Bariatric Surgery vs Dietary Weight Loss

A recent study, published in JAMA Surgery, this week compares the three-year outcomes of bariatric surgery versus lifestyle intervention for type II diabetics.  This particular study made the headlines of the Wall Street Journal because the outcomes revealed “Weight-Loss Surgery Better Than Diet and Exercise in Treating Type 2 Diabetes…”

Really?!  That is news to me, a baratrician that’s been treating type II diabetes for over 15 years!   This simple three year study in 62 patient contradicts what I’ve seen in my office for 15 years. This study and the media-hype associated with it are a serious problem.  Why? Because the study was based on a flawed design.

We all know that baratric surgery has significant weight loss as a result.  And, we all know that most of those patients with diabetes have significant improvement in their diabetes at the 2-5 year mark (what happens after 5 years is a completely different story).   But why compare that to a poorly designed lifestyle protocol that failed to show successful weight loss?  Yes, poorly designed.

obese-weightThis study was based on protocols from the Diabetes Prevention Program and the Look AHEAD trial, both of which were very large trials restricting calories, fat and increasing exercise.  Both of these trials failed to show any significant weight loss and failed to produce any significant reduction in overall mortality.  Why?  Because both trials used the wrong dietary approach. We’ve know for years, as was emphasized by the Women’s Health  Initiative study as well, that caloric restriction combined with exercise doesn’t reduce body weight in the long run by more than 1%.  So the bariatric surgeons in the study above compare a known effective treatment to a known ineffective treatment?  And, it gets Wall Street Journal Headlines.   It’s a sad day for medicine.  And an even sadder day for the treatment of obesity.

Is no one listening?  Weight loss is not a question of thermodynamics – it is not the calorie in / calorie out dogma we’ve been brainwashed into believing over the last 50 years.  Weight loss is hormonal.  The study published in JAMA Surgery this week proves that.  Baratric surgery effects grelin and the forced dietary changes reduce insulin (patients receive what equates to a low carbohydrate diet post bypass surgery).  Both of which have significant effect on weight gain and loss.  Caloric restriction and exercise affect neither of these.

Carbohydrate restriction, on the other hand affects insulin dramatically.  Carbohydrate restriction turns off the tremendous excess insulin hormonal response that occurs in up to 85% of the patient’s I see in my office.  Call me when the bariatric surgeons actually compare bariatric surgery to a true ketogenic diet.

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