Thursday, December 23, 2010

Nice synopsis of the limits of Sleeve

Just doing some reading of back issue links, and I think this article gives a good insight into the "art" of surgery and medicine that we physicians have to deal with when the data is not sufficient to give all answers.

I agree with the author though - the sleeve is a reasonable balance of risk vs benefit for a large number of patients, but they should each understand that there is a chance that it may require future revision. "Failure" of the operation does not mean that the patient, surgeon or the operation deserves any "blame" however. Unfortunately, it is usually the poor patient who blames him or herself - often unfairly.

No perfect operations, including sleeve!

Monday, December 20, 2010

"SLIMBRICATION" - Dr Dan Cottam Salt Lake City

Wow - what a great visit on Friday to see Dr Dan Cottam perform a laparoscopic gastric imbrication. This is a very exciting newer procedure that is probably the least invasive intervention yet. It will be some time before we have good medium and long term data though.

In the meantime, expect to see it offered in people who have a failed Lap Band, or who are reluctant to have the Gastric Bypass or Sleeve procedures.

Here is his great video - likely soon he will be performing a combination sleeve and imbrication - Slimbrication!

"> v

and here is the link to his YouTube Channel

I have also started a WMedlinMD YouTube Channel, though it currently has instructional lectures, not an updated information session. My old information session from 2007 is linked on the right side of this page, and here. Since it was on Google Video, I havent' figured out how to put it on YouTube yet...








Doing some Canadian reading

I have been getting acquainted with Vancouver a bit over the last year. I have avoided making too many direct contacts for fear of the lack of control of my billing as an employee surgeon. Now that I am independent, we can set some reasonable prices for consultation and Lap Band fills, followup for Out-of-Country patients, etc (planning to offer Vertical Sleeve Gastrectomy and Gastric Imbrication for competitive prices)

Anyhow, I found Dr Yoni Freedhoff's blog through CTV... havent' contacted him yet, but he is absolutely on base regarding the loss of access to care for Ontario residents!

Shout out to my friends in Thunder Bay!

False savings in access-restricting "cost containment" measures by Ontario


Monday, December 06, 2010

Sunday, November 21, 2010

Next Information Seminar Tues Nov 30, 6:00 PM

Same address - Health Education Center 3333 Squalicum Parkway, Bellingham

Our NEW OFFICE PHONE is working, and appointments being taken
(if you need to be seen before Dec 9, call PeaceHealth Cordata 738-2200)

Here is a link to a Bloomberg story about Diabetes in India

Video Link India Diabetes

I have only watched it once.. didn't hear all the audio.
Note that the surgeon interviewed is listed as a "Metabolic Surgeon"!

Thursday, October 21, 2010

Welcome to Pacific Diabetes and Weight Loss Surgery!

We are getting this address turned into a real website in the coming weeks. Look forward to seeing you at our first information seminar on Tuesday October 26 - at the St Luke's Health Education Center at 3333 Squalicum Parkway in Bellingham, Wa (just a block west of PeaceHealth St Joseph Medical Center).

We will be doing at least two information sessions per month once we get the practice officially started on December 10th, so don't worry if you miss this first one - there will be more opportunities!

Our new contact and office location will be published in future newspaper ads (and here online), but until December 9th, I am still seeing patients at PeaceHealth Cordata General Surgery clinic - at 4545 Cordata Parkway - 360-738-2200.

Side note - I am getting a "comment" message from a postoperative patient who wants to see me, but don't have an email address to reply to - please call office, or email - thanks!

Our online ad is in rotation this week at

Saturday, October 16, 2010

More on medical weight management

This make some sense - much of what we do in behavioral counselling doesn't require a medical degree.

That doesn't mean you don't need a doc for your health, though!

TOPS article

Telephone counselling effective

Sunday, October 10, 2010

Genetics and Obesity

Get ready for a lot more information like this in the next few years! True understanding is going to take decades to develop, though, and the complexity means that there will likely never be a single "magic pill"... Different people have different vulnerability (and different environments) - as well as different health effects from the same "disease"

Multicenter Genetic Study

Friday, October 08, 2010

Arthritis and Obesity - impact on productivity?

This is not surprising, but I don't see some employers recognizing the link, or the very significant impact on their most experienced workers. "Blue collar" industries are actually pretty far ahead on this issue, because they have experience with so many other work fitness issues (my best experience was a tour and interaction with the Bath Iron Works shipbuilding facility in Maine...)

Arthritis article

Wednesday, September 22, 2010






Friday, September 17, 2010

Irony from Ontario

Diabetes risks for pregnancy, baby in Ontario

The blind eye of policy as it relates to evidence. The quote at the end is just priceless - a glib pronouncement about prioritizing Diabetes prevention and treatment (as related to a very expensive study) in the same year that Ontario slashes the access of its patients to out of country care.

The real message is that millions are available to study and publish, but don't actually treat the greater population. Sorry for our Ontario peers - you are victims, but not alone in the world of policy hypocrisy.

Just to clarify - we need research, it just needs to translate into rational care. At some point, "we need more information" becomes a delaying tactic at the Governmental Level...

When your Minister of Health takes action based on evidence of Diabetes remission (hint hint) - I will eagerly highlight that here, too!

Saturday, September 11, 2010

Canadian Diabetes Summit Article

Average 5 year wait for surgery

This is only counting patients in the queue, of course!

Estimates quoted here of major cost savings for treating diabetes with surgery in appropriate patients, also.

Wednesday, September 01, 2010

Not a good day for the Drug Industry (and later update)

Increase in nonfatal heart attacks and stroke with Meridia - and NO change in survival

Contrast with proven survival benefits with surgery - see previous posts and Vancouver Sun article for Diabetes remission (Archives of Surgery source)

UPDATE late October - (now that Meridia is withdrawn from the market)

Qnexa FDA rejection (2 drugs in one week - not much left in "pipeline"

Here's a quote from the end... of the article

"If there isn't any kind of path forward for this drug I think it is going to shut down all obesity drug development for a decade," said Dr. Tim Garvey of the University of Alabama. Garvey conducted two clinical trials of Qnexa and has consulted for Vivus.
"Why would a company put all that investment into developing a drug if the FDA signals they aren't willing to approve it," he said.
With U.S. obesity rates nearing 35 percent among adults, doctors and public health officials say new weight-loss therapies are desperately needed. And even a modestly effective drug could have blockbuster potential.
But the search for a drug that helps patients safely shed pounds has been largely unsuccessful. Two weeks ago Abbott Laboratories withdrew its pill Meridia from U.S. and Canadian markets after regulators said it increased the risk of heart attack and stroke.

The answer is that Phen-Fen had 18 MILLION prescriptions, and made a lot of people money, even if there was ultimately more harm than good out of it... The drug companies will keep trying, as they should, but there is no "silver bullet" - even surgery is not a cure, but a tool.

Saturday, August 14, 2010

Sunday, August 08, 2010

Evidence at Endocrinology conference - Gastric Bypass Superior

Bariatric Surgery in Diabetic Adults Improves Insulin Sensitivity Better Than Diet, Study Finds

And yet the last paragraph (see link) Dr Korner appears to have an attitude of "well, we will research this" rather that "we need to get THIS tool to the sick people who need it" Maybe I am overly sensitive, likely her statements are very selectively edited (ie., maybe it is the reporter's bias), but where is the call to action for the excellent tool we already have?

Are researchers only interested in supporting the pharmaceutical industry? I honestly don't think so, but you would be hard pressed to show evidence otherwise from this article.

If your endocrinologist, dietitian, insurer, or employer want to ignore evidence, you need to get this article to them by registered mail!

Friday, August 06, 2010

More articles on epigenetics, life expectancy

Intrauterine environment important for later obesity risk

One of many studies showing that it's not just the DNA, but the womb that are important factors in predisposition to obesity.

(and another annoying "headless" photo - dehumanizing heavy people, and making the excuse of privacy)

Below are articles to bring to your HR director at work (especially the last one - shows them they are not just losing money having increased health costs...) Many seem to ignore the fact that newly treated WLS patients are often the most enthusiastic, loyal employees! Also, those who are the sickest are least likely to change jobs, due to worry about any new job not covering pre-existing conditions. Companies need to invest in treating this disease - but they need to be educated, and offered organized programs. To their credit, some insurers are actually working on this (I will deny saying most nice things about insurers, but they are not all bad)

Increasing Loss of Life to Obesity

Obese Employees Take More Sick Leave

Finally, I had a very nice visit tonight with a support group at Virginia Mason, and last night with the group here in Bellingham. Both groups are super impressive - both with good listening leaders, and great sharing, discussions, and real SUPPORT! I certainly felt supported as a patient - thanks!

Wednesday, August 04, 2010

More evidence on individual vulnerability to obesity

link to report on Science Daily

Tell your skinny friends - we're not all wired the same! This doesn't mean we can stop worrying about lifestyle, food choices, etc - but hopefully will keep people from completely blaming themselves... (see at least 5 posts below for the theme of "taking responsibility without shame/blame"!!!)

Wednesday, June 30, 2010

SIMPLE Timer tools for Eating, Separating Fluids from Solid

I saw a great timer/ eating utensil set at ASMBS meeting last week - I think they are very useful looking, and sure to get even more refined. I look forward to getting feedback from users.

I haven't had too much problem eating too fast, but know that is a long term issue for patients. Actually, I think many eat so fast in 10 minutes that they can't finish a reasonable amount of food, then get "hungry" an hour later (or spend 20 minutes washing down food with immediate liquids) , then next thing you know, they are "grazers"!!!

This tool for the Treo/Palm platform helped me watch time go by over a 30 minute timer for meals. Kept me pacing my bites, then a followup 45 minute clock reminded me when I could drink after my last bite.

It is very easy to set up all sorts of custom timers - and tickles me that it is borrowed from the meditation world! This is mindfulness! Seriously, though, I do try to meditate, but exercise seems to be my main meditation.

Found a similarly reviewed product for those with an iPhone or iPod Touch - looks to be just as good. I can honestly say this type of tool may save people a lot of painful drift away from healthy habits.

Here are some comments on it

Finally - FOOD LOG, and EXERCISE LOG are critical for me - but I have NO fancy, or even basic software.... Just make an entry every day in my Calendar (on Palm, but will migrate to Google Calendar when get new smart phone..) and put my meal time and a basic description under the "note" attached to the "food Log" event. Super Easy, Super Fast - but totally on the record!

With exercise, I just enter it directly on the Calendar as an event - "Run 30*** Northshore Trail, Lift C/S/T (my abbreviation for Chest/Shoulder/Triceps)*** 6 sets, 15 minutes Weight ___ @ gym

I only put down my weight a couple times a week, but do get on the scale every day. My other "Lifts" are B/B for Back/Bicep, and L/A for Legs/Abdominals. For me, a three way breakdown keeps the lifting brief enough that I get it done in 15-30 minutes, so have very little excuse not to get it in at least 3 times per week. If I try to do it all at once, it gets overwhelming. That's where everyone has to figure out what works for their life and personality.

Keep it simple, but don't try to live totally unstructured!!! We all need SELF support first and foremost.

Monday, June 28, 2010

Infertility, Cardiac risks

Just a quick couple of links to come back to later - want to spend some time on the maternal issue from Quebec data showing improved obesity rates in children born after mom had Bariatric Surgery (duodenal switch in that clinic)

We just had a great lecture two weeks ago from a Seattle OB/Gyn whose clinic has stopped doing IVF in any patient over BMI 50 - looks like those in the article below have even tighter criteria.

In vitro fertilization failure rates in obese moms

Also, this issue is in the news today after a major Diabetes Conference just ended. 100,000 extra heart attacks, failure, strokes, deaths possible with this single drug - wow! It is very commonly used. I don't think we have enough respect for how complex the systems are that we manipulate. Surgery is certain to have risks, but they are not usually so insidious.

Avandia bad outcomes for 100,000 - Event rate more than 1 in 60?

Thursday, May 27, 2010

Obesity Action Coalition - new campaign

I just got a paper copy of the magazine yesterday.

Your Weight Matters website

Not sure if it is replacing their regular magazine, or a separate publication, but it is very well written, and I think the campaign is admirable! We have to be empowered as a group, and this is how it happens!

There is a great article about Minorities - covering cultural and genetic issues. The Airline seat policy controversy is thoroughly addressed, and there are other great articles on advocacy, preop anxiety, and postop nutrition and mobility challenges.

I really commend OAC for taking on the controversies of Fattertainment and Childhood obesity also. Bigotry survives in our society by hiding in the shadows - those who struggled against all sorts of discrimination in decades and centuries past are very strong shoulders to stand on, but they have also shown that it requires real courage and active work!

Data doesn't lie, but it can fail to tell the whole story

article about HealthGrades Bariatric report (includes link to report)

These ratings are based on "expected" outcomes, but I can tell you from experience that the heroic Docs who run our University and major referral hospitals are taking care of unmeasurable levels of complexity in some patients. That does not make them automatically the best, but it is worth taking into consideration BEYOND the data.

My own personal care will not be chosen simply on the "star system", but I think these databases will continue to be more useful every year.

Excellent Blog Article from SCOAP

Return on Investment for Quality

This is really worth reading.
See previous post - SCOAP puts Washington State at the forefront of collaborative quality improvement.

Wednesday, May 26, 2010

Medications have risks, too

Liver Damage in 13 patients with Xenical/Alli

CBS link

This may or may not be the end of this story. We will only have to trust the FDA - Fen/Phen took a few years to have its major risks identified. 36 million people may have had prescriptions, but probably not 1 in 100 are taking it long term. How different would the data look if it ends up with 130, or even 1300 people injured out of 500,000 taking it more than a year? The benefit of taking this drug is not demonstrated to extend life expectancy (no non-surgical method has). What is the risk/benefit calculation if there is only minimal benefit???

I am not terribly worried about this drug, but the "next" med that actually has as much effect as Fen-Phen. Any new really effective med will sell like hotcakes (and be prescribed liberally). Any drug maker is in a huge rush to get to market for the BILLIIONS of dollars they will make with a winner. Just be careful with new things, whether operations or meds.

The sleeve gastrectomy only has a few large groups published more than 5 years out, but has been performed for more than 10 years... We have a lot to learn about exact techniques and effectiveness and patient selection, but the long-term issues seem to be limited to Reflux.

Thursday, May 06, 2010

Racism in BMI criteria?- need for new research to be reflected in Access to Care

92 million Diabetics in China

Here is the abstract of the New England Journal article

and even more than that on the borderline (148 million) note that the BMI's are much lower than the 1991 NIH criteria - see Dr Rubino videos below

This uncomfortable question is getting around the surgical community - if there is disease despite lower BMI, does using BMI as an exclusion for coverage constitute racism on the part of of providers and insurers? The NIH criteria were set in 1991 as expert opinion, which should/could be updated now with data from actual additional research (as loudly called for by many on that original panel!)

Washington State should be very proud

Tuesday I was able to attend the annual retreat for hospitals and medical centers involved in a massive coordinated safety and effectiveness group known as SCOAP (Surgical Care and Outcomes Assessment Program).

SCOAP homepage

Surgeons and anesthesiologists have been at the forefront of most major advances in systematic care improvement, from the residency training model, to hospital standards, to outcomes/evidence based care. Dr. David Flum is the brilliant leader of this, but I was just as impressed at the commitment of docs from around the state (from tiny critical access hospitals, to military hospitals, to huge University and regional medical centers) to take the time and contribute in so many ways to make the care of our fellow citizens better every day. It is measurable, and they have the data to prove it! These powerful cooperative tools require a lot from those who already give 110%. I am honored to know them, and hope that my hospital can participate soon.

The famous Atul Gawande MD, MPH was there as the keynote speaker (along with the Washington State Patient Safety Conference group), and gave a great lecture about Checklists in quality care. He stressed that the goal is quality, and the tools should not be confused with the mission. His articles are always insightful, and well written.

My former residency chairman Anthony Senagore MD MS MBA gave an invited lecture about recovery from colon surgery (Enhanced recovery protocol), and a great deal of new research is just starting to be applied - getting people back on their feet quicker, and avoiding costly and dangerous problems during the healing process. Thanks also to Dr Patch Dellinger for making the data on Surgical Site Infection more understandable.

Thanks also to Governor Chris Gregoire for the video greeting, and for funding the Governor's Life Science Discovery Fund that helps support all this.

Diabetes and Vascular disease

It's well known that most death from clinically severe ("morbid") obesity and from diabetes is related to heart and vascular disease - but this is a hint at HOW they are linked beyond just cholesterol and inflammation.

Your arteries may be suffering insulin resistance, too

ScienceDaily (May 4, 2010) — In people with insulin resistance or full-blown diabetes, an inability to keep blood sugar levels under control isn't the only problem by far. A new report in the May issue of Cell Metabolism, a Cell Press publication, shows that our arteries suffer the effects of insulin resistance, too, just for entirely different reasons.

Wednesday, April 28, 2010

Canadian impressions

I have been attending the monthly lectures at University of British Columbia - and got a chance to talk today with a few key players today in Vancouver. There is strong advocacy for Diabetes and Obesity issues there. Many thanks for the time!

One great piece of info is this: (unfortunately it is likely too late for me to try to get there)

McGill - First Canadian Summit on Surgery for Type II Diabetes

PDF of Diabetes Report

Metabolic Surgery Article Links (from Summit Website)

Dr Christou is the McGill surgeon who is part of the team behind the landmark Quebec study showing tremendous survival benefit with Bariatric Surgery in Quebec. Dr Rubino from Cornell (see other postings below) is co-chair.

Canadians enjoy 2.7 years more (and healthier) life than those in USA
ScienceDaily (2010-04-28) -- Compared to their neighbors south of the border, Canadians live longer, healthier lives. Research has found this disparity between the two countries, suggesting that America's lack of universal health care and lower levels of social and economic equality are to blame.

Some useful links specific for Canadians ----

UBC Department of Surgery

Victoria - Drs Amson and Tang I think this is the only active program doing all types of Bariatric Surgery - but haven't met them personally yet.

BC Association of Bariatric Advocates

Vancouver's Lap Band center (False Creek Surgery Center)

Canadian Center for Functional Medicine

Obesity Help's BC messageboard

Thursday, April 22, 2010

Dr Foote's 8 Rules to Success

This is copied from my palm pilot, so
format is rough, but good stuff!!!

1 daily 3 small meals, 1 high protein snack
2 Lowfat solid food, 60 gr protein/d
--- Limit fatty, sugary to 1-2 x/mo
3 Eat slow, chew chew chew (20/bite)
4 NO liquids 15 prior, 45 m after meal
5 Avoid liquid calories
--(incl soups, smoothies, protein drinks, alcohol)
6 Drink 64 oz noncaloric liquids/day
7 Listen to your body (stop B4 pain!)
8 Exercise every day - schedule!

Wednesday, April 21, 2010

Starting to work toward Bellingham pilot surgical program!

Good news! I am going to be doing more outreach and consultation. We are going to set up some information sessions, and talk to whatever group would like to have more information about Medical and Surgical weight management.

We already have a draft pathway for both medical and surgical approaches.

Also, the Washington State chapter for the American Society for Metabolic and Bariatric Surgery is formally getting under way. We have filed the preliminary application, and will be setting up a charter, etc in the next few months. There is a lot of work to be done for advocacy in Washington State, and I am excited to be part of it!

Since printing materials costs money, and we are just piloting, I am expanding the LINKS to explore to make this a good portal to exploring the world of weight management.

also, this is fairly big news from the ASMBS website...

TWO MAJOR INSURERS NOW COVER LAPAROSCOPIC SLEEVE GASTRECTOMY Aetna, United Healthcare Each Change Policy to Cover Newer Method of Bariatric Surgery

Sunday, April 18, 2010

Habits - find ones that work for you. This is a process, one that can be polished with support group attendance, and paying attention to your experience. I found MBSR (mindfulness based stress reduction) to be helpful to have perspective and stay in balance (or keep working toward it!)

link to Dr Kabat-Zinn's program

Duluth Clinic program (where I did training in 2006)

Priorities - we don't always get our way, but the only way to make any progress is to honestly put effort towards our goals. Be honest with your priorities. Examples for me are especially exercise and meal planning.

MEAL REPLACEMENTS were one of the tools from reinforced at the ASBP (American Society of Bariatric Physicians) meeting I just attended in Seattle. They really help with meal planning, and many people ask me what I use - here are some links:

They are not cheap, but much better price by the box.

Genisoy Bars These are very nice chocolate mint, and pretty chewy.

BALANCE BARS in chocolate chip, honey peanut, and sometimes the Balance Bare are favorites for me - they give good satiety, and are tasty without being "irresistable"

Zone Bars - some are stocked at Costco (usually 2 box sets with Fudge and Peanut Butter), but I like the mint ones best. Target and Fred Meyer stores stock them here in Bellingham.

EAS shakes are a good protein source, and great before the gym.

These are just some of the things I use as an example - it takes time to shop around and find what you won't mind using every day, but won't lose control over. There aren't a lot of foods that I can stock up on without abusing, but these don't seem to tempt me much. If you find a food that you can't keep away from, don't try to keep a stock!!!

I don't count every gram of protein, or every calorie, but it is nice to have a label to read, and to have a pre-limited amount.

Wednesday, April 14, 2010

Will we see more directed care toward patients in hospitals to help shorten future admissions (or prevent them altogether)?

A consultation for smoking cessation or alcohol treatment has been shown to be more effective when initiated during a related illness.



Quoting from above link...
Bennett says her study suggests that insurance companies "should be covering gastric bypass surgery in women of childbearing age because of the potential to reduce complications if we can reduce their weight before they become pregnant." Treating the obesity before pregnancy, she adds, also has the potential of saving a lot of money on treatment of complications in mothers, fetuses and newborns."


"Prior research has shown that rates of gestational diabetes (which also causes complications in pregnancy) decreases after bariatric surgery, and that weight loss can increase fertility in obese women."

Saturday, April 10, 2010

Diabetes Surgery in those with BMI<35
This is the future, especially for ethnic groups who have organ damage from diabetes long before their weight attains the 20 year old "expert opinion" based NIH guidelines (BMI>35). Get ready for some evidence!

I hope to have more info on Dr Rubino's work to pass along after the ASMBS meeting in June.

Thursday, April 01, 2010

Bacon or bagels? Higher fat at breakfast may be healthier than you think

ScienceDaily (2010-04-01) -- According to a new study mice fed a meal higher in fat after waking had normal metabolic profiles. In contrast, mice that ate a more carbohydrate-rich diet in the morning and consumed a high-fat meal at the end of the day saw increased weight gain, adiposity, glucose intolerance and other markers of the metabolic syndrome.

Link to article

Wednesday, March 31, 2010

Here is a great article about a leader in Obesity Medicine

I have been using this same "holding your breath" analogy for years in our information sessions.
(Probably got it from hearing him speak!)

Dr Louis Aronne article

Monday, February 15, 2010

Discrimination even for the famous - Director Kevin Smith

Give Southwest some credit for at least an apology. Many of the comments in the original post are somewhat more nuanced than I usually expect.

They say the worst crime an actress can commit in Hollywood is to gain weight!

Sorry about your issue, Kevin. I have had "the look" when getting on a plane - it's no fun feeling like you are putting others in discomfort, but it was nearly impossible to buy two seats ahead of time when I tried a couple of years ago.

I really appreciate it with my post-op body, being able to fly without that social anxiety.

Interesting that he has a second career as a Jay Leno segment star. Leno is a perfect example of making jokes about obesity that would get him FIRED if you substituted race, gender, or ethnic background.

Diseases with behavioral, environmental, and genetic components include alcoholism, heart disease, and emphysema - and there are a few jokes about Bill Clinton/McDonald's, Hollywood rehab, and Marlboro Man stuff, but not with quite the bite of contempt that we see with obesity.

Kevin is a very smart, strong person (witness especially his "Evening with Kevin Smith" DVD if you are a fan of his movies). Still, the acceptance of a disease is tough. I hope you can take responsibility for making healthy choices without the shame and self blame of unrealistic expectations.

Sunday, February 14, 2010

Bellingham, Washington has now been home since August, 2009. Many great things to put into future posts - the new web address WWW.BONUSLIFE.NET

New links to follow for Northwest networking, and to stay in touch with many friends and patients in Northern Minnesota, Wisconsin, and Ontario (hello Thunder Bay!)