Melting Mama

WLS News - WATCH NOW!

 (That's the lovely Leslie Thompson with Tom Kinder of Bariatric Advantage.)

In this week's edition of WLS News, find out what life-threatening condition weight loss surgery patients should be on the watch for up to a year after surgery. Also, stats say that weight loss surgery can help women bear healthier children post-op -- get the details. Plus, we'll share an investment tip that may surprise you, and Yvonne pops in with a special find from the World Wide Web. Get the latest medical updates and stay on track to a healthy lifestyle with WLS News!

Weight Loss Surgery Resolves Diabetes - but for how long?

More news on glucose and bariatric surgery from the recent ASMBS meeting.

From the ASMBS-

As many as 90% of patients had improved glucose control following bariatric surgery, investigators told attendees at the American Society of Metabolic and Bariatric Surgery.

Although many patients maintained the improvement for as long as five years, questions about the durability of the surgery's effects on diabetes remained unresolved.

"Beyond three years after Roux-en-Y gastric bypass there is a significant cohort of patients that experiences recurrence or worsening of their diabetes after an initial period of resolution or improvement," said Daniel Rosen, MD, of Columbia University in New York. "Poor weight loss and more weight regain were seen in the recurrence/worsening group."

"Before widespread acceptance and implementation of bariatric surgery as definitive treatment for diabetes, further study of this recurrence phenomenon is indicated."

Roux-en-Y gastric bypass led to early resolution of diabetes in 153 of 172 (89%) obese patients with type 2 diabetes, said Silas Chikunguwo, MD, of Virginia Commonwealth University in Richmond.

Patients who had complete resolution of diabetes had lost an average 70% of excess weight, and their mean body mass index (BMI) decreased from 50 to 31. The remaining 19 patients had persistent diabetes despite excess weight loss that averaged 58%, said Dr. Chikunguwo.

During follow-up of five to 16 years, 66 of the 153 patients (43.1%) had recurrence of diabetes, which was associated with weight regain.

Mean excess weight loss declined from 66% to 48.9% in patients who had recurrent disease.

"Long-term weight control appears important for durable resolution of type 2 diabetes," said Dr. Chikunguwo.

Data from New York University showed that 53% of patients with type 2 diabetes remained medication free five years after undergoing laparoscopic adjustable gastric banding.

In addition, the proportion of patients requiring oral hypoglycemic agents declined from 75% before the procedure to 39% at five years, said NYU's Samuel Sultan. Overall, 80% of the patients were medication free or on lower doses.

The analysis comprised 95 morbidly obese patients with type 2 diabetes who had weight-loss surgery from 2002 to 2004. Median and mean follow-up was five years.

Excess weight loss at five years averaged 48.3%. Mean BMI decreased from 46.3 at baseline to 35 (P<0.001), fasting glucose from 146 to 118.5 mg/dL (P=0.004), and hemoglobin A1c from 7.53% to 6.58% (P<0.001).

However, only 40% of patients met criteria for diabetes remission at five years: off all medication and either an HbA1c less than 6% or a blood glucose level less than 100 mg/dL.

Lack of diabetes remission at five years was associated with significantly lower excess weight loss (38.2% versus 57.3%, P=0.001).

Dr. Rosen presented data from a retrospective analysis of long-term results in 42 morbidly obese patients who had type 2 diabetes prior to gastric bypass surgery. The primary objective was to characterize patients who achieved long-term resolution of diabetes with those who improved but were not in remission.

Follow-up averaged five years, and all patients had been followed for at least three years.

He and his team defined resolution of diabetes as being off all diabetes medications plus either an HbA1c less than 6% or blood glucose less than 124 mg/dL. They defined improvement as a decrease in medication requirements.

Dr. Rosen said 27 patients met criteria for resolution after surgery and 15 were improved.

The high point for mean excess weight loss was 58.3%, and regained weight averaged 21%. Nine patients had weight-loss failure, defined as <50% excess weight loss.

Diabetes resolution was associated with slightly greater peak excess weight loss (61% versus 52%), fewer weight-loss failures, and lower baseline HbA1c and blood glucose levels.

Patients who had resolution of diabetes were significantly more likely to be on oral medications (P=0.0006), whereas significantly more patients who improved were on insulin preoperatively (P<0.0001).

During follow-up, 10 patients (24%) had either recurrence or worsening of diabetes.

Compared with patients who had no change in diabetes status at five years, recurrence and worsening were associated with:

• Lower preoperative BMI (P=0.05)
• Higher rate of weight loss failure (P=0.03)
• Higher percentage of weight regained (P=0.002)
• Higher postoperative blood glucose values (P=0.0002)

The reasons for diabetes recurrence are not entirely clear, said Dr. Rosen, but failure of the surgical procedure over time probably is not the cause. Upper gastrointestinal evaluations in five of seven patients with recurrence revealed no abnormalities.

More likely causes of diabetes recurrence are increased caloric intake (implied by weight gain), reduced insulin sensitivity, attenuation of the hormonal effects of the surgery, and progression of beta-cell dysfunction, he added.

This is how to get me motivated, slightly.

Apparently this is late 2002, noting the leech, I think we're on Martha's Vineyard, and yes Bob is horrified by his shirt.

Meet the President of the ASMBS - Dr. Scott Shikora

Thanks for this clip, Bariatric TV! PS. Dr. Shikora met with me pre-op. We had gastric bypass surgery at his bariatric practice at NEMC.

Asking YOU for input, right NOW.

Do you have a pressing question you might like to see answered during the WLS Channel's coverage of the ASMBS? ASK AWAY. They are filming right now at the ASMBS in Texas.

Fix My Stoma! I Want A Stoma fix! Stomaphyx!

Welcome Stoma-Searchers.  Apparently we ALL watched The Doctors this afternoon - where they reran the episode about the post weight loss surgery revision procedure called the Stomaphyx.  Everybody wants to tighten and refresh their gastric bypasses, eh?  Here's my original post on that episode.

StomaPhyx Featured on The Doctors

How many calories should a gastric bypass post-op being eating daily?

"How many calories should a gastric bypass post-op being eating daily?"

This is a question I see in the searches all. the. time.  I would assume that everyone that has weight loss surgery goes through a thorough program that educates you in the post-operative eating plan.  Some programs give you binder -- a book -- a website to fall back on.  It surprises me how many of us just don't know.  I didn't, I know that now, but the materials were available, but I don't think the nutritionists and doctors shared EXACTLY how many calories we should take in, it was more about the lower carb intake and higher protein levels, and a bit of don't worry about calories.  I feel NOW that I should have considered calories from the beginning.

The ASMBS guidelines (which is where many surgeons GET their recommendations for you) state:

• 1,000 to 1,400 calories depending on the individual and activity level.
• 60 to 100 grams of protein depending on the individual and activity level.
• 27 to 47 grams of fat based on 20 to 35 percent of a daily 1,200-calorie intake.

Even then, it's open to translation, there's no carbohydrate level listed, which is one of the biggest hurdles many of us have in this journey.  Just. how. many are we supposed to eat? Most bariatric meal plans say, "4-6 starches,"  and if a starch has an approximate 15-20 carbohydrate level per 1/2 serving, That's A Lot.  (And for people who might end up hypoglycemic after roux en y surgery, it's laughable.)

I started out with the mind-set of very low carbs, >20 a day, much like Atkins Induction Phase.  I quickly learned that each packet of sugar substitute was costing me a carb, and then a protein bar?  HA.  This leads to high protein, high fat, non-calorie counting eating.  That's fine, as long as your carbs are GONE.  It does NOT work when you start eating a normal amount of carbs again.  

Cheese, eggs, meat, olives...it's all good until you add that toast back -- don't forget the 20 carbs in the SLICE of bread!

And, we end up in calorie counting land again.  Trying to aim for 1-1,500 calories, protein first!  This is drilled into your head.  Here's a daily caloric chart for download.

Now, in "maintenance" phase, I still hit my basics every day, the only thing that I might vary drastically is the calorie intake, which ranges from 1,000 (on a watching-every-bite-day) to 2,000 or more (on a hungry-hippo day) 

I fall in the middle most days, which is why I am several pounds above goal.  ;)  My body can have very few* calories to maintain what I think of as my "goal weight," and it's extraordinarily hard to get there.  *Because I don't do any real scheduled exercise, if I do, I can take in a bit more.

• What about you?  Do you follow an eating guideline? 
• Did your surgeon or nutritionist give you a specific set of instruction about calories, carbs, fat or protein? Do you count calories, carbs, fat or protein? 
• Or - do you just EAT and not count anything?
• How is your plan working for you?

ACOG Issues Guidelines on Managing Obesity in Pregnancy, Pregnancy AFTER Bariatric Surgery Guidelines

Finally, a little more guidance about pregnancy after weight loss surgery.

Source:  Medscape from ACOG

The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin to summarize the risks for obesity in pregnancy and outcomes of pregnancy after bariatric surgery as well as to provide recommendations for management during pregnancy and delivery after bariatric surgery. The new guidelines are published in the June issue of Obstetrics & Gynecology.

"Obesity is associated with reduced fertility primarily as a result of oligo-ovulation and anovulation," write Michelle A. Kominiarek, MD, and colleagues from the ACOG. "The increased risks for gestational diabetes, preeclampsia, cesarean delivery, and infectious morbidity associated with obesity are well established....Obese patients are more likely to be admitted earlier in labor, need labor induction, require more oxytocin, and have longer labor."

To identify pertinent articles published in the English language between January 1975 and November 2008, the guidelines authors searched the MEDLINE database, the Cochrane Library, and ACOG's own internal resources and documents. The reviewers gave priority to articles reporting findings from original research and also consulted review articles and commentaries, but they did not consider abstracts of research presented at symposia and scientific conferences. Using the method outlined by the US Preventive Services Task Force, the reviewers evaluated the identified studies for methodologic quality.

Recommendations from professional societies including ACOG and the National Institutes of Health were also reviewed. Reference lists from identified articles were used to help identify additional studies. When reliable research findings were not available, the reviewers used expert opinions from obstetrician-gynecologists as a basis for their recommendations.

Specific conclusions and clinical recommendations based on limited or inconsistent scientific evidence (level B) are as follows:

• Because pregnancy rates after bariatric surgery in adolescents are twice that in the general adolescent population, contraceptive counseling is especially important in these patients.

• Administration of hormonal contraception by nonoral routes should be considered in patients with a significant malabsorption component after bariatric surgery because these patients have an increased risk for oral contraception failure.

• Testing drug levels may be necessary for medications in which a therapeutic drug level is critical to ensure a therapeutic effect.

Specific conclusions and clinical recommendations based primarily on consensus and expert opinion (level C) are as follows:

• There should be a high index of suspicion for gastrointestinal tract surgical complications when pregnant women who have had bariatric procedures present with significant abdominal symptoms.

• Bariatric surgery should not be performed with the intention of treating infertility, although fertility may improve in association with rapid postoperative weight loss.

• Bariatric surgery in and of itself does not mandate cesarean delivery, although the rate of cesarean delivery in these patients may approach 62%.

• Despite the lack of consensus regarding the treatment of pregnant patients who have had an adjustable gastric banding procedure, it is suggested that these patients have early consultation with a bariatric surgeon.

• For patients who have had bariatric surgery that may be associated with malabsorption and/or dumping syndrome, alternative testing for gestational diabetes should be considered.

• After conception, consultation with a nutritionist may facilitate adherence to dietary regimens and allow the patient to cope with the physiologic changes of pregnancy.

• For women who have had bariatric surgery, a wide-spectrum assessment for micronutrient deficiencies should be considered at the beginning of pregnancy.

As a proposed performance measure, the guidelines authors suggest documentation of counseling regarding weight gain and nutrition in pregnancy.

Additional points made by the authors of the practice bulletin include the following:

• Specific complications of obesity in pregnancy include doubling to quadrupling of the risk for stillbirth.

• Waiting 12 to 24 months after bariatric surgery before conceiving may be helpful to avoid exposing the fetus to an environment of rapid maternal weight loss and to allow the patient to achieve full weight loss goals.

• If pregnancy occurs earlier than 12 to 24 months after bariatric surgery, closer surveillance of maternal weight and nutritional status, including ultrasound for serial monitoring of fetal growth, may be beneficial and should be considered.

• After bariatric surgery, there is a reduced risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia, as well as of large-for-gestational-age infants and macrosomia.

• After bariatric surgery, the risk for premature rupture of membranes is increased, but the risk for preterm delivery, congenital anomalies, and perinatal death is not increased.

"As the rate of obesity increases, it is becoming more common for providers of women's health care to encounter patients who are either contemplating or have had operative procedures for weight loss, also known as bariatric surgery," the guidelines authors write. "The counseling and management of patients who become pregnant after bariatric surgery can be complex. Although pregnancy outcomes generally have been favorable after bariatric surgery, nutritional and surgical complications can occur and some of these complications can result in adverse perinatal outcomes."

Obstet Gynecol. 2009;113:1405-1413.

Duodenal Switch Surgery Better Against Type 2 Diabetes Than Gastric Bypass

University of Chicago researchers say that a duodenal switch is more effective at controlling obesity-related conditions like diabetes.

Source:  Diabetes Health  6/2009

...In gastric bypass surgery, surgeons create a small pouch that is separated from the rest of the stomach. Food bypasses the stomach, instead going through the pouch. The smaller size and capacity of the pouch lessens appetite and reduces the amount of food that the body can digest at any one time.

In contrast, duodenal switch surgery modifies the stomach itself, reshaping it into a long, narrow tube. At the same time, the small intestine is changed to reduce the amount of calories it can absorb.

Following either surgery, many obese patients are able to cease taking the medications used to treat their conditions. After tracking the results of the two types of surgery on 350 super-obese patients, however, the researchers noted that the duodenal switch had decisively better postoperative outcomes than the gastric bypass.

• One hundred percent of duodenal switch patients completely stopped taking their diabetes medications, versus 60 percent of gastric bypass patients.
• Sixty-eight percent of duodenal switch patients completely stopped taking their hypertension medications, versus 38.6 percent of gastric bypass patient
• Seventy-two percent of duodenal switch patients completely stopped taking their medications for high cholesterol, versus 26 percent of gastric bypass patients

However, one area in which the gastric bypass outperformed the duodenal switch was in the resolution of acid reflux disease. Almost 77 percent of gastric bypass patients enjoyed a cessation of the disease, versus 48.5 percent of patients undergoing duodenal switch.

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