Trading insights on obesity and diabetes

Trading insights on obesity and diabetes

Diabesity, defined as a combination of diabetes and obesity, is an epidemic problem in Israel and the United States, according to two Israeli doctors.

The two physicians, Tommy Hershkovitz and Arie Ariche, participated in the International Symposium on Weight Loss at the Kaplen JCC on the Palisades in Tenafly on June 5. The symposium, organized by Dr. Deane Penn of Alpine, brought together medical practitioners, including specialists in bariatric surgery, endocrinology, plastic surgery, oral surgery, and anesthesiology to discuss the latest medical and surgical treatments for obesity.

The two Israeli physicians are from the Western Galilee Hospital in Nahariya, Israel; they are guests of the Jewish Federation of Northern New Jersey’s Partnership 2Gether Nahariya-Northern New Jersey Program (originally called Partnership 2000). Hershkovitz, 53, an endrocrinologist, and Ariche, 66, a surgeon, spent time visiting local hospitals and exchanging information and experiences in managing obesity. The two doctors have worked to establish the first multidisciplinary center for weight loss in Northern Israel, which is in their hospital in Nahariya. The hospital, six miles from the Lebanon border, serves a diverse community of about half a million Jews and Arabs.

“It’s all about exchanging ideas with the Israelis,” said Penn, the medical task force chairman for Partnership 2000. He recalled how Partnership 2000-sponsored programs successfully teamed up Israeli and New Jersey doctors in robotic surgery and bloodless medicine. During this visit, Hershkovitz and Ariche visited Penn’s Englewood clinic and Englewood Hospital, where they observed bariatric (weight loss) surgery techniques. The Israelis also networked with New Jersey doctors at a meeting at Penn’s Alpine home. “The doctors were talking about their research,” Penn said.

Diabesity refers to Type 2 diabetes that is caused by being overweight or obese. “To prevent complications of obesity, metabolic surgery can get rid of diabetes,” Ariche said. “When a patient comes to the center [in Nahariya] he sees a dietitian, a psychologist, an endocrinologist, and surgeons.” The consultation with the patient leads to a decision regarding the best treatment, and if surgery is recommended, the discussion centers on which surgery would be best in that case.

“We have a mixed population in the north of Israel: 50 percent Arabs and 50 percent Jewish,” Ariche said. “Three quarters of them are overweight – they have a body mass index above normal – and 30 percent are morbidly obese.”

“It’s worse in recent years,” he said. “Young people are at home, working on the computer, not doing physical activity, and eating junk food. This leads to obesity and morbid obesity. There’s a higher incidence of Type 2 diabetes. And we see young people with Type 2 diabetes. We never saw that before.”

At Western Galilee Hospital, surgeons operate on obese patients who qualify medically for the procedures. Gastric bypass and sleeve gastrectomy are the most common procedures done for weight loss in Israel. Gastric bypass reduces the size of the stomach and bypasses part of the small intestine. In proximal bypass, about 1 meter of small intestine is bypassed. In distal bypass, practically all the small intestine is bypassed. In both procedures, the food that is ingested bypasses a large part of the gut. That means that fewer calories and essential nutrients are absorbed. “They all have to take vitamins, iron, zinc,” Ariche said. “If they don’t take supplements, they have big problems.” In particular, with distal bypass, “the patient has to be very, very serious and very compliant.”

Stomach banding was another procedure that had been popular in Israel, Ariche said. “In the United States they are still doing it a lot. But sleeve gastrectomy is a better operation. There are some problems with the band. In the U.S. they are pushing those very expensive banding devices.

“The sleeve is an irreversible operation,” he continued. “It’s done with a laparoscope – we take out the vast majority of the stomach and just leave a pipe-shaped part of the stomach. The patients feel they had enough to eat very quickly.” In Nahariya, he reported, about 50 percent of the procedures are sleeve gastrectomy and the other 50 percent are gastric bypass.

There can be serious complications for both operations. “For the sleeve, there are leaks; there’s a long staple line that can leak,” Ariche said. “The sleeve can twist and get an obstruction. If the patient eats a lot, it can enlarge the sleeve and can plug up the sleeve.” According to Ariche, leaks occur in 1 to 3 percent of patients, compared with complications in less than 1 percent of gastric bypass operations.

“Obesity is a huge part of diabetes,” Hershkovitz said. “Seventy to 80 percent of diabetic patients are obese.”

“Bariatric surgery is a procedure for curing diabetes,” he continued. “When we have diabetic patients who take lots of insulin but still cannot control diabetes, we recommend the gastric sleeve or gastric bypass. It can control diabetes and even cure it.”

Hershkovitz reported that 30 percent of Jewish females, 25 percent of Jewish males, 35 to 40 percent of Arab females, and 25 percent of Arab males in northern Israel are obese. “An explanation for the discrepancy in Arab females is that at an older age – 40, 50, 60 – they are moving less and have less exercise. And maybe there is some genetic factor as well. Their eating is also different. Being aware of what we are eating and how we are eating is more [common] in the Jewish population.”

The Israeli doctors visited Penn’s weight loss clinic, The Center for Medical Weight Loss of Bergen County, in Englewood. Penn, a board-certified gastroenterologist with special training in bariatrics, said that his clinic provides patients with a three-phase program guided by medical experts in endocrinology, surgery, psychology, and other areas. The first phase provides food products that are low in fat and carbohydrate, but high in protein. Penn noted that most of the products – shakes, bars, crisps, and soups – have kosher certification. Six weeks on the diet products are followed by a 4- to 6-week transition period where patients can reintroduce regular foods. The last phase is a maintenance program. The program incorporates information on calories in foods and an exercise program. “It includes time with doctors, quizzes, and counseling,” Penn said. “We rarely give weight loss drugs.”

Hershkovitz, who was listed as one of the country’s top 10 endocrinologists by the Israeli newspaper Maariv, is author of Diabetes in the Third Millenium, a Hebrew-language reference for medical professionals practicing in Israel.

Dr. Miryam Z. Wahrman is professor of biology at William Paterson University and author of Brave New Judaism (Brandeis University Press), which explores issues in medical bioethics.

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