The Medical News Report #48
Happy New Year 2016!! It is time to make your New Year’s resolution. The Obesity Series, if you read it carefully, should have you pumped up to lose that extra weight that has been holding you back. I know you can do it. I dropped 25 lbs. over the last year, and if I can do it, so can you!
Subjects for January:
I want to bring you up to date on a new information about Obamacare insurance plans regarding cancer drugs. They will not divulge which cancer drugs they will or will not cover, making it impossible to choose the right plan. Navigating insurance plans are awful.
Men have 15-20% body fat and women 25-30%, if they are healthy---Greater than 25% body fat for men and 33% for women define obesity. BMI correlates very closely with total body fat. However, very muscular individuals will have higher BMIs, and that fact needs to be taken into the consideration. Classes of obesity are correlated with the waist size as well. Click on to calculate your BMI-body mass index: http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Classes of Obesity
Factors involving Obesity
It should be noted that normal weight individuals with a “gut” are also at an increased risk for cardiovascular disease the same as those overweight.
Treatment for Obesity—A Multi-modality Approach
Successful treatment requires all aspects of medical oversight and coordination with a dedicated physician and patient. There will be no cutting corners, using crash diets, or expecting a quick fix to lose 5-10% of body weight. It takes a lifelong need to modify behavior, but the rewards will be great.
1. Nutrition—it is critical to understand, regardless of the method of dieting, to lose weight, you must consume fewer calories than you burn.
for weight loss for those desiring to lose 5-10% of their body weight should seek consultation from nutrition experts. The Lancet journal just reported that fat intake had little to do with the success in losing weight. A low carbohydrate diet however was superior in losing weight, primarily because protein and fat do not stimulate fluctuations in insulin level as much as carbs. This follows the recent information about allowing more fat into the diet. It will always be about calories in vs. calories out.
Also, a recent study found that skipping breakfast created a higher blood sugar later in the day in type 2 diabetics. Remember when insulin levels respond to a more elevated blood sugar in anyone, this affects the hunger hormones (previously discussed).
2. Physical Activity—walking for at least 30 minutes a day is a great way to start. Physical activity will increase your metabolic rate and make your body burn more calories. Try and include some more strenuous exercise 3-4 times a week (start slow and work up). Lifting weights will likely make you gain weight, because muscle weighs more than fat. Find what you enjoy!
3. Behavioral Therapy—some type of supportive therapy will increase the likelihood of sticking to a program, whether it is Weight Watchers or a support group. Exploring the reasons for being overweight are necessary to correct the reasons a person is overeating.
4. Pharmacotherapy--Weight loss medications--The most important thing a physician can do for patients needing to lose weight is to start with compassion and understanding. There are now evidence- based treatments for their patients.
Indications for diet pills--BMIs of greater than 30 qualify patients for diet pill prescription treatment, and greater than a BMI of 27 if there is at least one co-existing co-morbid state present (hypertension, diabetes, hypercholesterolemia, etc.), which almost all overweight people have.
Medical management of all related medical issues (co-morbid), is necessary in addition to taking these medications to be of maximum value.
If at 6 months, adequate weight loss has not been attained, consideration for stopping the medication may be entertained. It is not magic….it takes willpower and discipline. Insurance may or may not pay for these medications. Check with your insurance company.
Below is an exhaustive list of diet pills. The most recent medications include---Belviq, Qysmia, Xenical, and Contrave (just available) and Saxenda.
Contrave is very exciting, because it combines bupropion, a well- known drug used to treat the craving in smoking cessation and naltrexone used to treat addicts. Very few patients are taking these meds, and that is the fault of their physicians not being comfortable with them. Discuss this with your doctor.
To qualify for medication, you must have a desire to lose weight, diminish caloric intake 1200-1500 cal./24 hrs., have a BMI of 30 or higher (waist of 37 inches for women and 40 for men), or 27 if a patient has obesity related disease such as hypertension, type 2 diabetes, or high cholesterol. You must have a negative pregnancy test (causes birth defects), a good birth control plan, not have hyperthyroidism, closed angle glaucoma, or recent unstable heart disease. Some of these meds are FDA approved for weight loss and others are considered off-label.
For obese diabetics, it is recommended to consider drugs that lower the blood sugar and can enhance weight loss. Pramlintide is a man-made hormone that simulates a hormone secreted by the pancreas called amylin. This injectable drug is now being used along with metformin, an oral hypoglycemic agent commonly used in diabetics. Another drug recommended is Canagliflozin, which drops the blood sugar and helps reduce weight. These drugs are also used in insulin dependent diabetics. Insulin shots make patients gain weight, and these medications help prevent that side effect.
Drugs that can cause weight gain:
For obese diabetics, the use of oral contraceptives is recommended since injectable contraceptives tend to cause weight gain. Additionally, hypertension should be managed with ACE-inhibitors or calcium channel blockers rather than beta blockers, which can cause weight gain.
Studies have shown, with the above requirements being met, a loss of 10% of body weight in a year can occur over placebos. These standard weight reduction medications work by reducing the activity of the hunger center in the brain. Side effects are dry mouth, constipation, tingling of the fingers and toes, but no increased heart attacks or strokes were seen in these studies.
These are some of the enemies!
Weight Loss National Programs—I have researched most of the major programs and Weight Watchers is the best program for the money. No matter what program a person chooses, stick with it, and don’t get discouraged.
5. Bariatric Surgery--Surgical Consideration
There are several options for bariatric procedures. Your surgeon will determine the appropriate one for each individual. Most procedures today are endoscopic in approach preventing an open abdominal procedure.
There are basically 3 types of bariatric surgical procedures:
1) banding of the upper stomach (see drawing below) to allow less food into the stomach. This is the least successful for major obesity and trying to relieve type 2 diabetes.
2) Reducing the size of the stomach by removing a part of the actual size of the stomach as in the sleeve gastrectomy shown below. There are variations of sleeve resection. This is the most common procedure performed today.
3) Actual surgical bypass of the stomach essentially sends food from the esophagus to the second part of the small intestine (jejunum) bypassing the stomach and duodenum (first part of the small intestine). The Roux-en-Y bypass is the most common procedure but there are other variations as pointed out in the list.
Preparation before actual surgery---prior to bariatric surgery, endoscopy of the stomach and duodenum should be performed to rule out any existing diseases.
Drawings of the gastric sleeve and gastric banding procedures:
Roux-en-Y -gastric bypass is now approved for adolescent obesity including adults and is the most common procedure. It does create some malabsorption of foods (prevents significant digestion), which must be monitored carefully postop with supplements and vitamins. Loss of 100 lbs. or more can be expected.
A recent report stated that compared to diet and exercise, gastric bypass is 43 times more successful in reversing type 2 diabetes (defined as no diabetic meds and HbA-1c less than 6). Gastric banding is 7 times more successful.
To qualify for bariatric surgery, the requirements are similar to those for diet pills. Most patients are at least 100lbs. over weight.
Cost-effectiveness of surgery for weight loss--bariatric surgery for type 2 diabetics adds no more cost to the care of a diabetic than having non-surgical management using medications and treating the complications of the disease according to a recent study. That is great news. Obesity is very costly and we must have answers like bariatric surgery. Only 2% of actual candidates accept bariatric surgery. This hopefully will change over time. Insurance companies must cover the expense to increase the number of patients agreeing to bariatric surgery. Check with your provider.
97% of bariatric surgeries use the laparoscopic approach. The average stay in the hospital is 2 days in one Swedish study, and the majority of the patients were pre-diabetic and did not proceed to diabetic status thanks to the surgery.
Results of Bariatric Surgery
It is imperative that a very experienced bariatric surgical center be sought when and if medical management is not successful. The good news is that the success of bariatric surgery for weight loss (in the right hands) is showing enormous success. It is still imperative that the patient invests 100% of their effort over time to lose 5-10% of their body weight and follow closely the recommendations of their weight loss doctors, counselors, nutritionists, and nurses. The family must be on board as well.
Current evidence has suggested that this surgery can decrease fatty liver and non-alcoholic hepatitis, and cirrhosis. If a man with obesity causing low testosterone levels (50% do) has a sleeve gastrectomy, 33% of these men had the levels return to normal within a year. This correlated with successful reduction in the BMI and waist circumference. It is expected that most patients should be able to lose 100 lbs. (American College of Surgeon Clinical Congress 2015)
However, simpler procedures may be on the way with FDA approved pacemakers for the stomach (Enteromedics), different balloon systems (Reshape Duo) (Elipse) (Obalon), and a pill that expands (Gelesis100).
There will be a measurable reduction in diabetes, cardiovascular disease, and all the organs that have been affected by obesity with bariatric surgery.
These procedures may become as common as coronary bypass in the near future.
Lifelong Vitamin B12 shots, oral iron, Vitamin B-complex, folic acid, and calcium supplementation are necessary because of the malabsorption of nutrients created by gastric bypass surgery. Cholescystecomy (gall bladder) will be required in a percentage of patients because of excessive storage of fat and bile salts from the liver.
Because there is a significant rate of mental disorders in obese patients (double the normal population), it has been reported that suicide and self- harm occurs after the “honeymoon is over, and they have lost the weight, which increases by another 50% in these patients. Expectations for change can be high and when that does not occur, disappointment can occur and create escalation of mental problems. Attention to continued mental health therapy and family support in all these patients is highly recommended. It is critical the primary care professionals interview and lend support for their patients who want to or need to lose weight!! Careful screening for candidates includes mental stability prior to consideration for bariatric surgery. Reference-JAMA Surgery, 2015
Because of the major weight loss, body contouring surgery will likely be necessary in a significant percentage. Abdominoplasty, arm lifts, butt lifts, leg lifts, breast reduction with reconstruction, and face lifts all may be performed in stages after major weight loss. I will discuss these procedures when I start a cosmetic surgery series sometime this year.
Finally, there is great need for studies following these patients over decades to determine the lifelong benefits, risks, complications, and outcome. To date, most of the studies have been outside the U.S. In the coming year, I will update information on obstructive sleep apnea, a huge problem for overweight people. If you can’t wait, please see my special report on sleep apnea on this subject: SleepApnea.pdf
Reference- Lancet-Diabetes/Endocrinology, 2015,
This is not a sexy subject, but could be one of the most important health subjects in nutrition and health. Genetically modified organisms are bacteria used to modify the genetics in the growth of vegetables, most notably corn and soybeans. Simplified, this is performed to make crops more resistant to weeds harmful to vegetables. It was supposed to decrease the need for pesticides. Manipulating the DNA increased the yield of the crops. For poverty-stricken countries, it was supposed to provide more food to the masses.
64 countries have significant regulations limiting or forbidding GMOs in their country. The U.S. does not regulate GMOs. Monsanto is the chemical company that has been making millions off this engineering. Our Congress must address this issue.
2 factors have created more potential harm:
1. There has been increasing amounts of more toxic pesticides sprayed on American crops because the bugs have mutated and now require more aggressive spraying.
2. The International Agency for Research on Cancer has classified glyphosate , the most common herbicide used, a PROBABLE HUMAN CARCINOGEN----IT CAN CAUSE CANCER! Specifically, non-Hodgkins Lymphoma! Another herbicide, 2,4 dichlorophenoxyacetic acid (2,4 D) has been classified as a possible carcinogen. These herbicides are commonly used together and are called Enlist-Duo. They were formulated to more aggressively fight the the weed’s resistance to herbicides that compromise the crops.
The science supporting the use of these herbicides falls on the shoulders of the National Academy of Science.
One hundred million acres of crops now have herbicide-resistant weeds, now necessitating increasing amounts of carcinogens being sprayed on our crops.
The NEJM (New England Journal of Medicine), a very prestigious journal has condemned the research on these chemicals, stating that they did not study the effects on infants and children. This was approved by our government on the basis of studies performed before 2005. Because of flawed research and incomplete studies, the National Academy has agreed to form another committee to study the new issues created by increasingly resistant weeds, but will not report until later this year. In the meantime, we are ingesting potentially toxic and cancer causing chemicals in our food.
In the meantime, the NEJM has recommended that the EPA (environmental protection agency) delay approval of the combination herbicide Enlist-Duo. Second, they recommend that the FDA consider all GM (genetically modified) food be labeled, to let the public know they are taking a risk. The biotechnology is an evolving science, and it appears that the U.S. jumped the gun approving GMOs and genetically modified food. Reference –NEJM,
I hesitate to offer links to this controversial subject, because there is always two sides to this subject. Monsanto.com will be happy to let you know how safe they are, and there are conspiracy websites that will try and scare you to death. The bottom line, it appears to me that some Congressmen got sold a bill of goods on a solution to world poverty and starvation, and they accepted rather flawed research and should have insisted on more in depth research. You decide!
I previously described the hormonal functions of the pancreas in the Endocrine Series—the pancreatic islet cells produce insulin and glucagon to regulate the blood sugar.
The above 2 drawings demonstrate the anatomy of the pancreas and the duct that joins the bile duct.
The digestive portion of the pancreas (and 80% of the volume) provides vital enzymes (amylase and lipase) for digestion of protein and fats. I also described these functions briefly when reporting on the stomach’s contribution to digestion. It takes the stomach, the gall bladder, the liver, and the pancreas to digest protein, fat, and carbohydrates. The main duct (drainage tube) in the pancreas secretes pancreatic enzymes into the bile duct. The liver provides bile and concentrates it in the gall bladder. These enzymes all end up in the common bile duct and spill into the duodenum (the first part of the small intestine) to assist in digestion.
When inflammation occurs in the pancreas from alcohol abuse or obstruction of the pancreatic ducts, acute pancreatitis occurs. The pancreatic enzymes actually auto-digest the pancreas. This can heal and recur which causes chronic pancreatitis.
Symptoms of acute pancreatitis include abdominal pain (usually referred pain into the back), fever, nausea and vomiting. The blood pressure can be low due to dehydration. This can be life threatening or more mild. Weight loss can occur in the chronic form from lack of the proper enzymes to digest food.
Causes include gall stones obstructing the bile duct, alcohol abuse, medications, trauma to the abdomen, infections, high triglycerides, and pregnancy. Hereditary conditions such as cystic fibrosis can cause this disease. In 30% of the cases, the cause is not known.
The diagnosis is made also with testing the blood for amylase and lipase, the enzymes secreted by the pancreas.
An ultrasound may discover a pancreatic cyst (called a pseudocyst), which can occur from a previous bout of pancreatitis. They may need to be removed if they persist.
Surgical specimen of a pancreatic cyst
Cyst in head of pancreas on Scan
Treatment usually requires hospitalization for IV fluids, pain medications, placement of an naso-gastric tube to empty the stomach of contents, acid, and enzymes. 25% of cases requires admission to the ICU for monitoring and evaluation of damage to the heart, kidneys, and lungs.
If gallstones are the cause, removal of the gall bladder and or surgery to remove stones from the bile duct.
Unless severe, the patient usually recovers in a week or so.
Prevention of recurrent cases must include alcohol and smoking cessation, and good nutrition.
A Quick update on herpes simplex (fever blisters, genital blisters) and Alzheimer’s disease: There is an association between herpes simplex, which is an STD, and Alzheimer’s disease (AD). Those who have the lifelong viral disease have twice as likely chance of developing AD. This may be an association or a true causal relationship. It will be some time before it is known if treating AD with antivirals will have a positive effect on the progression of AD. Reference-Medscape
HIV-- Charlie Sheen has come out with his 4 year revelation that he is HIV positive, and since we are discussing STDs, an overview of HIV-AIDS is most appropriate. This website is a fabulous resource:
HIV-AIDS is the leading cause of death in the world from an infectious cause. Globally, 35 million people have HIV-AIDS and 1.2 million Americans currently are infected, but 1 in 8 people (14%) don’t know they have it! More than half of the cases come from the LGBT community (mostly men having sex with men especially blacks), Latinos, intravenous drug users sharing needles (60% report sharing needles), and youth ages 13-24. Half of the cases come from the Southern states.
Florida leads the nation in numbers of cases (2013) with 5,377. It ranks third in highest number of children with HIV infections (infected through the placenta). The rates are rising too (14% increase in 2014).
Only 40% of patients are being adequately treated with antiviral therapy. There are those who know they have HIV and delay treatment until they have the clinically active disease AIDS. There are those who do not seek care because of fear or the lack of access to care, are mentally ill, or suffering from substance abuse and refuse to come forward. Properly treated, patients can lead a normal long life. HIV-AIDS is no longer a death sentence, because treatment today is very successful with few side effects. But until public health principles are followed, this disease will never be well controlled. It is not curable, but controllable.
HIV stands for human immunodeficiency virus and AIDS stands for autoimmune disease syndrome. Viral suppression in the blood will keep the patients in good health if they follow the rules.
Stages of the care continuum is defined by the CDC as:
1. HIV testing and diagnosis
2. Getting and staying in treatment
3. Going on antiretroviral therapy (requires 3 or more drugs)
4. Achieving viral suppression (maintaining a low level of virus in the blood)
Below, the graph demonstrates the challenges this disease still has. Note that there are only 30% of those with HIV that are virally suppressed, which puts the rest at risk for developing AIDS (autoimmune deficiency syndrome). 9 out of 10, if diagnosed and treated early, will prevent developing the clinical illness AIDS. Taking daily treatment cuts the likelihood of transmission by 50%. Everyone needs to know their HIV status. When the virus infects a person, the symptoms are flu-like.
Practicing safe sex is a must to prevent HIV, but being on HIV therapy does not prevent other STDs. And yet, men having anal sex with men continue to not use condoms in an increasing number. The LGBT community needs to wake up!
13,700 died of AIDS in 2012! Over 600,000 have died of AIDS in the USA since the disease appeared in the 1980s.
Prevention in high risk people (PrEP)-a daily pill
Prophylactic medication for high risk groups
Pre-exposure prophylaxis should be taken by high risk individuals- tenovovir and emtricitabine (Truvada) must be taken orally each day. A recent study cited by the CDC stated the 25% of men having sex with men (who are not currently HIV+) are not using condoms when having sex with other men (includes bisexuals). It can prevent becoming HIV positive in up to 90% of cases if taken daily. This might be a good option for a partner of a positive individual, the LGBT community, or those immunosuppressed having sex with a high risk group. Condoms and other latex barriers are a must as well. Oral sex may be less risky, but can still transmit the retrovirus, especially if there are open sores, poor dental health, or presence of other STDs. Blood, semen, seminal fluid, open sores, and vaginal or anal secretions all contain the virus. Casual contact will not give you AIDS. 19% of intravenous drug users share used needles!! If they used fresh needles, they could prevent getting HIV!!
Every sexually active person should be tested for HIV. High risk individuals should be tested annually (some even say every 3 months). There are 2 home kits that can be purchased at drug stores. Free testing at health departments are always available. There is no excuse for not being tested. Without early diagnosis, the disease will progress resulting in AIDS. Globally 39 million have died of HIV-AIDS.
The latest thinking is that gay men should consider being tested every 3 months. Those who test positive must notify their sexual partners, but half don’t!!!
C. Signs and Symptoms—Stages of Infection
1. Acute stage—in 2-4 weeks after infection, flu-like symptoms are common. Sore throat, enlarged lymph nodes, fever, and rash can occur but some patients may have no symptoms!!
CD4 immune cells are killed off rather quickly dropping the immune system (the CD4 count can be followed). In this stage, the viral count in the blood is high and is easily transmitted.
2. Clinical latency—this stage is characterized by having no symptoms, but an infected person can still transmit the virus during this stage. This can last up to 10 years and even decades even if on ART—antiretroviral therapy. As the patient nears the end of the latency period, the immune system fails even more resulting in symptoms including secondary infections (TB, fungal, bacterial) and Kaposi’s Sarcoma.
3. AIDS—full blown infection—this is the clinical disease when treatment in the early stages is not received or if discontinued. There is little reason a person needs to suffer AIDS if early diagnosis and treatment are initiated.Once this disease gets to this stage, the patients is facing potential death. That is why it is so important for everyone to know their HIV status. Remember, 1 in 8 (14%) do not know they have the virus.
The average time from the beginning of AIDS to death without treatment is 10-12 months. If treated, the time to death can vary due to so many factors, but 3-51 months is quoted.
D. Complications of AIDS-Autoimmune disease syndrome
The most common diseases are:
Bacterial-tuberculosis (anyone diagnosed with TB should be tested for HIV). TB is the leading cause of death.
Fungal infections (candidiasis of the mucous membranes, cryptococcal meningitis, cryptosporidiosis)
Viral- cytomegalovirus. This disease affects the major organs causing weight loss, GI disease, weakness, and muscle wasting.
2) CancerKaposi Sarcoma (cancer of the skin, mucous membranes and GI tract. Lymphomas
There 6 classes of drugs to treat HIV-AIDS, but only 39% of infected patients in America are being treated.
These are anti-retroviral drugs to suppress the HIV virus and drop the count in the blood with resultant increase in CD4 counts. At least 3 drugs from 2 different classes is recommended. A specialist will determine the best combination.
F. Results—Even with the advances in this disease, 14,000 in the U.S. lose their lives each year. 39% are being actively treated, and many stop their treatment. When treated early, this becomes a chronic illness. Many health departments are woefully lacking in surveillance.
Reference—CDC, NEJM, Dec. 2015
It is known that breast conserving cancer surgery creates the same survival rate as mastectomy. 270,000 women in the U.S. will be diagnosed annually with operable breast cancer. 2/3 of these women will choose breast conserving surgery. The goal is to remove the cancer leaving a cosmetically appealing breast.
Re-excision rates vary from 10-50% of the patients with close or positive margins on their breast cancer. This creates huge financial, emotional, and cosmetic concerns. In an attempt to drop these re-excision rates, many doctors have started to do a “cavity shave”. That means removing a ring of tissue after the primary excision. Cavity shaving has reduced re-excision from 21 to 10% of the cases, and has been used since 2008 in some centers. It turns out that the second or cavity shave tissue had some cancer cells in approximately 34% of the cases in the studies I have read (NEJM). Surgical judgement is very important in taking up to 50% more tissue and still resulting in a satisfactory cosmetic result.
These are examples of lumpectomy (partial mastectomy with post-op whole breast radiation.
A reduction of 10% reoperations results in 10-20,000 cases not having to have re-excision surgery. Recent studies have proven this “cavity shave” technique to be valuable.
Whole breast radiation is likely to be recommended and will create breast scarring (fibrosis) and a woman has to consider that fact versus undergoing a more aggressive mastectomy . Reconstruction has been discussed in the previous breast cancer series found in the subject index on my website or click on: Reports\Medical Report 27.pdf
It is important to discuss with your surgeon this concept to hopefully prevent the heartache of re-excision. Hospitals are being graded on this issue, as it is considered a quality of treatment issue. Grading equates to Medicare reimbursement. No wonder re-excision rates are finally getting attention.
Everyone wants fresh breath. Here are some causes of bad breath: not brushing and flossing, gum disease, periodontal disease with pockets, hairy tongue, dental caries (cavities), dry mouth from any cause (radiation, medications, mouth breathing, and dehydration) acid reflux, belching, an certain foods especially protein, spices, garlic, onions, hidden cancers, food stuck in the crypts of the tonsils, infections such as thrush and canker sores. Sulphur compounds can come from the stomach (heard of smart mouth rinse?)
Certain skin diseases that have oral manifestations include lesions caused by immune diseases such as pemphigus, discoid lupus, epidermolysis bullosa; skin diseases with oral manifestations including lichen planus and psoriasis; liver and kidney disease, smoking or chewing tobacco. Even diabetes can cause gum problems that could cause bad breath.
Dry mouth is caused by more than 400 drugs and some autoimmune diseases (Sjogren’s Syndrome).
Dental insurance is the most common type of health care coverage that is unaffordable. 21% of the population can’t or won’t pay for dental coverage. 38% of low income Americans state they can’t afford coverage. Considering the importance of dental health in the face of causing major systemic health problems, it is time that dental care is covered by regular health insurance. Maybe when the one payer system gets here, it will be!
The Hippocratic Oath-a physician’s responsibility
New health screening guidelines for youth
STDs-all other causes besides viral—from bacterial to protozoan
An exciting new gene mutation affecting Alzheimer’s Disease.
This completes the first report for 2016. I hope the series on obesity has been a valuable tool and will perhaps motivate those who need to lose weight ….will!
Have a wonderful 2016, and God bless you all.
I leave you with some humor…..see next page!
Stay Healthy and well, my friends, Dr. Sam