Live Radio Interview with 93.8nowFM on Metabolic Surgery
On-Air Interview Transcript:
It takes more than an apple a day to keep the doctor away. Body and Soul, on 938NOW.
Daniel Martin: It’s Body and Soul right here on 938NOW. I’m Daniel Martin, welcome aboard. I always say let’s take charge of your health. In today’s edition I couldn’t mean it more. The surgery that we’re going to describe to you today could save lives. Most people are familiar with the term of maybe bariatric surgery, gastric bypass surgery or weight loss surgery. That’s how we the common person has heard about it, but really, at the end of the day, what it’s doing is on a metabolic level. It is known as obesity and metabolic surgery—it’s increasingly being known as obesity and metabolic surgery today. And it is not just about helping people cut down their figures, the life-saving proven benefits of this kind of surgery is what we’re going to explore because there are implications, for example of reversing someone’s diabetes, even helping prevent heart disease as well. So how can the right kind of patient truly have their lives saved through this. I’m finding out more on today’s edition. I’m joined by Dr Melvin Look, who’s a consultant general surgeon at the PanAsia Surgery Group, they’re located at Parkway East Hospital.
If you have any questions, I’ll be accepting WhatsApps and phone calls in the third segment of today’s show. Doctor Look, welcome back to the program. Thank you for being here.
Dr Look: Thank you for inviting me, Daniel.
Daniel Martin: Pleasure indeed. Let’s talk about that, I mean most people think of it like I said in those terms, but obesity metabolic surgery. Is it the same thing as weight loss surgery?
Dr Look: It is technically the exact same surgery that we do, but the indication is the difference. So now we are doing this operation not for obesity and weight loss alone, but we’re trying to do this for people who have metabolic syndrome, particularly diabetes to reverse some of these problems. So, the indication is what is different, that’s why it’s called metabolic surgery rather than weight loss surgery.
Daniel Martin: We’re realizing—now we’ve done it for so many years it’s been done for so long, hasn’t it?
Dr Look: Yes correct.
Daniel Martin: And we’re realizing the wider benefits and implications.
Dr Look: Yes, correct, not just weight loss alone and I think the indication part is important because a lot of people who are obese, they might think “Oh I accept that I am overweight, I don’t want something to look nicer,” you know. But now you’re saying that—
Daniel Martin: I don’t want to be full of this vain, as well.
Dr Look: —correct, but now we’re saying this is the operation that can actually reverse the medical problems that you have, so the indication is different. That’s important.
Daniel Martin: Yes. It’s not just appearance, the medical problems are significant. I’m talking about greatly increased risks of things like diabetes, disease hypertension, insulin resistance, sleep apnea, GERD and so much more. And for many people who might find themselves at that point where they are exploring this as an option, they are really on the precipice, where their doctors are warning them that a serious incident is right around the corner. Isn’t that true?
Dr Look: That’s right. Well as you know, metabolic syndrome is a complex disease and comprises things like hypertension, high cholesterol and diabetes. And that leads to heart disease, leads to stroke and all that. But by far, the most important component that we’re trying to reverse is diabetes because that one has at least two micro vascular problems; it leads to blindness, it leads to kidney failure, it leads to amputations. So, by reversing the diabetes, we can actually prevent you from getting all these complications.
Daniel Martin: So, we’re saying “reverse” reverse, “cure” cure, you will not have diabetes, there is good indication.
Dr Look: We don’t say “cure”, because diabetes is a lifelong progressive chronic disease, so you will always have diabetes, but we are reversing some of the effects so that you no longer require medication for diabetes.
Daniel Martin: For so many people who are living with diabetes, the thought of that is life changing. Talk to us about the evidence and the strengths of the evidence that we have that shows this.
Dr Look: Metabolic surgery actually started as an offshoot of obesity surgery and we started doing this for indications for weight loss, people who wanted to lose weight but as you know obese people have a high incidence of diabetes. We started doing the surgery and realized, “Hey these guys don’t require medication any longer for diabetes, even before they lose weight”.
Daniel Martin: What a wonderful by-effect that has.
Dr Look: Right, and therefore, we started realizing that actually the surgery is even more important in reversing the metabolic effects. So that was how metabolic surgery came about. And now we’re doing it for the main indication for reversing this diabetes. What’s the question again?
Daniel Martin: What is the evidence like?
Dr Look: When we started doing this, we realized, “Hey, every patient benefits from this”. But we lacked at the long-term data to see whether this treatment is effective in the long term, whether it’s durable and whether it has long term side effects. But two years ago, a very important paper was published in The New England from the Cleveland Group, and it is a randomised control trial with long-term five-year results.
Daniel Martin: Gold standard?
Dr.Look: Gold standard. It compares surgery with best medical treatment, intense medical treatment, and it is clearly proven that surgery offers better quality of life, surgery is effective, durable and it’s very safe.
Daniel Martin: That was what we were really looking for, the long-term data.
Dr.Look: Yes, the long-term, five-year data, and that got us very excited. That was two years ago, and I think metabolic surgery is something that’s going to explode.
Daniel Martin: Globally, do you see that, or in other economies. Is it already on the rise?
Dr Look: In those countries that are starting to be aware that this can be a long-term solution to this big medical problem, the number of surgeries has certainly increased.
Daniel Martin: OK so just explain to our listeners when you say that that study compared it to best practices that means people who didn’t have surgery and went about with regular treatment for–
Dr Look: –medical treatment intensive diet, diet exercise and all that, as ideal as you can. And most people who are diabetic don’t get ideal medical treatment. I talk about in Singapore; the data has shown that one in three diabetics don’t even realize that they are diabetic. One in three diabetics who are under treatment do not achieve optimal control. So these people who are not treated or who don’t have optimal control, these are the ones that are at risk for long term complications. So this is the group that is very important to screen them, and to pick them up for treatment, and to offer surgery when necessary.
Daniel Martin: And that’s exactly what I want to zoom in on. When is it necessary? Who is suitable for this? How does this work? We’ll talk more about the life saving benefits of metabolic surgery when we return with my guest, Dr Melvin Look, a consulting general surgeon from PanAsia Surgery Group, they’re at Parkway East Hospital. Stay tuned.
Daniel Martin: Now imagine a surgery that could reverse diabetes. Well you don’t have to imagine. It exists. Metabolic surgery is what we’re learning about from Dr. Melvin Look who is a consultant general surgeon at PanAsia Surgery Group at Parkway East Hospital. Tell us a little bit about the big question. How, how does this work?
Dr Look: OK. Like we said before, metabolic surgery is very like obesity surgery, weight loss surgery. And one of the first effects is that if you lose weight, your diabetes will naturally improve because the glucose insulin resistance improves. But there’s also a second mechanism which was a mystery, initially. We find that (after) we do the surgery and before the patient loses weight, that they no longer require medication for diabetes. So initially it was a mystery, but we understand it quite clearly now, that the gut is actually a very important organ for maintaining homeostasis of the body’s glucose and metabolic processes. By rearranging the gut, you can actually change some of the problems that you have with diabetes.
So, after the surgery, a lot of the hormonal mechanisms of the gut come into play to bring down the blood sugar independent of insulin. By doing this surgery, intestinal hormones bring down the blood glucose, so your diabetes is well-controlled, and because you no longer need to stress the pancreas so much with the insulin function, you preserve the pancreatic function for longer. So, this operation actually has the effect of preventing long term complications from pancreatic failure as well.
Daniel Martin: So, it’s a permanent change in the intestinal makeup of the gut?
Dr Look: Yes. Permanent change. Basically, one of the operations—maybe we discuss a little bit more in detail—itis called the laparoscopic sleeve gastrectomy, it is a keyhole operation that we do, that basically staples the stomach and removes part of the stomach. So, the stomach is converted into a sleeve, like a tube. OK. Now what happens is—
Daniel Martin: As opposed to its normal shape, which is like oblong?
Dr Look: Right, so the stomach is smaller, you feel full quicker after a small meal, so it’s a food limiting procedure. So, you start to lose weight because of that. You remove the part of the stomach, that produces the hunger hormone, ghrelin. So, you no longer have ghrelin, which means that you no longer feel hungry. So it alters the way you see food and want to eat food to appetite centre. And that the third mechanism is that the food that you eat is delivered quickly into the small intestines, it doesn’t hang around in the stomach. And when that happens, the intestinal hormones bring down the blood sugar, and that helps in controlling your blood sugar as well.
Daniel Martin: I can see that it’s just a physical change alone makes that difference already. So, you’re saying that even before the weight loss occurs, they can see some of the benefit?
Dr Look: Correct. That’s right.
Daniel Martin: Because that mechanism has been altered?
Dr Look: Correct. Another operation that we sometimes do, and some surgeons do is the gastric bypass surgery. That has an additional component in that, a lot of the gut is bypass and whatever food you eat is not absorbed by the gut. So that has an independent effect on glucose control as well.
Daniel Martin: Also, we need to explore this a little bit more and explain because it is working differently for different pathways that it is working along. Okay. Let me go into detail about the type of surgery as well. We’ll do that next, when we return with my guest.
How can this lifesaving surgery benefit you when it comes to possibly reversing diabetes? We’re looking at metabolic surgery today with Dr.Melvin Look, who is a consultant general surgeon at PanAsia Surgery Group at Parkway East Hospital. Start sending across the questions at our WhatsApp hotline 96311938 phone calls next at 66911938 as well.
Daniel Martin: Now we’re back on Body and Soul, right here on 938NOW, keeping you in the know and on the go. Let’s learn more about what you have in mind when it comes to metabolic surgery. I’ve been describing the procedure that could be lifesaving in so many ways, protecting you from the complications of diabetes in particular. There is strong evidence and good indication that this kind of surgery can actually reverse someone’s diabetes. Dr Melvin Look is joining me, consultant general surgeon out of Panasia Surgery Group at Parkway East Hospital. Keep sending those questions across a 96311938.
I’m also going to open up the phone lines right now at 66911938 if you want to talk to us directly.
Let’s go to the WhatsApps, Dr Look, this person has not left a name, but they want to know, can the surgery be reversed after the diabetes is under control? Or the cut, can that be removed as well, can it be permanently removed. Let’s talk about the idea of reversing the surgery in some ways. What do you say?
Dr Look: This operation is a permanent operation. It’s not meant to be reversed, because obviously diabetes is a chronic long-term disease. If you reverse the procedure, you basically get the problem back again
Daniel Martin: Even though you got it under control?
Dr Look: Yeah, even though you got it under control. So it’s not meant to be reversed, and the part of the stomach that’s removed is taken out permanently. So we don’t reverse it unless you have problems, then we do revisional surgery to correct those problems.
Daniel Martin: What kind of problems we’re talking about?
Dr Look: Long term wise, actually, this surgery is fairly durable. You know, as a person living by this operation basically lives quite a normal life except that that’s a food limitation effect. You don’t take as big a meal as you used to. You take a smaller meal, if you’re satisfied with that, and that’s basically about it.
Daniel Martin: Would you need to go back? For example, we didn’t take enough out the first time. Let’s take more out again.
Dr Look: OK. The amount of stomach left behind the tube that we create is calibrated such that it’s just nice for you. But this gastric tube can expand for a person who is not motivated, constantly overeating, it can stretch and that can lead to a loss of effect. In those cases, we can do revisional surgery to correct that problem.
Daniel Martin: Got it. OK. Thank you so much for the question. We got another WhatsApp coming in, and this person hasn’t left their name either, but they’re asking, “Hey, is there any age limit? I am diabetic, age 59, male. I also have high cholesterol, and also wants to know if this is considered as a form of cosmetic surgery”.
Dr Look, age limit?
Dr Look: Okay. There is no age limit. But first of the bat we have to say that this surgery is for type 2 diabetic. So it’s not for people with type 1 diabetics, which occurs mostly in teenagers and young adults, so that’s excluded. Most patients with metabolic syndrome will be in their 20s 30s 40s 50s. Obviously if you’re older and you have a lot of complications, then probably the surgery will not be worthwhile. So consider doing the surgery when you’re young, when you have more to benefit from the surgery.
Daniel Martin: But certainly, this person who’s 59 is not ruled out?
Dr Look: Yes, he’s a good candidate, an ideal candidate. We would say try to do the surgery early before complications set in.
And when do you consider surgery? I think that’s an important question.
You should consider surgery if your diabetes seems to be getting worse. You know when you’re taking one medicine and you’re well controlled, probably you don’t need surgery. If you’re well-controlled in diet and one medication, probably surgery is not required. But if you start needing two medicines, three medicines and your doc(tor) says “I think you’re going to start needing insulin soon,” you should consider doing the surgery at that point in time, before complications set in. Because once complications set in, then you’re not going to be able to reverse the complications.
Daniel Martin: So we’re talking about things like becoming at risk for lower extremity amputation, some diabetic retinopathy setting in.
Dr Look: Correct. And kidney dysfunction, kidney failure. The thing about metabolic surgery would be starting to realize that it is able to prevent complications. The effect of diabetes on all this end organ disease tend to come in about a decade later, with the surgery. It comes in a decade later.
Daniel Martin: Got it.
Dr Look: Let me make myself clear. It delays your problems by about 10 years.
Daniel Martin: If you’re doing the surgery at 59 and if it sets in when you’re 65, consider that when you’re 75, so you’re kicking it down the field?
Dr Look: Correct.
Daniel Martin: Got it. And I just want to reinforce something, I mean the complications are serious. In Singapore, we have some of the highest rates of low extremity amputation
Dr Look: Yeah, I think we’re the world leader.
Daniel Martin: Yes. And I think we have some of the highest rates of diabetes, kidney failure as well. So, these are these are real nationwide concerns at the end of the day.
Is it a cosmetic surgery?
Dr Look: It is definitely not cosmetic. We are not doing it for weight loss alone, we are doing it for a medical problem, primarily diabetes and metabolic syndrome. But of course, you do lose weight with the surgery and that is part of the intended effect. Once you lose weight, you lose a lot of the visceral obesity, and that is the cause of the insulin resistance.
Daniel Martin: So I think, part of the problem is when these surgeries first became very popularized, there was a lot of celebrity support for it, and people got to know about it when they read about it in those terms, about ‘how I cut the weight’ and ‘I look different now and I feel different’. And I guess in people’s minds, it is still classified as very cosmetic in nature. But that has changed as we’re explaining today. Another question coming in, this person wants to know, what about people who are not obese or overweight can they also benefit from this if they have poorly controlled diabetes?
Is it possible to be very slim and have poorly controlled diabetes?
Dr Look: Yes, these are people who are what we call normal weight diabetic or non-obese diabetics, or low BMI diabetics. Now we have the best data for surgery, for people who are who are obese and diabetic. We have the best robust, data. Obviously, this is the group that most of the studies are focused on. Traditionally, our indication are related to weight as well, and BMI as well. So, for Asians, we say that you will benefit most if you’re at least 27 BMI and above.
Daniel Martin: 27, that’s just at the definition of obese, isn’t it?
Dr Look: Because we realize that in Asians, we tend to get problems at a lower weight, rather than Caucasians. We tend to get medical problems at a lower BMI, so the indication for surgery is lower. OK. So traditionally we say at least 27 above. But there’s a lot of interest now in doing low BMI metabolic surgery as well, in order to reverse the diabetes even though you don’t need to lose weight.
Daniel Martin: Yes, but you see I think people will assume that if you haven’t got a weight issue then your poorly controlled diabetes isn’t because of weight. But again, we’re not just talking about the weight per se. It’s also about the gut in the intestinal area that can benefit from that change.
Dr Look: But for people who are more normal weight diabetics, there might be a secondary issue or rather a primary issue which is a pancreatic function issue. So, in those cases we got to think very carefully because if you have a pancreatic function issue this surgery may not be completely ideal for you.
Daniel Martin: Understood. OK. Coming up what’s the surgery like and what is life like after it. More with my guest on the program as we discuss this potentially lifesaving surgery that could reverse the effects of diabetes. Dr Melvin Look joins me, a consultant general surgeon out of PanAsia Surgery Group at Parkway East Hospital. Stay tuned.
Daniel Martin: Welcome back to the show everybody. Doctor Look, let’s talk a little bit then about the procedures as you described. You know there is a bypass option there’s a sleeve gastrectomy as well. Are these discussed with the patient, can you choose or are you only suitable for one or the other? What are we talking?
Dr Look: Yes. The choice of operation obviously depends on how we feel the patient will benefit from the operation and what will suit the patient most. We also discussed the risks of doing the surgery and the lifestyle changes and all that. Then the patient decides, and we make a joint decision together. As far as what the operation is like, for example the sleeve gastrectomy, is a keyhole surgery. It takes about two hours, after the operation, you stay in hospital for about three nights. So, it’s a relatively straightforward operation, the risks are very low. And it’s the operation that is fairly predictable in this effect. Most patients would do quite well with it.
Daniel Martin: That’s interesting because we often talk about variability or outcomes, but this, we’ve seen from the data good outcome.
Dr Look: Good outcome, almost everybody.
Daniel Martin: How interesting. What’s it like, adapting? Because when I first started doing interviews on this topic many many years ago when it first came to prominence a lot of people were focused on what is life going to be, like how do you eat properly, will you be on a soft diet, is it liquid all the way? Is that happening in the first few days?
Dr Look: Only in the first week you’ll be on a liquid diet and then you graduate onto a soft diet, and by the second third week, you are back to almost normal diet. And the good thing is you really can eat what you want except that—
Daniel Martin: We don’t want to eat too much anyway.
Dr Look: —he only the only thing that’s changed is the portion size. So, you still can enjoy your steak, but it’s a small portion or whatever.
Daniel Martin: And your brain wouldn’t want that much
Dr Look: Yes. In fact, a lot of patients say that the they view food has become different.
Daniel Martin: That’s fascinating. Satiety is affected as well.
Dr Look: That’s right.
Daniel Martin: Mainly because of the size of stomach in that case?
Dr Look: Because of the loss of the ghrelin producing part of the stomach.
Daniel Martin: The hunger. The urge. OK, let’s take a question from our listeners, Mrs. Lim has dialed in. Hello Ms. Lim, hi.
Ms Lim: Doctor, earlier you say the laparoscopic sleeve gastrectomy is safe and effective for obese adolescents, but I’ve also read that if lifestyle modifications fail after surgery, these adolescents will gain weight despite the metabolic modification effects of your surgery. So how do you respond to that?
Daniel Martin: Thank you very much, Ms Lim. That’s a good point. Let’s talk about the idea of rebound, or the weight coming back particularly done on younger persons, like you said, did we mention specifically adolescents?
Dr Look: Usually this operation is more for older people. Adolescents, they don’t get the metabolic syndrome problems so early on, they get a purely on more weight problem.
Daniel Martin: Yes. So, but this might be done for people in their 20s and things like that. So, what is that risk of it coming back?
Dr Look: OK. Obviously, motivation is the important factor. You know you need to really want this surgery. You want to have to get back on track. You need to be able to understand what the surgery is about. Therefore, not for young people can understand. You need to understand, be motivated and keep to the changes in lifestyle and diet post-operation. And if you do that, the results are very good. But obviously there are some cases where you don’t eat correctly. You continue to not follow the diet. You know, if you take a lots of ice cream, beer.
Daniel Martin: Prata.
Dr Look: Yeah.
Daniel Martin: I always say prata. One thousand calories per prata, man. Come on
Dr Look: (With) prata, you feel full, but if you take beer, it just passes through.
Daniel Martin: True.
Dr Look: So, you can pack on a lot of calories, a fatty liver that won’t go away. So, you need to be motivated as well. There are cases where people go off track then they start to get a weight regain.
Daniel Martin: Yeah, so what happens in that scenario?
Dr Look: Well, we try to sort out, even before the operation. Whether you are once someone who is not motivated, or you are emotional eater, you snack a lot, or you’re a compulsive eater. So those patients may not be so suitable for surgery.
Daniel Martin: Is there a psychological evaluation as a part of going through this?
Dr Look: Most people don’t require psychological evaluation. By the time we get to the end of our consultation, we can figure out whether you require one or not.
Daniel Martin: So as Mrs. Lee mentioned that portion of individuals where it does unfortunately take a U-turn and you’re back where you started. But your stomach is half the size already. Is the stomach stretching out? Are you taxing your body even more, with the diabetes come back worse?
Dr Look: Most cases where the weight rebounds, or the metabolic syndrome comes back, it could be due to the stomach stretching, so there are some corrective surgeries that we can do to—
Daniel Martin: To help in that situation.
Dr Look: Correct.
Daniel Martin: I didn’t turn on my own mic, so sorry. Let’s go to the phone lines where Juan is joining us. Hello, Juan.
Juan: Hi, good morning. But surely if this is untroubled by the doctor, I was just wondering if fatty is visceral fat around the organs are a problem. Apparently, there’s a Scottish surgeon that has pioneered a surgery that, you know, where he removes the visceral fat from the pancreas and all that has that. Is that viable? Thank you very much.
Daniel Martin: Thank you very much, Juan. Dr Look?
Dr Look: Yes. Some people do what we call omentectomy as part of the procedure. Omentectomy is removing of the visceral fat in the body. It’s the time for a funny story, Daniel.
Daniel Martin: Please.
Dr Look: Twenty years ago, when I started doing obesity surgery, you know we were doing all these gastric bands.
Daniel Martin: Yes.
Dr Look: And that’s the only option for losing weight. And this French guy comes, he says, “Doc, I don’t want a band in me. I just want you to make my stomach smaller and remove all the internal fat.”
Daniel Martin: OK. That’s all he wanted.
Dr Look: That’s all he wanted. We said no we don’t do that sort of surgery; we can only do bands. But now we realize, 20 years later, that’s exactly the surgery we require for metabolic syndrome. Make the stomach smaller and remove the visceral fat.
Daniel Martin: It’s come true?
Dr Look: Yeah. So he was ahead of his time.
Okay. But, we don’t do the visceral fat removal initially, because most patients don’t require that. We’d rather that come down with the weight that result with the weight. And also, we do believe that momentum has an important function in the body. It has a storage function. It also sort of protects the gut against illnesses and all that. So we try not to remove it unless necessary.
Daniel Martin: And we also recognize that with metabolic surgery we’re not just reducing the size of the stomach. Like you said we’re having some kind of almost permanent effect on the intestines, on the guts, on the flora that’s in there on your satiety, on your relationship to food, hormonal aspects would change as well, I would imagine. So, these are the things that are the factors that really go into a lifestyle change.
Dr Look: Correct, and once you lose the weight, the visceral fat will go away as well.
Daniel Martin: Yeah. Thanks for the questions everybody. Good to hear from you guys. Dr Look, a pleasure. Thank you for your time.
Dr Look: Thank you. Thank you for having me.
Daniel Martin: Good indeed to understand and hopefully change our perceptions of this kind of surgery. Now we understand the potentially lifesaving benefits of obesity and metabolic surgery. My guest on the program, Dr Melvin Look, consultant surgeon general surgeon of the PanAsia Surgery Group at Parkway East Hospital.
I’m Daniel Martin. This has been body and soul Body and Soul.
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