A Truckload of Info on Dumping

Photo by M Clock, on location

Names can be deceiving.  So can words, and I guess names qualify as words.

Take Dawn for example.  I was down in Florida this Spring and I was at the hotel pool for some vitamin D and a quick chlorinated swim.  I had to take a second look at the sign that was there in plain view.

I believe it said in the event of an emergency to call DAWN DUSK.  I did not know who she was, what her role was, or how to get hold of her.  I bet if I went to the front desk, I suspect they may have called for security if I pressed the issue.  You don't really want a lot of confusion if there's an emergency going down...

OK, I'll let it go.

Similar example with "Dumping Syndrome." When I ask patients in the office if they "dump", they are often quick to recall a forbidden food item they either ate too fast, or too much at one time, and then vomited.

That's not dumping...that's called "Behavioral Indiscretion".

Which finally allows me to get to my point of discussion for today's blog post - Dumping Syndrome.

As you are probably aware, Dumping Syndrome is fairly common after Gastric Bypass, as well as other gastric operations that involve bypassing or removing the pylorus, which regulates the passage of food into the small intestine.  In effect, the ingested food bypasses the stomach too rapidly, and as a result, the hyperosmolar chyme enters the small intestine quickly, resulting in fluid shifts and autonomic nervous system activation.

The common symptoms of Dumping Syndrome are based on when they occur, "Early" and "Late."

Early Dumping occurs very soon after meal ingestion, and causes nausea, vomiting, bloating, cramping, dizziness and fatigue.

Late Dumping, usually within 1-3 hours after eating, is manifested by weakness, sweating, and dizziness.

I had an interesting case recently where a patient was about to 'require' a pacemaker as she had experienced a few episodes of dizziness and sweating and near syncope.  She had a Holter report showing significant bradycardia associated with her symptoms of dizziness and diaphoresis, and it seemed logical she would need a pacer.

This 38 y/o was sent to see us to ascertain whether or not there was any contribution to her complaints due to her bypass.  Labs, including CBC electrolytes were within normal, and I spoke with her cardiologist about the possibility of Dumping Syndrome (as opposed to hypoglycemia - her home BG's were normal ) He was truly hopeful that she could be managed medically without the pacer, an intervention that was likely not going to truly fix the issue with her increased vagal tone, and her secondary bradycardia.

And, more than likely, the most efficacious treatment necessary for those that "Dump?" (Kind of like when someone asks you what to do when they point to a body part and say, "It hurts when I do this".  Answer:  Don't do that.)

It's behavioral!

Eliminate simple sugars from the diet, or other foods that may have triggered an episode.  And, no drinking within 1.5 - 2 hours after eating as not to 'rinse' the food down into the jejunum (Roux limb) too quickly. These interventions are often a big help, and minimize or eliminate complaints in the future.

Honorable Mention

The space above is intentionally blank.  I wanted to at least give a depiction or a screen shot of the new guidelines that were recently released by the American Association of Clinical Endocrinologists (AACE), but I didn't want to violate the "DO NOT REPRODUCE IN ANY FORM" rules on the spiffy algorithmic graphics.  A trip to Blog jail may be my fate.

The bottom line is,  yet another organization, with the backing of the ASMBS, describing the need to strongly consider Bariatric surgery for overweight patients with diabetes, or prediabetes in the Comprehensive Diabetes Management Algorithm for Treatment of Diabetes and Prediabetes Patients.

While that is nothing new, it is yet another updated consensus statement from a respected clinical group that decisively puts Bariatric surgery squarely in the mix of efficacious and necessary treatment regimens for the overweight Diabetes type 2 patient.  And it's the rare patient that doesn't have both.

Add this to a couple of the previous blog posts on the consensus suggestion to lower the BMI requirement for those benefitting most from surgery in the BMI 30-34.99 group ( Tell it like it T-I-S), and the International Diabetes Foundation's recommendation of March 2011, from a position statement on Diabetes and bariatric surgery as to recommend surgery for those with BMI >35 with DM2.

Overall, these statements are nothing all that new, except as the evidence mounts, so does the imperative to keep Bariatric surgery in the forefront of your Diabesity options.  And, as said here in this blog numerous times before...Earlier is definitely better for both short and longer term results.  Perhaps more than we probably truly have a studied grasp on yet, in terms of micro and macrovascular disease that can be substantially improved with surgery, and with an associated reduction in future morbidity and mortality.

So, take some time to look at the algorithm link as above.  For those of you on the front lines of Diabetes treatment in general, it gives a number of pages of comprehensive treatment guidelines throughout the disease spectrum of Diabetes.  The surgery comment is an important one in the treatment options, but honestly, it's a small part of the overall algorithmic publication.  Check it out!

Sugar Free... Temporarily??

From PlaidStallions.com

Some things are good to get rid of.

Likewise, some things will be unpleasant if they do return.

Dating myself, I did have a leisure suit when I was in Jr. High, and I didn't wear it that often, but when I did, I sure felt 'fly'.  I'm not sure if it was the look of the suit, the word descriptor 'leisure' that seemed to be an over-reaching adjective that implied that I was destined to enjoy myself at an event (a funeral, though?), or the stretchy, unrestricted feel of the polyester.... Good times, good times.

In some way, Diabetes is like those leisure suits, or like dated fashion that comes and goes, especially when it represents the worst of the times of a bygone era.

It's great to see the Diabetes go (after surgery) ...but will it come back ? If so, when?  And, how 'bad' will it be when it does return?

I did a literature review, prompted by recent patient requests for an idea of the likelihood of a return of their Diabetes, and looking for some help with a description of how long the post-surgical benefit will last from Bariatric surgery.

Also, an article was recently published in Obesity Surgery, a multisite, retrospective cohort study, looking at 4,400 patients over 13 years and their rates of long-term remission and relapse of DM2 after Gastric Bypass.  When they looked at rates of remission and relapse after surgery, they were also interested in possible predictors of complete remission and relapse.  Remission and relapse criteria were defined clinically by laboratory measures of glycemic control, as well as diabetes medication use.

Of the 68% that did respond to surgery early (within 5 years of the procedure), 35 % of those did relapse within 5 years from their remission.  The median duration of remission was 8.3 years.

Significant predictors of complete remission and subsequent relapse were:

* Poor preoperative glycemic control
* Insulin use
* Longer duration of Diabetes prior to surgery

Weight trajectories post op were also studied, and showed some differences among how the patients did with weight loss durably, and it did have a correlation with both remission and relapsing rates.  Interestingly enough, those with the slightly more significant and durable weight loss after surgery had a little higher relapsing rates.  Counterintuitive, but in need of further study.

You may remember the blog post on the Number 3 whereby I wrote about the study that was reporting a correlation between a C-Peptide level of 3 and predicting the remission rates of DM2 after Gastric Bypass.  As you may remember, C-Peptide acts as a surrogate lab test to measure Islet cell mass and therefore remaining endogenous secretion.

Well, C-Peptide was not a part of this study, but as you can deduce, knowing that level, and perhaps checking it serially post op, I suspect that it may give us a warning as to when a relapse is likely or about to occur. Especially in those that have a lower C-Peptide to begin with, if it was drawn preoperatively.

 The risk factors for relapsers were essentially the same as the above noted study delineated as the risk factors for those who were not as likely to immediately benefit from Bypass.  Again, the lab measurement for the suspected most significant risk factors would likely have to do with C-Peptide, and resultant endogenous insulin secretion.

Much more needs to be studied to put this all together.  Perhaps an algorithm is not too far off in the future.  I know that there is large prospective study currently underway studying may aspects of DM2 and remission-relapsing, etc.

We have started to order more C-Peptides these days on patients in a variety of settings (preop, periop, and post op) to see what correlation we can detect, starting on an anectodal basis.

What I have seen, even without laboratory values, is that even if Diabetes does not completely remit after surgery, it is much easier to control immediately after surgery, with greatly reduced need for meds and/or insulin.  Interestingly, I can recall a true type 1 Diabetic (C-Peptide of essentially zero, if we were to measure it) we did surgery on last year that has had her insulin needs cut by 2/3, with a much easier time at glycemic control and with improved glycohemoglobins. She is now over 9 mos out.

And to add one more layer to this information - Our sleeves seem to be doing nearly as well as our bypasses, at least initially, for improved glycemic effect.  They also seem to enact a return of "metabolic memory" as it may have existed before the metabolic syndrome took hold.

Leisure Suits may never completely return, which would not be a bad thing. I wouldn't mind getting back to the hair I had in the 70's though.... Doesn't that model above look like Bobby Sherman?

Going, Going...GONE!

Photo by M Clock

In the baseball world, the Home Run is one of the most exciting plays to watch.  Not really all that uncommon, but still a thrill to see one go out of the park, with the obligate carefree trot around the base paths that ensues, and the simple math of automatic addition of runs on the scoreboard. Fun stuff.

It's even exciting to listen to on the radio / computer, as I did this week, as my son was at bat, 160 miles away.  He hit one to the outfield wall only to be caught by the right fielder ("with back at wall"). So close, and yet so far from the much needed runs and a celebratory trot.

So it is with Diabetes and Bariatric Surgery these days.  The word is getting out through study after study, the lay press, talk shows, and from patient to patient as they share their good fortune.  This is a big deal!

The one thing that I think is not all that clear about Diabetes and Bariatric surgery is, how long will the remission last?

And as we have discussed with the proposition of Bariatric surgery and the potential for resolution of diabetes in the first place, how can we accurately predict the duration of said remission, for those we identify as likely to significantly benefit from Bariatric and metabolic surgery?

I don't know. Well I kind of know. But not really.

We have certainly seen in our practice, somewhat longitudinally since starting to draw some 'predictive' C-Peptides with more frequency, the expected (and occasionally surprising) Diabetes improvement / resolution after surgery.  There are reports, however,  of the potential return of Diabetes after a certain amount of time (years?).

The question remains, though, as with the case for who responds to surgery initially, and who doesn't, that  there is likely a physiologic basis to predict this post operative effect as well.  I would expect it be tied in to the reserve of physiologic pancreatic function, as preserved by the surgery relative to the state of the islet cell function at the time of surgery.

There may be some other variables, along with age of the patient, duration of diabetes, degree of improvement in blood glucose regulation post op, etc.  Perhaps in the post op setting, just repeating the C Peptide at Q6 mo intervals in conjunction with other updated labs (including a fasting glucose) may elucidate a pattern that is consistent with the eventual return of elevated sugars.

I do suspect further, that even if the diabetes does return, it would most likely be a milder form and easier to control in the setting of significantly reduced weight and much less insulin resistance as compared to the preoperative diabetic state.  I have seen this be the rule in those that did not get the "Home Run" in the hospital, and get the free pass of being discharged after surgery OFF meds, that they needed much less in the amount of basal insulin, or just metformin to get back to decent blood sugar control and a normalized HgbA1C.

So, this was all about what I think, and some of what I have seen so far.  Let me put together a little literature review of some studies that may help us a bit more to give evidence-based medicine a crack at the product of my deductive reasoning.

I am honestly not sure what I will find on this topic of predicting the return of diabetes after it has gone into remission after surgery, but hopefully I am not too far off.

Tell it Like it T-I-S

Sometimes it pays to be direct.

Literally.

On a similar note, here's another musical reference in regards to the title of this post for those interested in an 80s challenge.

Check your guess at the band and the song at the link that follows: http://www.youtube.com/watch?v=OhLByM96XRg



So, why all the fuss?

I just saw in a recent issue of Medline Surgery, an article entited "New Bariatric Surgery Guidelines Reflect Rapidly Evolving Field."

The article went on to describe updated clinical practice guidelines for bariatric surgery refelective of its therapeutic potential for patients with lower body weight who have cardiometabolic risk factors.  Also included were affirmations that Sleeve Gastrectomy is an equally acceptable option with similar weight and metabolic benefits.

Sound at all familiar?  (Just telling it like it T-I-S)

The guidelines were developed by a 12-member panel, and issued jointly by the American Association of Clinical Endocrinologists, The Obesity Society, and the ASMBS (American Society for Metabolic & Bariatric Surgery).  They were published online March 25 in the journals of those 3 organizations.

Not only did they recommend surgery at a lower BMI for those at most risk, but also included peroperative nutritional and non-surgical perioperative support for surgical weight loss patients, aimed at keeping pace with the latest available evidence in the field.

The current version of those who should be advised surgery includes those with BMI > 40, or those with significant comorbid conditions and a BMI of 35 or higher.  This update added that those with a BMI of 30 - 34.9 and Diabetes or metabolic syndrome "be offered a bariatric procedure, although the current evidence is limited."

The first intent of the surgeries is obviously to lose weight, but as time and experience shows consistent efficacy against metabolic disease, and the mechanisms of those disease states are further delineated, bariatric surgery deserves to be in the mix of targeted therapeutic options that can be of benefit across the spectrum of that disease state.

And, as this article, the newest clinical practice guidelines, and experience continues to show, Earlier is Better - both in terms of BMI as well as duration and severity of Diabetes, in order to get the biggest bang for your surgical buck!

Now the next part of this equation is consensus along the insurance spectrum as far as reimbursement for these procedures against that comorbidity backdrop.  That will likely take a while,  but the latest disclosed information is a few steps in the right direction.

In the Beginning... (A Very Good Place to Start)



From Milky Way Blog

Two more aspects to cover to finish this topic of microenvironmental influences that have been shown to have an impact, in this case long lasting, on weight and metabolism and energy balance. 

The previous few posts were about some of those aspects that we have some degree of control over.  These last two to be discussed deal with the earliest aspect of upbringing.  I mean early earliest, like prenatal / in utero, and also post natal influences, such as whether you were breast or bottle fed.

The in utero environment can have a direct influence on the weight of the baby,  post partum and beyond.  Genetic and gene-environment factors are also being studied in this emerging field of research.

From an International Journal of Pediatrics review article, factors that did have an effect in utero were amount of maternal weight gain, h/o Gestational Diabetes. as well as maternal smoking. The article also described the potential changes that may occur by limiting maternal weight gain, as well as improving maternal nutritional exposure and dietary composition as well. 

Post natal effects of breastfeeding on weight have been studied, and the mix of results is essentially inconclusive.  I reviewed the 'Up to Date' reference that stated that "based on the current evidence it remains unclear as to whether or not breastfeeding is associated with a reduced rate of obesity".  At this time it certainly is not conclusive, and this is a polarizing issue on a number of fronts.

So in summary, the result I wanted to achieve from this most recent review was to try and spell out some of the newer thoughts on what has an impact on weight, metabolism and energy balance, and include both those we have "control" over, and those we do not.

 As is definitely true with this issue, it really is quite complex, and we really don't even know what we don't know yet, so to speak, in regard to all the elements in play, and how they interact.

What we can hopefully have a better appreciation for is that it is 'head in the sand-like' to approach obesity from a strictly calories in - calories out perspective.

Of  additional note, when you reverse the argument, it can likely be said with some conviction that someone who maintains themselves at a reasonable weight may have a lot more going for themselves than their behavior and choices.  Sorry to knock us down a peg or two.  Our DNA, our genes, of which we certainly have no control, may be the overarching factor of grace keeping everything in balance, or not.

And who do you have to thank for that?

Word to your Mother.  And Father...

And, if you can make them guilty enough, maybe they'll even pay for your next attempt at weight loss, as you personally answer your part of that $60.9 Billion question!

the $60.9 Billion Dollar Question, part 3

Photo by M Clock

I saw this sign yesterday.  I had to take a second look, and try to gain some context.

Being Easter Sunday, I should have known what the sign meant. 

I honestly thought it was part of a new night club promotion, or possibly a mail order bride service for the small town we were in.

If things were only so easy when I was on the prowl...

Taking a second look at something often helps you to really get a grasp on the situation, the relationships involved, the more likely understanding how something really is important, or isn't.

Honestly, so was the case with me as far as the issue of meds and associated weight gain.

I didn't doubt that there was some relationship between meds and obesity, but I didn't really take the time to investigate whether some of these reported untoward effects were more closely associated with the disease process itself, or the patients and his / her behavior who 'happened' to have said disease, or truly as a pharmacological effect encouraged / caused weight gain.

Pushing me toward defining that relationship is the fact that alot of the meds reportedly at fault are used in obesity-associated conditions such as DM2, HTN, and psychological conditions such as Bipolar and Depression.

Research does seem to support the fact that a variety of meds do cause either weight gain or interfere with reasonable efforts at weight loss.  The effects are related to a differential specificity and sensitivity of binding to receptors involved with appetite regulation.

The fairly common meds that are on the hit list to varying degrees include:

Paxil
Depakote
Prozac
Remeron
Zyprexa
Prednisone
Thorazine
Amitriptylline
Allegra
Chlorpropramide
insulin
Atenolol
Many of the OC's

So, what to do? 

The Bottom Line:  At first, just being aware of the relationship is a good place to start.  The old risk vs benefit test is the next step, and then considering trying other meds that may be as efficacious, but without the weight side effect, is the next in line.
.
I will finish this post with our last area to mention, and that is stress. 

"Stressful eating" is a well known psychological maladjustment , and can certainly cause weight gain and difficulty losing weight.  As you may have heard in the past, "It's not the Monster in your life...It's how you react to the monster" that determines how significant a stressful a situational trigger is in your life.  And, to some degree, as psychologists will agree, we should have some degree of control over our reactions, or even the situations that lead to increasing stress in the first place. A good place for counseling to sort that out, and help patients get a handle on environmental management.

To be fair, there is a component of heightened Cortisol secretion to increase appetite, as well as the repetitive behavioral reinforcement for the initial sensation a patient gets from being satiated (usually with CHO and high calorie, "comfort foods"). 

There are some tricks of the trade that seem common sense enough, but I do think that this maladaption to stress is certainly more emotional than rational, and often difficult to unravel willfully.

Bottom Line:  Articles abound on-line regarding Emotional eating, and this Web-MD article has some great tips to try and break the cycle, and the resultant weight issues.

So there it is.  A few of the more noted aspects of a patient's environment that may be manipulated in a positive sense to make a difference in weight, and weight maintenance.  Complicated stuff, and I think we've just scratched the surface of these influences over these last 3 posts.


So, that comment about those 'Words to your Mother" I made in the last post.  Obviously, no way a patient could have control over their en utero environment, but I'll make a few comments on that, as well as the Breast vs Bottle discussion as it relates to obesity next.

The $60.9 Billion Dollar Question, part 2

From Burningtheground.net

You want control?

I'll give you Control.

Janet Jackson style Control. (Now I'm all grown up)

Anyway, we have a few more areas to cover in the arena of "control" as far as our weight is concerned.  You may be surprised ( or not ) about the areas studies that do effect metabolism, energy regulation, and therefore body weight.

Eating Schedule, or when you eat during the day, can also have an effect on weight loss, and it is something we can theoretically control.

From a January 2013 study in the International Journal of Obesity, timing of food intake had a notable effect on the effectiveness of weight loss.  Surprisingly, energy intake, dietary composition, estimated energy expenditure, appetite hormones and sleep duration were similar between the 2 groups studied, yet the timing of macronutrient distribution did make a difference.  Those participants that ate lunch later lost appreciably less weight, and had slower weight loss overall,  than those that ate earlier in the day.

Bottom Line:  More so an interesting finding from a recent study, rather than an earth-shaking breakthrough, but something to keep an eye on.  It adds to the notion that weight loss and energy balance really is a complicated, multi-variable thing.  How important this aspect is remains to be seen, and further studied.

"Physical Activity" is often a "P.C." way to say exercise without "offending" someone. 

On one hand it does dilute the message that true exercise is what we are looking for to lose weight, maintain lean body mass after surgery, improve overall health and fitness, etc., but in reality (and especially for our generally minimally-mobile population) activity may be a more appropriate term for what is most benefiting to the population 'at large' (pun intended) anyway.

According to consensus information on the CDC website, 'activity' requirements can be as easy as 150 mins per week of moderate walking in order to start to achieve significant benefits.  Trading a little over 20 mins per day (of less immobile screen time - phones, computers, videos, TV!) into this activity level will make a profound difference in a patient's health, as well as their weight.

Bottom Line:  Activity of some type is almost always better than waiting until the universe aligns and patients hopefully at some time start to 'exercise' as we recommend.  While all patients may not buy into it, working toward the goals of exercise takes time, salesmanship on our part, and is often made easier once the desire of weight loss and 'healthier living' takes over. As they see their efforts are making some significant gains, such as after weight loss surgery, they sense that momentum starts to get on their side, finally.

Only a few more to address in the next post, but this is a good start.  Again, each one of these aspects of the patients environment have some impact on weight, and we can only control what we can control if we know these influences exist.  Lastly, 2 more, and then one I thought was interesting, although definitely beyond our control. 

You could blame your Mother, however, if you were that kind of a person....