Tripling weight loss surgeries would cut type 2 diabetes treatment bill

Up to two million people could be eligible, though it is not seen as a long-term solution for obesity

The number of obese people having weight loss surgery needs to double or triple in the UK so the soaring bill for treating type 2 diabetes can be cut, according to NHS advisory body Nice.

Up to two million people could be eligible for surgery, said Rachel Batterham, head of obesity and bariatric services at University College London Hospital NHS Trust who helped update guidance for the National Institute for Health and Care Excellence (Nice). Only 6,500 people a year had it in 2009/10.

Nice says bariatric surgery can greatly help type 2 diabetics. The most modern operations, the stomach bypass and the gastric sleeve, do more than reduce stomach capacity – “they alter how the body handles glucose”, said Batterham.

Of the 4,000 patients who had surgery because of type 2 diabetes, 65% were not on any diabetes medication within two years, she said. “If you look at the healthcare savings from drugs alone, the surgery pays for itself in two to three years.” That was without taking into account the savings from avoiding the severe side effects of the disease, which can include blindness, amputations, renal failure, heart attacks and stroke.

“The benefits are so great it really needs to be considered as part of their treatment pathway,” she said.

Nice does not back the routine use of very low calorie diets, often 400-800 calories. “The problem is that most people will lose weight but most people will also regain much of that weight that has been lost,” said Prof John Wilding, a diabetes consultant and obesity specialist from the University of Liverpool. We don’t see [diets] as a long-term solution for people with obesity. They could be used in people who need to lose weight quickly because they are going to have a knee replacement operation, for instance.”

One in 20 people have type 2 diabetes and the numbers are growing because of the obesity epidemic. The toll is high. “Every year 24,000 people die prematurely because of type 2 diabetes. There are 100 amputations every week in the NHS and these are all preventable,” said Batterham.

Wilding said the number of NHS operations could realistically rise to about 15,000 a year. There are currently serious delays in many parts of the UK, however, because obese patients need assessment and counselling over several months before embarking on surgery and many hospital trusts do not have the services in place.

The cost of each operation is about £6,000, which includes follow-up care. Nice says it is vital that people should be seen regularly because their diet and exercise habits need to change. But surgery will, over the long-term, reduce the annual £10m bill for care of diabetes and its complications, says Nice.

However Simon Stevens, the NHS England chief executive, has strongly backed efforts to prevent obesity and some experts agree with him.

But Prof Iain Broom, director of the centre for obesity research and education at Robert Gordon University in Aberdeen, said Nice had missed lots of evidence.

“The Nice guidance could send tens of thousands of Britons towards unnecessary surgery, with its known morbidity and mortality, and costing taxpayers many millions of pounds, when all that is required is a different dietary and lifestyle approach including the use of low carbohydrate diets and low calorie diets,” he said.

Nice says obese people (BMI of 35 or over) with recently diagnosed type 2 diabetes should be assessed for weight loss surgery. People of Asian family origin and those recently diagnosed with type 2 diabetes should be considered for an assessment even if their BMI is lower than 35.

• This article was amended on 27 November 2014. An earlier version lost a zero from a figure of 100 amputations mentioned in a quote.

By Sarah Boseley

Source: http://www.theguardian.com/society/2014/nov/27/obesity-weight-loss-surgery-type-2-diabetes-treatment-health

Lack of Cortisol characteristic for young obesity patients Plus Self Esteem Changes During Puberty Would Actually Increase Diurnal Cortisol Production

Cortisol is not your enemy. In fact, cortisol is one of the few hormones you really need to survive.

Cortisol is a problem. However, just as it is the case with insulin, its not the fact that your body produces it thats problematic. Its the fact that it tends to so in copious amounts and chronically, simply at the wrong time or - believe it or not - not at all / enough. All that, i.e. changes / problems with the natural rhythm, the up and down, the spikes and troughs that get lost, when you are chronically stressed and/or inflamed - thats the actual problem and not the fact that your body produces a hormone without which you cant survive.

You can learn more about cortisol at the SuppVersity

Kaatsu, cortisol, gains?

Roibos for relaxation

Leucine + cortisol = bad news

BB = max cortisol = max fat loss?

7-keto save and effective?

Cortisol reducing bites

Against that background, it may go against everything the supplement industry is trying to tell you, but still cannot be really surprising to hear that E. Allansson Kjölhede and colleagues from the Linköping and Ume a Universities present in their latest paper in Acta Pædiatrica results that show that obese children have low, not high cortisol levels (Kjölhede. 2014).

Using three salivary samples from 342 children aged 6–12 years the scientists had tried to reconcile previous, inconsistent findings and found that the

"average cortisol levels in early morning, late morning and evening were significantly lower in overweight and obese children than in their normal weight counterparts."

Whats particularly interesting is that the early morning spike, we have identified as critical component of a healthy biorhythm, previously (see "All About Cortisol"), was reduced by -33% (see Figure 1):

Figure 1: Morning (8:30 am), late morning (10:30 am) and evening (9:00pm or pre-bed, if earlier) salivary cortisol in 342 normal-weight, overweight and obese children (Kjölhede. 2014).

As Kjölheide et al. point out, these results should be followed up by more comprehensive studies that would allow us to better classify and understand the "relationship between stress and obesity in
children" - and I would like to add: Which of these comes first - being obese or having low morning cortisol and thus not being able to benefit from the "wake-up and get going" effects of cortisol.

This is not a statistical outlier: The results of the study at hand are not a statistically irrelevant outlier or something that would be observed in children, only. In 2013 Champaneri et al. a corresponding correlation between high early morning cortisol levels and lower body fatness and waist circumference, when they analyzed data from the 1,002 subjects of the Multiethnic Study of Atherosclerosis (Champaneri. 2013)

Thats also interesting, because previous studies by Toledo-Corral et al. have shown that a dampened cortisol awakening response is not just associated with obesity, it is also a predictive factor of higher carotid artery intima-media thickness (CIMT) in overweight African American and Latino youth (Toledo-Corral. 2013), which in turn is a risk factor for myocardial infarction and stroke.

And Ursache et al. (just because its funny: "Ursache" means "cause" in German ;-) report that  dolescents with insulin resistance exhibited

• a blunted cortisol awakening response (CAR),
• smaller hippocampal volumes, and 
• greater frontal lobe atrophy 

compared to controls. Closer scrutiny of the data also revealed that "a smaller CAR was associated with higher BMI which was in turn associated with fasting insulin levels" (Ursache. 2012).

Despite the fact that it is virtually impossible to tell what exactly the "ursache" for the irrefutable correlation between low morning cortisol levels and high body fatness, artery intima-media thickness, myocardial infarction and stroke is, the cumulative evidence clearly speaks against the use of cortisol-reducing drugs and supplements - at least if their effects are not extremely short-lived and will thus not mess with the natural up-and-down thats lost not just in obese, but also in chronically fatigued patients.

Bottom line: In view of the data presented above, people with low morning cortisol levels would thus be better advised to start their day with some "delicious" licorice - or better a capped extract - to benefit from its cortisol boosting effects, instead of "cortisol blockers".

Figure 2: Comparison of reduction in % body fat in response w/ licorice (blue, Tominaga. 2009) and no dietary restriction vs. 7-keto + dietary restriction (red, Zenk. 2002 - sponsored study).

Bullshit? Well, what about the side-effect free (no change in Hb1AC, improved not worsened blood pressure and pulse rate and in range serum electrolytes) reversal of fat gain Tominaga et al. observed in obese subjects who consumed a polyphenol-laden licorice extract (main ingredient glabradin) at dosages of 300mg and 1800mg per day for 12 weeks (Tominaga. 2006), then?

Or the significant decrease in body fat the same researchers observed in another study, three years later with 300, 600 and 800mg/day of a licorice flavonoid oil (see Figure 2)? Significantly more than in allegedly only 8 weeks on 7-keto, by the way; and that a despite the fact that the sponsored study on the DHEA-metabolize by Zheng et al. (2002) used a combined diet + supplementation protocol (see Figure 2).

Reference: 

• Champaneri, Shivam, et al. "Diurnal salivary cortisol is associated with body mass index and waist circumference: the Multiethnic Study of Atherosclerosis." Obesity 21.1 (2013): E56-E63.
• Toledo-Corral, Claudia M., et al. "Blunted nocturnal cortisol rise is associated with higher carotid artery intima-media thickness (CIMT) in overweight African American and Latino youth." Psychoneuroendocrinology 38.9 (2013): 1658-1667.
• Tominaga, Yuji, et al. "Licorice Flavonoid Oil Effects Body Weight Loss by Reduction of Body Fat Mass in Overweight." Journal of health science 52.6 (2006): 672-683.
• Tominaga, Yuji, et al. "Licorice flavonoid oil reduces total body fat and visceral fat in overweight subjects: A randomized, double-blind, placebo-controlled study." Obesity research & clinical practice 3.3 (2009): 169-178.
• Ursache, Alexandra, et al. "Preliminary evidence for obesity and elevations in fasting insulin mediating associations between cortisol awakening response and hippocampal volumes and frontal atrophy." Psychoneuroendocrinology 37.8 (2012): 1270-1276.
• Zenk, John L., et al. "The effect of 7-Keto Naturalean™ on weight loss: A randomized, double-blind, placebo-controlled trial." Current therapeutic research 63.4 (2002): 263-272.