Chocolate cake and an important message for bariatric surgery patients

The writers of House MD on Fox-TV did a public service last night. Unlike most television shows, House continues to punch through popular stereotypes about fat people and take on obesity sacred cows with that cutting, impudent honesty that only Dr. Gregory House can get away with. Last night’s drama weaved a difficult story line with subplots of humor and sexual tension and even medical ethics. Simultaneously, it brought an important educational message to bariatric surgery patients and medical professionals that no other media has dared to touch.

Like all entertaining television, everything on House moves faster than life and teeters at the brink of reality. But while the diagnostic investigations are sensational, the underlying message last night was genuine.

Synopsis

The segment opens with an exercise coach making a fitness video for fat people. While she leads the class to push themselves, encouraging them to get thin and healthy with exercise, she passes out and careens down a set of bleachers, ending up in the hospital. While her health continues to deteriorate, Dr. House’s diagnostic team can’t figure out what’s wrong with her and finally do an MRI. They are surprised to learn that she had recently had gastric bypass surgery and was keeping it a secret, even from the doctors.

Since she now makes her living selling health and fitness to fat people, it turns out she was terrified of being exposed as a hypocrite and fraud should anyone learn the truth. Even though she knew diet and exercise didn’t work to make fat people thin, if she admitted that, she could lose her business and reputation.

Suddenly, upon discovering her secret, everything changed. Their diagnostic efforts took an entirely new direction and became exceedingly more complicated. Dr. House told them they had to think of her as a naturally fat person because bariatric surgery doesn’t actually cure anything. Bypass surgery may have made her look different, he said, but inside she’s still tons of fun. But all of the stereotypical obesity-related problems like sleep apnea and diabetes were negated, in typical House style.

“Let me give you the Cliff Notes version,” he said. “Gastric bypass only changes the skin on the outside, it doesn’t change anything on the inside.” But altering the intestines and causing malabsorption creates a mountain of new problems, and they had to turn their focus on complications from the bariatric surgery. One by one, they investigated tracheal damage from vomiting, nutritional problems from malabsorption, bacterial infections from the blind loops of bowel, multiple sclerosis, brain and neurological damage, myasthenia gravis, Guillain-Barre, biliary tumors, central nervous system lymphoma and other brain tumors, and a few exotic, tongue-in-cheek possibilities thrown in for entertainment.

Throughout it all, as her symptoms escalated from fainting to increasing numbness and muscular weakness and hallucinations, she insisted that bariatric surgery had made her healthier and that she had only had the surgery to be healthy. She said she had tried everything to lose weight — every possible diet, pill, behavioral modification and psychological counseling — and nothing worked. She fervently believed that she was now eating “healthy” and was lots healthier now that she was thin.

The doctors weren’t buying that and pointed out that her restrictive diet was not normal or healthy and she never allowed herself even a splurge. Instead, the healthy lifestyle that she believed she was leading was obsessively focused on weight loss. Dr. House told her she had really only had surgery to look pretty and thin, but she got mad and insisted that she had done it to be healthy. She said losing weight had made her healthy and happy.

Her obsession to exercise and follow her health regimen was so extreme, that during the sleep apnea study, she escaped in the middle of the night after just a few hours sleep and sneaks to the lab. They found her running on the treadmill — on a broken ankle with her leg bleeding. The growing numbness of her extremities had dulled the pain, but just as they were trying unsuccessfully to get her back to her room, she collapsed again.

Finally, one of the doctors coaxed her to the cafeteria and she confessed her favorite treat had always been chocolate cake and it was what she most wanted. A few hours later, Dr. House discovered her exercising and all of her symptoms were gone. The chocolate cake had fixed her!

The dessert led Dr. House to the diagnosis. He came into her room with a chocolate cake and sat down beside her and explained that she had a rare disease called hereditary coproporphyria that is treated with a high-carb, high-sugar diet and avoiding fasting. When she was fat, she ate normally and would allow herself chocolate cake when an attack was coming on and she had been able to keep the disease under control. But gastric bypass meant the disease would get worse and she would have increasing brain and neurological damage, seizures and could die prematurely. They told her that she needed to have the gastric bypass reversed if she wanted to be healthy. Without it, all they could do was give her medicines to help manage the symptoms.

She refused to have the bypass reversed, even if it meant she could die. She said she would rather be thin than healthy. Finally, the truth had come out and she admitted that bariatric surgery wasn’t really about health, it was about being pretty.

Dr. House said there aren’t many people “who have the guts to admit that they’d rather be pretty than healthy.”

The creditable message

The writers of this plucky episode may have helped medical professionals think to ask patients presenting with odd neurological symptoms about bariatric surgery and to begin to consider how many systems in the body are affected when the digestive tract is altered and the widely varied complications that can result.

Perhaps the most uncomfortable and unpopular issue they raised was for the tens of thousands of young women in examining the real reason they might be having these surgeries and try to help them consider the potential consequences. While this show was a dramatization, it was unique in that complications aren’t often mentioned or given the same air time as before-and-after weight loss miracle stories.

The most important point House highlighted may help to save lives. It is critically important for patients to understand the seriousness of potential complications and to not keep their surgeries secret from their doctors, as it could mean missing a critical diagnosis. Not everyone will have a diagnostic team like House to figure it out in time, let alone before the next commercial break.

It is especially important for patients to completely understand the exact procedure done on them because bariatric procedures vary widely between individual surgeons. They need to be able to fully describe it to any future care providers and understand the possible complications.

Dr. Edward Eaton Mason M.D., Ph.D., Professor Emeritus of General Surgery at University of Iowa Hospital, is the inventor of gastric bypass and began performing them in 1966. In the Fall 1999 issue of ISBR Newsletter he wrote of his concern about the increasingly complex and invasive bariatric procedures being performed. Even within “bypass” type of operations, they are increasingly malabsorptive procedures, he said.

Recently, I wrote a paper reviewing risks of various operations and encouraging surgeons to inform their patients of the exact pouch size and (for bypass operations) lengths of the biliopancreatic, alimentary and common limbs. Patients need to know what they are getting into and should not choose an operation without knowing the true risks.

Dr. Mason also regretted that both patients and bariatric surgeons were more focused on weight loss and appearances, rather than the long-term health consequences:

Bariatric surgery still does not have sufficient data from enough patients with any procedure to say which operation is best. I am concerned about the goals of surgeons and patients and their level of interest in what really goes on inside the body after alterations of the anatomy. I am concerned about the focus on the superficial and results from the first year with a lack of concern about how life will be affected when patients are 10 and 20 years older…

For the vast majority of patients today, there is no operation that will control weight to a "normal" level without introducing risks and side effects that over a lifetime may raise questions about its use for surgical treatment of obesity.

Several years later, Dr. Mason wrote an impassioned article to people considering surgery. Coming from the father of bariatric surgery for weight loss, it was an extraordinary article. Its message reads like a doctor troubled about what he was seeing and wanting to save lives. His admonitions should be read by every patient and prospective patient:

Know the Changes to Your Body Created by Weight Control Surgery

Whether you are considering an operation or have had an operation to help you control your weight, you should educate yourself regarding that operation. These operations change your anatomy and the way you eat, digest and absorb food. Operations differ…

Operations have both a goal and side effects. You need to know both. You may need to eat more of certain foods and avoid other foods. Eating habits should change. You may need to supplement your diet with vitamins, iron and calcium. You need to watch for certain complications and be able to tell any physician you might see at some time which one of the operations you have. You have special anatomy that many physicians know nothing about. If you are injured or develop vomiting or abdominal cramps, distention and inability to have a bowel movement or if blood shows up in your vomitus or stool can you draw a diagram of your anatomy and tell the physician some of the things to look for? Probably not now, but you could if you educate yourself about your operation. It could help the physician to determine what to look for. This is education that could save your life. You are a special person. You also can be a specialist with regard to your new anatomy and what it may mean tomorrow or years from now…

Operations vary in the length of intestine that is bypassed. You should know the measurements of bowel that is bypassed and that is still in use so that you can eat accordingly and so that you can tell any physician you see later in life. You need to know the size of your pouch and whether you have a bypass of most of your stomach, duodenum and a length of your small bowel. Bypass operations usually decrease iron and calcium absorption. That is because the duodenum is the chief site for absorption of these minerals and the food, fluid and medications no longer pass through that important part of the anatomy. The result may be anemia, which is usually due to a decrease in total body iron. It can be due to a decrease in folic acid or vitamin B₁₂. Special tests may be needed to determine the type of anemia and the treatment. You could develop anemia years after the operation so you need to know if your operation has that potential by knowing the anatomy and the changes in function.

We have known for many years that the duodenum is the site of absorption of calcium and that any operation that bypasses the duodenum may result in bone disease…An operation that bypasses the duodenum increases the risk of bone disease. Osteomalacia is another bone disease that may occur when the duodenum is bypassed because vitamin D absorption requires pancreatic enzymes that are normally mixed with the food in the duodenum. These enzymes assist in the digestion and absorption of fat. Vitamin D is a fat-soluble vitamin.

These are just two examples of increased risks that result from bypass operations. There are others that are less common but that can be serious. These other risks also require a knowledge of the new anatomy to understand how complications occur and what needs to be done to diagnose and to treat them if they occur and before it is too late. When you choose an operation to control your weight you are choosing not only a method of weight control, but also certain risks that go with that operation…

You should be able to draw a diagram of your anatomy and how it is different from normal. You should be able to label the esophagus, duodenum, small bowel and any changes in the small bowel. You should be able to explain how a closed segment obstruction might occur and why it is an emergency. You should be able to explain where a bleeding stomal ulcer can occur and where a bleeding duodenal ulcer might occur. Very few patients have educated themselves to be able to do these things but it could be life saving…

"[T]oo little knowledge is dangerous" and "educate yourself now and don’t ever quit educating yourself.".. Be a well-trained personal specialist. The doctor is still the one to advise you, but you are the one to make final choices about your care… Study, draw diagrams, and ask questions. Take notes and do your homework. Nobody said education was easy, but it is very worthwhile.

House’s fast-paced medical puzzles and exotic, rare diagnoses are entertaining and fun. But sometimes, helpful information that might save a life is found where we least expect it.