AACE Austin Texas: What s new in Diets and Bariatric surgical dilemmas 2017

Transcription

1 AACE Austin Texas: What s new in Diets and Bariatric surgical dilemmas 2017 Ken Fujioka, M.D. Director of Nutrition and Metabolic Research Scripps Clinic Dept. of Endocrine Panama Boca Del Toro 2015

2 What do the Guidelines say about Diet 2013 AHA/ACC/TOS Guideline Any one of the following methods can be used to reduce food and calorie intake: 1. Prescribe kcal/d for women and kcal/d for men Prescribe a 500-kcal/d or 750-kcal/d energy deficit 2. Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low- fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.

3 Study to end the debate of the Best Diet Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates (NEJM Sept 2009) Frank M. Sacks, M.D., George A. Bray, M.D., Vincent J. Carey, Ph.D. et al 811 pts randomized to 4 different diets 20% Fat, 15% protein, and 65% carbohydrates 20% Fat, 25% protein, and 55% carbohydrates 40% Fat, 15% protein, and 45% carbohydrates 40% Fat, 25% protein, and 35% carbohydrates

4 The Diet study All diets used similar foods All patients instructed to eat the same number of calories All diets used heart healthy foods Group and individual instructions offered for 2 years Main study parameters Percent Weight loss whether overweight pts have a better response (the long term) to diets that emphasize a specific macronutrient composition

5 Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates (NEJM 2009;360: ) Frank M. Sacks, M.D., George A. Bray, M.D., Vincent J. Carey, Ph.D. et al

6 Change in Body Weight from Baseline to 2 Years According to Attendance at Counseling Sessions for Weight Loss, among the 645 Participants Who Completed the Study. Sacks FM et al. N Engl J Med 2009;360:

7 Take home message: For the Average Healthy Person There is no best diet but rather all diets that lower calories will work if you can follow them No rocket science: The better the patient can follow (adhere) the diet the better they do or the more weight they lose Clinically: have the patient do a diet that you and the patient think they can follow

8 Personalized Nutrition Choosing a specific diet that meets the individuals needs medical information Example: prescribing a high fiber diet for patients with constipation Example: prescribing a Diabetic diet for patients with diabetes Example: prescribing a diet based on ones genetics or genetic predispositions Nutrigenomics or Nutrigenetics

9 Diets 2017 come get them while there HOT!!! High protein Low Carbohydrate diet Low fat high carbohydrate diet Genetic Testing to determine the best diet Alternate day Fasting (ADF) Organic Clean Raw Food Gluten Free diet topped off with a High end Enema after lunch

10 Fibroblast growth factor 21 (FGF21) FGF21 is a circulating protein with metabolic actions pharmacological doses of FGF21 produce antidiabetic, lipid-lowering, and weight-reducing effects in rodents Potential benefits have translated to non-human primates and obese humans with type 2 diabetes specific receptor complex in adipose tissue, liver, and brain; several pathways lead to enhanced fatty acid oxidation, increased insulin sensitivity, and augmented energy expenditure. Gimeno RE 1, Moller DE 2 Trends Endocrinol Metab Jun;25(6): doi: /j.tem Epub 2014 Apr 5

11 Let say we know the patient s Genetics Macronutrient Intake Associated FGF21 Genotype Modifies Effects of Weight-Loss Diets on 2-Year Changes of Central Adiposity and Body Composition: The POUNDS Lost Trial Diabetes Care 2016;39: DOI: /dc Yoriko Heianza,1 Wenjie Ma,2 Tao Huang, et. Al.

12 Fibroblast growth factor 21 (FGF21) Proposed as a potential therapeutic agent in type 2 diabetes. Data suggests that FGF21 ameliorates obesityassociated hyperglycemia and hyperlipidemia by effects on adipose tissue and the pancreas. FGF21 has been reported to play a regulatory role in starvation and ketosis. human cohort studies have shown a paradoxical regulation of plasma FGF21 in obesity and type 2 diabetes

13 Background FGF21 protein Prior studies reported that circulating levels of FGF21 increased in response to carbohydrate intake (1) The more carbs you eat the more FGF21 goes up in the blood elevated blood concentrations of FGF21 were positively increased BMI increased waist circumference Increased fat mass Increased visceral adipose area suggesting obesity as a FGF21- resistant state 1. Sanchez J, Palou A, Pico C. Response to carbohydrate and fat refeeding in the expression of genes involved in nutrient partitioning and metabolism: striking effects on fibroblast growth factor-21 induction. Endocrinology 2009;150: Zhang X, Yeung DC, Karpisek M, et al. Serum FGF21 levels are increased in obesity and are independently associated with the metabolic syndrome in humans. Diabetes 2008;57:

14 Genetic variance of the FGF21 C allele The C allele of the rs was associated with lower carbohydrate intake (3) The frequency of the FGF21 rs carbohydrate intake decreasing C allele was 44.8% in this particular study. 3. TanakaT,NgwaJS,vanRooijFJ,etal.Genome- wide meta-analysis of observational studies shows common genetic variants associated with macronutrient intake. Am J Clin Nutr 2013;97:

15 Low carb vs High carb diet in patients with the C allele variant Total fat loss on a Low carb diet with the C allele Approximately 1% (TT genotype) Total fat loss on a High carb diet with the C allele Approximately 4% (CC genotype) Change in waist circumference on Low carb Approximately 3 cm decrease in waist circumference TT genotype Change in waist circumference on High carb Approximately 5 1/2 cm decrease in waist circumference CC genotype

16 New diets that have some scientific data Alternate day fasting (ADF) Patients eat a relatively healthy diet but on alternate days or a few day a week they take in 25% of their caloric needs Typical needs 2200 kcals per day 25% would be 550 kcals per day

17 Does that mean you can skip breakfast? Randomized controlled studies actually do not say that we all need to eat breakfast Randomized 24 overweight pts to having breakfast or not having breakfast Then measured their food intake after having breakfast or skipping breakfast In this study they served a typical carbohydrate rich breakfast cereal with milk, toast and orange juice E A Chowdhury, 1 J D Richardson, 1 K Tsintzas Int J Obes (Lond) Feb; 40(2):

18 Energy intake 100kj=24kcals

19 Appetite scores

20 Skipping Breakfast Skipping breakfast did not significantly affect the size of lunch or dinner later that day Subjects did not report increased hunger skipping breakfast later in the day The group that skipped breakfast ended up eating 450 kcal less that day

21 Back to Alternate Day Fasting (ADF) Randomized 26 patients to either fasting alternate days (Zero calories) or calorie deficit of 400 calories per day for 8 weeks Both groups lost 8 Kilos or about 2 pounds per week for 8 weeks The group that did ADF ended up cutting their calories by about 376 calories per day At the end 24 weeks no change is weight regain Catenacci VA 1,2, Pan Z 3, Ostendorf D 2, Obesity (Silver Spring) Sep;24(9): doi: /oby.21581

22 Does ADF cause compensatory hunger or Change in satiety hormones Had 59 patients do ADF for 8 weeks 25% of caloric needs on fasting days Patients lost about 4 kilos over 8 weeks Patients decreased their RMR by 100 Kcal per day

23 Change in satiety hormones Ghrelin went up (increase hunger) PYY went up (increased fullness when pts ate) Subjects overall did not feel more hungry at the end of the study This shows a lack of compensatory hunger to weight loss? Patient may also have had a bit more fullness after eating with ADF (slightly higher levels of satiety hormones)

24 AACE Austin TX Bariatric surgery Ken Fujioka, M.D.

25 Current Surgical Options Laparoscopic Gastric Bypass Laparoscopic Gastric Band Laparoscopic Sleeve Gastrectomy

26 Current Surgical Options paroscopic Gastric Bypass Laparoscopic Gastric Band Laparoscopic Sleeve Gastrectomy

27 Laparoscopic Sleeve Gastrectomy

28 Sleeve Gastrectomy Wikipedia 2011

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30 Case 1 42 year old female comes in had Gastric bypass 2 years ago No follow up with surgeon She was a diabetic on two oral medications and stopped diabetic meds and is doing well Wants to know what nutritional supplements should she be taking?

31 What do they need to be taking in terms of nutritional supplements Multivitamin with Iron Calcium 1,500 to 2,000 mgs per day With Vitamin D What kind of Calcium? Calcium citrate is better absorbed than calcium carbonate Vitamin B12 sublingual, nasal or oral Fujioka K. Diabetes Care 2005

32 Additional history Pt. had a bypass 2 years ago Doing well but very tired Craves and chews ice Actually bought an ice maker What is your diagnosis and work up?

33 What labs or diagnostic work up would you order? Complete chemistry panal CBC B12 PTH Vit D 25 OH Iron work up Ferritin or TIBC and Iron level Diabetic work up

34 Iron deficiency Very common in menstruating females after bypass Will present as Pica Unusual food preferences Iron work up Ferritin TIBC and serum Iron Treatment?

35 Menstruating Females If Hgb. Hct, and iron stores are low then replace by intravenous route Due to bypass, patients will have a very hard time absorbing iron Replacement easiest Iron to use IV is Iron Sucrose Comes in 100 mgs vials out-pt procedure

36 Patient with osteoporosis after gastric bypass 52 year old female who is 7 years status post gastric bypass Lost 90 pounds and has regained about 25 pounds Has been in menopause four years You get your Dexa and the scan shows moderate osteoporosis How do you work this up?

37 Osteoporosis after bypass Chemistry panel normal Normal Calcium Normal albumin PTH = 120 (should be less than 70) Vitamin D 25 OH 15 ( should be above 30) Optional: 24 hour urine calcium Diagnosis? Hyperparathyroidism secondary to vit. D and Calcium malabsorption

38 How do you treat Osteoporosis in a gastric bypass pt Replace Calcium and vitamin D Start with Ergocalciferol Titrate up till PTH is down to normal range Occasionally need to add Calcitriol Bisphosphonates which Bisphosphonate and how do you give it? Give IV

39 Confusion after Bypass? Patient brought in by husband Complaint of feeling very bad about 60 to 90 minutes after eating Not all the time just once every few weeks nauseated, sweaty, and very light headed Eating sometimes helps Husband concerned because the last time it happened the patient appeared confused

40 Confusion after bypass 28 year old mother of two In general very good health except obesity had bypass 3 years ago for morbid obesity Weight down 95 pounds from 285 to 190 Vitals all normal Exam normal Neurologic: completely normal

41 Confusion after Bypass? Saw surgeon who did the surgery and told delayed dumping syndrome Told to stop eating ice cream Diagnosis?

42 Follow up of Gastric Bypass Dumping syndrome: Happens with in a few minutes of eating 1. light headedness, may actually need to sit or lay down 2. Diaphoresis 3. Nausea but rarely vomiting 4. In severe cases actual diarrhea 5. other people at the table will observe a pale ill appearing patient

43 Nesidioblastosis: Hyper insulinemic Hypoglycemia after gastric-bypass Etiology: suspect over stimulation of the small intestines with large releases of GLP-1 leading to increased growth of beta cells (in debate) Treatment removal of part of the pancreas? take down gastric-bypass diet and meds (acarbose) Convert bypass to Sleeve? (our surgeon does not agree) Recommend sending off to a specialty center as these are very difficult cases F.J Service Aug 2015 Up To Date

44 Nesidioblastosis: Hyper insulinemic Hypoglycemia after gastric-bypass What is your work up? Diagnostic work up: Give the patient a lab slip with a insulin and random glucose checked off blood sugars less than 55 Insulin level of greater than 3uU (C-peptide of 0.6) Service GJ, Thompson GB, Service FJ et al. hyperinulinemic Hypoglycemic with nesidoblastosis after gastric bypass surgery NEJM 2005:353:249-54

45 Dumping vs. Reactive Hypoglycemia Dumping After a high carb meal Diaphoresis Pallor Increased pulse With in 15 minutes after eating Fujioka, K. Encinitas Brew Club weekly blog Hypoglycemia After a high carb meal Diaphoresis Pallor Increased pulse Usually 1 to 2 hours after eating Neuroglycopenic manifestations

46 B12 deficiency Can often replace by sublingual B mcg once or twice a week Will often require IM Unclear if they need IM due to non-compliance or if it is true inability to absorb Trivia question: what percent of B12 will a patient absorb orally even if the stomach is removed? One percent

47 Zinc Copper Other deficiencies Fellows if you give zinc replacement what do you need to check or follow (lab wise) Be careful with replacement of Zinc or Copper these two trace elements compete for the same transport mechanism into the small intestine Example: if you give too much Zinc for too long you will make the pt copper deficient

48 Recommended follow-up of the bariatric surgery patient 1 month 3 months 6 months 12 months 18 months 24 months Annually Chemistry panel (lytes, LFTs, Cr and BUN) Magnesium Complete blood count Iron studies B12 levels The End Vitamin D (25 OH) Parathyroid hormone Bone density: frequency depends on needs of patient Fujioka Diabetes Care 2005 Optional Zinc, Copper, thiamine, vitamin A Clinical Practice Guideline J Clin Endo Met 2010:95(11);