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?

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  2 comments for “Malabsorptive Thinking by Pat Conrad MD

  1. Kurt
    February 15, 2017 at 5:41 pm

    Surgery is not a cure-all, do-all. Where I’m at a person has to commit to 12 months of
    indoctrination. The literature shows if they don’t, the failure rates are horrendous.
    The reason why the obese aren’t “flocking” to surgery is many don’t want to do the lifestyle
    changes necessary (ie. eating less). For the few who are motivated, surgery can be a Godsend.
    Those who half-assedly fall into it because “the state pays for it” are doomed to stretch out the
    gastric pouch and failure.
    Again, nothing is going to change in this country until people are held accountable for their
    lousy health behaviors and encourages me to advise students to stay away from primary care medicine. Unless of course they want to be penalized for behaviors they have no control over.

  2. HJR
    February 13, 2017 at 10:15 am

    Bingo. I fear that when all is said and done, this will probably also get thrown on the trash heap of history’s bad medicine just like Swan’s and bloodletting.

    “You don’t need an operation. JUST DON’T PUT THE FOOD IN YOUR MOUTH.”

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