Los grupos de discusión en el C.E.A.S Arturo Eyries

obesity surgery (Steinbroook, 2004; Tessier & Eagon, 2008). For example, in the United States, the number of WLS procedures being performed annually rose from

practitioners offering these surgeries increased fourfold (Steinbrook).3 Rates of WLS interventions continue to rise with about 75% of WLS procedures being performed on women (Maggard et al, 2005). I suggest that there is a third epidemic, a bandwagon, ‘me-too’ propagation of obesity-surgery research by surgeons and companies trading in these procedures.

Evidence-based medicine in relation to weight/health remains in question (Cundiff, 2007; Tanne, 2005). Ties to the industry amongst doctors who write treatment guidelines or carry out research affect the quality of medical advice and decision- making within the clinic (Tanne). For instance, the proliferation of WLS series research, supported by technology companies and conflicted by other aspects of trade such as surgeon reputation, impacts understanding of WLS outcomes. It has been suggested that the benefits of WLS have been exaggerated (Mitka, 2003): While the merit of WLS interventions requires quantitative investigations with subject controls and statistical measurements, even so, quantitative research will contribute only limited clinical understanding (Malterud, 2001).

Research into WLS is beset with potential conflicts of interests. This is demonstrated in practitioner/experimenter projects confounding current Australasian work (Dixon et al, 2008;4 He & Stubbs, 2004). For instance, some patients who undergo WLS show remission of Type 2 diabetes. But these findings are confounded when they result from uncontrolled surgical series, participant/patients are not randomised, or, the control groups do not receive appropriate interventions (Pinkney & Kerrigan, 2004). One gastric banding study (Dixon et al), contained many of the elements of the ethically compromised pharmaceutical studies. While surgery intervention was shown to be associated with metabolic improvements, this was with a very small group of patients who had early Type 2 diabetes. As in an earlier study out of Monash (O’Brien et al, 2006), qualifying BMI for the surgery and therefore into the study is disputed (Padwal, 2006; 2008). Allergan Health made an unrestricted grant available to Monash University and provided the gastric bands free for Dixon’s (2008) research. Applied Medical provided the laparoscopic instruments. INAMED Health, Novartis and the US Surgical Corp5 supported the Melbourne study (O’Brien et al).

3_{New Zealand statistics are inaccurate in relation to private WLS uptake (personal communication,} NZHIS).

4_{It is unclear what was involved in conventional treatment for the non-surgical group.}

5_{Stating potential conflicts does not eradicate bias. Besides the Australian Lap-Band studies (O’Brien} et al, 2006) there is also a coordinated series of LAGB studies emanating out of Italy (Angrisani, Favretti,

When a surgery group is compared with a conventional therapy group, it is clearly troublesome if conventional treatment differed in any way between the two groups. Overall, better non-surgical interventions might need to be attempted rather than moving to the surgery option (Padwal, 2006). When conventional treatment is the non- operative comparison, the Hawthorne effect (Mayo, 1975) may be operating. This raises concerns that if any intervention brings some positive effect, then the surgery group could have improved with appropriate and intense non-surgical intervention. Questions remain about the influence of these researchers on the participants and how numbers in non-operative control groups came to languish. In the latest Swedish obesity study, conventional treatment ranged from advanced lifestyle interventions including behaviour modification to no treatment at all (Sjöström et al, 2007). Both the Monash studies had short term follow-up and when meta-analysis is limited to studies of two years or less of follow-up, this clearly limits the quality of the evidence (Buchwald et al, 2004).

WLS research abounds but its calibre is questionable. Consequently, rigorous commentary constitutes an important function in relation to publication of research about radical treatments. Reviews and studies require stringent peer review. When Padwal (2008), for example, reviewed Australasian research he showed a clear bias in favour of surgical interventions for obesity. In suggesting surgery for teenagers with diabetes, Padwal failed to consider that diabetes recurs in 50% of surgery patients. This statistic alone should have alerted Padwal to take a more conservative position for young patients: For instance, achievable exercise programmes might have proved the much superior intervention without initiating young patients into a career of yoyo weight loss and regain, noted even in the longer-term Swedish obesity studies (Sjöström et al, 2007). Such weight regain following gastric bypass may well lie in the contradictory finding around glucose tolerance (Roslin, 2009): Rather than curing diabetes, many patients who undergo gastric bypass surgery begin to exhibit abnormal glucose tolerance.

Renewed concerns are emerging about the connection between thinning bones and WLS. A Mayo clinic study has demonstrated that WLS participants were twice as likely as other Minnesotan residents to suffer at least one fracture in years following

Decreased hip-bone density is related to the amount of weight lost through WLS (Fleischer et al, 2008). These are problematic findings particularly when these technologies are sold to teenagers who are still developing bone mass and to older patients who may be at risk of hip-bone fracture. A loss of 10 per cent density in hip- bone in the year following WLS is a significant loss with long-term effects for morbidity and mortality. While there is some novelty in these findings, clearly this is not news. Metabolic bone disease is “a well-documented long-term complication of obesity surgery” (Goldner, O’Dorisio, Dillon & Mason, 2002, p.685) and this raises questions about whether patients are routinely told about these effects before they choose WLS. As well, a number of studies have tied cardiovascular and other health effects to weight loss (Berg, 1999; Cogan, 1999; Miller, 1999; Stunkard, 1958; Wadden, 1993). Patently, WLS remains an experimental treatment:

The number of patients who undergo Roux-en-Y gastric bypass (RYGB) and gastric banding (GB) surgeries has increased dramatically over the past decade, yet the long-term impact of these surgeries on body weight, co-morbidities, and nutritional status remains unclear, as do the mechanisms of weight regain (Shah, Simha & Garg, 2006, p.4223).

While the success of WLS has been widely proclaimed, I suggest that success requires efficacy and a lack of side effects. For instance, there is variable weight loss with significant weight regain for some patients (Livingston, 2005; Tessier & Eagon, 2008). The safety of WLS remains unclear particularly for younger and older patients (Barlow, 2004; Jan, Hong, July, Pereira & Patterson, 2005; Holtermana, Brownea & Holtermana, 2008). Nutritional problems following surgery are impacted by surgical decisions into, for example, the optimal length of the roux limb (Sanchez, Schneider & Mun, 2006). While particular surgeries may reduce some co-morbid disease in some patients for some period of time (He & Stubbs, 2004; Pories et al, 1995; Sjöström et al, 2004), this is not without significant iatrogenic side effects (Mizón et al, 2003; Livingston; Tessier & Eagon; Sanchez, Schneider & Mun).6 Questions of patient

6_{The very public WLS in February 1982 of a former leader of the Opposition and then Prime Minister}

of New Zealand is recorded in Working with David: Inside the Lange Cabinet (Bassett, 2008). For instance, Lange “would stare at a poached egg and have to make a decision as to whether he wanted the yolk or the white” (p.65); He experienced “ ‘dumping syndrome.’ Lange would break into sweats and would push his fingers into his eye sockets to gain relief” (p.66); Lange’s surgeon “used the term ‘failure’ when “his patient began to put on weight” within a year of the surgery; by the end of 1984, only two years out from this life changing surgery, Lange is described as “sicker than even his closest friends realized” (p.137) and almost six years later Lange’s health was said to be “hovering between good days and not so good. He was still prone to sweating a lot, […]dumping syndrome kept recurring […] his

preferences for different surgeries have not been resolved (Ternovits, Tichansky & Madan, 2005; Shayani, 2004). The need for patients to manage a very restricted diet over a lifetime may affect success (Livingston). Death may result from the surgery (Flum et al, 2005; Steinbrook, 2004; Tessier & Eagon), or following WLS surgery, WLS participants may experience “a substantial excess of deaths owing to suicide and coronary heart disease (Omalu et al, 2007). The long-term prognosis for patients who lose large amounts of weight and/or regain weight is unknown (Berg, 1999; Kassirer and Angell, 1998). For instance, a recent Finnish twin study showed that losing weight was associated with higher mortality for those who were otherwise healthy and moderately overweight (Sørensen, Rissanen, Korkeila, & Kaprio, 2005).

In questioning both the effectiveness of WLS and its safety into the future, McCullough (Mitka, 2003, p.1762) commented on the "[…] the classic problem in surgery - innovation without the research to guide it.” He called for WLS to be brought within experimental protocols, with informed consent based on advising the patient that the procedures are in trial format with unknown long-term outcomes. In all the concentration on whether or not WLS works, the question that has too little purchase is whether WLS should be performed at all. At the very least, there needs to be a whole- of-life perspective in relation to WLS interventions:

I am concerned about the goals of surgeons and patients and their level of interest in what really goes on inside the body after alterations of the anatomy. I am concerned about the focus on the superficial and results from the first year with a lack of concern about how life will be affected when patients are 10 and 20 years older (Mason, 1999, p.3).

The medicalisation of weight has been associated with an expanding presence of advertising for bariatric surgery on the Internet (Salant & Santry, 2006) and television, often accompanied by celebrity endorsement (Mitka, 2003; Steinbrook, 2004). With the evidence of weight loss for some patients who qualified under the NIH guidelines for surgery (1991), there have more recently been calls to promote surgery for those who are overweight and obese7 rather than limiting surgery to the morbidly obese group; there are instances of deliberate weight gain by some patients to increase their chances of surgery (Smith, 2008). Thin may be preferred at any cost: WLS patients who have lost weight but incurred serious side effects have been unwilling to consider reversal

procedures (Gallagher, Sarr & Murr, 2005; Ravitch & Brolin, 1979). The conflation of health and appearance ushers in a culture of greater tolerance for experimental health interventions at both an individual and societal level. This is particularly an issue for women who are targeted by and attracted to thinned body projects, including radical WLS options,

3.4 Insalubrious weightfull women bodies. Eurocentric society over the last 100