Extreme Measures to Treat Diabetes
For Alan Vaughn, surgery proved the solution to his serious weight problem.
At 135kg he had been comfortable with his weight, but the diseases associated with his obesity had turned his life sour: his diabetes gave him a constant thirst, poor vision and flaky feet; sleep apnoea forced him to be strapped up to a CPAP (Continuous Positive Airway Pressure) machine every night, and his blood pressure was through the roof.
He’d tried every diet in the book, and while he typically lost a lot of weight, he never kept it off. When his GP told him he was looking at daily insulin injections, Vaughan decided to take a radical step: gastric bypass. “I’d lost 15kg leading up to the operation and since then I’ve lost another 20kg. I sleep fine, and my blood pressure and diabetes are under control,” says Vaughan.
No other medical intervention has such an overall success in achieving weight loss and improving long-term morbid-obesity-related health issues as surgery.
Gastric banding boasts a 60-85% improvement rate in cases involving obesity and obesity-related conditions such as hypertension, high cholesterol, diabetes and sleep apnoea. Perhaps even more surprising, gastric bypass surgery claims an 87% remission rate for type 2 diabetes.
“If I was a drug rep recommending a tablet that would cure 87% of type 2 diabetes, GPs would be falling over themselves to prescribe it,” says Brisbane bariatric surgeon Dr Philip Lockie. (Bariatrics is the branch of medicine concerned with obesity.)
No wonder, then, that the number of obesity operations is booming: Medicare figures for 2008-09 show 14,370 procedures were performed in that period.
There are different types of obesity surgery.
With gastric banding, the stomach is reduced to about 30ml capacity (adjusted via a port to suit individual patients). Studies suggest this reduction mimics the squeezing action of the stomach, which sends a signal via the vagus nerve to the brain and makes us feel full.
Another operation is the Roux-en-Y gastric bypass, in which a small stump of stomach is attached to the small intestine, bypassing the duodenum. In a normal gut, this lower part of the small intestine sees almost fully digested food, but after a bypass operation the food is only partially digested.
Another spectacular benefit of this surgery is that it cures type 2 diabetes in most patients.
That’s even before any weight loss has occurred. Doctors still don’t fully understand why, but they suspect that the increase in GLP-1 – a gut hormone – boosts the body’s beta cells, which make insulin.
However, surgery is not an easy option.
After surgery, patients can only manage puréed food, and even afterwards it takes time and effort to adapt to a new way of eating. Vaughan, for example, can’t eat a normal-sized mouthful of meat, and he has to chew for a considerable time if he’s to keep food down. Eating food too high in sugar or fat causes a surge of insulin that makes him feel clammy and sick.
“These problems bear no comparison to how I was feeling before,” says Vaughan. “I wouldn’t go back.”
All surgery carries risks, and surgery on obese patients is more dangerous than most: anaesthetising is tricky and they’re more likely to develop blood clots. There’s a one in 1000 worldwide mortality rate with gastric band operations, and one in 200 with gastric bypass, but obese people are more likely than most to die if they fall sick or have an accident, says Dr Lockie.
Research is underway internationally to find a pill to treat obesity.
There are currently few pharmaceutical options available to clinicians, so a “medical bypass” is the holy grail of obesity medicine. Until then, surgery remains the best option for very obese people to lose weight.
Nurse Sandra Carter has lost 41kg since having a gastric sleeve operation more than two years ago. She can now chase her grandchildren around and buy clothes off the rack.
“It has been life-changing,” she says.
“I don’t feel so hungry, and when I do eat, I get the satisfaction from a smaller amount. I was $4000 out of pocket but it was worth it. I wish I had done it years ago.”
Lisa Cookson had a gastric band fitted in a last-ditch attempt to lose 45kg.
Hoping it would be the solution to her permanent hunger – “I have never had the feeling of being full” – the 33-year-old shelled out $14,500. “I feel so defeated,” she says. “It was my last resort.”
Despite the fact that for some patients, gastric banding simply doesn’t work, the number of procedures being performed has skyrocketed.
Because it is a relatively simple surgical process – done in about 45 minutes using a laparoscopy – experts are concerned that some surgeons are making a significant income by offering the operation but not necessarily providing the psychological support needed for long-term success.
“In many situations people are getting surgery without an assessment of the reasons why they have gone so far above their healthy weight,” says weight management specialist Dr Rick Kausman.
“If we don’t look at the reasons, we have got much less chance of helping people make a permanent change.
“People put on weight due to a complex mix of behavioural, biological and environmental factors.”