Myth Buster #4: Diabetes Improvement after Bariatric Surgery is Dependent on Weight Loss

Photo by M Clock

Hopefully if you have been even a somewhat  faithful reader of this Blog this one doesn't surprise you.

But some facts that were contained in the article may.

As a direct result of Obesity on the rise, the burden of Diabetes Type 2 is staggering:

*  At present, approximately 8.3% of the US population (25.8 million children and adults) have DM2, with approximately 7 million unaware currently of their disease state / diagnosis.

*  An estimated 79 million adults have prediabetes.

*  In 2010 alone, 1.9 million cases of DM2 were diagnosed in people aged     20 years and older.

*  The cost of treating Diabetes and its associated complications was estimated to be $218 Billion in 2007, while Diabetes also contributed to more than 230,000 deaths.  

And now to the MythBuster.  As discussed earlier in this Blog in numerous places, the benefits of Bariatric Surgery, especially for diversionary procedures and VBG, start rapidly after surgery and are independent of weight loss.  The weight loss does seem to reinforce the initial direct metabolic effect of the surgery, and enable a durable benefit for Diabetes and other metabolic conditions. .

LAGB (Laparoscopic Adjustable Gastric Banding) also aids in weight loss and Diabetes benefit, but through the dual effect of reduced dietary intake and weight loss over time.  Even with medical (non-surgical) weight loss, the same is true of early blood sugar benefit in Diabetic patients via reduced dietary intake associated with "dieting" in most cases.

These facts about the severity and prevalence of the Diabetes epidemic are important to get us to act and be aggressive about treating Diabesity early through medical, and then possibly surgical means where indicated.

The facts about the metabolic benefits of the various surgical procedures also helps the differentiate among the different procedures.  We keep this in mind as we discuss your patient's procedure of choice, but it its best for you to know, as the PCP, some of the basics about these procedures and their anticipated benefits, matching up the patient with their best option(s) when they first arrive to see us.

Of additional note, as you may have already noticed, patients of South or East Asian origin tend to have a much lower BMI with the same level of metabolic derangement than the typical patients that have metabolic syndrome / DM2 of European or African descent with a higher BMI.

Again, and in summary, once the specific metabolic benefits of surgery are more succinctly identified, they may be able to be harnessed pharmacologically without the need for surgery.

Maybe then it will be time to look for a new job... in sales and marketing?


Adapted form "Diabetes improvement after bariatric surgery is dependent on weight loss."  Kaplan, Seeley, and Harris.  Metabolic Applied Research Strategy, a supplement to Bariatric Times, Vol 9, No 9; Sept 2012.

Merry Christmas!

For those celebrating Christmas today...

Merry Christmas!

For those, like the extended family I saw in the Tampa airport a few days ago welcoming back a family member in the Army who was overseas for an extended leave, having a new appreciation for being together as a family to celebrate the season of Love...

Merry Christmas!

For those away from home, away from family, or for some reason away from a familiar environment that they now understand more deeply as 'tradition'...

Merry Christmas!

And for those that care for people burdened by chronic illness and disability who long for the days of old, when they could reflexively react to this season of joy, excitement, and active participation, and remember when they used to think of others more naturally than they do now regarding their own personal health concerns...

Merry Christmas!

And lastly, for those in need of Hope, whether patient or Provider, no matter what the reason...

Merry Christmas to All, and to All a good night!

Myth Buster #3: Vertical Sleeve Gastrectomy Is Not a Metabolic Procedure

MythBusters Discovery Channel

Metabolic Surgery as a term is used throughout this Blog.  Aside from the dramatic weight loss associated with Bariatric Surgery, this is as exciting an effect, often times resulting in remission or resolution of previously difficult to control Diabetes.

Relatively new to the scene of Bariatric surgery as a stand alone procedure, VSG can also impart metabolic effects for those obese patients with concomitant DM2, even without the "intestinal rerouting" associated with the the Gastric Bypass.

More and more studies are coming out showing a favorable  impact of VSG  on Diabetes type 2, which leads to the question of how, and requires taking a look into the physiology beyond the weight loss that imparts this effect.

VSG is typically viewed as a restrictive procedure, whereby 80% of the stomach is removed, creating a column of a stomach along the lesser curve, without the bypassing the normal route of food from the stomach to the small intestine, as is a part of a Gastric Bypass.

Aditionally, studies have borne out the following after VSG:

   *Improved post prandial glucose levels, associated with a potent increase in the early insulin secretory response to nutrients in the GI tract.
   *Circulating GI hormone levels are also affected, with a dramatic increase in GLP-1 post prandially
   *Additional to glucose regulation, Triglycerides in plasma are also reduced, which points to an dual effect on the liver post operatively.

Controversy remains, however, regarding which procedure reigns supreme for its metabolic effect, but in either case, surgery wins out again over medical management.  The data is still unclear, although studies are ongoing longitudinally, regarding which procedure should be performed for which type of patient. However, what is clear is that there is more to a VSG than just a restrictive and associated weight loss component at the heart of this metabolic surgical procedure.

Adapted from L Kaplan, R Seeley, J Harris. "Myth #3:  VSG is not a metabolic procedure".  MARS initiative publication, Bariatric Times Vol 9 No 9. C12-C13.

Myth Buster #2: Bariatric Surgery Induces Weight Loss via Restriction and Malabsorption

This one got me at first, too. 

This was an interesting idea of a myth that has it's root in the perception of the actual problem with obesity, and how we traditionally have thought of the corresponding benefit of Bariatric Surgery.  Restricting the amount the patient eats, and inducing malabsorption have their part in the success of these procedures, but there is more at work than just that, owing to the uniquely high efficacy of these procedures for weight loss and metabolic benefit.

Restriction 
  
   So what about a patient that has had a jaw wiring?  Why do they remain hungry, and seek the means to override their mechanical restriction?

Malabsorption

   Other operations that create an isolated protein-calorie malabsorption cause an increase in hunger - is there a CNS modulation effect at work with Gastric Bypass and BilioPancreatic Diversion?

Physiological Changes

   Several additional clinical observations support a primarily physiological model for weight loss after Bariatric Surgery.  Few patients become underweight after surgery unless a complication ensues. It would be expected to "overshoot" on occasions if the effect of surgery was purely mechanical. Also, patients that become pregnant after surgery gain weight at an appropriate rate, suggesting that the physiological changes of pregnancy can overcome those as changed by the surgery. And lastly, reports of Bariatric surgery performed on relatively "thin" patients (BMI<30), or animal models, consistently show relatively minimal weight loss.

   Changes in several GI peptide hormones (GLP-1, PYY, CCK, Amylin) likely contribute to a changed physiology post-surgery.  In contrast, the opposite changes are observed after dietary restriction alone (medical models of weight loss), which suggests the body attempts to counter-regulate the induced weight loss physiologically, through increased hunger and decreased energy expenditure.

   Beyond altering gut hormones through surgery, there seems to be other factors that regulate energy balance and metabolic function.  There also seems to be a change in the set point (see last "Myth Buster's" Blog entry), whereby a lower set point for weight is defended as the higher one once was.

In summary, to the degree whereby Obesity is viewed primarily as a behavioral, rather than a physiologic disorder, so goes the thinking of how to respond to the disease state- medically (calorie reduction and increased energy expenditure) or surgically.  Thinking of surgery as a powerful medical therapy, a "pharmacology on steroids" may make the surgical option more acceptable.

From MythBusters

Adapted from L Kaplan, R Seeley, J Harris. "Myth #2:  Bariatric Surgery induces weight loss primarily by mechanical restriction and nutrient malabsorption"  MARS initiative publication, Bariatric Times Vol 9 No 9. C8-C11.


  

  

IN-FLAM-MA-TION...

From whotalking.com

This might take you back.

Or date me...

Remember that Electric Company song about "-tion"?  That's when TV was exciting, even though we in our family were limited to just an hour a day. We usually chose wisely.

That's what my mind went to when I heard a recent CME Audio Digest talk on the Metabolic Syndrome.

The reason why is that the speaker, Bariatric Surgeon Dr. Sayeed Ikramuddin from the Cleveland Clinic Florida, stated that the basis of the Metabolic Syndrome and all of its associated end-organ havoc is secondary to inflammation.  Interesting concept.

Here's the breakdown, and the punchline comes in when we discuss what happens to inflammatory markers, and disease processes, after Bariatric Surgery and the associated rapid weight loss that is expected.

Metabolic Syndrome has as its hallmark insulin resistance, usually thought of as an extension of Type 2 DM.  It is heralded by increased glucose production, with elevated fasting BGs, and relatively insufficient Beta-cell secretion of insulin.  Adipose tissue, liver and muscle tissue are all effected, and as they are effected, they further impair insulin signaling and insulin sensitivity, furthering the metabolic derangement.  Inflammation increases overall via cytokines, M-1 pro-inflammatory cells, and can be measured clinically by C Reactive Protein, and Tumor Necrosing Factor (TNF).

Completing the inflammatory syndrome is central obesity, elevated serum triglycerides, and HTN.

Studies have shown that with the relatively quick reduction in adipose (inflammatory) tissue after Bariatric Surgery, TNF decreased as  measured at 3, 6, and 12 mos post op.  This reduction in inflammation, was also evident in the other paramaters in the metabolic syndrome, that is reduced LDL, Glucose, and Free Fatty Acids.

So, now the quality measures in Diabetes...the ever-elusive goals / composite measures as put out by the ADA:  

           *LDL <100
           *Glycohemoglobin <7
           *Sysytolic BP <130

Again, Dr. Ikramuddin gave a study that demonstrated a 5% to 39% success rate in getting patients to goal in a study at his institution after successful Bariatric Surgery.  And, he contrasted that with the national averages of getting Diabetic patients to those goals: 7%.

He closed by saying that the disease process of Metabolic Syndrome and insulin resistance will take care of itself if we do not. The diminished fertility rate alone, let alone the increased mortality of the syndrome, will become self-selecting.

Sobering thought... Season's Greetings...

Exhibit F

Photo by Wonderlane

And now, another case report.

This is a patient I saw in the office today, a young female S/P Gastric Bypass with a history of Type 1 DM. Definitely not the majority of our Diabetes patients in general, as most are Type 2's, but an interesting look at the early changes that occur in a type 1 patient after a metabolic surgery such as the Bypass.

I saw this patient recently as a 1 mos post Bypass check up.

Demographic:  21 y/o F

Start Weight:  252   BMI:  46

Date of Surgery:  11/12  Laparoscopic Gastric Bypass

DM Hx:  DM 1 since 13 years old.  Note from Endocrinology stated she had gained 100# over the previous 6 years while under their care.  Glycohemoglobins in the past never below 10%, control consistently poor.  Poor compliance with self monitoring of BGs.  Regimen prior to surgery was 56 units of Lantus once daily, and Novolog 1 unit for every 4 CHO.

Current DM Hx:  Lost the prerequisite 20# prior to surgery with a mild improvement in insulin sensitivity.  Now, 1 mos after her Bypass, her Lantus dose is decreased to 38 units once daily, and Novolog 1 unit for every 10 CHO.  She describes an easier time with her Diabetic control now, and has gained some momentum with weight loss, with her weight at 219 today, down 40# since start of the pre-surgical process.  

Take Home Point:  An overweight type 1 patient, while not being the rule for that disease state as they are classically lean, can also benefit from weight loss and the metabolic effects of Bariatric Surgery.  Again, her improvement in insulin sensitivity was noted perioperatively, as she was able to be sent home on almost half of her previous basal Lantus dose.  Her insulin sensitivity was also significantly improved as measured by her meal time dosing ratio that went from 1 unit of Novolog for every 4 CHO to 1 unit for every 10 CHO.  

Her new found consistent blood glucose control on an advancing "regular" diet (from post op liquids and pureed foods) in conjunction with steady weight loss has her on a 'health high'.  She is now taking much better care of herself, eating right, exercising, and enjoying her new appearance- a slimming version of her previous self.  Good stuff.

On another note, this patient was being seen by Endocrinology, who had mentioned the need for weight loss on numerous previous visits, mentioned surgical possibilities, and was ready to refer her for weight loss surgery when she was ready.  As mentioned in other places in this blog, given the necessary component that behavior enables to determine a successful outcome, a patient "talked into" surgery, even when indications are strong, often fares sub-optimally   Timing really is everything.  

Again, nice to see that in this case, a somewhat uncommon case of an obese type 1 patient in need of much better glucose control, not to mention comorbidities of asthma and intermittent low back pain, was introduced to the concept of surgery for weight loss, the referring MD had the additional metabolic benefits in mind, and she is now well on her way to healthier living.  Awesome!

Myth Buster #1:Weight Control Can Be Easily Achieved Through Lifestyle Modificatioln

From EHow Myth Busters

I was reading a recent published set of articles in the Bariatric Times (yes that is a legit title for a magazine...) and from a new initiative called the Metabolic Applied Research Strategy that published 5 myths that have direct applicability to this Blog, and I will post a few of them here and there over the coming weeks.

The first one is the most basic, and debunks the myth that lifestyle modification is alone sufficient for substantial weight loss in the obese (BMI > 30) population. It was interesting to me to find that there are many factors at work in undermining success, rather than the typical return to the previous indiscretions of poor dietary practices and lack of regular exercise.

Studies have shown that 80% of those who intend to lose weight through exercise and dietary change may initially lose at least 10% of their body weight, but more than 95% of those will regain all of their lost weight (or more) within the subsequent 2 - 5 years.

Surely there are volitional forces at work, but the regain in weight is not purely a matter of "choice". There are physiological factors at work that are intent on countering that weight loss for the long term.

It is true that body weight is a regulated by delicate balance between caloric intake and energy expenditure. Due to elaborate mechanisms, however, losing and maintaining that weight is quite difficult.

Fat mass is the primary source for both expected and unexpected (e.g. infection, illness, injury, increased physical activity) energy expenditures, and 'adequate' reserves are necessary.  The amount of stored fat is highly regulated based on genetic, developmental, and environmental influences.  Additionally, the physiology of body weight regulation is complex, with robust and redundant systems to ensure sufficient, but not excessive energy stores. Metabolic adaptation can occur, however, in the setting of overeating with resultant weight gain, as well as food restriction and weight loss.

The overall effect of these physiological mechanisms are to defend a stable body fat mass, or "set point" for energy storage.  Hence, the key to obesity is why certain individuals have such elevated set points.  Like so many other metabolic and physiologic 'set points' of the body (blood glucose, LDL, BP, Hct, etc.) they are not firmly "fixed" and reflect the integration of genetic predisposition.

Genetics, developmental history  and environmental exposure seem to contribute to an individual's set point for body fat mass, but the recent epidemic in obesity likely results from a change in the modern environment, leading to an inappropriately elevated set point.  Once that new set point is established, however, normal physiological mechanisms work to defend it.

Some environmental factors at work in our modern society:

*Alterations in the chemical and nutrient of food, that effect both intake and fat mass set point

*Lack of exercise and their resultant change in physiology of the body

*Chronic stress, personal distress, and disruption of regular circadian rhythms promoting obesity and metabolic dysfunction

And, unfortunately, the physiological mechanisms leading to the set point are so strong that even in the setting of willful contradictory actions (lifestyle modification), physiology almost always wins.

Fortunately for those that are morbidly obese, and perhaps beyond the ability to lose substantial amounts of weight due to chronic lack of success, and/or significant life-compromising co morbidites, there is Bariatric / Metabolic surgery which has been shown to induce the needed profound metabolic and physiologic effects that can lead to long-term durable weight loss.



Adapted from L Kaplan, R Seeley, J Harris. "Myth #1 Weight can be reliably controlled by voluntarily adjusting energy balance through diet and exercise."MARS initiative publication, Bariatric Times Vol 9 No 9. C5-C6.

"What About Exercise?"

"What about it?" patients often ask in return.

From Pati.Clark.blogspot.com

I must say I ask the exercise question at least 15 times a day seeing patients in follow up after their Bariatric procedures. The answers honestly often disappoint, but it is a teaching and coaching start point nonetheless.  It is an essential part of the path toward wellness after surgery.

So, What is considered exercise?  What role does exercise play in the post-procedure lifestyle of a surgical patient?  What do we expect from them? Furthermore, what is to be expected from a regular exercise program to lose or maintain weight?

Exercise certainly has its numerous literal definitions, but in the obese and unfit population, the definition becomes a bit more relative and has to be taken in context to their current health situation.  We are certainly not going to expect a patient with a BMI of 50 who hasn't been very active, and has little prior formal exercise experience to 'work out' 5 x per week for 30 minutes each time right off the bat. That may be a long term goal, but initially needs to be scaled back.

Essentially, any increase in their current energy expenditure through informal or formal exercise is a plus, on the way to a healthy lifestyle that includes regular exercise. This may include parking farther away from your car when you shop, walking at lunch time while on a break at work, consistently doing stairs instead of the elevator, walking instead of a cart for 9 holes, etc.

Now, our expectations do certainly increase for those who have had surgery and are losing weight, and those patients are required to get into regular exercise as a part of their usage of their "tool" that surgery has created for them.

In Band patients, who customarily lose weight at a slower rate, exercise may be the missing component that is needed to lose more weight / more consistently, when the Band is tuned up reasonably well and their diet is relatively sound (portion size and quality of foods).  Additionally, whatever they tell me as far as frequency and duration of exercise when I ask, if their weight loss is lacking, I usually say that they can do more than they currently are doing (exercise)...either more frequently or more intensely.  Those that do take it to heart are usually very surprised at the results!

Additionally, with the Sleeve and Bypass patients, regular varied exercise helps to maintain lean body mass when weight loss is occurring  rapidly. This often requires at least the 60-80+ grams of protein per day we recommend to inhibit muscle breakdown, depending on the intensity of the exercises performed.

Once patients start to lose weight, get some momentum going, and feel better about their body image, it gets easier to get them out there - to the gym or the great outdoors.  Many come to experience that they actually love exercise, and/or return to love it like they did when they were younger and more fit.

During the weight maintenance phase, generally starting 12 - 15 mos after their surgery when they are near or at their goal weight, exercise also plays another key role, stabilizing the their weight in addition to making up for some other behavioral / dietary indiscretions that will occur now and then.

And when all else fails, bring sex into the equation... It is one of the studied benefits of regular exercise!  That often gets some attention.  Other benefits, especially in our obese, post operative population include:

     *Improving Cardiovascular Fitness and Lipid Profile
     *Improving Bone Density
     *Preventing or Delaying development of Type 2 DM
     *Increasing Lean Body Mass and Strength
     *Controlling Anxiety and Depression
     *Promoting a Sense of Well-Being
     *Increasing Resistance to Infection
     *Improving Energy Level and Quality of Sleep
     *Reducing Symptoms of DJD
     *And, Yes, Improving Sexual Desire, Arousal, and Performance.  There, I said it.

Whatever it takes!  Just Do It.
 

Exhibit E

Photo by M Clock

It's time for another patient profile.  And it's time for a Band Diabetes success story.

If you haven't already done so, make sure you take a look at the previous section of posts exclusively on the Gastric Band (Backstage Pass to the Band), and take note of it...

The Band is a valuable tool in the battle against Diabesity as well. 

 Maybe not as sexy as the near immediate metabolic benefit of the Sleeve and the Bypass, with the gastric transection required to do the procedure, but it still has it's place and a potential long term benefit.  

Again, as the studies show, surgery beats non-surgical weight loss, in terms of durability, hands down.

Here is this patient's story, I saw her this week in follow up.

Demographic:  45 y/o F

Start Weight:  230 lb  BMI:  35.6

Date of Surgery:  5/2010  Laparoscopic Adjustable Gastric Banding

DM Hx:  Onset of Diabetes type 2 9/2009.  Started oral agent at that time, Glucophage, but quickly discontinued due to GI side effects.  Glipizide ER 7.5 QD was then started with less side effects, with good results.  Meds were initiated after  failed attempt at weight loss to improve her insulin sensitivity and improve her glycemic control.  BG 180 random, glyco was 8.0 at time of referral for Band. Patient wanted a way to curb her appetite and achieve a durable weight loss to help her DM2 and Hyperlipidemia.  No DM complications at time of surgery.

Current DM Hx:  Current weight is 189, BMI of 30.  Off oral DM meds, last Glycohemoglobin  was 6.1.  Much more active now with exercise, and enjoying her sense of decreased hunger in between meals and the reinforced nature of appropriate portion control.  She is also happy about the improvement in her lipid panel- had labs drawn per her PCP recently and she reported an improved total cholesterol, but I didn't get her actual breakdown yet in the mail.  

Take Home Point:  Nice to have a young patient with mild early Diabetic disease undergo a surgical procedure and see such a drastic improvement in her control of glucose, currently off all meds.  That's the way to get the biggest bang for your Bariatric buck.  Add to that her improved sense of well-being, more palatable / tolerable exercise, and improvement in other co morbidities, and we have a winner!

Who also wins though?  The PCP for an easier time managing this patient as far as her co morbidities go.  The health care system for less burdened care with additional Rx and specialist consults potentially in the future, etc. And of course the patient, for the reasons listed above.

In some ways, this is a simple patient presentation, but it also highlights catching the patient early at a lower BMI, earlier in their Diabetic disease, and being responsive to her desire to have the surgery for her well-researched reasons for health benefits beyond medicines. I believe that's a Trifecta!

It also illustrates the fact that even modest weight loss, in the right  setting, can make a huge difference in a patient's health.  Some of you doubters out there may say that the same results can be achieved with lifestyle modification or other non-surgical means, and you may be right... but surgical weight loss has repeatedly stood the test of time vs. non-surgical means.  I agree though, neither is perfect.

Ask someone who has a substantial weight / BMI how many diets and weight loss programs they have tried...and how much weight they have lost...and kept off...   If it were only that "easy"...

  

Thanksgiving, The Day After

Great day yesterday.  A time to take a few moments out to think about gratitude, and to celebrate the family traditions that go along with Thanksgiving Day.

Photo by M Clock

Fried turkey.  A day in the kitchen, working on the uniquely special meal all day, with it's attendant aroma.  Lazing around watching TV.  Some much needed lawn work to complete... not sure why I did it, I guess because "it was there" and it was such  nice day weather-wise.  The post-meal snooze, or this year, a Black Jack tutorial from a seasoned Uncle.  And, most importantly, just taking some time out to enjoy being together as a family, as it subtlety but progressively changes from year to year, starting to really appreciate all that we have as a family, and all the we have had as a family.

Speaking of appreciation, if you take a look at our Ellis Medicine Bariatric Care Center page on Facebook, you will notice a number of appreciative posts.  It may be a sense of a new beginning as a patient prepares for surgery or starts the preoperative weight loss phase.  Or a patient who has a surgery date and is looking forward to the day of that new beginning. Or the postoperative patient that is off many of her meds, (especially Diabetes meds!), or a patient enjoying all of his new found quality of life benefits as their weight loss is occurring rapidly and they are able to do so much more than before.

Add to that the multitude of stories we hear in the office nearly every day regarding goals met, milestones achieved, and the numerous outwardly obvious and intimately personal benefits of weight loss surgery success...  These keep us going when the days can be challenging at times.

I guess when you really boil it down the the basics- Thankfulness is as simple as being aware of and appreciating something that you 'have' that you may not necessarily deserve.  And whether you work for it or not, in some way you really don't have total control over that thing, that situation, that relationship- yet you really do, in some way, have it now. Being thankful is a way to enjoy it in a different, but very satisfying way now. We have a choice to see the glass half full all the time!

Happy Thanksgiving!

How Low Can You Go? Post Op Hypoglycemia part 2

From EndlessGroove.com

Now that you suspect a post- Bypass patient is presenting with symptoms of, or issues related to hypoglycemia, here's the work up, treatment modalities, and the attendant potential long term implications.

First off, we want to ascertain whether the hypoglycemia is physiologic (related to behavior and / or dumping syndrome), or from an associated hyperinsulinemic state (which has been described after Bypass).

The vast majority are the former, related to dietary indiscretion of repeated ingestion of simple CHO, not eating enough protein at a meal, and/or not eating in a regular fashion / skipping meals with a prolonged fasting state.

Lab workup should include a fasting glucose, C-Peptide, and fasting insulin level, with perhaps a glycohemoglobin.  Again, an elevated insulin level may indicate the need for further testing, imaging studies, and likely and Endocrine eval for the possibility of Pancreatic Nesidioblastosis.

Blood glucose sampling at the time of the patient's symptoms may help confirm the hypoglycemia, as well as the history of an efficient response to a small amount of simple CHO will also be helpful.

Getting back to proper Bariatric behavior in the way of 3 (or more) meals per day high in protein and low in CHO (especially simple CHO), and avoiding prolonged periods of 'fasting' in between meals has been advocated. Avoiding eating and drinking together slows down the entry of chyme into the small intestine.  Our Dietitian helps the patient sort this out, and reinforce the proper habits.

Having the patient check their BGs prior to driving, exercise, at HS, etc. may help them to have a better sense of control and correlate symptoms with triggers and situations where lowered BG (or syncope) may pose a significant issue.

Should the episodes still continue despite behavioral change, Acarbose can be prescribed.  At 50-100 mg TID, preferrably 10 mins prior to a meal, case reports have shown that the medicine-induced delay in CHO absorption helps with minimizing the associated hypoglycemia as a rebound from a rapid increase in glucose associate with dumping syndrome. Other meds such as Octreotide and Calcium Channel blockers have also been mentioned as potentially helpful.

So, now that we are keeping in mind the presentation of hypoglycemia in post-op Bypass patients, we also need to mention it as a cause of weight regain after surgery.  We always stress the behavioral component as the main etiologic factor, of which there is very often sufficient evidence in the history of repeated indiscretions. However, unchecked hypoglycemia can be a possible factor.  Having a patient go through cycles of hypoglycemia with an acute desire to eat to resolve their symptoms, and have that pattern recur repetitively,  can certainly cause substantial regain of weight over time.

And again, getting back to Bariatric basics for behavior, such as eating properly, exercise, and follow up visits to be reevaluated, is paramount to getting back on track and maintaining good health and weight maintenance long term.

How Low Can You Go? Post Op Hypoglycemia, part 1

From Endless Groove.com

Hypoglycemia is a pretty easy thing to diagnose, usually associated with a Diabetic patient that has a relative excess of insulin from treatment for their Diabetes. The mild symptoms are often either treated by the patient on their own, or perhaps first verified by finger stick and treated accordingly with simple CHOs.  The patient fairly rapidly gets better, and that is that.

How about in the setting of the absence of anti Diabetic meds, and with the surgical history of a prior Gastric Bypass?

Well, with all good things, there is not uncommonly a downside.  Here is another such case.

The metabolic benefits of Gastric Bypass so touted in this Blog do have the possibility of causing symptomatic hypoglycemia. Although relatively rare, it can occur months to years after surgery, with the associated significant and rapid weight loss.  In some patients, with hypoglycemia unawareness, it can progress to to neuroglycopenia, occasionally resulting in syncope.

What are the mechanisms, presentations, treatments, and what about the potential association with weight regain?

Possible mechanisms encouraging hypoglycemia post-Gastric Bypass:

1.  Lack of reduction of beta-cell mass from pre-weight loss pancreatic state

2.  Gut hormonal activation of new beta-cell formation in the Pancreas

3.  Increased insulin sensitivity after weight loss

4.  Inappropriate beta-cell secretion as a part of the dumping syndrome of early entry of ingested nutrients into the small intestine, and

5.  Abnormal counter-regulatory hormonal responses (Glucagon)

The above article was mainly written for the discussion of a hyperinsulinemic state discovered in an even smaller proportion of hypoglycemic Bypass patients, although the mechanisms are the same for the garden variety cases as well.  The latter is more closely linked to the dumping syndrome described above, which is typically managed with dietary manipulation and/or meds.

Most articles I reviewed described the hypoglycemia as occurring 2-3 years after successful Bypass, and most commonly 2-3 hours after an ingested meal.

The symptoms were fairly typical, with palpitations, sweating, visual changes, diaphoresis, dizziness, and mental status changes.  As described earlier, with a degree of 'unawareness', the first manifestation may be syncope.  Admittedly, there is never really a good time for syncope during one's daily activities.

In Part 2 we will review the workup, the treatments from dietary to pharmacologic, and discuss the likely association of hypoglycemia with the possibility of weight regain years after surgery.

The Who-What-When and Where's of Bariatric Follow Up

Photo by M Clock

Follow up.

Common for medical practices, usually less so for surgical practices.  Bariatric surgery is different. We get to know our patients very well, starting with a number of preoperative visits in preparation for surgery. We often comment that our 'surgical' practice is more like Family Practice as far as follow up goes.

We have heard from more than a few referring practices commenting that staying aware of how their patients are doing can be challenging.  We are moving forward to an EMR early 2013 which should help greatly.  For the time being, we try and send notes through our transcription service, but admittedly it can be inefficient at times. All labs are currently CC'd to the PCPs to keep you in the loop.  This is an area we are working on to improve in our practice.

You as the PCP still retain control over the patient's medical condition for all things, while we see them for surgery-related issues, for both acute care and regular follow up. There can be times of overlap, and our goal is to stay in touch and communicate effectively with you if we get in to a grey area as far as HTN or DM management, or an issue such as anticoagulation is concerned.  

All our patients follow a pretty set schedule of follow up.  Bypasses and Sleeves come in for a 1 week post op check, then 3 weeks later for a 1 month check.  After that, we see them at 3, 6, 9, and 12 mos post surgery, and then every 6 - 12 mos thereafter as well, long term.  We draw labs starting at the 3 mos check, and usually check blood work at each successive visit there after. Again, we do CC all labs to the PCPs to allow you to stay informed of any issues that may arise. 

Our Band patients are a little different.  We also see them 1 week and 1 mos post op, and we start adjusting their Bands at that 1 mos post op visit.  We usually see them every 3 - 4 weeks thereafter for re-evals, and adjustments as needed.  Once their Bands (and their behavior) are tuned up and they are on track, we can safely stretch out their visits.  Given that the Band is much less likely to produce nutritional / micronutrient deficiencies, labs are done a little less frequently, usually around 6 mos and 12 mos after their surgery, or as needed if clinically indicated.  Our Band patients know that if they are in need of an acute visit, we can see them usually the same day to remedy an over tight Band, or within a few days if they have any issues of lesser acuity.

As most of you are aware, we are available daily M - F to see patients acutely for a 'sick visit', for an acute Bariatric issue, or one that is suspected to be so.  We are always available to speak with you on the phone if you have a patient management question or a Bariatric issue that needs attention.  Ask to speak with our Nurse Clinical Coordinator, or myself at 518-831-7001 as needed.  We will be happy to take the call.

Coming in the next post is an interesting issue that is fairly common in follow up after a Gastric Bypass, and can lead to both acute problems and long term frustration in the form of weight regain - Hypoglycemia.

Coming To a Neighborhood Near You

View of a snowy Giant Mt. from the Ausable Mt. Club  11/4/12

How many shopping days left 'til Christmas?

Spent the day hiking in the Adirondacks today, and saw what is to come...maybe even a Nor'easter is forecast this week!

As one who loves weather and Winter, it was kind of fun to see it.  Today was  good mental health day-away.

But now that I have you captive, please help me to help you with this Blog by leaving comments or feedback as to any questions that may have arisen regarding a post, or a topic we haven't covered yet that you need some more information on.

We are just geting started!

Thanks!!

This Post is Brought to You By the Number 3

Photo by L Clock

Yes, the number 3.

 This isn't a Sesame Street thing, timed as a 'November Surprise' to help sway the election.  This may actually be more important than that to a lot of patients out there with type 2 Diabetes and obesity.

I already let you know we were in Vegas recently, some of the Bariatric group at Ellis, to attend the Fall meeting of the ASMBS.  One of the eventful things I got out of the meeting was a review of a recent study that qualified the preoperative predictors for a Diabetic patient and the likelihood of Diabetes remission after Gastric Bypass at 1 year post op.

"Predicting the Glycemic Response to Gastric Bypass Surgery in Patients with Type 2 Diabetes" was a study published in Diabetes Care  October 1, 2012.  It looked at 154 ethnic Chinese subjects, and how their glycemic response was influenced by Bypass at 1 year post op.  It defined remission as a HbA1c of less than or equal to 6%.  Remission was achieved in 107 patients (70%) at 12 mos.

The three (as in 3, our magic # for this post) independent preoperative predictors, and therefore 3 clinically useful cutoffs were as follows:

   1.  Diabetes duration of < 4 years.
   2.  BMI of > 35
   3.  Fasting C-Peptide concentration of 2.9 (let's call it 3 for the fun of it...)

The study further concluded, the combination of 2 of 3 of the clinical predictors allowed for a sensitivity of 82% and a specificity of 87% for remission.

This is huge, Caroline, HUG-E.

I have detailed in this Blog, in previous posts, specific Case Studies supporting this degree of remission after Gastric Bypass surgery.  We have discussed the physio-endocrine mechanisms for the remission, or at least, substantial improvement of glycemic control following Bypass, and to a similar degree Sleeve Gastrectomy.

What this study now shows is two-fold, as I see it.  One, it further underscores the power of the procedure- Gastric Bypass causing Diabetes remission.  And two, it shows that sooner is better, and qualifies the clinical cutoffs for when referring a patient sooner is better.

Sending patients for Bariatric surgical consideration when they still have significant Pancreatic Islet Cell reserve, as implied by the "less than 4 years of Diabetes",  and specifically measuring it by C-Peptide as above 2.9 (greater than 3) will give your patient the best chance at the best result from their Bariatric procedure.

So, perhaps the C-Peptide is a more sensitive indicator for referral then which / how many PO Diabetes medicines the patient is on; how much insulin the patient is on; what type of insulin the patient is on (short or long acting); or how heavy (BMI) the patient is.

It is said, Everything happens in 3's... and maybe it's true...

*3 clinical cutoffs for the best timing for Bypass for best chance of Diabetes remission

*A C-Peptide of 3 or higher will likely lead to greater likelihood of Diabetes remission after surgery

*and, of the 3 common procedures we offer,  Bypass and Sleeve are the most likely to give you the greatest metabolic (Diabetes) benefit for your buck perioperatively.

Lastly, 3 has always been my son's favorite number.  Go Red Dragons!

Enough said.  Viva Las Vegas!

Backstage Pass, Part 3...

                                                                                                   Photo by M Clock

OK, so what's the catch?

What's the catch for a shorter operation time, outpatient procedure, quicker return to work, and no transection of the stomach or intestinal interposition?

Less complications!  I guess that's not really a catch, but it is something to think about, and it holds up over time vs. Bypass and Sleeve, reported as "3x less than Sleeve Gastrectomy and 4x greater than Gastric Bypass" on the Lapband site.

Those would be the complications of bleeding, staple line leak, and port site infection early; and port site hernia, stricture, marginal ulcer, bowel obstruction and nutritional deficiencies, which may occur later.

So, what's the catch?  Still haven't answered the question, have I?  Maybe I should go into car sales- the best answer is another question... Using my insight and experience, as well as Risk Information from the Lapband site let's clarify:

1. There are the practical issues of slower weight loss -generally 1-2 lbs a week if all goes well.  Not really a 'complication', but a side effect, and one that the patient may forget from time to time even when they are doing well with the Band.

2. Temporary "over-restriction"  which is a relative over-tightening of the band, either by too much fluid given at an adjustment, or a patient eating in a non Band-friendly fashion (too fast, too much, too dry, too coarse of a texture).  Usually treated quite easily by removing a small amount of fluid, with dietary re-education as needed.

3. Mechanical failures of port malfunction (usually leaking, although rare), band leakage (never seen it, but reported), and detached or poorly positioned access port which may cause pain and may need reattaching to the abdomina wall.  Occasionally a port is very difficult to access, and may need X Ray / fluoro to access.

4. A "slip" (11%) is another way to describe a gastric prolapse that may occur over time, usually as a result of recurring vomiting, as a result from, again, over-tightening of the Band and/or behavioral influences.  It can run the spectrum of asymptomatic to the severe pain of impending gastric infarction if not recognized early.  A re-operation may be needed if the patient does not respond to the conservative, but very often successful, removal of fluid to let the band / stomach pouch rest.

5. An erosion of the Band (1%) can occur due to the foreign body effect of the Band over time, certainly encouraged by smoking and NSAID usage.

6. The more nuisance side effect of GERD (34%), is usually remediated by taking some fluid out of the Band, or coaching the patient again on proper eating habits.

Yikes, sounds worse than it really seems to be in every day practice.  We have done well over 500 Bands in our practice, and although there is an occasional difficulty with the Band patient and "side effects", most Band patients love their Band and come to enjoy it's automatic portion control and hunger suppression as they lose their weight.

In our experience however, the Band seems to be the procedure that's easiest to beat.  It relies the most on proper behavior and frequent follow up to achieve significant and lasting weight loss, and likely has the lowest weight loss of the 3 procedures, net, in comparison.  That being said, in some studies, such as the Swedish Obesity Study the Band held it's own over the 15 year study time period.

To summarize - you get what you pay for.

Avoiding some possible complications of a likely more effective procedure, for a simpler technical procedure that has the higher potential to be suboptimal in its effect is a patient's choice.  Often a Band patient will either have a Band or no weight loss surgery at all. We inform all of our patients the risks and benefits of all the procedures we offer (Band /Bypass/Sleeve) during their 2 preoperative visits with the surgeon, and generally let them decide which is best for them.  Having a patient "buy in" to how the surgical tool of their choice will work is a huge part of the process, is reviewed and reinforced preoperatively by our Registered Dietitian, and is linked directly with weight loss success.

In final summary, all information aside, all 3 of these tools are safe and effective, significantly more effective than non-surgical weight loss, and very likely markedly safer than no weight loss at all.  The choice is up to the patient, and up to you to be informed and have a good idea of potential candidates that would benefit form weight loss surgery, whether it be Band, Bypass, or Sleeve.

Sometimes, even in Obesity, To Cut Is To Cure.

Next Stop, Vegas Baby!

 That old adage won't be true this time.

 Presently at a Bariatric Surgical conference for ASMBS in Vegas, and will bring home the latest info on weight loss surgery and Diabetes, Sleeves, etc.

So, at least that part of what happens there will not stay there...as for the rest, we'll leave it at that.

Stay posted.



Photo by M Clock



Backstage Pass, Part 2...

                                                                                                     Photo by M Clock

   Banding is a kind of enigma.

   There are Bariatric Surgery practices that are almost exclusively Banding practices, offering few, if any other options.  There are leaders in the field of weight loss surgery that are staunchly opposed to Gastric Banding as an acceptable procedure.  Emotions flow on both sides.

  Practically speaking, it works, but as in most medical interventions that require a behavioral input from the patient, the results can be variable.

   So, for Diabetes,  the major drawback is that without any transection of the stomach, or intestinal malabsorption, there is no immediate metabolic benefit to placing the band, as does occur perioperatively with a Sleeve or Bypass.  The upside is potentially less complications, no staple lines, outpatient-type of  length of stay, and likely less micronutritional deficiencies as the procedure is only restrictive, and not malabsorptive.  Further, the downside of that is a slower (1-2 # / week) weight loss, vs. more drastic weight changes early on with the other procedures.

   Even so, weight loss is weight loss, and with the 10% weight loss requirement we have before surgery, and the attendant weight loss after surgery, especially if coupled with appropriate changes in dietary content (more protein, less CHO) and volume / portion size, easier regulation of blood sugars  will usually be seen early in the post operative period, just not in the immediate postoperative time frame.  Medicines for Diabetes are often steadily reduced in the preoperative weight loss phase, and monitored to be reduced in subsequent post surgery visits as we adjust the band for optimal restriction.

   Studies have been done on looking to find the optimal patient for a Band, and there really is no consensus that can be drawn from them.  They have looked at BMI, socioeconomic status, dietary practices, and psychological profiles. Some suggest this may be the best approach for a surgical treatment of adolescents, avoiding more 'irreversible' surgical methods, while potentially reinforcing proper dietary habits.  This is experimental at this time and not FDA - approved.

  The other way to look at the lack of a clear cut patient profile that is likely to succeed is that anyone is as likely as another to succeed that applies themselves and follows the rules of proper diet and followup with adjustments as needed.  It is easier to 'beat the Band' than the other procedures if the patient does not comply with regular follow up and adjustments, but most that do adhere to the rules usually do well.

   The FDA did approve last year an indication for Gastric Banding starting in the 30-35 BMI range for a patient with Diabetes, although insurance companies have been reluctant to approve this, and it usually requires a case review, but may be approved on an individual basis. Traditional NIH criteria, as you are likely aware,  starts at 35-40 BMI with comorbidities to qualify for surgery.

    This may be a nice niche for the Band in Diabetes - catch it early, reduce a mild amount of weight, and maintain that balance of weight and insulin sensitivity for a prolonged amount of time.  Success!

   In the third and final part of this Band discussion, I will focus on the practical standpoint of side effects and complications from Gastric Banding.



 

 

Your Backstage Pass to The Band, Part 1

 

                                                                                                    Photo by M Clock

   And now for a few posts on the Band.  The other Band - not DMB.

   Gastric Banding is one of the surgical options we offer for weight loss, and it does have a role in Diabesity as well.  There are patient factors to consider, both behavioral and medical, as you (their PCP) either guide a patient to or from this choice as an appropriate surgical option.  Again, as detailed earlier, the surgeon that sees the patients before surgery go over each option with your patient, centering on the patient's choice and why, and their medical history and what can be expected from their desired procedure.  Rarely do they "talk them out of" their procedure of choice.

   Occasionally a patient has done their research and ONLY wants a Band, due to the "extreme" nature of the other options that require either intestinal "rewiring"(Gastric Bypass), or removal of a good part of their stomach (Sleeve Gastrectomy).  For these patients, it's likely a Band or nothing else.  Interestingly enough, other patients choose "anything but the Band" due to their worries about the safety of a long term implant.  Obviously, both have their merit.

   Is there a perfect patient for the Band that will definitely have long term success?  No.

   We have many Band patients that do well, sometimes losing over 100 lbs over 1.5 to 2 years, and love their Band.  We have some lesser BMI patients that plateau or don't lose much, usually owing to poor followup- which is the most important way to "guarantee" success with the Band.  Let's face it- the advantage of adjustability with the Band is also it's greatest downfall in that if the band is not adjusted properly, and/or  the patient does not "adjust" their lifestyle and dietary practices to the Band, suboptimal results will be realized.

   Furthermore, if you ask a patient how they are doing with their Band, and they have realized a modest weight loss, have newfound control over their dietary intake, and have either an improvement in quality of life or their medical co-morbidities, they definitely feel like they are on the road to success (See previous posts on Success in this Blog).  Again, all it takes, in most cases of obesity, is a sustained 10% weight loss to see modest benefit in quality of life and associated medical conditions.

   So, yes, the Band has a definite role in the surgical treatment of Diabesity.  In the next post, I will detail the Diabetes benefit and how the Band assists in that realm.

Exhibit D: The End of the Rainbow

                                              Photo by M Clock

We haven't had a Sleeve Gastrectomy Case Study yet.  Wait no longer.

I saw this patient in the office last week. She was ecstatic that she took charge of her health care, went to see her Endocrinologist in regular followup earlier this year, and popped the question: "What do you think about a Sleeve for my Diabetes?"

Here's what happened...

Demographic:  46 y/o F

Start Weight:  240#   BMI:  35.6

Date Of Surgery: 10/16/12 
                               Laparoscopic Sleeve Gastrectomy

Diabetes Hx: DM2, uncomplicated, on Insulin. Lantus 65u BID, Novolog scale with meals, averaging 38 units TID. Glycohemoglobin A1C 9.2 upon entry to program.  Sees PCP and has Endocrine also helping to manage her Diabetes.

Current Diabetes Hx:  Currently 3 mos post op, weight down to 181, with BMI of 27.  Off Insulin, and now "Diet-Controlled". BGs at home normal, Glycohemglobin pending from Endocrine visit recently.  Was told on her last visit there last week that she and her PA provider would have to "Break-up" seeing each other, as her sugars, and her (DM2) disease process, was essentially in remission.

Take Home Point:  Sleeve Gastrectomy, as mentioned earlier and in numerous places in this Blog, works well for Diabetes.  Studies have borne this out, and the data is increasing as these patients experience long term results.  In the past, the Sleeve was a portion of the BilioPancreatic Diversion / Duodenal Switch (BPD-DS), but 'recently', within the past 5-10 years, it is now an accepted stand-alone procedure producing sound results.

Due to recent improvement in insurance coverage for the procedure, and it's additional appeal as far as lack of malabsorption (and the patient's conception of what that entails surgically, as with a Gastric Bypass), and a typically shorter stay in the hospital (1 day vs. 2), it has garnered notable patient interest.  

Of additional note, again an example of a patient taking it on themselves to become educated about their health, seek out alternative treatments, and, as detailed here, reap significant benefits.  Weight reduced.  Eating in check.  HTN and Hyperlipidemia much improved, off meds.  Improved quality of life.

Where would she be, health-wise, in 10-15 years with stable weight, or more likely slight but steady weight gain,  and further increasing insulin resistance?

Success, Defined!

So, here are a few of those success principles we look at to ascertain the degree of success, or lack thereof, when evaluating a patient post operatively.

1.  Weight Loss of approximately 60-80% of Excess Body Weight, generally achieved one year after a Bypass or Sleeve, and 2 years after the Gastric Band.                                         

                                                                  Photo by M Clock

2.  Maintenance of that weight loss to a reasonable proximity, years after surgery.

3.  Resolution of CoMorbidities, such as DM2, which may occur independent of the weight loss component of aforementioned success principles.  The improvement / resolution of other disease states (HTN, Lipids, OSA, Chronic Pain / Arthritis, PCOS / Infertility, etc) usually includes great financial benefit, as well as #4 Quality of Life benefit, below.

4.  Quality of Life is still a central, and somewhat less-precisely measured, point on the Success curve.  It likely is not as definable an endpoint as the others may be, but again, query a patient on how their life has changed in the context of where they are currently reside on their weight loss journey after surgery. These are usually very personal, and emotion-laden mile posts on that journey, and carry much more impact for most folks than a 'goal weight', even if achieved, can ever give, such as these:

     *Fitting in a chair on an airplane comfortably for the first time.

     *Being able to see my shoes to tie them.

     *Being recognized at a store as a 'true customer' at Walmart, as I shopped for clothes I actually fit in.

     *Going to see a movie with a friend for the first time since childhood.

     *Making my daughter angry that I could wear her clothes!

     *Being able to play on the floor with my Grandchildren comfortably.

     *Knowing that I am modeling to my kids the priority of good health, and hopefully prevent their need for surgery someday.

     

...And the list goes on and on...

So, you can see 'It's not (all) about the weight', but it really is, in a way.  

I guess the point is this.  It's not as easy /simple as a "100 #" weight loss, and from the patient's side, it's not as hard as that in order to get benefit from such a drastic thing as surgery for being overweight.            

 And, also, one thing we stress to our patients is that once the surgery is done, the journey to better health is really just beginning.  However, keep in mind,  there are many scenic vistas along the way before the patient, and their health care providers, consider them arriving at success!

It's as easy as:

     Success is getting what you want. Happiness is wanting what you get. 

          - Dale Carnegie

Or as complicated as:

If your success is not on your own terms, if it looks good to the world but does not feel good in your heart, it is not success at all.

          -Anna Quindlen