The Doctor Weighs In

By William Bestermann MD

Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions.

Many professionals in positions of leadership today were educated in the 60s, opposed the Vietnam War, and viewed military intelligence as an oxymoron. But my oldest son, a West Point graduate, has taught me lessons that have changed my life and are relevant to the major conundrum facing medical practice today.

West Point places a primary stress on technical adaptation.  These young cadets are taught “Tactics Lag Technology.”  That is to say if the officer applies tactics appropriate to the last war in the face of more deadly weaponry in the current war, he will likely be responsible for the deaths of hundreds if not thousands of his personal friends, team mates, and countrymen.  Military officers, in their movement upward in rank and responsibility, learn of our own new technical capabilities, those of potential enemies, and how to integrate these into best military practices to minimize casualties while increasing the likelihood of success of the mission.  This is a central focus in military culture.

First, a bit of military history

These cultural attributes of the modern American military officer did not just drop out of the sky.  West Point cadets study the American Civil War in some detail.  That conflict saw the beginning of dramatic technical change including railroads, rifles in large number, and trenches that transformed warfare forever.  Prior to the War Between the States, for thousands of years, generals managed the attacking force in the same way.  The defenders would line up over a broad front, in ranks perhaps two or three deep, over a couple of miles depending on the size of the force. The attacking force would assemble in front of them in full uniform with color guards and regimental bands playing marching music.  Then the attackers would march to within effective range of their weapons.  As the Civil War began, most units were armed with muskets and the effective range was 40 yards.   So the Union and Confederate units would march to within 40 yards, fire one volley or perhaps several followed by a bayonet charge.  The carnage was not terrible and the loser was the one who lost his nerve and abandoned the field.  

As the war progressed, both sides replaced muskets with rifles and the defenders dug trenches.  As the Confederates prepared for Pickett’s charge at Gettysburg, the Union troops were behind a stone wall defense and armed with rifles.  Nearly a mile of open field lay between the opposing forces.  The Southern Commander Robert E Lee had ordered the charge, but Corps Commander Longstreet objected, simply knowing by observing the situation that the mission was impossible.  General Lee ordered him to charge the Union force in spite of the objection and Pickett’s Division was cut to pieces in a matter of minutes.

The following spring, US Grant had assumed command of all Union armies.  He was determined to end the war by capturing Richmond and crossed the Rapahannock River to begin what became the Overland Campaign.  In battle after battle, the Union forces charged entrenched confederates, with the same resulting horror the Confederates suffered at Gettysburg.  General Grant suffered 60,000 casualties in the month of May 1864 alone.  The puzzle of the rifle and the trench never was solved in the Civil War.

Amazingly, when WWI started 50 years later, tactics had still changed very little, though the technology of war had changed dramatically.  The forces involved had tanks, airplanes, machine guns, repeating rifles, mortars, breech loading artillery, trenches, and barbed wire at their disposal.  The method of attack had not changed.  The frontal assault was still the order of the day.  The British suffered 60,000 casualties on the first day of the Somme offensive.  The generals still did not get the message and over the new few months 500,000 promising young men were shot down in that single campaign.  WWI ended and the puzzle of the repeating rifle, trench and machine gun was still not solved.

The wrath of the status quo

The terrible carnage of WWI broke the spirit of Europe and there are still residual cultural effects on that continent.  In the aftermath, the promising young American officers Dwight Eisenhower and George Patton wrote infantry journal articles describing a new kind of attack that would later be called “blitzkrieg” or lightning war.  In this assault, all of the heavy weapons of the attacking force would be combined in units actually making the assault.  All of the tanks, artillery, bombers, machine guns, mortars and mechanized infantry would be thrown at the weakest point in the enemy line. They would break through, and turn left and right to “roll up” the force in the trench.  History has shown this to be a brilliant disruptive innovation in warfare and frontal assaults no longer occur.

How did the senior army leadership respond?  The Chief of Infantry called Eisenhower in and told him that his articles did not represent sound infantry doctrine and that if he wrote any more articles of that nature he would be court-martialed.  Billy Mitchell actually was court-martialed for advocating similar valid innovative disruptions in the army air corps.  Thank goodness the innovations advocated by Eisenhower, Patton, and Mitchell were adopted and played a critical role in WWII.

The change from frontal attacks to the attack of supreme violence aimed at a point is a very dramatic example of paradigm change.  The whole dynamic of combat changed from a defense that could not be overcome to an attack that could not be resisted.  The officers directing the blitzkrieg assault were not more diligent, more industrious, smarter, brighter or more dedicated than their predecessors.  No, they were not superior in any way-they had simply used a new system, a new application that was more effective.

So what does all of this have to do with medicine?  

You might think “How could these people be so blind? We would never do such a thing.”

Think again!  The science around medical practice in the treatment of atherosclerotic vascular disease has utterly changed.  The evidence that demands a change in paradigm has become irrefutable.  The technology of vascular medicine has progressed at a pace fully equal to that seen in the military.  The old attack on vascular lesions in stable patients aimed at fixed narrowings – bypasses and stents – are as thoroughly discredited as frontal assaults in the face of machine fire. (More on this in another post.)

The Institute of Medicine is the medical arm of the National Academy of Sciences.  The IOM membership is composed of 1,400 of the best minds in medicine.  In its 2001 report, “Crossing the Quality Chasm,” the IOM summarized what was needed to treat chronic conditions:

“The current systems cannot do the job. Trying harder will not work.  Changing systems of care will.”

This document is the medical equivalent of the infantry journal articles written by Patton and Eisenhower.  It is a call to action and change, yet little in practice has changed since it was published in 2001.  Why?  The Chief of Infantry is alive and well.  Paradigm change has dramatic consequences and, for the leaders of the old order, the changes are negative.

The consequences of the utter failure of leadership in this case are exactly the same as a frontal assault: thousands of dead and disabled as a monument to our inaction.  Heart attack and stroke accounted for roughly 800,000 deaths in 2003. Many of these deaths were premature and avoidable. The bodies may not lie in heaps before a trench-line, but they mean the same thing: a failure to bring the full benefit of new technology to those we have promised to protect. 

There is a very real price to be paid for our failure to translate our new scientific knowledge about vascular disease into practice.  The Steno II trial compared optimal medical care (that is, drug therapy) in type 2 diabetes to usual care, and reduced the number of vascular events by half.  Only a small percentage of the study's patients had to be treated more aggressively to prevent a heart attack or a stroke.

The type 2 diabetic has a lifetime risk of dying from a vascular event of 65-80%.   Each risk factor - glucose, pressure, and cholesterol - treated to goal using the right medication reduces the risk of a vascular event by half.  Only 7% of type 2 diabetics have all three risk factors simultaneously to goal. 

Our failure to provide more aggressive risk factor management in these patients obviously is very damaging to their health.  The economic cost is equally painful.  Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions. In stable angina patients, optimal medical therapy was just as good in preventing a heart attack in a stable angina patient as optimal medical therapy plus a stent—for one third of the cost.

If current trends are any indication, medicine, the insurance industry and government will be slow to lead on transformation.  Patients and businesses that pay the bills must demand better or continue to receive medical care that is not what it could be.

Dr. Bestermann is medical director of the Vascular Medicine Center at the Holston Medical Group in Kingsport, Tennessee.

A reader takes issue with my positive presentation of VBLOC. Read on:

"Pat - I am surprised you would be advocating for VBLOC that is in the same category as bariatric surgery and does not "require any change in diet or exercise"! I personally believe that most chronic illnesses and conditions such as obesity are emotion-based - including my own, Crohn's - and that drug/technology interventions -are ineffective or short-lived solutions....of course I am not mainstream in this thinking...”

I think many of you who follow my TDWI posts know I am a strong advocate of diet and exercise. Sometimes, I feel like the diet and exercise nag. But I am also a pragmatist who recognizes that some people can't/won't/will never be successful in achieving a healthy weight with diet and exercise as their only options.”

There are alot of reasons why people fail good old fashioned lifestyle change. Some people have a physiologically stronger appetite drive than others and yes, some people with the thrifty genotype may be better at storing excess energy as fat. Some people preferentially store bad fat (aka visceral fat) and end up with the complications of cardiometabolic syndrome. And some folks have socioeconomic factors that make it harder to lose weight via life style changes alone - they live in unsafe neighborhoods, work long hours, and don't have easy access to healthy foods like fruits and veggies.

I think we make a mistake when we send a message that there is only one right way to lose weight; that is, eat less and exercise more. Yes, we should all do that if we can. But, medical and surgical approaches, including bariatric surgery are viable and valuable options for some people.

"Memoirs of a Fat Broad" by Wendy Hanawalt is a powerful story that opens your eyes to how hard it is to live with fat and its metabolic consequences. Wendy describes in detail what it is like to be really, really fat and she tells us how a doctor who suggested gastric by-pass saved her life. She was suffering so many complications of her obesity that she had contemplated suicide. That is not to say she didn't have problems after her surgery, she describes her life after her gastric by-pass surgery in a follow-up article to her Memoirs....nothing in life is completely free after all but compared to her life before, she says, post-by-pass and post-weight loss, the changes in her life are "miraculous."

So, diet, yes. Exercise, absolutely. But, if you can't get where you need to be without adding something more aggressive, I say keep your options open. Scientifically-proven medical adjuncts to weight loss may help you get to goal.

Pat Salber, MD, MBA

Lose weight without diet or exercise! You’ve seen ads for devices and drugs that purport to melt away the fat without much help from you. They’ve been around for years and they make some companies a ton of money. You really like the idea (right?), but deep down inside, you know they don’t really work.

Typical Hoodia ad - take a pill and look like me!Hoodia, an extract of a cactus from the Kalahari desert is all the rage. It is supposed to block your drive to eat and slash calorie intake in half. The problem is there are no good medical studies that I can find to show that it works. Further, some Hoodia products have been studied and found not to have any Hoodia in them – remember that unlike the pharmaceutical industry, the nutritional supplement market is like the Wild West -- anything goes.

So a small article out of Australia caught my eye, mainly because of the involvement of Surgeon James Toouli, a Flinders’ Professor of Digestive Surgery who has written a ton of medical papers and even a couple of surgical text books. Apparently, his medical center in Adelaide is involved in testing a new obesity treatment called VBLOC. VBLOC stands for Vagal Blocking for Obesity Control. It involves the use of a pacemaker-like device that sends low power electrical signals that block the vagal nerve.

The vagus nerve has a number of different functions in the control and function of the gastrointestinal system. It is the nerve that allows communication between the brain and our digestive system. It not only plays a role in stomach function and control of digestive juices, but it also plays a role in the sensation or hunger and fullness.

In the old days, before the availability of effective drugs for peptic ulcer disease, people with intractable symptoms used to undergo an operation called a vagotomy. Many of these people lost their appetite, had reduced absorption of nutrients from the gut, and lost weight after the operation although they eventually gained both back for reasons that aren’t entirely clear.

The medical device behind VBLOC is made by EnteroMedics, a Minneapolis company whose tag line is “Orchestrating Obesity Solutions,” (pretty nice). According to information on the company’s website, it is important to only block the vagus nerve intermittently so that the body does not develop ways to accommodate for the loss of information from the nerves that occurs when it is completely cut, such as in a vagotomy operation.

The company has farmed out its clinical trials to a variety of institutions. Prof. Toouli’s lab is one of the research centers that is testing whether or not the device works. The Mayo Clinic in Rochester, Minnesota is another center studying the device. If you want to participate in a clinical trial of the device, you can sign up online. Your information will be forwarded to one of the testing centers to determine if you are eligible to participate (Note: this is information only on my part and should not be considered a recommendation to participate. If you want to learn more about why your should participate in clinical trials, check out this link.)

According to the online news report that caught my eye, early results from Prof. Toouli’s lab are quite promising.
Graphic of VBLOC implantation The first person (of ten people) implanted with the device lost 20 kilograms (that’s 44 pounds) “without changing her dietary habits or exercise regime.” Prof. Toouli is quoted as saying: “These nerves [the vagus], control the movement of the stomach and they control some of the secretions used for digestion, and by blocking these intermittently, what it does is it slows down the aching of the stomach so consequently people don’t feel as hungry.”

Sounds too good to be true. Well, it may be. But then again it may actually end up working. We have to await the results of studies, such as the ones described above to be subjected to peer-review and published in reputable medical journals. Meanwhile, there are some peer-reviewed animal studies that support the contention that vagal nerve stimulation may cause weight loss in pigs (pigs!)

As exciting as it is to read that a handful of people lost weight with the device, it does not necessarily mean the results will hold up when larger numbers of people are tested in randomized controlled trials (the gold standard in medical research). The history of device and biotech companies is full of stories of companies who had promising early results only to fail when subjected to rigorous testing.

I think the best news of all about this story is that obesity research is now attracting the best and the brightest, innovators who understand the complex regulation of appetite and body weight. This fuels hope that one day we will have an effective treatment that doesn’t require starvation and sweat. Until then, I'll see you at the gym.

Pat Salber, MD, MBA