5 ms·

The more recent generation of bari surgery approaches are more gentle than the first generation. That said, I agree, it’s not a free pass. Thing is, we have ab

The more recent generation of bari surgery approaches are more gentle than the first generation. That said, I agree, it’s not a free pass. Thing is, we have about half a century of consistent clinical findings saying, without exception, no diet-based approach shows long term weight reduction. The most successful have zero effects by 5-10 years out. Bari surgery is the first and only intervention we’ve had that has shown sustained weight loss over 10 years. I don’t mean to in any way understate its dangers or its difficulty. But from a medical standpoint, I have to raise a red flag when someone says “hey, instead of using the only treatment that’s ever been shown to have a sustained effect, you should use a variant of a treatment we’ve spent half a century proving doesn’t generally work.” The linked article phrased it as being for people for whom bari isn’t an option, but even the Lancet article proper - iirc, as I read it at the beginning of the week - phrased it as, “there aren’t enough bari surgeons to go around, so in the meantime...”

throwaway5752 9y ago
Thank you!
brooklyn_ashey 9y ago
Yes, the problem is (i am someone who was put on a VLCD of 800 calories a day- and didn't lose that much weight from it) that your body has a set metabolism that keeps slowing down as you lower calories over the years. I had no problem going on the vlcd besides fatigue. The reason is I was already only consuming 1200 calories a day. These diets don't work over the long haul. I realize my case isn't the most common, but they are now looking into microbiome therapy as a possible solution. This resetting of metabolism plagued the biggest losers from "the biggest loser" as well. I do hope more research is done, because in my case, following diets (and perhaps other medical factors like igg)slowed my metabolism to a ridiculous level. And I don't have diabetes or high blood pressure, luckily.
- nradov 9y ago
  The notion of a metabolic set point is mostly a myth. The actual changes in resting metabolic rate from mild caloric restriction are very small. Most people underestimate how many calories they consume unless they carefully weigh and log everything.
  - vevoo 9y ago
    My reading of the last 3 years of findings regarding changes in resting metabolic rate due to caloric restriction is that they could become big enough to explain the pattern of weight regain. Now, the specific quantification of the relationship between amount, lenght of caloric restriction and resting metabolic rate is, in my opinion, waiting for a trove of data we do not have yet.
  - brooklyn_ashey 9y ago
    well, my doc is head of bariatric surgery at nyu, so I'll pass on what you said. Btw, I do weigh and log everything.
    - buttcoinslol 9y ago
      "It is difficult to get a man to understand something when his salary depends upon his not understanding it" -Upton Sinclair Your surgeon's income depends on people getting bariatric surgery. You can add in exercise to increase total calories burned to support a larger food intake and still lose weight.
      - fao_ 9y ago
        > Your surgeon's income depends on people getting bariatric surgery. Surgeons are usually good at doing other surgeries as well...
      - arkades 9y ago
        (1) that’s not a meaningful support of any kind of argument. It’s borderline vacuous. (2) I’ve never heard a bari surgeon Not recommend lifestyle change. Most will ask you to do your best pre-op, to make the surgery as safe as possible. They will counsel you on the same post-op. Many have in-house dietitians to assist. (3) Your argument implies the following: Bari surgeons pretend and contend diet doesn’t work, to keep the supply of customers coming. Fact check: diet was failing for decades, and only the resultant epidemic made something as extreme as cutting out pieces of a non-diseased GI tract not entirely insane. Go read another hundred diet books of the week; proclaim their findings from the rooftops. I’m pretty sure the bari surgeons aren’t going to run out of willing customers.
derefr 9y ago
I wouldn’t conflate “only diet” with “only treatment.” Stimulant drugs are a treatment that works over the long term—just not one that’s particularly free of side-effects.
- IntronExon 9y ago
  —just not one that’s particularly free of side-effects. Especially for the target audience of chronically morbidly obese people with diabetes!
taneq 9y ago
> Thing is, we have about half a century of consistent clinical findings saying, without exception, no diet-based approach shows long term weight reduction. This baffles me, because these results are trivially disproved. It's not particularly rare for people to lose weight and keep it off long term by changing their diets. Are the studies poorly constructed or are they just being misinterpreted?
- aantix 9y ago
  But long-term, 10, 20 30 years out? I can't name a single friend who has successfully dieted short term that has kept it off long term.
  - taneq 9y ago
    Is 30 years a reasonable expectation? Does someone who loses weight in their 50s have to literally die of old age before you'd grant that they'd 'kept it off'?
    - aantix 9y ago
      Actually... Yes. Obesity related complication occurr with excess weight. So, if they were at their ideal weight at 50 yrs old and gained it back at 80 when they also incurred high blood pressure and diabetes, then they weren't successful. That's why it's difficult. Most can lose weight at some point in their lives. But the weight eventually comes back, along with the other complications.
      - wutbrodo 9y ago
        This seems like an odd way to split the data. Is it not the case that healthy-weight people sometimes gain weight in their old age? Your claim seems unfalsifiable: Whatever mechanism is at play that makes healthy-weight people gain weight later in life could also be at play for people who lost weight, and 30 years later regained it in their old age. To put it another way, it's a silly bar to use to say that weight-loss programs must move their adherents level of health wrt weight past those of normal slim people, and that any weight gain from a former dieter is proof of a diet's failure of efficacy (while any weight gain from a formerly-healthy-weight, non-dieter is just happenstance). It's tough to look at just the existing data to tease this out, but if you need to resort to a bar as absurdly stringent as that to make your point, I'm afraid it's not a very convincing one.
nradov 9y ago
There are obviously some exceptions. I've met people who have maintained long term weight loss purely through lifestyle changes. There may not be many but they certainly exist.
epmaybe 9y ago
There are also some interesting ideas in the interventional field regarding minimally invasive embolization of the left gastric artery to reduce hunger via inhibition of ghrelin production.
- arkades 9y ago
  I hadn’t heard about that. But jfc, even with collateral circulation, I can only imagine the number of perfs you’d see! I mean, h. Pylori already destroys local microvasc - embolism the LGA and you’re begging for some tragic endings. Or such is my arm chair hypothesis, at least.
siddharthdeswal 9y ago
Studies will also show that inducing and keeping them in coma is one of the foolproof ways to ensure a person never tells another lie over a period of 10 or 20 or 30 years. Controlling or having a low calorie diet isn't a medical treatment [1], it's simply a choice an individual (in most cases) makes. They choose to not continue with the original choice after some time, so to club diet-control under 'medical treatment', and say that it doesn't work, is incorrect. [1] https://www.wisconsin.edu/workers-compensation/coordinators/osha-record/medical-treatment/ https://www.wisconsin.edu/workers-compensation/coordinators/... Edit, grammar.
Parcissons 9y ago
Its a protestantic thing. If you have sinned, as in you couldnt keep your behaviour under controll- you must suffer and punish for your sin and repent. Its the same thing that creeps into every drug discussion. Its one of those caddisfly larva conglomerates, where people glue lots of pseudo science onto theire "feel-good" opinions instead of really trying to solve the issue with realistic solutions. You could sell the realistic solution to these individuals by telling how much the "sinners" suffer after the operation and how heartily they regret taking the left hand path.
woodandsteel 9y ago
>Thing is, we have about half a century of consistent clinical findings saying, without exception, no diet-based approach shows long term weight reduction. The most successful have zero effects by 5-10 years out. Does "diet" mean counting calories and eating less than you want to eat? I ask because another approach, as in Susan Robinson's book The I Diet, is to eat as much as you want but just make sure it is foods that are moderately low in calories. In particular, avoid refined carbohydrates, potatoes, and fatty foods. I have been following this approach for 5 years. I lost 50 pounds, I have no will power when it comes to food, but the pounds have stayed off.
- woodandsteel 9y ago
  I forgot, another principle is lots of fiber.
- GeekyBear 9y ago
  I have also lost a large amount of weight and kept it off for over a decade by changing what I eat. In my case, I cut out refined carbohydrates (white rice, white bread, pasta, potatoes, etc.) and sugar (sweetened beverages, desserts). I still eat plenty of carbs that come with a large dose of fiber, such as oatmeal, peas, and beans. At the same time, I increased my intake of animal fats and dairy.

throwaway5752 9y ago

Thank you!

brooklyn_ashey 9y ago

Yes, the problem is (i am someone who was put on a VLCD of 800 calories a day- and didn't lose that much weight from it) that your body has a set metabolism that keeps slowing down as you lower calories over the years. I had no problem going on the vlcd besides fatigue. The reason is I was already only consuming 1200 calories a day. These diets don't work over the long haul. I realize my case isn't the most common, but they are now looking into microbiome therapy as a possible solution. This resetting of metabolism plagued the biggest losers from "the biggest loser" as well. I do hope more research is done, because in my case, following diets (and perhaps other medical factors like igg)slowed my metabolism to a ridiculous level. And I don't have diabetes or high blood pressure, luckily.

nradov 9y ago
The notion of a metabolic set point is mostly a myth. The actual changes in resting metabolic rate from mild caloric restriction are very small. Most people underestimate how many calories they consume unless they carefully weigh and log everything.
- vevoo 9y ago
  My reading of the last 3 years of findings regarding changes in resting metabolic rate due to caloric restriction is that they could become big enough to explain the pattern of weight regain. Now, the specific quantification of the relationship between amount, lenght of caloric restriction and resting metabolic rate is, in my opinion, waiting for a trove of data we do not have yet.
- brooklyn_ashey 9y ago
  well, my doc is head of bariatric surgery at nyu, so I'll pass on what you said. Btw, I do weigh and log everything.
  - buttcoinslol 9y ago
    "It is difficult to get a man to understand something when his salary depends upon his not understanding it" -Upton Sinclair Your surgeon's income depends on people getting bariatric surgery. You can add in exercise to increase total calories burned to support a larger food intake and still lose weight.
    - fao_ 9y ago
      > Your surgeon's income depends on people getting bariatric surgery. Surgeons are usually good at doing other surgeries as well...
    - arkades 9y ago
      (1) that’s not a meaningful support of any kind of argument. It’s borderline vacuous. (2) I’ve never heard a bari surgeon Not recommend lifestyle change. Most will ask you to do your best pre-op, to make the surgery as safe as possible. They will counsel you on the same post-op. Many have in-house dietitians to assist. (3) Your argument implies the following: Bari surgeons pretend and contend diet doesn’t work, to keep the supply of customers coming. Fact check: diet was failing for decades, and only the resultant epidemic made something as extreme as cutting out pieces of a non-diseased GI tract not entirely insane. Go read another hundred diet books of the week; proclaim their findings from the rooftops. I’m pretty sure the bari surgeons aren’t going to run out of willing customers.

derefr 9y ago

I wouldn’t conflate “only diet” with “only treatment.” Stimulant drugs are a treatment that works over the long term—just not one that’s particularly free of side-effects.

IntronExon 9y ago
—just not one that’s particularly free of side-effects. Especially for the target audience of chronically morbidly obese people with diabetes!

taneq 9y ago

> Thing is, we have about half a century of consistent clinical findings saying, without exception, no diet-based approach shows long term weight reduction. This baffles me, because these results are trivially disproved. It's not particularly rare for people to lose weight and keep it off long term by changing their diets. Are the studies poorly constructed or are they just being misinterpreted?

aantix 9y ago
But long-term, 10, 20 30 years out? I can't name a single friend who has successfully dieted short term that has kept it off long term.
- taneq 9y ago
  Is 30 years a reasonable expectation? Does someone who loses weight in their 50s have to literally die of old age before you'd grant that they'd 'kept it off'?
  - aantix 9y ago
    Actually... Yes. Obesity related complication occurr with excess weight. So, if they were at their ideal weight at 50 yrs old and gained it back at 80 when they also incurred high blood pressure and diabetes, then they weren't successful. That's why it's difficult. Most can lose weight at some point in their lives. But the weight eventually comes back, along with the other complications.
    - wutbrodo 9y ago
      This seems like an odd way to split the data. Is it not the case that healthy-weight people sometimes gain weight in their old age? Your claim seems unfalsifiable: Whatever mechanism is at play that makes healthy-weight people gain weight later in life could also be at play for people who lost weight, and 30 years later regained it in their old age. To put it another way, it's a silly bar to use to say that weight-loss programs must move their adherents level of health wrt weight past those of normal slim people, and that any weight gain from a former dieter is proof of a diet's failure of efficacy (while any weight gain from a formerly-healthy-weight, non-dieter is just happenstance). It's tough to look at just the existing data to tease this out, but if you need to resort to a bar as absurdly stringent as that to make your point, I'm afraid it's not a very convincing one.

nradov 9y ago

There are obviously some exceptions. I've met people who have maintained long term weight loss purely through lifestyle changes. There may not be many but they certainly exist.

epmaybe 9y ago

There are also some interesting ideas in the interventional field regarding minimally invasive embolization of the left gastric artery to reduce hunger via inhibition of ghrelin production.

arkades 9y ago
I hadn’t heard about that. But jfc, even with collateral circulation, I can only imagine the number of perfs you’d see! I mean, h. Pylori already destroys local microvasc - embolism the LGA and you’re begging for some tragic endings. Or such is my arm chair hypothesis, at least.

siddharthdeswal 9y ago

Studies will also show that inducing and keeping them in coma is one of the foolproof ways to ensure a person never tells another lie over a period of 10 or 20 or 30 years. Controlling or having a low calorie diet isn't a medical treatment [1], it's simply a choice an individual (in most cases) makes. They choose to not continue with the original choice after some time, so to club diet-control under 'medical treatment', and say that it doesn't work, is incorrect. [1] https://www.wisconsin.edu/workers-compensation/coordinators/osha-record/medical-treatment/ https://www.wisconsin.edu/workers-compensation/coordinators/... Edit, grammar.

Parcissons 9y ago

Its a protestantic thing. If you have sinned, as in you couldnt keep your behaviour under controll- you must suffer and punish for your sin and repent. Its the same thing that creeps into every drug discussion. Its one of those caddisfly larva conglomerates, where people glue lots of pseudo science onto theire "feel-good" opinions instead of really trying to solve the issue with realistic solutions. You could sell the realistic solution to these individuals by telling how much the "sinners" suffer after the operation and how heartily they regret taking the left hand path.

woodandsteel 9y ago

>Thing is, we have about half a century of consistent clinical findings saying, without exception, no diet-based approach shows long term weight reduction. The most successful have zero effects by 5-10 years out. Does "diet" mean counting calories and eating less than you want to eat? I ask because another approach, as in Susan Robinson's book The I Diet, is to eat as much as you want but just make sure it is foods that are moderately low in calories. In particular, avoid refined carbohydrates, potatoes, and fatty foods. I have been following this approach for 5 years. I lost 50 pounds, I have no will power when it comes to food, but the pounds have stayed off.

woodandsteel 9y ago
I forgot, another principle is lots of fiber.
GeekyBear 9y ago
I have also lost a large amount of weight and kept it off for over a decade by changing what I eat. In my case, I cut out refined carbohydrates (white rice, white bread, pasta, potatoes, etc.) and sugar (sweetened beverages, desserts). I still eat plenty of carbs that come with a large dose of fiber, such as oatmeal, peas, and beans. At the same time, I increased my intake of animal fats and dairy.