Bariatric Surgery in Context: An Obesity Consult
Bariatric Surgery in Context: An Obesity Consult
Henry R. Black, MD: Hi, I'm Dr. Henry Black. I'm Clinical Professor of Internal Medicine at the New York University School of Medicine, a member of the Center for the Prevention of Cardiovascular Disease at that institution, and immediate past president of the American Society of Hypertension. I'm here with my friend and colleague, Dr. Louis Aronne, from the Weill Cornell Medical Center. Lou?
Louis J. Aronne, MD: Hi, I'm Dr. Louis Aronne. I'm Director of the Comprehensive Weight Control Program at New York-Presbyterian/Weill Cornell Medical Center.
Dr. Black: What do you do with someone who has either failed behavioral therapy or wants to have behavioral therapy plus something else to get them going? How do you approach those people?
Dr. Aronne: If someone has failed behavior, diet, and exercise, we'll approach them from a medical perspective, and it really depends on their body mass index. If they qualify for surgery, we'll have the surgery discussion with them to be sure that they understand that they could qualify for it. We think that's important, given that surgery is the gold standard; we don't want someone coming back later and saying, "Oh, you didn't tell me that I would qualify for surgery." So we make that very clear.
Then, when it comes to medical therapies, it depends on what's wrong with the patient. If someone has an impaired fasting glucose, for example, we'll follow the results of the diabetes prevention program and we'll use something like metformin. Metformin is turning out to be a very good medication. There's evidence that in patients with impaired fasting glucose, it can help with weight loss. It provides moderate weight loss that persists over years. Now, this is off-label use. It is not indicated for this use, but you asked me what we do -- that's what we do.
Dr. Black: I'm interested in what you do, but other diabetes drugs often cause one to gain weight.
Dr. Aronne: That's right. So an approach that we use in analyzing the patient is what we call the weight-centric management of disease. We look at patients and say, "Let's see. Let's look at what this patient is taking." The average patient we see is taking 8 medications. Which of those medicines are making them gain weight, and which ones are weight-neutral? What could be helping them lose weight? And can we change their regimen to help them lose weight?
Dr. Black: Which are the medications that make you gain weight?
Dr. Aronne: There are dozens of medicines, primarily in the area of psychiatry and neurology, and also some of the cardiovascular drugs. Beta-blockers can make it difficult to lose weight; alpha-blockers can make it difficult. Sleep medicines, over-the-counter sleep medications, can make it difficult, as well as a variety of hormonal therapies. And in the diabetes drug areas, if you follow the standard weight-gaining algorithms, you go from metformin to either insulin or thiazolidinediones and sulfonylurea; that's the most common scenario we see. It's very difficult to get that patient to lose weight. If we switch them over to either a dipeptidyl peptidase 4 inhibitor or, even better, a glucagon-like peptide-1 agonist, we'll often see weight loss right away, because you're taking away a weight-gaining medicine and you're starting a weight-losing medication.
Dr. Black: There was a recent study about the value of 2 different types of bariatric surgery compared with usual medical therapy, which showed after just a year that hemoglobin A1c went down and people lost as much as 25 or 30 kilos with the surgery. What was your opinion of that study?
Dr. Aronne: People have criticized the study as not being as good as it could have been, but it's very, very tough to do these studies and to randomize people. I give credit to the authors of the studiesthat were done, both of the studies that were done. One of the authors, Francesco Rubino, is from our institution, I should mention. I want to point out that, given the difficulties of doing a good trial in that setting, where you're trying to randomize someone to a surgical procedure or medical therapy, I believe the results -- that people do better with surgery. That being said, is there more risk in surgery? Sure.
One thing they didn't study is the type of approach that I'm talking about, which is a newer approach that hasn't been accepted by the American Diabetes Association or the Endocrine Society, but I think this is going to push them toward that type of weight-centric approach. They're going to realize, "Gee, we can't leave weight out of the equation," because it's so clear that in the minds of the public, physicians, the New England Journal of Medicine, everybody, that losing weight seems to make a lot of sense if you have diabetes.
Dr. Black: This is something that somebody can look at and say, "Boy, I lost 25 pounds -- that's great." It's very hard to do that with behavioral therapy.
Dr. Aronne: It is very hard, but we're getting there when it comes to our medical therapies, especially in people with diabetes, because when we use some of the medical therapies for diabetes in conjunction [with behavioral therapy], we are seeing some patients -- certainly not all, but some patients -- do extremely well. When you add the right kind of diet to the right medications, we see substantial weight loss. So, maybe we just take those people off the table. They don't need surgery, and maybe the other people do.
Dr. Black: There's an interesting analogy, I think. In the 1940s, Smithwick did a global sympathectomy for people with really dangerous hypertension. In the 1960s and a little bit after that, we did ileal transpositions for people who needed lipid reduction. Then along came thiazides and other [drugs], and along came statins and others, and we didn't need those [procedures] anymore. We don't have a drug for obesity that can fit into those things, but that doesn't mean we won't.
Dr. Aronne: We're definitely getting there, and the analogies that you're using are the ones that we look at. It's interesting that you say that, because about 25 years ago I had a discussion with John Laragh, who you know well, about how hypertension treatments evolved. He told me these stories, and I looked in the whole field and said, "Obesity may be similar," and he agreed. He said that this is the exact same thing that people were saying back in the '50s and '60s about hypertension; they're saying it now about obesity. And this was the '80s and '90s. So I agree with you completely.
It has been very difficult, because when it comes to treating obesity, the system is so complicated. It's a very complex mechanism. There was recently another paper showing that there are at least 8 hormones that compensate when you lose weight; some go up, some go down. That's why it has been so difficult to come up with durable and very good results for weight loss.
Dr. Black: Who do you recommend surgery for?
Dr. Aronne: We follow the guidelines for surgery, but with a twist. In other words, we have a division of diabetes surgery. We have a surgeon, Dr. Francesco Rubino, who has a protocol to do surgery on patients with diabetes, and he has operated on patients with normal body weight. So besides the obese type 2 diabetic patients, besides the very obese patients with a BMI of 40 and above, we've found that some people with diabetes respond quite well to gastric bypass. There's something about not letting food touch the duodenum that dramatically improves glucose, and there's no medication that can duplicate that.
Dr. Black: I agree completely. Thanks very much, and thanks for coming in.
Henry R. Black, MD: Hi, I'm Dr. Henry Black. I'm Clinical Professor of Internal Medicine at the New York University School of Medicine, a member of the Center for the Prevention of Cardiovascular Disease at that institution, and immediate past president of the American Society of Hypertension. I'm here with my friend and colleague, Dr. Louis Aronne, from the Weill Cornell Medical Center. Lou?
Louis J. Aronne, MD: Hi, I'm Dr. Louis Aronne. I'm Director of the Comprehensive Weight Control Program at New York-Presbyterian/Weill Cornell Medical Center.
Dr. Black: What do you do with someone who has either failed behavioral therapy or wants to have behavioral therapy plus something else to get them going? How do you approach those people?
Dr. Aronne: If someone has failed behavior, diet, and exercise, we'll approach them from a medical perspective, and it really depends on their body mass index. If they qualify for surgery, we'll have the surgery discussion with them to be sure that they understand that they could qualify for it. We think that's important, given that surgery is the gold standard; we don't want someone coming back later and saying, "Oh, you didn't tell me that I would qualify for surgery." So we make that very clear.
Then, when it comes to medical therapies, it depends on what's wrong with the patient. If someone has an impaired fasting glucose, for example, we'll follow the results of the diabetes prevention program and we'll use something like metformin. Metformin is turning out to be a very good medication. There's evidence that in patients with impaired fasting glucose, it can help with weight loss. It provides moderate weight loss that persists over years. Now, this is off-label use. It is not indicated for this use, but you asked me what we do -- that's what we do.
Dr. Black: I'm interested in what you do, but other diabetes drugs often cause one to gain weight.
Dr. Aronne: That's right. So an approach that we use in analyzing the patient is what we call the weight-centric management of disease. We look at patients and say, "Let's see. Let's look at what this patient is taking." The average patient we see is taking 8 medications. Which of those medicines are making them gain weight, and which ones are weight-neutral? What could be helping them lose weight? And can we change their regimen to help them lose weight?
Dr. Black: Which are the medications that make you gain weight?
Dr. Aronne: There are dozens of medicines, primarily in the area of psychiatry and neurology, and also some of the cardiovascular drugs. Beta-blockers can make it difficult to lose weight; alpha-blockers can make it difficult. Sleep medicines, over-the-counter sleep medications, can make it difficult, as well as a variety of hormonal therapies. And in the diabetes drug areas, if you follow the standard weight-gaining algorithms, you go from metformin to either insulin or thiazolidinediones and sulfonylurea; that's the most common scenario we see. It's very difficult to get that patient to lose weight. If we switch them over to either a dipeptidyl peptidase 4 inhibitor or, even better, a glucagon-like peptide-1 agonist, we'll often see weight loss right away, because you're taking away a weight-gaining medicine and you're starting a weight-losing medication.
Dr. Black: There was a recent study about the value of 2 different types of bariatric surgery compared with usual medical therapy, which showed after just a year that hemoglobin A1c went down and people lost as much as 25 or 30 kilos with the surgery. What was your opinion of that study?
Dr. Aronne: People have criticized the study as not being as good as it could have been, but it's very, very tough to do these studies and to randomize people. I give credit to the authors of the studiesthat were done, both of the studies that were done. One of the authors, Francesco Rubino, is from our institution, I should mention. I want to point out that, given the difficulties of doing a good trial in that setting, where you're trying to randomize someone to a surgical procedure or medical therapy, I believe the results -- that people do better with surgery. That being said, is there more risk in surgery? Sure.
One thing they didn't study is the type of approach that I'm talking about, which is a newer approach that hasn't been accepted by the American Diabetes Association or the Endocrine Society, but I think this is going to push them toward that type of weight-centric approach. They're going to realize, "Gee, we can't leave weight out of the equation," because it's so clear that in the minds of the public, physicians, the New England Journal of Medicine, everybody, that losing weight seems to make a lot of sense if you have diabetes.
Dr. Black: This is something that somebody can look at and say, "Boy, I lost 25 pounds -- that's great." It's very hard to do that with behavioral therapy.
Dr. Aronne: It is very hard, but we're getting there when it comes to our medical therapies, especially in people with diabetes, because when we use some of the medical therapies for diabetes in conjunction [with behavioral therapy], we are seeing some patients -- certainly not all, but some patients -- do extremely well. When you add the right kind of diet to the right medications, we see substantial weight loss. So, maybe we just take those people off the table. They don't need surgery, and maybe the other people do.
Dr. Black: There's an interesting analogy, I think. In the 1940s, Smithwick did a global sympathectomy for people with really dangerous hypertension. In the 1960s and a little bit after that, we did ileal transpositions for people who needed lipid reduction. Then along came thiazides and other [drugs], and along came statins and others, and we didn't need those [procedures] anymore. We don't have a drug for obesity that can fit into those things, but that doesn't mean we won't.
Dr. Aronne: We're definitely getting there, and the analogies that you're using are the ones that we look at. It's interesting that you say that, because about 25 years ago I had a discussion with John Laragh, who you know well, about how hypertension treatments evolved. He told me these stories, and I looked in the whole field and said, "Obesity may be similar," and he agreed. He said that this is the exact same thing that people were saying back in the '50s and '60s about hypertension; they're saying it now about obesity. And this was the '80s and '90s. So I agree with you completely.
It has been very difficult, because when it comes to treating obesity, the system is so complicated. It's a very complex mechanism. There was recently another paper showing that there are at least 8 hormones that compensate when you lose weight; some go up, some go down. That's why it has been so difficult to come up with durable and very good results for weight loss.
Dr. Black: Who do you recommend surgery for?
Dr. Aronne: We follow the guidelines for surgery, but with a twist. In other words, we have a division of diabetes surgery. We have a surgeon, Dr. Francesco Rubino, who has a protocol to do surgery on patients with diabetes, and he has operated on patients with normal body weight. So besides the obese type 2 diabetic patients, besides the very obese patients with a BMI of 40 and above, we've found that some people with diabetes respond quite well to gastric bypass. There's something about not letting food touch the duodenum that dramatically improves glucose, and there's no medication that can duplicate that.
Dr. Black: I agree completely. Thanks very much, and thanks for coming in.