vary patient to patient.) I am sure that this is why I have not struggled with keeping the weight off. I'm also sure that if I started playing games with myself trying to find the "safe" amount of sugar I could consume, my body would remember "the good old days" of sugar-coma bliss, start building a "tolerance level" for sugar, and I would end up back where I started more than 6 years ago--a slave to my sugar addiction.

I follow the other rules too. I don't use straws, I don't drink carbonated beverages (OK--this one is really hard for me. I genuinely miss Diet Coke, especially on a hot summer day! Still, it's not worth it.), I eat slowly, and genuinely enjoy the colors, flavors, aromas, and textures of my meals, as well as some really good company as often as possible (aka, family dinner)! I eat several small meals a day. (You will rarely find me without a baggie containing a variety of nuts and Kashi Heart-to-Heart cereal in my purse!)

I am so grateful for the time and discipline that by-pass surgery gave me. It's the best decision I ever made for my health and quality of life. I would never go back!

With warm, fond regards and much gratitude,

Joanna Baker

Avoiding Skin Fold Irritation

Avoiding Skin Fold Irritation in Warm Weather

We have had several very warm days already this Spring. Summer will soon be upon us.

During warm weather my patients often complain of a rash or skin ulceration especially in the abdominal skin fold or under the breasts. These are areas where skin lies on skin and there is little opportunity for evaporation. As the weather becomes warmer we sweat more. These dark moist, regions are a "set up" for the yeast (or fungus) we all have on our skin to grow much more rapidly. The yeast can be irritating to the skin, deposit a white paste like material and result in a foul smell.  The skin becomes red and irritated like a diaper rash and can lead to skin break down bleeding and ulceration.

If you have this problem and may have interest in having the skin removed by a plastic surgeon I would suggest you take pictures of the irritation and keep the pictures on file to show your plastic surgeon. This may you get insurance coverage for removal of the skin since it would be considered medically necessary and not cosmetic.

I discussed this with a friend of mine who is a dermatologist and he suggested a great product that I have found works really well. This is a powder that you can purchase at your local drug store over the counter called Zeasorb-AF. This seaweed based powder is excellent for absorbing liquid that can accumulate on the skin and the AF is for the anti-fungal ingredient Miconazol Nitrate that will kill the yeast.

Here is how I would suggest you use it.

Clean the areas well during your morning bath or shower and gently pat dry with the towel. If necessary dry with a hair drier but make sure not to burn the skin. Apply Zeasorb-AF powder to the affected area. Repeat later in the day if necessary.

This product is great to prevent groin irritation and athlete's foot as well.

So stay dry and enjoy your Summer without the skin fold irritation!

Gastric Sleeve: Eating for Success

Successful Weight loss after a Gastric Sleeve Operation

Remember, for those of you who have had a Gastric Sleeve Operation, you have asked your bariatric surgeon to reduce the size of your stomach to only about ¾ to one cup is size.  The outlet of the stomach is restricted by the Pylorus, (the circular muscle located at junction of the stomach and small intestine). The Pylorus opening is only about the size of the end of your ring finger. This is what gives you the resistance to eating too fast and too much at any one time.

Consistently applying the following principles will help.

1). Liquid calories are not your friend

            Your sleeve and narrowed outlet from the pylorus is like a funnel. The purpose is to hold solid food in your pouch for a time, allowing the solid food to slowly leave the pouch and therefore suppress your appetite by releasing a small amount of the food over the next couple of hours.

            I often hear, “but liquids go down so easily!” but that is exactly the point; too easily! The restriction caused by your pylorus is not made to hold back liquid food. All liquids will run straight through the narrow outlet. So take your calories as solid food not liquids.

Avoid milk, (even skim since it has too many sugar calories), ice cream, cream soup, soda and fruit juices. Fruit is just sugar water with some fiber. One serving of fruit a day is reasonable. More fruit may sabotage your goal of weight loss.

Get your protein in solid food and only use protein shakes if you cannot get enough protein in your solid foods.

Instead drink water, tea with sweetener, and Crystal lite or other non caloric beverages. This is an easy way to reduce your overall calorie intake and help you lose weight.

2). Minimize crunchy foods

            Crunchy foods like chips, crackers, pretzels and cookies, after saliva is added, go to mush and will go into the sleeve and pass through the narrowed outlet too quickly. One small Ziplock bag a day may be OK but more may sabotage your goal of weight loss. These types of foods can be your downfall. I am not saying you should never eat them but when you see them train your brain to flash “DANGER”. It is a question of portion size.

One of my patients did a video on my blog sharing how she deals with this problem. She swore off ever eating out of a bag or box again. Now when she brings home the groceries she breaks down the crunchy foods into small zip lock bags for portion sizes. She no longer takes the large bag to the TV for her snack but goes to the pantry to get a zip lock portion size for her snack.

3). Apply the “rule of 30s” consistently

            Chew 30 times before swallowing

            Wait 30 seconds before your next bite

            Wait 30 minutes before drinking

4). Avoid feeling chest pressure after eating

            Chest pressure after eating is a sign that you have eaten too much too fast for the time it take for your sleeve to empty through the pylorus into the small intestine and the food, drink or air is backing up into your esophagus. The esophagus is pressing the food downward but it has nowhere to go so the pressure just builds up in the esophagus causing the pressure sensation in your chest or even into your mid back.

            Instead use your eyes and brain to determine how much you can eat over what period of time so you do not cause the chest pressure. This frequently occurs in social situations when you are distracted and not paying attention.

5). Establish a “No Fly Zone”

            I want my patients to establish good boundaries for what comes on their property and tell their friends and family, “Certain foods just don’t fly here.” We all have what I would call trigger foods; that is foods that comfort us and when these are around we have difficulty staying away from them. For me it is cookies, so guess what? My wife only buys one type of cookies to bring home from the grocery; Fig Newtons. That is because I really don’t like Fig Newtons much and they will stay around along time. If she brought chocolate chip cookies they would be gone in a flash because I have difficulty staying away from most other cookies. Without fully realizing it my wife has established a “No Fly Zone” at our home. Cookies just don’t fly at our house.

            Maybe your food trigger is pizza or soda or ice cream. Whatever it is you should establish a no fly zone at your house. You don’t bring these things into your house and family or friends and not welcome to bring these things as well. Let them know they are welcome to go out for these things but these foods just don’t fly at your house.

Applying these principles consistently is the key to understanding what is going on with your body after having a gastric sleeve operation. If you are doing these things consistently you are more likely to understand what is going on if you are having difficulty.

I wish you the very best as you continue on your journey to better health!

3 Suggestions for Transition Foods

This week I saw a patient of mine, Robert Johnson, who had a Robot Assisted Gastric Sleeve operation just 6 weeks ago. He is doing great and he agreed to have me share about his early weight loss and about some things he has found that may help you as well.
He is right on track and has lost 24 lbs since his operation 6 weeks ago. Thanks to the great nutritional teaching from our dietitians he lost an additional 51 lbs. prior to surgery as he went through the bariatric surgery program at the Weight Management Center here in Reading, Pa for a total of 75 lbs. of weight loss since he entered our program a few months ago. He is feeling great and very happy with his results so far.
He had 3 "finds" that has helped him through the transitions in the first 6 weeks after surgery. Here are his suggestions:
1). He found that putting Progressive Soups in a blender allowed him to have hardy liquids soon after surgery. He could vary the consistency by the time the soup was in the blender. He would heat the soup and separate into two 1 cup containers for 2 servings. Each cup has less than 300 calories.
2). To make sure he got 60 grams of protein each day that we recommend for men, (50 grams for women), he bought New Whey liquid protein at our local Walmart which has 42 grams of protein, 0 carbs and 0 fat per 6 once tube and comes in watermelon, grape or fruit punch flavors. You can buy them individually or as a package of 6. They are a bit pricey at about 2 dollars a tube but the amount needed will decrease as you are able to take more of the 60 grams in other foods.
3). He also found Hormel's pre-packaged Thick and Easy Puree' foods for adults at Walmart and he recommends the homestyle beef with potatoes and corn.
Great suggestions! Hopefully Robert's suggestions will help others as they transition from liquids after surgery to regular food.

Study About Robotic Surgery Published in Obesity Surgery

Last week I heard from the journal Obesity Surgery that a study I have been working on for nearly 3 years was just published. The article name is Robot -Assisted Versus Laparoscopic Gastric Bypass; Comparison of Short Term Outcomes. I would like to share its findings with you.

I compared the short term outcomes of my first 100 gastric bypass operations I performed with the use of the da Vinci surgical robot with 100 gastric bypasses I performed using the more traditional laparoscopic approach. The patients in both groups were very similar in age and weight and most of their medical problems. There was no mortality in either group and complications were low in both groups as well.

I found that there were two major differences that were statistically significant; 1). shorter hospital stay and 2).less bleeding when the robot was used.

• 60% of the patients in the robot assisted group were discharged form the hospital after only one night stay compared to only 4% of patients in the laparoscopic group
• Fewer patients in robot assisted group (2 vs 6) required blood transfusion compared to the laparoscopic group

I believe the reason patients left the hospital earlier after a robot assisted operaion is they had less pain because the incisions were overall smaller and the robot "pushes" less on the abdominal wall. I suspect the reason there was less bleeding was because the connection between the gastric pouch and the small intestine was created with a robot assisted hand sewn approach instead of a circular stapling device. In fact no patient in the robot assisted group had gastrointestinal bleeding.

Although it took time for me to become comfortable with the da Vinci surgical robot, I am convinced this is a superior approach for me.

• I see better with the 3-D high definition view
• The instruments have tiny "wrists" that provide much easier and more precise sewing
• I am more comfortable doing the operation while sitting at the console a few feet away from the operating table instead of standing to do the operations

I prefer using the robot for nearly all of my bariatric surgery cases including both gastric bypass operations and gastric sleeve operations. It is especially helpful when a patient requires a revision of a previously performed bariatric operation.

If you want to view the full article please click on the link below. It should be available there for at least a few more weeks.

http://www.springer.com/home?SGWID=0-0-1003-0-0&aqId=2439249&download=1&checkval=e6832a360938861a0cec2c23c8c2fa7a