It's The DIet, Stupid

From Musingsofahousewife.com

Remember when "It's the economy, stupid" helped get bill Clinton elected in 1992?

I had a ah-hah moment recently of a similar nature, during a discussion with one of our surgeons about striking differences in post op glucose control, despite two seemingly similar patients. 

Both had Bariatric / metabolic procedures - one had a Sleeve, the other a Bypass.

Both had longstanding histories of DM2,  both had slightly advanced ages (late 50s, early 60's), and both ended up OFF insulin post op; Patient A in the hospital, and Patient B within days of coming home, despite requiring it (as a new medicine to her regimen, needed to control her sugar from perioperatively in the 300s, to mid 100s by POD 2) immediately post op.

Patient A I expected to follow a similar course as with Patient B, namely needing aggressive Novolg scale, initially on a Q2 hr basis, to asses his new insulin needs, with a goal to maintain BGs in the 150s or lower, especially given his preop  Lantus maintenance dose of 144 units (Yes, that's one hundred forty four), last dosed the night before surgery. 

By the way, Patient B came to the day surgery area, an hour before surgery at 110, and with a most recent A1C of 6.2.  And, with his preop 60# weight loss (about double of what was 'required' as his 10% to get to the OR), he was actually off 3 of his other antidiabetic meds, and with a slightly reduced dose of Lantus to boot. Pretty good control heading into his surgery.

Not so similarly, Patient A was the epitome of poor control. She was someone who probably needed insulin long before surgery day, but was reluctant to start it, to say the least.  She was hopeful that the 5-10% weight loss and low calorie diet preop would help her, and she was assumptive that post op she would be fine.

I wasn't so sure, when I saw she arrived at the day surgery unit just 1.5 hr preop at 302 for her BG.  She had stopped her Glucophage 1000 BID about 6 weeks earlier due to slight LFT elevation, aware of her NASH diagnosis (Cirrhotic changes from steatosis, on our intraop liver Bx) as her PCP was following apparently both and didn't want to insult her liver potentially further.

In any event, her most recent A1C before surgery was 12.2, certainly out of control, and for some time. 

She (Patient B) however, was the one that really ended up surprising me.

For both patients, and for that fact any T2 Diabetic patient that has surgery, after a Sleeve or Bypass, due to their beneficial metabolic effects, there are many significant metabolic changes occurring very rapidly, often within the first few hours after surgery, that can make control of BGs post op most challenging at times.

Each patient is a little (or a lot) different, but there are a number of trends we keep in mind for post op monitoring and insulin orders, and we let the patients perioperatively declare themselves as one of 3 general types of post op Diabetics. 

#1 is the patient we do Q 6 hr fingersticks on, have a scale ready, and they don't require much if any insulin coverage.

#2 is the patient we start out the same way, and ends up needing a little insulin, which the patient generally reacts to appropriately in reducing their BGs. We usually send them home after a typical 2 night stay off any further DM meds / their pre op maintenance DM meds, and have them monitor BGs at home, with the goal to keep BGs in the 140-160 range or less.  This hands-off approach prevents potentially overdoing it (with resultant hypoglycemia) with PO or injectable meds while the metabolic changes of improved insulin sensitivity,  advancing diet (still very minimal CHO), and decreasing post operative stress is theoretically diminishing. Those 3 factors make you think of a decreased need for meds anyway. Should they then have spikes in BG or a few readings over 180's, etc. they call their PCP for further management before we see them at a  standard 1 week post op visit.

#3 is the wildcard. These patients are usually under not-so-optimal control preop, and are on multiple meds, often with crazy amounts of insulin (both rapid acting and basal) required; sometimes they even have a pump with total doses of insulin easily in the 200 plus unit range.  We have seen a few of these patients on U500 insulin (5x the potency of standard insulin) as well to minimize the volume needed to control the BGs.

You know you have one of these patients when you monitor their BGS in the PACU just out of surgery, and their BG is already in the 200s, especially if they were closer to euglycemic as they went into surgery.  Another not so subtle tip-off is when the aggressive Novolog scale does nothing (BG substantially rises) when checked about 2 hrs after administered.

These patients will often require a number of 'catch up' rapid-acting doses to get back on top of BGs, the dose dependent upon how they react to the doses being given, which usually approximately the dose that would be given in the outlined 'aggressive' scale.

This is when you start thinking about needing a basal dose of a peakless, once daily insulin (Lantus or Levmir) that evening, to give you some help with some background coverage.  I usually start with a dose in the 0.3 - 0.5 units per KG dosage, and expect to possibly start to see its effect within 6-9 hrs, as far as maintaining BGs and lessening the need for the 'catch up' short-acting doses.  If the patient is already on a basal insulin preop, usually we look at 1/2 to 1/3 of that dose to start.

So, back to Patient B. SHe followed the #3 pathway pretty well, and required 3-4 catch up Novolog dosings Q2 h to get her sugars to the mid 100s, started Lantus close to 40 units, and she did well the following day, with less and less Q6 hr scale requirement.  

Interesting enough, she refused the Lantus when she went home, and reports now (I saw her last week) that her BGs are in the 120s and less at home. Well, I'll be....

Anyway, back to what led to this whole discussion, and the picture at the top of the page.

I suspect her "glucotoxicity" of such poor preoperative control, and longstanding at that, created a post op situation that, even with the rapid immediate BG-beneficial effects from the surgery (as essentially declared to be adequate enough to control her BGs off all meds a week post op) was a significant factor in making her look like she would need at least some short term help from exogenous insulin.

What was the other factor?

Diet.

Yes, a very low CHO diet (especially immediately post op), and the limited quantity that could be eaten due to her restrictive procedure, a sort of 'forced' behavior modification. It provided the consistent background of a fixed amount of calories IN, and likely gave the pancreas a fighting chance to keep the BGs controlled.

Which led myself, and the surgeon I was discussing this with, to think:

"How often does this happen in the real world of Diabetes treatment, that we are acting as if the meds aren't adequate, when they cannot possibly overcome maladaptive diets of poor quality and excess amount, in addition to little to no regular exercise?"

I am not in Primary Care anymore, but I think I know the answer to that one.

Age Limits vs. Term Limits, part 2

So when is "old" too old?

As in so many other areas in medicine, this has a relative answer.

Relative risk of age needs to be viewed in terms of potential benefit, as is also the case with younger morbidly obese patients that undergo surgery.  As most now (as opposed to a number of years ago) are in agreement that Bariatric surgery is not solely a "cosmetic procedure" to reduce body mass and "improve" a patient's appearance, the potential for significant health benefit is always in the equation.

Obstructive Sleep Apnea, Diabetes, Hyperlipidemia, HTN, symptomatic / activity- limiting weight bearing OA, and other comorbidities have been shown to substantially improve with surgery and its attendant weight loss.  Advancing age has not been shown to consistently diminish the potential benefits from surgery.

Also keep in mind a patient's genetic risks / predispositions, as well as the potential for increased risk of malignancies with age and decreasing quality of life, on the continuum of time,  as a further characterization of what life may be like if the condition of excess (and likely increasing weight) over continued time is allowed to persist. As the saying goes, there aren't too many significantly overweight people in nursing homes, in their 80s and beyond, these days.

There certainly is a generally agreed upon increased risk as the aging process continues, with the added effects of time and comorbid conditions,  under admittedly variable control (lipids, glyco, BP, etc.), which I think we are quicker to add up than the potential benefits of surgery in a patient of increased age.

Patients are cleared all the time for other types of surgery in their 70s and beyond.  The workup for such a patient is understandably more detailed to qualify end organ status, to assess perioperative risk, as well as to establish whether or not the patient is as optimized as they can be prior to elective surgery.

Our guidelines state that anyone over age 50 sees cardiology preop for potential further evaluation, in order to obtain clearance before surgery.  All patients, regardless of age,  have an EKG in the office as part of their preop workup and data base establishment. Anyone with DM2 of 5-10 years duration, and on insulin, and/or under poor diabetic control should see caridology as well,  given their risk for silent cardiac events.  Most patients are also cleared by their PCP prior to surgery as well just before the time of their procedure.

How do the insurance companies deal with this issue?  Most are in agreement that anyone over the age of 65-70 requires a peer to peer discussion (Insurance Company Medical Director to Surgeon) .  In our experience, the patient usually gets through that review,  as long as our workup is intact, they have been cleared by Cardiology have had adequate diagnostic testing, and stand to experience significant health benefits from surgery and weight loss (from comorbidty reduction / resolution).

to further put it in perspective, and I think I have mentioned it before, but it is worth restating here. (hint: NEJM 2007)

The risks of surgery / anesthesia do slowly increase with advancing age.  However, when you can show the substantial health benefits in the comorbidites listed above, with improved quality of life, and significant disease-associated mortality reduction, (actually greater than Coronary Artery Bypass Grafting) and you have an interested patient of increased age questioning whether Bariatric Surgery is right for them, it pays substantial dividends to be in-the-know!

Exhibit K: Age Limits vs. Term Limits (Part 1)

From Finra.org

Age can be limiting factor for many things, both via legal mandate, or by the progressive experience of bodily function diminishing or lost.

The opposite may also be true of aging, such as with the accumulation of wisdom, a valuable asset that increases in proportion to age.

(I would venture a guess that the negative effects of advancing age are easier to tabulate than the positive when it comes to aging, but that's just a guess.)

Furthermore, certain events in life occur at an arbitrarily set time and circumstance, as depicted in the image on the right.

Other, often more subtle effects of the aging process, occur progressively and can have just as a defining outcome when it comes to bodily function, physiology, cognition, and physical function. Frequently the additive effects of time can be unforgiving based on genetics, behavior and preexisting medical conditions.

Now, how about  Term Limits for a politician? I suspect that would bring about some well-needed change....

Where am I going with this? Good Question.

Another "Exhibit" whereby I describe a clinical presentation of an actual patient, and some real-time results, illustrating a new wrinkle in the daily care of our Bariatric patients.

In this presentation, from a patient I saw in the office last week, we will see the effect of surgery in a patient of moderately advanced age.  Interesting enough, I had a conversation about this very subject with a local Cardiologist who wanted to refer a patient to us, but was concerned that the patient in question was in her 60s.

Well, check this out.


Demographics:  73 y/o WF

Start Weight:  238   BMI 42

Date of Surgery:  1/28/14

DM2 History:  Longstanding h/o Diabetes, albeit "borderline", and on no anti-diabetic medicines. Her Glyco on our initial labs showed 6.5. She was concerned about the long term effects of her Diabetes, and whether or not it would lead to medicines and/or Insulin, or rapidly deteriorating health.

Other comorbidites were HTN (on 3 medicines), Hyperlipidemia (on a statin), and OA pain to her lower extremity joints, GERD on a PPI,  as well as Hypovitaminosis D.

Current DM2 and Post op Changes:  I saw her recently at her 6 mos post op check and she was 'Beaming' on the outside, but it came from the inside.  She said she felt wonderful with her new weight of 159, BMI of 28, and had a new found energy and zest for life.  Her BP meds were reduced to just one, and her BGs had been stable since surgery, to the point that she rarely checked them anymore.  She was incorporating a new level of exercise to her life, and her ADLs were getting easier and more enjoyable with much less OA pain.  She had taken to her new post op Bariatric diet, and was exploring new foods and optimizing her dietary intake calorically for protein and limited CHO.

Wow. Not a bad body of work for 6 mos post op.

Take Home Points: The more I have thought about this part of this Case Report, I have a number of related points that will make this THP section a little long to read.  I intend to neaten it up a bit by making this a Part 1 of 2 to go into these issues in a little more detail.

Additional related points of discussion I need to review revolve around the idea of risk vs. benefit in this population of more advanced age, and our standards as far as preop workup.  I want to briefly mention the position of most insurance companies when it comes to age and bariatric Surgery. And a few other salient points. So look out for that in Part 2 coming very soon!

In any event, in conclusion for this part, there seems to be no limited 'Term Limit' on the ability of the human body to bounce back from the effects of increasing weight-related comorbidity even with advancing age.

I believe I characterize our group's feeling well, by stating that age is a relative factor, and not an absolute factor, in considering the overall fitness / risk for surgery, especially in light the potential gains (as described here) that can knowingly be appreciated in the context of that relative surgical risk.

I would assume that Orthopedic Surgeons (total joints) and Cardiothoracic Surgeons (CABG, Valve Replacements, etc.) do the same, yet are met with far less less scrutiny than Bariatric Surgeons are, seemingly in the same regard. Is that fair?

Part 2 coming up next......