Metabolic MoJo, part 2: Putting It In The Rear View Mirror

                                                                          Photo by M Clock

One of the benefits of being a fresh empty-nester is the newfound ability to travel more, and taking advantage of 'non-committed' time. We never had the time in the past to even contemplate such a thing, but now our two active boys are in college.  So, it did happen, and it's actually quite OK.  It just seems now to have come on us kind of quick.

The other aspect of a little more free time is to be able to stop and smell the roses a little more, hence this photo of a beautiful Central NY sunset, as seen in the rear view mirror while driving this past weekend.

So, now time for part 2 on the mechanisms of the physio-metabolic benefit of bariatric surgery. Here's the way to potentially put your patient's DM2 in the rearview mirror, and maybe even a distant memory if all goes well.

To start off, as you may have seen, 2 landmark studies were recently published in NEJM that definitely showed the powerful effects of Bariatric Surgery on Diabetes.

Here's the deal.  Cutting the stomach, whether to create a pouch as in a Gastric Bypass, or creating a narrow linear portion of stomach left behind as in a Sleeve Gastrectomy, causes significant changes in gut hormone secretion that greatly encourage euglycemia from many different angles.  There does seem to be a slight difference between the Sleeve and the Bypass as far as Diabetes benefit goes, mostly owing to duodenal exclusion with the Bypass, but both do have substantial anti-Diabetic effects.

While this is an area of new and evolving discovery, here's a quick look at what we do know:

*Bypass of the Foregut impairs ghrelin secretion, which causes generally decreased hunger, and quicker satiation.

*Stimulated secretion of Peptide YY (PYY), which also increases satiation and impairs gastric emptying, and a delayed effect of elevation in post prandial bood sugar.

*Stimulated secretion of Glucagon-like Peptide-1 (GLP-1), which causes a classic incretin effect of stimulated insulin secretion via unburdened and enhanced pancreatic Beta cell function. Also, further inhibits gastric emptying and decreased food intake.

Surely there will be much more to come on these and further gut hormone discoveries when they happen.  They are being longitudinally studied. as we speak, in a bariatric surgery registry that is an ongoing account of the effects of weight loss surgery on such markers as Diabetes.  The implications for the pharmaceutical industry for a similar medical trigger, in pill form, and for the more than 8.3% of the US population with Diabetes type 2 (25.8 million people) will likely be game-changing.

But for now, the only place for one-stop metabolic shopping for Diabetes benefit that is this rapid and clear cut, is in the surgical subspecialty of Bariatric Surgery (pun intended).

Metabolic MoJo, Part 1

Photo by M Clock

So, I spent the weekend on Cape Cod recently, and saw this hurricane evacuation sign and I thought about an "Evacuation" of sorts from Diabetes after Bariatric Surgery.  Kind of cheesy, I agree, but I'm going with it anyway.    Diabetes and the 'storm' of Glucotoxicity (see 'Tale of 2 Fish'...above) might just seal the assimilation...

The big question I get asked from both patients and Providers alike is, "So how does it work that the surgery is so good for Diabetes, and works so fast?

This is a 2 part answer; here's part 1.

The initial weight loss advantage of the surgery parallels the amount of weight loss directly.  As you have likely seen in your practices, even a 10% loss in weight via lifestyle alteration by a patient can significantly alter their Diabetes meds and insulin sensitivity.  We require a near 10% weight loss prior to going to the OR not solely for that reason, but for the benefit of liver shrinkage, the diuretic effect on the internal structures, and to help improve co-morbidities (HTN, Respiratory function, DM, etc.).

Studied averages of percentage of excess weight lost (Excess weight is true body weight over Ideal body weight, reported as % lost):

Laparoscopic Sleeve Gastrectomy 60% 

Laparoscopic Adjustable Gastric Banding ~50+%

Laparoscopic Gastric Bypass 70%

And now, the physiology of how weight loss itself effects Diabetes:

1. Dramatic increase in insulin sensitivity which unburdens the pancreas

2. Reduction in glucotoxicity, as well as lipotoxicity (FFA, Adipokines) which restore beta cell function and increase insulin sensitivity

3. Increased level of Adiponectin, which increases muscle sensitivity to insulin

Our next post will go over the NON weight loss associated benefits of the surgeries, focusing on the Sleeve and the Bypass.  That is where we even further deliver our Metabolic Mojo.

Dr. J and a Tale of 2 Fish



                                                                                                       Photo by M Clock

 Rock Harbor, Orleans Massachussets -   It's all about the environment. 

Not the land, not Global Warming, not even the Ocean temperature, although that's an important part of this story.

I had an interesting talk with Dr. Jameson last week, a noted Seasoned-Statesman of the Endocrine world in Schenectady, about Diabetes care, new trends in treatment, and the role in metabolic surgery in the management of the disease.

He is a big proponent of surgery for the obese patient with Diabetes, especially when other co-morbidites are involve such as OSA, HTN, Hypercholesterolemia, etc.  He wishes death certificates more accurately reflected the true role of Diabetes in the cause of death, either primary or secondary, as it could result in more Federal funds allocation for Diabetes treament and research (see previous post "Roid Rage" and link to top 10 US causes of death).

Our conversation got to the root of the problem with Diabetes: Glucose Toxicity. 

He said, "You can't see it, you can't touch it- and although you can test for it and you know it's there, the damage exerted by it's presence on the body is additive over time", and needs to be treated definitvely and early, and maintained consistently throughout the patients life. Medicines can do it for a while, maintaining euglycemia, but in patients with increasing insulin resistance /   more adipose tissue / elevating weight over time causing even more resistance (as well as it's own toxic effects), leading to sustained hyperglycemia and elevated glycohemoglobins- the net effect of the toxicity is disastrous to the body and its organ systems (it's environment).

His analogy was this question:

"Why do you think the D.E.C. (N.Y. Department of Environmental Conservation) has a list of fish that you can't eat more than once per year?" It's not the fish's fault, in fact the D.E.C. specifies the species, their location where caught, and the limit of what is healthy to ingest.  It's their environment.

As some of you may be aware, Striped Bass are a key resource that keeps the Rock Harbor Fleet busy May to October in the Cape Cod Bay.  I have seen some of those fish to be nearly as tall as the lesser-statured members of the families that come on board the charter boats they go out on.  Beautiful black and silver-white striped fish.  Delicious fish.

So, where would you rather eat one from? The Cape Cod Bay, or the Hudson River? 

Exactly.

Exhibit B

Photo by Wonderlane

Here's another case study, a patient who had surgery last week.  Before I put up another report, I will put together a post detailing the pathophysiologic mechanisms at work that make Bariatric Surgery so beneficial for Diabetes.

Demographic  66 y/o WF

Start Weight  278 /  BMI 42

Date Of Surgery  9/12  Laparoscopic Gastric Bypass

Diabetes Hx  Glimepiride 4 mg QD, Victoza, Metformin 500 QD, Actos 30 mg QD.  Controlled pretty well per the patient, had started meds for Diabetes 12 years ago.

In Hospital  We put her on Novolog sliding scale immediately post op, and let her settle out over the next 24 hrs to see what she would need.  The stress response to surgery sometimes causes a transient rise in BGs, and seems to quiet down in most patients by POD 1.  First reading after surgery was 244, then 157 next AM on no other maintenance coverage. On POD 2, the last 2 readings before she was D/C were 98 then 78, again requiring no insulin, PO meds, or Victoza.  She was sent home on no meds, and we will see her in the office in 1 week for follow up.

Take Home Point  Again, a fairly typical, yet profound, improvement in restoration of euglycemia after surgery, and sent home off all antidiabetic meds. 

A couple of interesting points.  She had DM2 for 12 years, on a good mix of medicines, and sometimes that duration of disease alone is enough to diminish the favorable metabolic effect of the surgery. Add to that her age, and it was a little surprising she did so well after surgery.  She will have to be watched long term for the slight chance of the return of her Diabetes, but with additive weight loss as expected from the surgery, she should do well for quite a while after surgery at a minimum.

Also, she said she lost 30# preoperatively on a Lean and Green diet, exceeding our requirement of 10% loss required to get to surgery.  That is usually enough to make a dent in DM2 meds needed, as often evidenced by patients getting hypoglycemic on their usual meds for DM2 as they lose weight in our preoperative phase, prepping for surgery.  She told me there was no change in her meds despite the significant weight loss preop, and that makes you think about significant insulin resistance, or the start of an insulinopenic state potentially brought on by prolonged DM2.  

In any event, she's through the surgery, did well, "Sugar-Free", and we'll recheck her next week.

You Wear it Well

It was one of those days in the office...

Crazy, unpredictable, variably inefficient … too many people to see in a fair amount of time. And we didn't even have one Drug Rep! Sounds like a day in Family Practice, right?

Anyway, the day has left me in a kooky mood, so I thought I'd relate a patient story I heard recently, with a brief commentary.

When I asked a patient yesterday if she introduced the idea of her referral for Weight Loss Surgery, or her PCP did, she said

“No, it was my idea. In fact I had to bring it up at my office visits 2 or 3 times in a row until she decided it was OK for me to go. Her response to my first request was for me to tell her my weight. I said I was 5'1” and 198# (BMI 37.4). Her response was that 'You wear it well', and didn't want to refer me. We did discuss lifestyle change, and I did my best, but ended up here for surgery when I kept gaining.”

All I could think of initially was the Debarge song from the '80s of the same name. I still am playing it my head, it's stuck there.

So, what's my commentary? Many issues, but to start just one. Maybe 2.

Firstly, from her response to her PCPs reaction about having surgery for her weight, she was initially frustrated, concerned, and embarrassed. She didn't know how to read her Doctor's reaction. Indifference, discomfort with the idea of surgery, or was she  unaware of the benefits of Bariatric Surgery? Of note, she did have OSA, HTN, Impaired Fasting Glucose, and mild dyslipidemia.

Next, when exactly does a Bariatric Surgery referral fit in to the plan for a patient with obesity and associated co-morbidities? I suspect this is a personal provider decision based on experience, comfort level,  and documented lack of success with prior attempts at lifestyle modification, which is always first line. I hope we will talk in future posts about this topic, as it gets down to the nuts and the bolts of every day practice, and I'd love to hear your take on it.

Suffice it to say that Weight Loss Surgery is NOT for everyone, and is NOT first line for obesity or associated disease states.

But in the case of this patient that went to her Doctor's office, is a good candidate for the surgery, is well prepared with why she wants to have it done, and asks her PCPs permission- I think she was looking for a better response. Even a 'physician supervised' lifestyle mod plan with dates attached for followup, and a timeline for surgery, if she agreed with her choice, would have been preferable.

By the way, she's 4 mos out now from Gastric Bypass, over 40# lost, euglycemic, normotensive (off meds), and with an improved lipid profile, off meds. She does in fact Wear it Well now...

Exhibit A

Photo by Wonderlane

Evidence.

Here is the first case report of many, whereby I will post an illustrative case scenario of an actual patient that I have seen recently in the office or hospital,  exemplifying how Bariatric Surgery altered the course of a patient's Diabetes.  

Here's "Exhibit A".

Demographic  46 y/o WF

Start Weight  358 lbs / BMI  55

Date of Surgery  8/2011 Laparoscopic Gastric Bypass

Diabetes Hx  Relatively well controlled, requring numerous PO meds and Insulin.  Glyco upon referral was 7.9, with FBG of 203.  Diabetes meds: Actos 30 QD, Glumetza 1000 BID, Glipizide ER 10 BID, Lantus 80 mg HS.  Near 10 year history of Diabetes as diagnosed and treated.

Current Diabetes Hx (8/2012)  Currently off all DM meds, maintaining euglycemia with diet, lifestyle and maintenance of her weight off after surgery.  Current weight is 258 with a BMI of 39.

Take Home Point  A vivid, but fairly commonplace example of what a Gastric Bypass can do for an "average" patient with significant obesity, profound insulin resistance, and a notable list of necessary antidiabetic meds.  

Even though her Glyco was not initially in the 'panic mode' range, this patient benefitted greatly from the weight loss-related, as well as the purely metabolic effects of surgery.  Speaking with her just last week, she is overjoyed to be off her multiple DM meds, not needing insulin injections, and not having to pay constant attention to her BG's.  She relishes the added benefit of improved quality of life (that 100 # lost affords her), as well as the resolution of her other comorbidities of OSA, HTN, and hypercholesterolemia. 

A future post will be dedicated to detailing the physiologic mechanisms of diabetic improvement resulting from Bariatric Surgery. Our society (ASMBS) is called the American Society for Metabolic and Bariatric Surgery for good reason.

" 'Roid Rage" : A Personal Perspective

As I mentioned in the initial post of this blog, I share Diabetes with those folks we speak of in this Sugar Free Surgery Blog, albeit mine is type 1 vs. the type 2 that is the predominant type for the obesity related surgery discussion.

I am blessed to have had excellent control throughout my nearly 30 years of disease, but have had some significant challenges of late.

I have had a recent recurrence of a painful condition called Brachial Neuritis, which causes sporadically intense pain along the Brachial Plexus. It can last for weeks, and then is followed up by a few months duration of weakness to segmental aspects of the muscles effected by the demyelinating process that created the pain initially.

In any event, the treatment now is a series of 1 G IV infusions of Methylprednisolone which obviously gives rise to a 24-48 hr period of significant disruption to my normal blood sugars, mandating significantly more vigilance than usual. Diabetics, (especially ones that are in good to tight control) as you likely are aware, are dedicated creatures of habit, often out of necessity. With a brand-new set of rules as far as coverage scales and atypical responses to typical CHO loads, it can get dicey, and quick. I haven't seen readings like today's (over 330) thankfully, in a long time!

It just got me thinking.

I know, and I am sure you do as well, many Diabetics as patients (talking T2DM now) that essentially live by how they feel. Even though they may feel the relatively acute difference of a 65 reading vs. a 250 reading, when they exist in the range of 180 (maybe a good day) to the 300's (as a patient told me recently, her averages before surgery), they are re-establishing what feels normal to them. They often sense a powerlessness about trying to get any better control than they have, and while as their frustration turns to indifference, they still may not feel all that bad.

Add to that the component of maxing out medical therapies, and their inability to lose weight , and/or eating “correctly” for nutrition / weight / and glycemic balance, it with sustained hyperglycemia it truly becomes not a matter of if there will be a problem, but when a related comorbidity irreversibly effects their current level of health.

I suspect you don't need a reminder, but 4 of the top 10 causes of death in the US are related closely to Diabetes. Oh, and by the way, you an add at least one more to that list of 4 (Cancer), to make 5/10 as obesity-related causes of death as well.

Keep that in mind as you see that poorly controlled, obese Diabetic this week in the office. If they applied for life insurance this week, guaranteed that the insurance agency most certainly would.