What is Metabolic About Metabolic Surgery? The New ADA Recommendations

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

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

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

www.thelancet.com Vol 386 September 5, 2015

Weight Independent Antidiabetic Effects of Bariatric Surgery Rapid post-op remission of diabetes - 1160 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 2005 15: 474-81

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

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

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

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;17:183-190; 2. Nielsen LL, et al. Regul Pept. 2004;117:77-88

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

Duodenal Exclusion

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.

Diabetes Care 2016;39:1510 1518 DOI: 10.2337/dc15-2481

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

Overweight/Obesity Treatment Treatment Diet, physical activity & behavioral therapy Pharmacotherapy 23.0* or 25.0-26.9 Body Mass Index Category (kg/m 2 ) 27.0-29.9 27.5* or 30.0-34.9 35.0-39.9 40 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

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 500-750 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

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

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

Current Biology 26, 410 417, February 8, 2016

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

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

Federal Agricultural Subsidies 1995 2010 $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

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%

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 35.0-39.9 (32.5-37.4*) 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 30-34.9 (27.5-32.4*) 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