What is Metabolic About Metabolic Surgery? The New ADA Recommendations

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1 What is Metabolic About Metabolic Surgery? The New ADA Recommendations Obesity Symposium September 16, 2017 Timothy Howland, MD Lourdes Endocrinology

2 Bariatric from the Greek root bar- ("weight" as in barometer), suffix -iatr ("treatment," as in pediatrics), suffix -ic ("pertaining to")

3 n engl j med 376;3 nejmn engl j med 376;3 nejm.org January 19, 2017.org January 19, 2017n engl j med 376;3 nejm.org January 19, 2017

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7 Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5-Year Outcomes n engl j med 376;7 nejm.org February 16, 2017

8 Vol 386 September 5, 2015

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10 Weight Independent Antidiabetic Effects of Bariatric Surgery Rapid post-op remission of diabetes pts undergoing RYGB. Average inpatient LOS of 3 days. - 1/3 of T2DM pts discharged with normal blood sugar on no diabetes meds. ( Similar remission not seen with restrictive procedures.) Obes Surg :

11 Distal Bowel Hypothesis Expedited delivery of nutrient chyme to the distal intestine Enhanced release of a physiologic signal that improves glucose metabolism

12 Lower Gut Theory With bypass surgery, there is expedited delivery of nutrients to the distal small bowel (shortened length of small bowel) Increased nutrient exposure causes increased release from the L cells GLP-1 and PYY

13 Enteroglucagons GLP-1 GLP-1 levels increased 6x following RYGB, but unchanged in obese subjects with similar weight loss on hypocaloric diet. GLP-1 levels rise progressively for 12 months following gastric bypass surgery

14 Continuously Infused GLP-1 Improves the Defects of T2D T2D Defects 1 Continuously Infused GLP-1 1,2 Insulin production First-phase insulin response Glucagon; glucose output Gastric emptying Food intake 1. Aronoff SL, et al. Diabetes Spectrum. 2004;17: ; 2. Nielsen LL, et al. Regul Pept. 2004;117:77-88

15 Duodenal Exclusion Hypothesis Exclusion of the duodenum may prevent secretion of a signal that promotes insulin resistance.

16 Duodenal Exclusion

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19 Weight Independent Antidiabetic Effects of Bariatric Surgery Occasional late onset of beta cell hyperactivity. - late onset following RYGB typically 1-9 years following surgery hyperinsulinemic hypoglycemia nesidioblastosis on pathology. Occasionally requires partial pancreatectomy.

20 Diabetes Care 2016;39: DOI: /dc

21 Diabetes Care 2016;39: DOI: /dc

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26 Benefits of Weight Loss Delay progression from prediabetes to type 2 diabetes Positive impact on treatment of type 2 diabetes Most likely to occur early in disease development Improves mobility, physical and sexual functioning & health-related quality of life American Diabetes Association Standards of Medical Care in Diabetes. Obesity management for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63

27 Overweight/Obesity Treatment Treatment Diet, physical activity & behavioral therapy Pharmacotherapy 23.0* or Body Mass Index Category (kg/m 2 ) * or Metabolic surgery * Asian-American individuals Treatment may be indicated for selected, motivated patients. American Diabetes Association Standards of Medical Care in Diabetes. Obesity management for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63

28 Recommendations: Diet, physical activity & behavioral therapy Diet, physical activity & behavioral therapy designed to achieve >5% weight loss should be prescribed for overweight & obese patients with T2DM ready to achieve weight loss. A Interventions should be high-intensity ( 16 sessions in 6 months) and focus on diet, physical activity & behavioral strategies to achieve a kcal/day energy deficit. A American Diabetes Association Standards of Medical Care in Diabetes. Obesity management for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63

29 Recommendations: Diet, physical activity & behavioral therapy Diets should be individualized, as those that provide the same caloric restriction but differ in protein, carbohydrate, and fat content are equally effective in achieving weight loss. A Patients who achieve short-term weight loss goals should be prescribed long-term maintenance programs. A American Diabetes Association Standards of Medical Care in Diabetes. Obesity management for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63

30 Metabolic Surgery Evidence supports gastrointestinal operations as effective treatments for overweight T2DM patients. Randomized controlled trials with postoperative follow-up ranging from 1 to 5 years have documented sustained diabetes remission in 30 63% of patients, though erosion of remission occurs in 35-50% or more. With or without diabetes relapse, the majority of patients who undergo surgery maintain substantial improvement of glycemic control for at least 5 to 15 years American Diabetes Association Standards of Medical Care in Diabetes. Obesity management for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63

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33 Current Biology 26, , February 8, 2016

34 Current Biology 26, , February 8, 2016

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39 CMAJ JULY 17, 2017 VOLUME 189 ISSUE 2CMAJ JULY 17, 2017 VOLUME 189 ISSUE 288

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41 USDA Dietary Guidelines for Americans Emphasize consumption of fruits, vegetables, whole grains, protein Limited consumption saturated fats, sugars, salt, refined grains

42 Federal Agricultural Subsidies $170 billion spent on 7 commodities and programs (corn, soybeans, wheat, rice sorghum, dairy, livestock) 30-40% corn; 50% soybeans; nearly all sorghum feed for cattle and livestock 5% corn for high fructose corn syrup

43 Subsidy Score Proportion of intake (in calories ) derived from the 7 major subsidized commodities (corn, soybeans, wheat, rice sorghum, dairy, livestock) 0.0 = 0% 1.0 = 100%

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46 Recommendations: Metabolic Surgery Metabolic surgery should be recommended to treat T2DM for all appropriate surgical candidates with BMIs > 40 (37.5*) and those with BMIs ( *) when hyperglycemia is inadequately controlled despite lifestyle & optimal medical therapy. A Metabolic surgery should be considered for the treatment of T2DM in adults with BMIs ( *) when hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications (including insulin). B Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and gastrointestinal surgery. C American Diabetes Association Standards of Medical Care in Diabetes. Obesity management for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63

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Treating Type 2 Diabetes with Bariatric Surgery. Goal of Treating T2DM. Remission of T2DM with Bariatric

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