Tag Archives: BMI

New recommendations on the bariatric surgery and diabetes

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New recommendations out of a recent conference in Austria as reported by the Heart.org.  This comes on the heels of the most recent changes in BMI recommendations, as we reported last month.

As reported by Steve Stiles over at the Heart.org,  in”Case made for metabolic bariatric-surgery eligibility criteria,”  new evidence and recommendations suggest that surgery should be done earlier in the course of the disease process (diabetes) in patients with lower BMIs.  Currently the BMI restriction criteria enforced in North America and Europe prevent the majority of diabetic patients from receiving gastric bypass surgery, which is the only proven ‘cure’ for diabetes.  That’s because the majority of type II diabetic patients are  overweight but not morbidly obese.

As reported previously on this site, Latin American bariatric surgeons have been at the forefront of the surgical treatment of diabetes.  Many of the surgeons previously interviewed for numerous projects here at Cartagena Surgery were involved in several early studies on the effects of surgery in moderate overweight patients with diabetes.

More interestingly, researchers at the conference are also suggesting possible gastric bypass procedures for patients with ‘pre-diabetes’ or patients with an hemoglobin A1c greater than 5.7 % but less than 6.5% (6.5% is the cut off for diagnosis of diabetes.)

This is wonderful news – it means committees and such are finally getting around to following all of the research that has been published and presented over the last ten years..  But then it just one more important step…

Call it by its name

So I have my own suggestion to doctors and researchers – and it’s one that I’ve made been – a nomenclature change.  We need to stop calling it “pre-diabetes”, because the name is a falsehood – and leads everyone (patients, nurses and doctors astray.)

– Greater than 95% of patients with ‘pre-diabetes’ will develop diabetes – so without a drastic intervention (far beyond diet and exercise)  it’s pretty much a certainty.

– Many of the devastating complications of diabetes develop during this so-called pre-diabetic period.

– Doctors are now recommending surgical treatment to cure this “pre” disease state.

So….  

if almost everyone who has ‘pre-diabetes’ gets diabetes, and it’s already causing damage PLUS we now recommend a pretty radical lifestyle change (surgical removal of most of the stomach) —> that sounds like a disease to me.  Call it early diabetes, call it diabetes with minimal elevation of lab values, but call it what it is….Diabetes..

This is critical because without this firm diagnosis:

– insurance won’t pay for glucometers, medications, diabetic education, dietary counseling (or surgery for that matter).  That’s a lot of out-of-pocket expenses for our patients to bear, for something that is treated like a ‘maybe’.

– patients (and healthcare providers) alike won’t take it seriously..  Patients won’t understand how crucial it is to take firm control of glucose management, patients won’t be started on preventative regimens to prevent the related complications like renal failure, heart disease and limb ischemia.

– Patients may not receive important screening to prevent these complications – and we already know that at the time for formal diagnosis (usually SEVEN years after initial glucose derangements are seen) – these patients will already have proteinuria (a sign of kidney disease), retinopathies, vasculopathies and neuropathies..

I work with providers every day, and the sad fact is that too many of them (us) shrug their shoulders and say – yeah – he /she should eat better, get more exercise, shrug.. But they don’t treat the disease – they don’t start checking the glucose more often, they don’t start statin drugs, the don’t screen for heart disease and they don’t consult the specialists – the diabetic educators, the nutritionists, the endocrinologists – and yes, the bariatric surgeons…

Chances are if your doctors and your nurses don’t take it seriously; and don’t make a big deal out of it – and don’t talk to you, at length about what “pre-diabetes” IS and what it really means for your life and your health –

then neither will you.

For related content:  see the Diabetes & Bariatric tab

the Weight of a Nation: the obesity epidemic

Bariatric surgery and non-alcoholic fatty liver disease

The Pros & Cons of Bariatric Surgery

Gastric bypass to ‘cure’ diabetes goes mainstream

More gastric bypass news

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In a new story by Megan Brooks over at Medscape, “Gastric Bypass Has Advantages in Less Obese Patients” – the latest news from an Orlando conference confirms what cartagena surgery fans already know; that gastric bypass surgery is a viable and effective option in moderately obese patients (particularly patients with diabetes.)  This is encouraging in the continuing battles between patients and insurance providers.

As we’ve said before – it’s important to treat obesity definitively before patients develop serious and potentially life threatening complications such as diabetes and hypertension, and the sequelae related to this (coronary artery disease, ischemic limbs, stroke, renal failure).

In order to treat this effectively and aggressively, we shouldn’t wait until the problem is out of control.  A patient shouldn’t have to be 600 pounds for the doctors to consider bariatric surgery – we should help people before that.

I’ve re-posted the article below. [italics are mine.]

Gastric Bypass Has Advantages in Less Obese Patients

June 16, 2011 — There are benefits to performing laparoscopic Roux en Y gastric bypass (RYGB) in obese patients who have a body mass index (BMI) below 35 kg/m2, according to a study reported at the American Society for Metabolic and Bariatric Surgery 28th Annual Meeting in Orlando, Florida.

Among patients who underwent the surgery, the rates of remission of type 2 diabetes were higher in those with a BMI below 35 kg/m2 than in those with higher BMIs. The “less obese” patients also lost a greater percentage of their excess weight in the first year after surgery than their peers with higher BMIs.

“The study raises the question of whether early referral leads to better outcomes,” John Morton, MD, director of bariatric surgery at Stanford Hospital & Clinics at Stanford University in Palo Alto, California, and an investigator with the study, noted in a conference statement.

“Bariatric surgery is tremendous for weight loss, but its other big advantage is improving medical problems, in particular type 2 diabetes,” Dr. Morton noted in an interview with Medscape Medical News.

Outcomes Better at Lower BMI

Current guidelines from the National Institutes of Health recommend that gastric bypass be reserved for patients who have a BMI of 35 kg/m2 or higher and an obesity-related condition, or who have a BMI of at least 40 kg/m2.

Dr. Morton’s team took a look back at 980 patients who underwent laparoscopic RYGB at their institution between 2004 and 2010. “We ask patients to lose some weight before surgery because it’s a good way to make sure they are committed to the program, and it makes the surgery a little bit safer,” Dr. Morton said. “Therefore, we had some patients below a BMI of 35 kg/m2 at the time of surgery.”

For the analysis, the patients were grouped according to their presurgery BMI: below 35 kg/m2, 35 to 39.9 kg/m2, 40 to 49.9 kg/m2, and above 50 kg/m2.

“When we examined type 2 diabetes resolution rates, we found that those with the lowest BMI had the best resolution rates,” Dr. Morton reported. All 12 patients with a BMI below 35 kg/m2 no longer had type 2 diabetes after surgery, whereas patients with higher BMIs had remission rates of roughly 75%.

“We are looking to entertain the idea that maybe obese patients should have the option of surgical intervention for their diabetes sooner rather than later because, as the study showed, as the BMI gradient goes up, your diabetes resolution rate with surgery goes down,” Dr. Morton said.

The researchers also found that patients with a BMI below 35 kg/m2 who had the surgery had lost more of their excess weight at 3, 6, and 12 months than patients with a higher BMI.

After 1 year, the patients with BMIs below 35 kg/m2 had lost 167% of their excess weight. By comparison, those with a BMI from 35 to 39.9 kg/m2 had lost 112%, those with a BMI from 40 to 49.9 kg/m2 had lost 85%, and those with a BMI above 50 kg/m2 had lost 67% of their excess weight.

Laparoscopic RYGB also took less time in patients with the lowest BMI (170 minutes) than in those with higher BMIs (177 minutes, 182 minutes, and 194 minutes, respectively).

Reevaluation of BMI Guideline Needed

In an interview with Medscape Medical News, John David Scott, MD, a bariatric surgeon at Greenville Hospital System University Medical Center in South Carolina, who was not involved in the study, said that “the BMI level of 35 is an arbitrary standard set many years ago that certainly needs to be reevaluated.”

“Most of the evidence that has been coming out lately has shown not only a positive weight loss benefit for that particular group, but also positive overall health effects,” he added. “In particular, the resolution of diabetes is astounding. To be able to offer patients a surgical cure for their type 2 diabetes is very exciting,” Dr. Scott said.

Dr. Morgan has disclosed no relevant financial relationships. Dr. Scott reports receiving speaker fees from WL Gore & Associates and fellowship support from Ethicon Endo Surgery.

American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting: Abstract P-54. Presented June 16, 2011.

In other news, from the same conference (Megan Brooks reporting) – patients undergoing successful bariatric surgery (with resultant weight loss) had decreased rates of heart attacks and stroke.
“Bariatric Surgery good for the Heart”

June 16, 2011 — Bariatric surgery and the significant weight loss it achieves can  significantly reduce the incidence of myocardial infarction (MI), stroke, and premature death, according to a study presented at the American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting in Orlando, Florida.

“In addition to weight loss, bariatric surgery offers patients a whole host of health benefits, including a reduction in the risk of major cardiovascular problems,” study presenter John David Scott, MD, a bariatric surgeon at Greenville Hospital System University Medical Center in South Carolina, noted in an interview with Medscape Medical News.

“There is a long line of studies showing that bariatric surgery affects cardiovascular outcomes,” Dr. Scott noted. “The difference between our study and other studies is that we looked at major cardiovascular events (heart attack and stroke), whereas a lot of other studies have looked at risk for these events.”

The researchers reviewed data on 9140 morbidly obese individuals, 40 to 79 years of age, who had undergone bariatric surgery (n = 4747), gastrointestinal (GI) surgery (n = 3066), or orthopedic surgery (n = 1327) in South Carolina between 1996 and 2008.

The GI group (hernia or gallbladder) and the orthopedic group (joint replacement) served as control groups because of their similar health and risk profiles, the authors note.

All patients had similar a health status before surgery and no history of MI or stroke. The patients were followed to the end points of first MI, stroke, transient ischemic attack, or death.

“Life-table analysis demonstrated significantly improved event-free survival in the bariatric patients within 6 months of surgery, and it was sustained over time,” the authors note in the meeting abstract.

Five years after surgery, an estimated 85% of bariatric surgery patients were free of MI and stroke, compared with 73% of orthopedic patients and 66% of GI patients, the researchers say.

At 10 years, event-free survival was 77% in the bariatric group, 64% in the orthopedic group, and 62% in the GI group (P < .05).

After adjustment for differences in age and relevant comorbidities, bariatric surgery was an independent predictor of event-free survival. Compared with orthopedic surgery, the hazard ratio (HR) was 0.57 (95% confidence interval [CI], 0.47 to 0.69); compared with GI surgery, the HR was 0.35 (95% CI, 0.29 to 0.43).

“Important Area of Emerging Study”

In a statement from the ASMBS, Anita Courcoulas, MD, MPH, director of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center, Pennsylvania, who was not involved in the study, said: “The impact of bariatric surgery on both cardiovascular risk factors and events is an important area of emerging study.”

The findings, she said, are “suggestive of an association between undergoing bariatric surgery and improved event-free survival. This relationship needs to be further explored with prospective clinical data, but still highlights the importance of understanding the broader impact of bariatric surgery on long-term outcomes.”

In an interview with Medscape Medical News, John Morton, MD, director of bariatric surgery at Stanford Hospitals & Clinics at Stanford University in Palo Alto, California, who was also not involved in the study, made the point that “obesity affects every single body part and if you are able to affect the weight, you’re going to help other medical problems — particularly the ones that are inflammatory-mediated.”

“Obesity is really an inflammatory-mediated disease, and stroke, cardiac risk, and even diabetes are now being recognized as inflammatory-related. With weight-loss surgery, direct markers of inflammation go down and, more importantly, these diseases get better,” Dr. Morton explained.

Studies have shown that morbidly obese patients can lose 30% to 50% of their excess weight in the first 6 months after surgery, and 77% as early as 1 year after surgery.

American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting. Abstract PL-105. Presented June 15, 2011.