Malabsorptive Thinking by Pat Conrad MD

The January 2017 issue of Family Practice News has gone whole hog on the obesity issue, with articles on insurance-mandated pre-bariatric surgery diets; commentaries on obesity and weight watchers; whether joint replacement or bariatric surgery should come first; overweight pregnancy care; “weekend warrior” exercise patterns and mortality; and plenty of the latest exciting diabetes opinions. But it was their cover story that gave me the bloat: “OBESITY: What referring physicians need to know about bariatric surgery success rates.”

The article begins with data showing that lower pre-op BMI’s tend to result in lower post-gastric bypass BMI’s. While that seems intuitively obvious, the derived logic was that primary care doctors should refer the morbidly obese sooner rather than later in order to achieve more sustainable weight loss and fewer post-op complications. Dr. Oliver Varban told the Obesity Society and American Society for Metabolic and Bariatric Surgery that getting patients in after they cross the 40 kg/m2 threshold results in “inferior outcomes.”

Call me a cynic. I encourage anyone with relevant data or better insight to argue with me. I think that rerouting GI tract to achieve malabsorption for the purpose of weight loss is awful both physiologically and ethically. I don’t understand why the medical community is increasingly promoting this procedure, and no, I don’t typically wonder that about most other surgical procedures that attempt to make a faulty or damaged organ system work better, which is the opposite of what is done with gastric bypasses. Who is making money on this, and who is paying for it? And why should the taxpayer ever be on the hook for this procedure for Medicaid/Medicare patients, or is it too impolite to ask?

“These patients are being referred to us. We don’t seek them out”, Dr. Varban said. And he also said, “Society at large should recognize that bariatric surgery is the most effective treatment for obesity, but its also the most underutilized one.” Blue Cross/Blue Shield of Michigan certainly must agree, since they underwrote his research. I wonder how their actuaries took into account the long-term anemia, malnutrition, chronic abdominal pain, recurrent pancreatitis, and concurrent depression that seems to so often afflict these post-op patients? The failure to reach post-op weight loss goals was most pronounced in minority and lower income groups. Could this simply a metabolic result, or do cultural impediments to motivation call into question the efficacy and propriety of the procedure in the first place?

The point of the article is that referring physicians should refer sooner rather than later in order to achieve better outcomes. Dr. Varban notes that many referring doctors wait until the BMI exceeds 50 kg/m2 because the alternate referral criterion of a year of supervised attempted weight loss is just too tough. Yes, it is very difficult to help obese patients, and yes, they definitely carry many additional morbidity/mortality risks. But is surgery really the best alternative? Dr. Varban used data on 19,764 gastric bypass patients from 2006-15… just in Michigan. What the hell is wrong with this profession, and with this society, that so many of us are willing to perform, encourage, refer for, pay for, choose, and suffer this procedure?

96120cookie-checkMalabsorptive Thinking by Pat Conrad MD