The Surgeon’s Viewpoint: Swedish Obese Subjects Study and Bariatric Surgery

The Swedish Obese Subjects study is a fabulous example of how very-useful practical knowledge can come out of a well-conducted cohort study.  Not everything has to be a prospective randomized controlled trial!   This study has produced a number of landmark papers which provide convincing evidence that:

1.       Bariatric surgery offers survival benefit over the long term for the morbidly obese, despite the up-front mortality risk from the surgery itself.

2.       Bariatric surgery reduces cardiovascular and cancer deaths

3.       Bariatric surgery is durable: most patients do not regain the weight back

4.       Not all bariatric procedures are the same.  Some work better than others.

5.       Diets, behavioral modification, and “professional” weight loss coaching doesn’t really work for the morbidly obese in the long haul.

6.       And now….bariatric surgery prevents onset of diabetes!

The strength of the Swedish Obese Subjects trial is in the follow-up.  Since Sweden has a nationalized health care system, follow-up was completed on >95% of the initial cohort.  Such a trial could never be conducted in the United States….our people change jobs, towns, or insurances just way too often!

And there is just one more thing you should know about the Swedish Obese Subjects trial: the vast majority of the surgery cohort underwent vertical banded gastroplasty (VBG).  What’s that, you ask?  It was a first-generation bariatric operation that has been abandoned worldwide in favor of better (i.e. more effective) operations, such as gastric bypass and sleeve gastrectomy.  So if this trial were repeated in 2012, we would expect even better results in the surgical arm with fewer complications.

So where does that leave us?  For any patient with BMI > 40 (or BMI >35 with metabolic disease), you should really get them thinking about surgery as an option.  It’s not just about weight, and certainly has nothing to do with cosmetic appearance.  It’s about getting serious about treating metabolic disease: diabetes, hypertension, sleep apnea, hypercholesterolemia, PCOS, and others.  It’s about making sure that those diseases never develop in the first place.  It’s about reducing overall cancer risk, stroke risk, and heart attack risk.  And it’s about improving overall quality and quantity of life.

So why, then, with such powerful clinical evidence, do less than 1% of adults who would benefit from bariatric surgery actually get it?  That, my friend, is complicated, and probably worth another blog in its own right!

Jonathan Carter, MD


FitBit activity monitor: I’m a believer

While eyeing things like the Jawbone Up and FitBit for the last year or so, I’ve stayed out of the fray until recently.  As part of my mission to develop a better sense of empathy and understanding for what it is like to have to monitor oneself all the time, I finally started using a FitBit Ultra recently.

I was skeptical, now I believe.  These little things really do have the power to change behavior.  It is not going to overhaul your life, but merely nudge you in the right direction.  But those nudges add up to real change.

I’ll admit, I was formerly a bit lazy and usually took the elevator at work, even to go up a few flights.  I looked for the closest parking spot I could find to where I was going.  Wearing the FitBit the last few weeks, I find myself taking the stairs at every opportunity.  Where I used to take the elevator from the 5th floor of the hospital to the 11th floor in-between our Wednesday conferences, I now take the stairs.  I park my car further away.  Perhaps embarrassingly, I even pace up and down my halls at night while brushing my teeth if I’m a few hundred steps short of a badge, trying to reach that next level.

But how do these seemingly small changes in behavior translate to real-life changes?  I run and I consider myself generally to be in good shape, but in the past, when walking up to our endocrinology clinic on the 5th floor, I would get slightly winded between floors 3 and 5.  This morning, I noticed that I bounded straight up to 5 without much of an issue.  Even more impressive is my weight change.  My medical residency and its incumbent poor diet and sleep deprivation put me up to 180 lbs.  Since residency, with improvements in diet, sleep, and exercise, I have held steady at between 167-171 lbs for the last 18 months, not once wavering out of that range.  However, this morning, I weighed in at 164.5 lbs, more than 2 full lbs lower than I’ve been previously.

Obviously, this is very anecdotal and does not guarantee that everyone using a FitBit will see a result like this.  Nor does it yet mean that my improvements will be sustained.  However, it does mean that a small device that you clip on to your waist can nudge you to make small changes in what you do minute to minute and those small changes can add up to make real differences.

I’m a believer.

FitBit daily dashboard:

FitBit steps log: