After Bariatric Surgery - Patients' Perspectives

There is no doubt that bariatric surgery is a hot topic of research these days.  Most of this research focuses on the medical benefits that can be enjoyed after bariatric surgery, such as improvements in diabetes control, high blood pressure, sleep apnea, and so forth.  Much less qualitative research has been done - the kind of research that looks at things that are hard to measure with numbers, such as psychological effects and changes in quality of life. Most of the qualitative information that has been published is on small groups of individuals, and it is challenging for patients or clinicians to synthesize this smattering of data as a whole.

Coulman and colleagues recently collected information on this topic in the first systematic review of qualitative research in the bariatric surgery field.  Published in Obesity Reviews (and free to download!), they included 33 studies reporting on the patient perspective on living with the outcomes of bariatric surgery.

Three themes were identified:

1.  Control.  Patients reported making the decision to undergo bariatric surgery to gain control over eating, weight, and health.  In general, a feeling of improved control was experienced in the first year after surgery, but after a year, there was less of a sense of physical control (described as 'stomach control'), and it became more about relying on their own 'head control' to manage food intake.

2. Normality.  A sense of 'normality' was something that many patients were striving for after bariatric surgery - lives less burdened by physical and psychological ill health, ability to participate in normal everyday activities, and what patients described as a more 'socially acceptable' appearance.  While many people felt more 'normal' after surgery, there were also several issues identified that challenged patients' desire to feel 'normal'.  This included a change in their own or others' perceptions of their bodies, unpleasant gastrointestinal side effects (eg vomiting or diarrhoea), not being able to eat like others, and loose hanging skin.

3.  Ambivalence. Patients reported that while some things changed for the better, other changes were difficult to cope with or adapt to. This included physical pros (improvement in metabolic health) and cons (gastrointestinal and nutritional side effects of surgery).  This also included psychological pros (improvement in depression, self esteem, control) and cons (eg continued depression and self esteem issues with a realization by some that bariatric surgery was not going to fix these issues; challenges of finding ways other than food to cope with emotions; feeling a loss of protection from the outside world and a feeling of vulnerability with weight loss).

This review is a treasure trove of information, including quotes from patients, and is a great read in its entirety.   These findings highlight that while bariatric surgery is an excellent treatment strategy for some people, for others it may not be the best choice.  These findings certainly speak to the need for long term follow up for patients who have had bariatric surgery, including long term psychological and nutritional support.

As the authors write: Surgery was not the end of their journey with obesity, but rather the beginning of a new and sometimes challenging path.

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www.drsue.ca © 2017

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Is The Birth Control Pill Less Effective In Obesity?

The birth control pill is used by many women for prevention of pregnancy.  While generally very effective to prevent pregnancy if taken correctly, failure to prevent pregnancy can occur.

It has been noted in observational studies that women with obesity may have a higher risk of birth control pill failure, compared to women without obesity.  How could this be?

It turns out that the oral contraceptive has altered pharmacokinetics in obesity - meaning that the way the body handles the medication is a little bit different. Specifically, some research has suggested that the half life of the birth control pill is longer, meaning that it takes longer for the pill to reach therapeutic levels in women with obesity (ie at the beginning of the pack each month).

Strategies to minimize birth control pill failure in women with obesity have been suggested, such as taking the pill continuously, or using a higher dose than the low dose regimens that are commonly prescribed.   However, these strategies would have to be weighed against the potential for increased risks such as potential increased risk of blood clots with higher estrogen exposure.  One thing I feel we can conclude from this information is that taking the pill correctly (not starting a new pack late, not missing doses, and taking it within the required time frame each day) is especially important.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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New Cholesterol Medication Evolocumab Reduces Cardiovascular Events

In follow up to my recent blog post, we now have the detailed results from the FOURIER trial, demonstrating that the PCSK9 inhibitor evolocumab reduces cardiovascular events in patients with cardiovascular disease.

Published (and free to read online) in the New England Journal of Medicine March 17th, this large study randomized 27,564 patients to either evolocumab or placebo, to examine the impact on the primary endpoint of cardiovascular death, heart attack, stroke, hospitalization for unstable angina, or coronary revascularization.  Patients in the study already had existing cardiovascular disease, had a bad cholesterol (LDL) of 1.8 mmol/L or greater, and were all on statin therapy (the current gold standard group of lipid lowering medications).

After a median of 2.2 years, evolocumab reduced cardiovascular events by 15%, with 9.8% of patients on treatment having an event, vs 11.3% of patients on placebo. This difference was driven by a reduction in heart attack, stroke, and coronary revascularization, with no significant difference in cardiovascular death or hospitalization for unstable angina.

Evolocumab reduced LDL by 59%, from a median baseline value of 2.4 mmol/L to 0.78 mmol/L. The reduction in cardiovascular events was consistent, regardless of baseline LDL.  The only side effect that was significantly different between the evolocumab vs placebo groups was injection site reaction, seen in 2.1% vs 1.6% of patients respectively.

While these results give us important information regarding the benefit of evolocumab in patients with established cardiovascular disease, we still need data to know if these benefits would also be enjoyed by people with high cardiovascular risk but without established cardiovascular disease. We also need to know more about long term effects of PCSK9 inhibitors.  As noted in the accompanying editorial, it is not known whether prolonged exposure to extremely low LDL levels could affect neurocognitive function (though no difference was seen in the FOURIER study); longer term studies are underway.

The benefits of additional LDL lowering with evolocumab in addition to statins to reduce cardiovascular events in patients with established cardiovascular disease are clear from this study.  Cost of currently available PCSK9 inhibitors (evolocumab and alirocumab) are currently a major limitation to their use, but hopefully this will change with time as evidence regarding benefits hopefully accumulate.

Disclaimer: I have been involved as an investigator in a clinical trial of PCSK9 inhibition.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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Excess Weight Is Risk Factor for Developing Multiple Myeloma

We know that carrying excess weight is a risk factor for many types of cancer, including colon, breast, liver, kidney, and several others.  A new study suggests that in people who carry a risk factor for multiple myeloma called MGUS, having excess body weight increases the risk of developing multiple myeloma.

MGUS stands for Monoclonal Gammopathy of Undetermined Significance.  When people have MGUS, their bone marrow makes too much of one type of white blood cell, which makes this MGUS protein.  In most cases, MGUS does not lead to any problems, but in some cases, MGUS can progress to a cancer called multiple myeloma.

The study, published in the Journal of the National Cancer Institute, analyzed data on 7,878 patients from the US Veterans Affairs database (predominantly men), diagnosed with MGUS. Over a median of 5-6 years, they found that 4.6% of patients with overweight and 4.3% of patients with obesity went on to develop multiple myeloma, compared with only 3.5% of patients with normal weight.

In the multivariable analysis that controls for other factors, they found that patients with overweight and obesity with MGUS had a 55% and 98% higher risk of progression to multiple myeloma, respectively, than normal-weight patients with MGUS.

I have seen many online agencies reporting on this study leading with titles like 'Weight Loss May Help Prevent Multiple Myeloma'.  While this study does suggest that carrying excess weight increases the risk of multiple myeloma, this does not prove that weight loss decreases the risk.  Additional studies need to be done to understand whether healthy weight loss in people with MGUS helps to prevent progression to multiple myeloma.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2017

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