Disclosure Effect of Bariatric Surgery on Research support from Bariatric Advantage Cardio-Metabolic Outcomes (supplements donated for research study) Anne Schafer, MD Associate Professor of Medicine and of Epidemiology & Biostatistics UCSF and the San Francisco VA Objectives Case 46 y.o. woman w/ severe obesity, type 2 • Describe the effects of bariatric surgery on DM, HTN, GERD cardio-metabolic outcomes and mortality • Wt increased from 240 to 280 lbs over • Identify basic eligibility criteria for surgery last 10 years (BMI 40 to 46 kg/m 2 ) • Apply recommendations for post-op • Lost 20 lbs with Weight Watchers then medical management, monitoring regained 10 lbs • Walks 30 min 3 times/week Weight loss surgery? 1
Obesity is an important and growing public health problem • 38% of US adults (Men 35%, women 40%) 1 ▫ Stage 3 obesity (BMI ≥40 kg/m 2 ): 7.7% Men 5.5%, women 9.9% • Lifestyle changes usually do not result in clinically meaningful and sustained wt loss ▫ Rarely of the magnitude needed for those with extreme obesity Wadden, N Engl J Med 2011 1 Flegal, JAMA 2016 Growing demand for bariatric surgery Malabsorptive Restrictive Biliopancreatic Adjustable Almost 10-fold increase in operations diversion with gastric band performed annually in the early 2000s duodenal switch • 25,000 operations in 1998 à 220,000 in 2009 1 1 Buchwald, Obes Surg 2009 DeMaria, N Engl J Med 2007 2
Comparative weight loss outcomes Sleeve Roux-en-Y gastrectomy gastric bypass (RYGB) Control LAGB VBG RYGB DeMaria, N Engl J Med 2007 Sjostrom, JAMA 2012 Comparative weight loss outcomes LAGB Sleeve RYGB Maciejewski, JAMA Surg 2016 3
Type 2 diabetes Why does diabetes improve/resolve? • Completely resolved in 77%, and • All procedures: Weight loss resolved or improved in 86% 1 ▫ ê Weight à ê Insulin resistance ▫ 84% resolved after RYGB, 48% after • RYGB: Additional endocrine effects 1-3 gastric banding ▫ é GLP-1 à é Insulin secretion • Resolution often occurs days after • “Incretin effect” RYGB, even before marked weight loss 2 ▫ ê Ghrelin, é PYY à ê Hunger, é satiety • Weight-dependent and weight- independent mechanisms 1 Rubino, Ann Surg 2004; 2 Laferrere, JCEM 2008; 3 Cummings, JCEM 2004 1 Buchwald, JAMA 2004; 2 Rubino, Ann Surg 2004 Diabetes RCTs HbA1c 1. More diabetes remission with RYGB Intensive medical therapy (75%) and BPD (95%) than conventional Sleeve gastrectomy medical tx (0%) at 2 yrs 1 Roux-en-Y gastric bypass 2. 150 obese pts w/ uncontrolled DM underwent intensive medical therapy +/- Intensive medical therapy RYGB or sleeve gastrectomy 2 # DM Meds ▫ 12% (medical tx alone) vs. 42% (RYGB) vs. 37% (sleeve) had A1c <6.0% at 12 months Sleeve gastrectomy Roux-en-Y gastric bypass 1 Mingrone, NEJM 2012; 2 Schauer, NEJM 2012 Schauer, NEJM 2012 4
Hypertension Dyslipidemia • SBP and DBP ê as early as 1 week • Hypercholesterolemia improves in post-op 1 71%, hypertriglyceridemia in 82% 1 ▫ Weight-independent as well as -dependent mechanisms • Resolution of dyslipidemia after 3 yrs • HTN resolves or improves in 79% 2 in 62% of RYGB pts and 27% of LAGB pts 2 • Complete resolution after 3 yrs in 38% of RYGB pts and 17% of LAGB pts 3 1 Ahmed, Obes Surg 2009; 2 Buchwald, JAMA 2004; 1 Buchwald, JAMA 2004; 3 Courcoulas, JAMA 2013 3 Courcoulas, JAMA 2013 Cardiovascular outcomes: Swedish Cardiovascular outcomes: Swedish Obesity Subjects Study Obesity Subjects Study No interaction with Stronger CV effect if high Fatal CV Events Total CV Events baseline BMI baseline insulin level • CV deaths: adjusted HR 0.47 (0.29-0.76) Sjostrom, JAMA 2012 Sjostrom, JAMA 2012 5
Mortality: Swedish Obesity Subjects Mortality: Utah gastric bypass study • Covariate-adjusted mortality: 40% lower in surgery group • Death rates for specific causes: • Lower for CVD, diabetes, cancer • CVD: HR 0.50 (95% CI 0.36-0.69) • Higher for suicide/accidents • 29% reduction in risk after 10 years Sjostrom, NEJM 2007 Adams, NEJM 2007 Mortality: Stronger protective effect Objectives in patients with diabetes • Describe the effects of bariatric surgery on cardio-metabolic outcomes and mortality • Identify basic eligibility criteria for surgery • Apply recommendations for post-op medical management, monitoring Lent, Diabetes Care 2017 6
Case Bariatric surgery: Eligibility criteria 46 y.o. woman w/ severe obesity, type 2 Typical criteria: • BMI ≥40 kg/m 2 , or BMI ≥35 kg/m 2 with an DM, HTN, GERD obesity-related co-morbidity • Wt increased from 240 to 280 lbs over • Failure of lifestyle/medical weight control last 10 years (BMI 40 to 46 kg/m 2 ) • Absence of psychological or medical • Lost 20 lbs with Weight Watchers then contraindications regained 10 lbs Undertreated psychiatric conditions Low likelihood of adherence to post-op requirements • Walks 30 min 3 times/week Poor coping strategies, lack of social support Weight loss surgery? Eating disorders Case Bariatric surgery: Eligibility criteria 46 y.o. woman w/ severe obesity, type 2 Typical criteria: • BMI ≥40 kg/m 2 , or BMI ≥35 kg/m 2 with an DM, HTN, GERD obesity-related co-morbidity • Wt increased from 240 to 280 lbs over • Failure of lifestyle/medical weight control last 10 years (BMI 40 to 46 kg/m 2 ) • Absence of psychological or medical • Lost 20 lbs with Weight Watchers then contraindications regained 10 lbs Potential exclusion criteria (varies by practice): • Walks 30 min 3 times/week • >400 lbs, tobacco or other substance use/abuse, CHF or pulmonary HTN not responsive to medical therapy, O 2 - Weight loss surgery? dependent COPD, cirrhosis 7
Objectives Post-op management: Diabetes • Anticipate potentially abrupt decrease in • Describe the effects of bariatric surgery on insulin/oral diabetes med needs cardio-metabolic outcomes and mortality • Often, stop sulfonylureas at surgery • Identify basic eligibility criteria for surgery • Decrease insulin doses • Apply recommendations for post-op • Metformin often continued medical management, monitoring • Self-monitoring and self-titration Post-op management Other medication strategies • Oral meds: crush in initial post-op months • Anti-hypertensive medications • Avoid NSAIDs • No preemptive D/C of agents • Monitor closely at visits and adjust • Caution with meds dosed based on weight ( e.g., levothyroxine) • Lipid-lowering medications • Caution about potential malabsorption of • Many bariatric surgery pts will continue to meds meet criteria for statin use • Caution about creating expectations that statins will be d/c’ed post-op 8
Potential metabolic and nutritional Micronutrient deficiencies complications • Vitamin B12 • Weight regain • Gallstones • Calcium, vitamin D • Micronutrient • Nephrolithiasis • Iron deficiencies Malabsorption • Acute gout • Thiamine • Protein deficiency Less food • Bone loss • Folic acid • Dumping syndrome Different food • Hypoglycemia • Vitamin A • Vitamin K; zinc; selenium; copper Routine supplements Biochemical monitoring • Multivitamin • Pre-op, q 6 months x 2 years, annually • 1-2 daily (often 1 bariatric-potency chewable) • Vitamin B12 • Vitamin B12 • 350-1000 mcg/day po or 1000 mcg/month IM • Calcium • Vitamin D • Intact PTH • 3000 IU daily • 25(OH) vitamin D • Iron • Ferritin • Menstruating women; take with ascorbic acid • Thiamine • Calcium citrate • (Folate, vitamin A, zinc, copper) • 1200-1500 mg elemental Ca daily from diet + Ca Heber (Endocrine Society), JCEM 2010; citrate supplement (more for BPD/DS) Mechanick (AACE/TOS/ASMBS), Surg Obes Relat Dis 2013 Parrott, Surg Obes Relat Dis 2017 9
Other prevention, treatment Objectives • Protein deficiency • Describe the effects of bariatric surgery on • Eat protein first; 60-120 g/d or 1.5 g/kg IBW cardio-metabolic outcomes and mortality • Gallstones • Ursodiol, or simultaneous cholecystectomy • Identify basic eligibility criteria for surgery • Nephrolithiasis • Hydration; low oxalate diet; oral Ca; KCit • Apply recommendations for post-op • Acute gout medical management, monitoring • Prophylactic therapy in appropriate pts • Bone loss and fracture • Ca and vit D; consider DXA in at-risk pts Heber (Endocrine Society), JCEM 2010; Mechanick (AACE/TOS/ASMBS), Surg Obes Relat Dis 2013 Thank you! 10
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