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