The Swiss Army Knife of Metabolic Lab Tests

From Amazon.com

Isn't it enjoyable to find an additional use for something that is already useful?

Examples that come to mind are the hanger that you 'reused' to aid in reception for your boom box when the antennae broke, the banana peel that goes into the compost pile to feed future plants rather than the garbage can, or the leftover driveway sealer bucket that can hold baseballs for BP for years to come.

At the risk of practicing zealotry (yes, I looked it up, and it is a word- ), I was looking into a few studies regarding C-Peptide, and I came across an interesting study published in the Canadian Medical Association Journal from earlier this year.

I know we have gone over a number of practical, actual and theoretical uses for the laboratory test C-Peptide in the Bariatric surgery circles in this blog.  We've discussed how it can identify and predict the severity of metabolic (Diabetic) disease, and how it can predict the potential effect that bariatric surgery can have on Diabetes and the chances of its remission.

This new study was news to me, and it dealt with C-Peptide levels and the risk of death among adults without diabetes mellitus.

I understand the measurement of C-Peptide as a surrogate level for endogenous insulin secretion, and therefore pancreatic islet cell function.  Not a far stretch to equate that level with either a high level (early diabetes) or a low level (once pancreatic function is in decline, implicating marked severity of diabetes -  essentially creating a type 1 out of a type 2 diabetic) and it's implication on death from Cardiovascular diseases.

But, that C-Peptide levels correlated in a direct way, in Non- Diabetic patients, with the risk of death... that caught my eye.

It seems that C-Peptide may potentially be considered a bioactive peptide in it's own right.

5902 participants aged 40 years and older with no Hx of Diabetes were evaluated in terms of their baseline C-Peptide levels.  The primary outcome was all-cause, cardiovascular-related and coronary artery disease mortality.

What's also interesting is that as C-Peptide rose there were significant and graded increases in mortality regardless of whether or not there were increases in the level of glycated hemoglobin and fasting glucose.

In essence, higher C-Peptide levels were associated with increased mortality among strata of glycated hemoglobin and fasting serum glucose, but also independent of those markers.  Now some of these patients may have been 'pre-diabetic', with their baseline C-Peptide being the only evidence of the impending disease process, resulting from cumulative diet, aging, genetics, and increasing weight.

Given the epidemic nature of Diabetes these days, that probably represents a good chunk of the results, but there is very likely something more involved.

However, generally speaking, the levels in the study were noted to be higher in those patients with a Hx of HTN, hypercholesterolemia, or MI; and among those with a higher BMI, and with higher levels of C-reactive protein, total cholesterol, serum insulin, glycated hemoglobin, and fasting serum glucose.  What else do you need for the toxic stew to end up with heart disease?

So, consider a C-peptide the next time you do those annual labs on that patient in for a followup.  It could provide yet another objective data point to set the stage for 'the talk' to get them thinking about the urgency and necessity of making some changes before it's too late.

Whether or not that means that Bariatric Surgery is in their future, the main thing is that in preventing death and disease, the Heart, Brain, and Pancreas are literally of vital importance.

Bariatric Beriberi (Not a new flavored juice for weight loss)

From Brucemhood.wordpress.com

Say that 3 times... bet you can if you try (Mr. Rogers flashback, anyone?).

                 Nicely done.

Beriberi, or classic Thiamin (B1) deficiency is not all that uncommon in Bariatric surgery circles.  And, that makes some sense, especially in post-Bypass patients, and yet we are finding it so as well for Sleeve Gastrectomy patients, as reported in the literature.  B1 acts in the body as a cofactor in several enzymes associated with CHO metabolsm and energy production.  It's effects are most noticeable in the cardiovascular and neurological organ systems.

Thiamin is preferentially absorbed in the duodenum, with decreasing absorption caudally along the small intestine in an intact GI tract.  Therefore, a Bypass certainly increases the risk of having an issue with Thiamin, as the procedure essentially re-routes nutrient exposure away from these areas of maximal absorption.

Literature reviews show that 'Bariatric Beriberi' is most common in the setting of protracted vomiting, typically within the first 2-3 mos after a Gastric Bypass.  It is purported to be brought on by rapid weight loss and dietary insufficiency, as well as lack of strict adherence to required vitamin regimens.

For post op vitamin regimens, as detailed earlier in this blog, we usually advise a MVI and B Complex, among others,  which along with a reasonably sound diet, should keep their Thiamin levels up to snuff, even with the varying degrees of malabsorption between the Bypass and the Sleeve patients.

And the risk of not being mindful of a patient with potential Thiamin deficiency and the need for IV fluid replacement?  They can exhibit signs and symptoms of Wernicke's Encephalopathy if given Dextrose in their IV fluid, with this coexistent micronutrient deficiency.  Manifestations of WE include ataxia, opthalmoplegia, nystagmus, and mental confusion.  In the worst case, it can be non-reversible, or even fatal.

We will always give a banana bag with MVI, 100 mg Thiamin, and even a Gram of Folate in our initial IV as to negate this risk when we admit a post op patient who fits this description.  As much as we educate our hospital staff, and the ER staff, we still cringe when we see an occasional patient with D5(name your flavor....) hanging as an initial IV in a sick patient that has been vomiting, and with poor PO intake.  For additional monitoring, we do include a B1 level on our post op labs that we check regularly in the post op setting.

You should see a copy of those labs we check as we CC you on the labs as much as possible.

No Term Limits for Obesity

From Bariatrictv.org

I was in attendance at the NYS Chapter of the ASMBS meeting in NYC last week, and we were fortunate to have Dr. Jaime Ponce, the president of the ASMBS, address our group about updates on many hot topics in the Bariatric surgery world.  He spoke of access to care with new health care laws starting to take effect,  and he made note of his busy week he had experienced with two politicians in succession making it known that they had undergone weight loss surgery recently.

The ASMBS sent out a press release last week regarding New York Congressman Tom Reed who underwent Bariatric Surgery recently, after he went public about it just last week.

As the press release states, Obesity knows no particular class of person.  It does not discriminate amongst the celebrity or common man.  And certainly, the associated comorbidities are just as destructive and quality of life diminishing each group.

What is a little different though, between a public and a non-public figure, is the attention that surgery like this gets when a public servant chooses to undergo a weight loss operation due to significant obesity and related diseases.

Such is also the case with the Buffalo Representative Mr. Reed.  He made the decision to have a Gastric Bypass earlier this year has left him 70 pounds lighter, and now Diabetes-free.

It is hoped with this increased focus on this particular case, in combination with potential legislative sensitivity to the issues of access to surgical care of obesity and Diabetes, so that advances could be manifest in this area as well.

So who do you think might be next?!

Personal, Politics, or Just Paparazzi?

From abcnews.com.go

I actually like Chris Christie, the Governor of NJ.  Or maybe I liked him more in the past,  prior to Sandy.  I am not sure.  However, his recent news that he had a weight loss surgery (LapBand 2/13) was interesting on a number of fronts.

It is kind of sad that when you are a public figure, because you are a public figure, and fair game.  His weight has always been an issue on many fronts, and he stands to gain in those same areas:

 Personally.  Certainly the health aspect of hauling around such excess weight for so long.  Although I think he did proclaim himself as the "healthiest fat person I know"on Letterman recently, we all know that really isn't completely true, and irreversible health consequences are already likely very underway. (Has he ever had a sleep study?)  Better health is hopefully right around the corner.

As a related aside, I find it interesting that if a patient doesn't carry an official diagnosis of a weight-related malady, then they are 'healthy' until proven otherwise.  Another reason to stay away from the Doctor's office, I guess...

Politically.  Most say that to be able to run for a national office, weight loss is essential, as there is no way he could make it physically through such quest, fulfill his job requirements satisfactorily, or decisively  prevail in the arena of public opinion while exhibiting such a degree of obesity.  That's a sticky subject, especially given the degree of obesity in our US populous as it stands now - he may be actually more relatable than others because of his obesity.  Which leads me to the next area of discussion, Pa-Pa-Paparazzi.

And, by Paparazzi in this context, I mean not only the media and it's relentless pursuit of the facts to support their own agenda, but the stereotypical ideas and perceptions and faulty conclusions of those in the public.  In a word, US.  All of us.

When I started to work in Bariatric Surgery about 6 years ago, I thought I entered in with a reasonable and open mind about patients with obesity, their struggles, and their desires to get well.  I also thought I had a decent handle on what they go through psychologically as they come to see us for help.

I had to honestly set aside much of what I had expected.   I listened as I discovered what was truly important to them, and what convinced them to come and see us for a chance at a healthy remainder of their lives.  Usually it was because they could see what was coming, and soon, down the pike if their weight was not controlled durably and definitively.  They had too much to live for, but not able to keep up.

Alos, how had they arrived at our office for treatment?  These stories area always unique and interesting, and parallel their journeys as they look for help along the way toward wellness.  There are certainly some common ideals that surround this group of patients, as you can imagine.

The desperation of these patients is pronounced and visible, and they seek true connection and engagement from their health care team.  We are fortunate to have a group of providers that exhibit that they are comfortable with who that individual patient is,  and what they have become, as impacted upon by obesity.  Taking the 'blame' and judgement out of the equation makes them feel more respected, and allows us to get down to the business at hand - durable surgical weight loss.

They hope for a chance at really turning things around for their health, their quality of life, and their relationships.  They are  poised but uncertain of their impending success,  Having failed at many other attempts at weight loss, as well as potentially other important battles in their lives, they are ready for a victory that matters, one that will be life-changing, and hopefully long - lasting.

Being a part of a team that makes this happen as a daily occurrence makes coming to work fun.

Speaking of which, I had a patient today who came in at an initial weight over 500 #.  She is now 18 mos S/P Bypass.  A young woman, mid 20's, and she now has gotten her weight down 280# to just over 225... She is a new creation, literally.  Good stuff.

To finish, I think the Chris Christie story is a combination of all three components, and that makes it an intriguing look into a public figure deciding to have Bariatric Surgery.  Public or private, there are probably more similarities than differences with the patients that you refer for weight loss surgery.

The part of the story that is likely the most important will probably end up being a mere footnote to his future success. I am sure he will be in touch with his buddy Rex Ryan across town, who has already shared some trade secrets on living with his Band.  The Jets may have been better for Rex pre-Band, but his story is not concluded yet either.  Go Jets!

Addendum:  Just after I hit 'publish' last night I was checking emails, and I saw one from the ASMBS on the Chris Christie issue, with the added aspects of access to bariatric surgical procedures, as well as the impact of Health Care Reform on the potential limited availability of weight loss surgeries in the future.  Take a look at the press release here.

Tradition Dies Hard

Photo by M Clock

Tradition dies hard.

Especially when there is a building that can truly physically embody the symbolism of the tradition,  a place that personalizes that significance to so many people, and in so many ways.

For those of you in the Capital District of New York, you may have been aware of the sad story of St. Patrick's church demolition in Watervliet, NY.  It had stood for 122 years, and is in the process of being cleared to construct a Price Chopper supermarket.

122 years is a long time.  A number of lifetimes, actually.  Just think of all the good and bad times this church has been an institutional refuge for.  Weddings.  Funerals.  Easter Sunday masses.  Baptisms.  Last masses before young men went to war.  First masses for immigrants coming to the area.  

Religious or not, I think you get the picture.  And to see the necessary way the process is taking place, with  an apparent systematic purpose and  an implied intent to destroy.  Resulting dust, noise, and unchaste heavy construction equipment.  In such a Holy place. I am sure it makes the whole process a bit harder to take for those that are intimately involved.  But, it is what it is.

On the flip side, some things are necessary, some are needed, and there may never really be a good time to do what has been required. I am honestly not aware of all the factors involved in this specific case, but maybe it is the best time to do what has to be done.

Likely there are financial issues of the diocese.  Declining parish priests, and diminished numbers of parishioners in the region may also be at fault.  Recent lawsuits may have taken a toll.  Price Chopper is obviously interested in the site for their own business interests, and the residents of the area may be well served by the addition of a new and updated grocery store in that locale.

Treatment protocols, and 'step-care' approaches to controlling the blood sugar of patients with Diabetes have certainly been steeped in tradition as well.  I am old enough to remember glucose urine strips,  then later, speedy 2 minute Accucheck self-glucometry.  First, then second generation sulfonylureas. And certainly the previous laissez-fare attitude of Type 2 DM treatment, essentially utlilizing ADA diets and avoiding sugar-laden foods along with basic lifestyle and behavior modification,  only initiated once overt symptoms of hyperglycemia ("the 3 P's") developed.  Times have definitely changed for the better!

This is a good time to take stock in where we are now, as I noted the 67 Blog posts that are a part of SugarFreeSurgery, and the over 1400 hits the site has received overall.

The take home points of the 'New Traditions' in Type 2 Diabetes care?

   Get Care Early:  

Be aggressive with multimodal medical treatment to get to best practice goals, with a goal-oriented, limited time frame for behavioral modification and weight loss as needed.

And, For Those That Fail Medical Intervention after a reasonable amount of time:

Start early and often discussing the benefits of metabolic / Bariatric surgery.

Time is Pancreas.

Remember:  The benefits you will see from surgery 'today' may not be as durable as they may have been if there had been less delay in scheduling a Bariatric referral earlier. This could be due to the resulting incomplete Diabetes remission,  and/or the irreversible effects of the Diabetes with its toxic additive effect of hyperglycemia on vital organ systems.