Drs. Westman & Vernon on Gastric Bypass and Diabetes

So I was getting my morning news fix the other day and of course the new study mentioning gastric bypass as a cure for diabetes was discussed.  One of the many mainstream press articles about two recently published articles in NEJM can be found here.  The full texts of both studies are available online free:  Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes - Mingrone et.al. and Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes - Schauer et.al.  I've discussed some other studies previously here.  Lastly on the links for now, I have not followed all contained in this post, but from a surgery center blog we have:  Gastric bypass to ‘cure’ diabetes goes mainstream (you are forewarned that the last one is a "medical tourism" clinic in Colombia).



So on a recent LLVLC podcast, Jimmy Moore had both Drs. Eric Westman and Mary Vernon on to discuss this surgical "cure" issue.  Westman, was a co-author of The New Atkins (with Volek & Phinney) who treats people with low carb at Duke and has published various studies conducted there in this regard.  Vernon served on the Atkins Physicians Council and wrote Atkins Diabetes Revolution.  Both are associated with the American Society of Bariatric Physicians:

To ensure the highest standard of medical practice, ASBP has developed Bariatric Practice Guidelines that outline four medical (non-surgical) body fat reduction/weight loss methods: dietary modification, exercise prescription, behavior modification and when appropriate, medication.

Vernon is a past President, and Westman is the President elect of ASBP.   I think it is important to note that ASBP is not only a non-surgical organization, but their position statements lead me to believe they are anti-surgery.  There's a difference, because while I'm not a big fan of weight loss surgery (WLS), especially of the permanent gastric bypass variety (GBP), to discount surgical options entirely in the face of increasing evidence of benefits independent of weight loss smacks of blinded bias.   Jimmy directs us towards their Innovative Metabolic Solutions site, that seems to have been abandoned (?) around a year ago.  Ahh ... LOL, Gary Taubes is (was?) their entire Science/Medical Advisory Board.  I came across this success story on their site a while back.

By October of 2009 Pam’s blood sugar level was usually 350-400 even though she was taking 80 units of insulin at each meal and 125 in the evening. ... After her initial comprehensive evaluation, Dr. Vernon suggested specific dietary and medication changes for Pam. In her first month under Dr. Vernon’s care Pam lost approximately 15 pounds. What Pam finds even more exciting than the weight loss is what is happening with her diabetes and the way she feels. Her blood sugar levels are now 180-200 and she has reduced her insulin intake by half.

It sounds to me as if Vernon is so overly predisposed to reducing medications/insulin that she's willing to post this interim report as a success story despite blood glucose levels ol' Wheat Belly would be horrified by after consuming a bowl of battery acid.  For Westman's part, it seems he could replace Vince selling the Schticky.  Because his peer review journal articles are not without their own "baggage" at this point.  In Diabetes Crash Cures ~ VLCal vs. VLCarb I touched on how, in his study, Westman exaggerated by statistics the effectiveness of the Atkins essentially induction diet vs. a low GI diet.  When the dropout rates and number of completers in each group on medications at baseline are considered, the results are not as spectacular as claimed, though I'd be remiss if I didn't acknowledge the significant improvements.  NOTE:  Please read that blog post for further analysis.  However they don't stack up favorably compared to the crash dieting that ASBP decries in a specific position statement..

VLCarb diet all 24 weeks at <20g/day carb,
VLCal diet for 8 weeks 600 cal/day, then return to "healthy diet recs"

Low carb diets do not cure obesity-induced hyperglycemia and restore glucose tolerance.  It is an inconvenient fact for low carb advocates, that both crash diets and gastric bypass do just that, in relatively short order, and in the case of GBP, even prior to significant weight loss.   What's saddening to me is that those who do succeed on low carb are actively discouraged from even realizing they have restored glucose metabolism.  

I've not listened to a lot of Westman lectures/interviews, there aren't many out there that I'm aware of, but I've listened to quite a lot of Vernon.   I won't mince words ... Vernon just irks me with both her attitude and her arrogant air of "knowing better" while spouting supposed knowledge of physiology and metabolism that would put even Nora Gedgaudas' manglings to shame.  But ... you know ... everyone should be eating low carb!  (Eenfeldt interview).

So in the podcast Jimmy got all upset about recent headlines about how GBP can put diabetes into remission or "cure" it.  WTF is this about?  Can't be, right Jimmy?   So it's kind of funny that Westman starts out describing ASBP as being around for 60 years and how they teach doctors on how to treat obesity through diet and perhaps medications.   Paging Dr. ... umm Mr. Taubes!  Obviously what the ASBP has been advocating and teaching physicians hasn't been working, right??!!    Next up Vernon tells us how ASBP has been the patient champion when that  "push back from the table" advice was first shown to be inadequate.  To be fair here, if ASBP has been around 60 years, then in their early years they were fighting the noble fight ... e.g. back when the obesity doctors were treated was far more related to genetics than lifestyle.  However the "best emerging science" is in carb restriction.  Oh yeah, and let's take a gratuitous dig at those working with animal models generating a lot of that science.  

Vernon launches into her sunburn analogy of diabetes.  Only it ultimately makes the case for GBP, etc. and against VLC.  Basically some are predisposed (fair complexions) to burning so they adopt coping strategies to avoid burning.  Does this not describe low carb almost to a tee?  Because sunscreen does not alter your skin's ability to tolerate full sun, it only reduces the dose of sun.  So it's an odd example to use, because GBP does seem to have the equivalent of restoring proper glucose handling, not a bunch of coping strategies, and LC seems to be a way to mask/cope.  And yet there are few identified examples of humans with innate inability to process carbs.  (Indeed a recurring meme in LC circles is that we can get away with all this when we're young, but we're gonna pay!!)  

Take it away Eric!  Vernon kicks it back to Westman to discuss the Schauer et.al. study.  Oddly he begins by acknowledging the almost immediate effects seen with GBP (before major weight loss) but then goes on to lament the inadequacy of the medical treatment (because it's not LC) not having effected the desired weight loss.  The next argument he makes is odd.  Yes, I'm sure if a surgeon group advertises for participants in a study you probably do get more folks interested in getting a free bypass, and if you're not assigned to that group you're more likely to drop out -- whereas you can't really "drop out" of the surgery group other than to miss follow-up.  However Westman has done enough studies of his own to know that the drop out rates in weight loss studies are notoriously high.  However listening to him and then going to the Schauer study he's referring to and reading this:

During the first year of follow-up, 8 patients withdrew from the study (1 who did not undergo sleeve gastrectomy and 7 in the medical-therapy group who did not have any follow-up visits). Another 2 patients in the medical-therapy group missed follow-up visits at 9 and 12 months, leaving 140 patients (93%) who completed all analyses. 

I'm left to believe this reasonable sounding man has drifted over the bias line.  I mean 93% and he's blaming dropout rates?  But he tells Jimmy's audience that had a third party done the study the results would have been different.  Vernon chimes in on how now endocrinologists may not have the knowledge that bariatricians have.  Here I thought this was about hormones and metabolism, but who am I ...   It's all about physiology to burn fat instead of storing it after all.  She's still all about surgery forcing a dietary change removing the carbs from the diet.  She's had one patient come off insulin in 3 days.  Well, looking at the "success story" of her's on IMS, well ....   Vernon says we need a head to head study.  I don't think so.  We haven't had head to head, but we've had the long term studies, etc.  "We get those outcomes all the time"  -- And then Westman chimes back in about how the 12 month average weight loss for the medical group was like 10 lbs.  Well, it's not much more for low carb studies of similar length (1 year).  In the Westman VLC study weight loss averaged about 25 lbs at 6 months so how did that compare to the WLS group in Schauer?

Listening to Vernon I always cringe.  If you're in for some torture listen to her KU lecture on the IMS site.  In the Jimmy podcast she talks about how GBP forces lifestyle change to low carb, but folks don't want to do what it takes -- by conventional standards -- to make good choices what they put in their mouths to lose weight.  We'll ignore Jimmy's idiocy about thin folks getting GBP to cure diabetes.  Oh and he worries that too many folks will run to surgery to cure diabetes.  I do share some of that worry, however he seems to be worried for different reasons and I'll leave it at that.  I'm down with Westman and others who consider the risk of the surgery itself, but really, if you're going to be all hyperbolic like Wheat Belly, Rev. Rosedale and Dr. Cate over glycation, perhaps let's place some blame there too.  Because this fear mongering over glycation and glucose levels in general is certainly adding to the rampant fear of imminent death when an obese person posts an even slightly elevated FBG.

And now, at the risk of being accused of being rude or personally attacking these docs, I just can't hit publish on this piece without posting a few pictures.  Mary Vernon was, after all, yet another one of those low carbers I encountered when I went looking for women around my age (turns out she's around 10 years my senior from what I can figure) who are not exactly stellar examples of the wonderfulness that is low carb eating.  When I was first "introduced" to Vernon in 2009, she was rather large.  Or at least in the pictures.  Perhaps (and I can relate here) it's the bustline that makes her look heavier than she really is, but in her most recent video interview with "Diet Doctor" Andreas Eenfeldt, she just doesn't ... umm ... inspire.

from Nov.  2003 news story

In this interview she says that she adopted this lifestyle -- <20g/day -- 14 years ago, which would put her at 40's at the time.   I love how in the comments over at Andreas' site there's all this white knighting and sisterhood going on over there about how she shouldn't be expected to be Barbie doll proportioned at her postmenopausal age.  This is a point well taken, but needs to be applied to ALL women "of a certain age" or none at all.  You can't make claims about LC and then say "well, nothing's going to work for some hopeless cases".    By my math, 14 years ago (in a 2011 interview) would put her 35 lbs lost she didn't realize she had to lose (really?  as a doc?) would put us back to 1997 six years before the pic to the right there.   She claims to have been constant size since.   I'm smelling an eau de fibe here.   

While I don't think either is obese, the pictures below are screenshots from the BBC Atkins special.  This originally aired in 2003 so was perhaps shot in 2002 or so -- roughly a decade ago.

And now let's look at Westman at NMS in 2010 (he's in a few pics here), and Vernon in 2011 from here:

To be clear, I'm not picking on anyone's weight here.  But these are docs boasting over successfully treating patients managing body weight with low carb diets.  Physician heal thyself?  I mean clearly Westman has packed a few on and Vernon has yo-yo'd a bit remaining overweight.  Amazingly Vernon says they should have WLS candidates try out the LC diet first to see if they can live with it.  As if there is no presurgical screening?  Is she for real?  

I also can't publish without mentioning that Jimmy is becoming increasingly hypocritical.  In th podcast he discusses his own mother having GBP just before he embarked on Atkins in 2004.  She has regained all her weight, apparently, while Jimmy has regained roughly half of his total weight loss.  That would put him roughly in Carnie Wilson territory in that regard.  Why can't we be honest about this folks.  There is NO one plan that will work for everyone for weight loss, and maintenance is TOUGH.  Go to a WLS forum and you'll see folks desperate not to regain (and most do rebound about 10% over min weight even if they don't regain a ton).  Lots of people struggling to maintain losses.  Whether they lost with Jenny or WW or Nutrisystem or Atkins or whatever.  If carbs were the issue/answer it should solve it, right?  So I'll do my own Kumbaya thing here ... let's work together to figure out how to keep the hard earned weight off and stop shouting down those who  take a route other than low carb to get there, K?

And let's be consistent.  If biomarkers are to be touted, you simply can't discount those surgery produced results out of hand.  If a person is unwilling or unable to enact lifestyle changes, and perhaps this is hormonal (perhaps even inherently/genetically so), then why ignore a surgical procedure that may well be a lifesaver for some??