EACH ISSUE OF THE WELL NEWSLETTER will feature one or more articles from health care professionals. Our contributing writers will be medical doctors, PhDs (or PhD students) and fitness trainers who will tackle issues that are important to your health and wellness.

Have Diabetes? Find a Surgeon!

 by Dr. Arya Sharma
» Dr. Sharma's website

TYPE 2 DIABETES MELLITUS is one of the most prevalent and expensive "lifesyle" diseases.

Here some numbers from the website of the Canadian Diabetes Association:

• The personal costs of diabetes may include a reduced quality of life and the increased likelihood of complications such as heart disease, stroke, kidney disease, blindness, amputation and erectile dysfunction.
• Approximately 80% of people with diabetes will die as a result of heart disease or stroke.
• Diabetes is a contributing factor in the deaths of approximately 41,500 Canadians each year.
• Life expectancy for people with type 2 diabetes may be shortened by 5 to 10 years.
• People with diabetes incur medical costs that are two to three times higher than those without diabetes. A person with diabetes can face direct costs for medication and supplies ranging from $1,000 to $15,000 a year.
• By 2010, it's estimated that diabetes will cost the Canadian healthcare system $15.6 billion a year and that number will rise to $19.2 billion by 2020.

So imagine, what if a relatively straightforward laparoscopic operation, which takes 30–90 mins and lets you go home the very next day, cures this condition — in most cases forever?

This may very well be the case if we trust the results of a sytematic review by Henry Buchwald and colleagues from the University of Minnesota, published in this month's edition of the American Journal of Medicine.

The paper reviews over 600 surgical studies in a total of over 135,000, of whom around 22% had type 2 diabetes.

These are the results:

• Type 2 diabetes was resolved in 78% and resolved or improved in 87% of patients undergoing bariatric surgery.
• Both weight loss and diabetes resolution were greatest for patients undergoing biliopancreatic diversion/duodenal switch, followed by gastric bypass, and least for banding procedures.
• Clinical findings were substantiated by the laboratory parameters of serum insulin, HbA1c, and glucose.
• These findings were maintained for 2 years or more.

To be fair, the authors note several limitations of their study, the most important being the high attrition of patients available for follow-up, the diversity of reporting formats for diabetes outcomes, and the lack of information on specific subpopulations such as different ethnic groups. However, they also note that the the pattern of results for key outcomes in this meta-analysis are so consistent across studies, that they are hard to refute.


Although most of these studies did not study "hard outcomes", we do know from the SOS Study (with a post-operative follow-up of 15 years and a follow-up rate of 99.9%) that surgery in patients with severe obesity can reduce total mortality by 30% and in a study from Utah, diabetes-related mortality was reduced by around 92%.

In contrast, recent studies of medical diabetes treatment failed to find any significant effect of better glucose control on mortality in patients with poorly-controlled diabetes (e.g. the Veterans Study).

I guess it is fair to ask — should perhaps bariatric surgery now be considered the "Gold Standard" for the treatment of type 2 diabetes, at least in patients with severe obesity? Should conservative diabetes treatments be reserved only for patients who do not meet surgical criteria? Tough questions that challenge much of current diabetes management — after all, why treat a condition for life, when it can be cured?

However, before running aboard with this idea, a word of caution — as I have blogged before — bariatric surgery involves far more than just surgery.

Nevertheless, in the light of these findings it does seem strange to me that a search for the term "bariatric surgery" on the website of the Canadian Diabetes Association comes up empty — I wonder why.

Make War on Obesity — Not on Obese People!

 by Dr. Arya Sharma
» Dr. Sharma's website

[RECENTLY] I BLOGGED ABOUT how many folks with extra pounds do not see their excess weight as a health risk. Readers of these pages will also recall that I am the first to acknowledge how difficult it is to lose weight and keep it off or that successful weight management starts with stopping the gain and not with losing weight.

So yesterday, a regular reader pointed me to an article in the Globe and Mail by Edith Honan on the fat-acceptance movement which lobbies against weight discrimination and promotes the idea of being as healthy as possible at any weight rather than pursuing unrealistic (and according to some fat-acceptance advocates, unnecessary) weight-loss targets.

As Kate Harding, one of the most prolific fat-acceptance advocates is quoted, “Being fat doesn’t make me lazy or stupid or morally suspect”.

While many of the issues and arguments of the fat-acceptance folks are very real and sensible, I also have no doubt that when excess weight is, or threatens to become, a health problem, there are also very real benefits to effective weight management. In fact I have very rarely met patients, who after successful weight management would voluntarily go back to regaining their lost weight (that many do, is besides the point).

So while I am definitely not a militant weight-loss advocate, I am certainly an advocate for sensible obesity-management. I fully support the notion that weight discrimination is very real and unfair (e.g. the airline seat issue) and very much know that for many, successful weight management simply means not getting any heavier.

None of this, however, makes me an advocate for weight gain and I certainly would not promote the notion that excessive weight gain is OK as long as it makes you happy. I simply see too many patients in my clinic for whom the mental, mechanical, and metabolic health problems directly related to their excess weight are very real.

So, while I am all for fighting weight discrimination, I am also all for increasing access to evidence-based obesity treatments for those in whom excess weight is destroying their health and quality of life.

I fully agree with Yale University’s Rebecca Puhl, who in the article is quoted as saying, “We do need to fight obesity, but not obese people”.

p.s. Hat Tip to regular reader Ann Hastings for pointing me to the G&M article

Blue Zones & The Island of Long Life

FOUNDED BY explorer and author Dan Buettner, Blue Zones is leading the way in healthy-living and aging research by identifying and exploring hot spots around the world where people live the healthiest, longest lives. The cool part? They're doing it with the help of folks at home through an interactive, online educational project known as the Blue Zones Quest.

So far, Buettner and his team have identified five of those healthy hot spots, or what he calls Blue Zones (hence the organization's name): Sardinia, Italy; Okinawa, Japan; Loma Linda, Calif.; Nicoya, Costa Rica; and the most recent, Ikaría, Greece.

From their findings to date, Blue Zones has identified the Power9, nine common denominators that all of these cultures share, despite being scattered around the world and having no connection to each other. They are:

1. Move (find ways to move mindlessly, make moving unavoidable)
2. Plan de Vida (know your purpose in life)
3. Downshift (work less, slow down, rest, take vacation)
4. 80 percent Rule (stop eating when you're 80 percent full)
5. Plant-Power (more veggies, less protein and fewer processed foods)
6. Red Wine (consistency and moderation)
7. Belong (create a healthy social network)
8. Beliefs (spiritual or religious participation)
9. Your Tribe (make family a priority)

Ikaria, Greece

Making it to 90 years old is awe-inspiring in much of the world. But on a tiny Greek island in the North Aegean Sea, nonagenarians barely merit a second glance. The island of Ikaria could be the newest of the world's so-called blue zones — places where residents have unusually long life spans.

Dan Buettner has crossed the globe many times over the years in search of blue zones, and he recently teamed up with AARP and National Geographic to study Ikaria. Buettner and a team of demographers work with census data to identify blue zones around the world. They found Ikaria had the highest percentage of 90-year-olds anywhere on the planet — nearly 1 out of 3 people make it to their 90s. Plus, Buettner says, "they have about 20 percent lower rates of cancer, 50 percent lower rates of heart disease and almost no dementia."

Our life spans are about 20 percent dictated by our genes, Buettner says. The rest is lifestyle. People in Ikaria live in mountain villages that necessitate activity every day. "They have gardens," he says, for example. "If they go to church, if they go to their friends' house — it always occasions a small walk. But that ends up burning much more calories than going to a gym for 20 minutes a day."

"They also have a diet that's very interesting," Buettner continues. "It's very high in olive oil; it's very high in fruits and vegetables." It's also very high in greens; about 150 kinds of veggies grow wild on the island. "These greens have somewhere around 10 times the level of antioxidants in red wine."

And though they live on an island, Ikarians don't eat much fish. Buettner says pirates pushed the culture up in the highlands and villagers couldn't depend on the sea as much as might be expected.

Particularly unusual to this new blue zone are the villagers' drinking habits. Tea drinking, that is. Ikarians drink herbal teas every day, morning and night, Buettner says. This seems to be one of their secrets to longer living.

"We had five of these herbal teas sent to Athens and analyzed for their chemical composition," Buettner reports. "We found out that most of them were diuretics." "It turns out that diuretics actually lower blood pressure," he says, "so when you're chronically lowering blood pressure every day with these herbal teas, that does help explain why there's lower rates of heart disease."

"That's something we haven't seen in Okinawa or Costa Rica or Sardinia or any of the other blue zones," Buettner says.

Liposuction Does Not Make You Healthy

 by Peter Janiszewski, MSc, PhD Candidate 
Peter is a PhD candidate in the School of Kinesiology and Health Studies at Queen's University. For more health and fitness news, visit his website at obesitypanacea.com

AT THE OUTSET, this notion may seem a tad counterintuitive. If obesity, or excess fat, is bad for your health, how can removing some of that excess fat not improve your health? Unfortunately, while liposuction might make you look better, a number of studies have shown it is unlikely to improve your health — read on to find out why.

Let's start a bit upstream.

First, it is important to understand that fat, or adipose tissue, which is mostly composed of many individual fat cells (adipocytes) is not inherently unhealthy. To the contrary, adipose tissue is absolutely necessary to allow the body to store excess calories during times when we ingest more calories than we expend through activity and resting metabolism. By doing so, adipose tissue acts as a buffer of excess calories, and thus protects other tissues of the body from accumulating fat (i.e. heart, liver, muscle). This notion is best represented by the fact that individuals who completely lack fat tissue (a disorder known as congential lipodystrophy) are very unhealthy and are at great risk of diabetes and heart disease, despite having an athletic and lean appearance.

In other words, fat tissue is essential for health.

Where many people get into trouble is when they have exhausted their body's ability to store more calories in adipose tissue — we all have a certain threshold to which our fat depots can expand. When we get to that point, our fat cells become so big that they are no longer able to buffer excess calories and thus cannot protect other tissues from fat accumulation and damage. This is when many of the classical metabolic problems of obesity become apparent — increased blood fats, blood glucose levels, etc.

But wait, isn't losing fat through diet and exercise good for health?

Yes, when we expend more energy (exercise) or reduce the amount of food we ingest (diet), or both, our body draws on our extra stores of energy in our adipose tissue — this process gradually reduces the size of the individual fat cells. That is, fat loss occurs due to a reduction in size of fat cells, not a reduction in the number of fat cells. Not surprisingly, your pants start fitting better. Also, this process makes fat cells more efficient at sucking up excess calories the next time we again eat more than we expend — think Thanksgiving weekend.

This is completely different from the scenario of liposuction, where a whole bunch of fat cells are removed from the body — that is, you reduce the number of fat cells, but the remaining ones don't get any smaller or healthier — in fact, the opposite may be true (less place to store excess calories than before surgery, so enlargement of those fat cells left behind).

As an example of the lack of health benefit from liposuction, I decided to discuss a paper which was published back in 2004 in the prestigious New England Journal of Medicine. This paper was actually the first paper I discussed with my lab during journal club when I initially arrived at Queen's to do my Master's back in 2004.

In this study, Klein and colleagues investigated the health effects of liposuction of subcutaneous (under the skin) fat in the abdominal region in 15 obese women.

The liposuction procedure removed between 30- 45 % of the subcutaneous fat in the abdominal region, which was equivalent to approximately 10 kg of fat tissue (see above picture from the study). This represented a 20% reduction in total fat mass — a very substantive change!

However, with regards to the women's health — the results were rather disappointing, although not surprising given the above discussion. Specifically, 12 weeks after the surgery the women did not show improvements in any of the metabolic markers assessed (insulin sensitivity — a precursor to diabetes, blood pressure, blood glucose, insulin, or lipid levels) as well as any of the other novel markers of disease risk (CRP, adiponectin, IL-6, TNF-?).

Thus, as this paper concludes, while liposuction may be of benefit for cosmetic causes, it should not be considered a clinical treatment for obesity. In other words, surgically removing fat tissue will not bring about the health benefits of weight loss as induced via a negative energy balance (more physical activity and less calorie consumption).

Klein, S., Fontana, L., Young, L., Coggan, A.R., Kilo, C., Patterson, B.W., & Mohammed, B.S. (2004). Absence of an Effect of Liposuction on Insulin Action and Risk Factors for Coronary Heart Disease New England Journal of Medicine, 350, 2549-2557