June 11, 2018

Obesity is a complex problem with many contributing factors including a dysfunctional consumer food system that maximizes taste and calories over health benefits coupled with a sedentary American lifestyle and frequent contact with obesogenic chemical toxins. The problem is that the medical system has been relatively ineffectual at moving the needle on obesity towards a healthier paradigm. Americans are very tied to their food choices and emotionally find it very difficult to move away from high calorie sugar, salt and fat laden foods towards whole anti-inflammatory food types like vegetables and fruits. This follows in line with the fact that medicine has been woefully ineffective at curing or even controlling most chronic lifestyle related diseases.

What the American medical system has been very good at over the last few decades is acute disease management and especially surgical interventions. When Dr. Eric Malico and I first started discussing the benefits of gastric surgery to control the obesity epidemic, I never expected to learn that this procedure is wildly beneficial to obese

Americans. Over many lunches, we would talk repeatedly about the future of medicine and the intestinal microbiome as it relates to caloric storage, weight control and inflammatory disease prevention.

I decided to do a deep dive into the literature and look at the root cause of the weight loss. Was it just that the surgical recipients could not eat enough food to gain weight? Was it hormonal? Was it the microbiome?

What I found was astounding to say the least! The two major surgeries that are effective and used often today are the gastric sleeve and the roux en y gastric bypass. Both of these procedures reduce the area for which food can have access to the stomach by partitioning the stomach into a smaller segment. Both procedures cause more than 80% of patients with diabetes to lose their insulin insensitivity. Metabolically, this surgery is a better treatment for type 2 diabetes than any drug on the planet. That is profound.

The initial thought of having a reduced volume of food and therefore total calories in as the primary driver of weight loss turned out to be false. A person can easily consume the same volume of calories by breaking the meals up into many smaller meals keeping the intake identical.

It turns out that these procedures markedly alter the bacteria that live in our intestines immediately after the procedure. The exposure to oxygen and the changes in the stomach's architecture and downstream acidity causes the environment of the intestine to change in a way that allows a different set of bacteria to proliferate. These bacteria, serendipitously, decide to harvest less energy from food thereby storing less energy as fat. They also effect glucose control by increasing insulin sensitivity in the intestine reducing circulating glucose levels and in effect eliminating the disease diabetes.

Furthermore, we now know that appetite stimulating hormones like ghrelin are reduced post surgery. This effectively makes one less hungry. Taking it a step further, what happens if you transplant the intestinal microbes from a post gastric bypass mouse into an obese sham surgery mouse?

From the Journal Science of Translational Medicine, Dr. A Liou writes, "Transfer of the gut microbiota from RYGB-treated mice to non-operated, germ-free mice resulted in weight loss and decreased fat mass in the recipient animals relative to recipients of microbiota induced by sham surgery, potentially due to altered microbial production of short-chain fatty acids. These findings provide the first empirical support for the claim that changes in the gut microbiota contribute to reduced host weight and adiposity after RYGB surgery."

Taken all together, we have a surgical intervention with a post-surgical complication rate of <<1% but a ridiculous upside of weight loss, diabetes resolution and decreased systemic inflammation. There is no other current way to effect change so quickly with long lasting health benefits.

After completing my research, I again discussed the procedure with Dr. Malico and was very impressed with the national effort to make sure that this procedure is safe and regimented. Patients need to follow a 6 month program of diet, exercise and other lifestyle changes to make sure that they are invested in and ready for this event to occur. The surgery is very safe. It is safer than gall bladder surgery by a factor of 10 despite being more intense.

As with any disease, I am all for fixing through lifestyle modification first and foremost. However, as we have seen over the last few decades, this is not happening. If you are struggling with severe weight control problems, have type 2 diabetes and want to have a chance at a healthier life, look into this procedure. You never know whether this is the spark that helps you heal for life.

Drs. Magryta and Malic

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