Another benefit to breastfeeding

On December 21, 2009, in Pregnancy after WLS, by Andrea

While most of my readers are post-RNYers, I know that some are going to be Banders or VSGers — ones that don’t have an automatic “cure” or “remission” to diabetes due to the intestinal switch done from RNY or DS.  So I’m including this for any Banders or VSGers that might decide to get pregnant at some point.

I couldn’t nurse my two kiddos post op, wish I could have — but there’s nothing to say that those who have had surgery cannot and here is more reason to do so.

From Medscape:

Breast-Feeding May Protect the Mother From Metabolic Syndrome

Laurie Barclay, MD

December 17, 2009 — Breast-feeding may protect the nursing mother from the metabolic syndrome, according to the results of a prospective, observational cohort study reported in the December 3 Online First issue of Diabetes.

“The Metabolic Syndrome is a clustering of risk factors related to obesity and metabolism that strongly predicts future diabetes and possibly, coronary heart disease during midlife and early death for women,” lead author Erica Gunderson, PhD, from Kaiser Permanente’s Division of Research in Oakland, California, said in a news release. “Because the Metabolic Syndrome affects about 18 to 37 percent of U.S. women between ages 20-59, the childbearing years may be a vulnerable period for its development. Postpartum screening of risk factors for diabetes and heart disease may offer an important opportunity for primary prevention.”

The multicenter, population-based US cohort used for this study consisted of 1399 nulliparous women (39% black, aged 18 – 30 years) enrolled in the ongoing Coronary Artery Risk Development in Young Adults Study. Participants were free of the metabolic syndrome at baseline from 1985 to 1986 and before subsequent pregnancies. At 7, 10, 15, and/or 20 years after baseline, participants were re-examined, and National Cholesterol Education Program criteria were used to identify incident cases of metabolic syndrome.

The investigators used complementary log-log models to estimate relative hazards of incident metabolic syndrome among time-dependent lactation duration categories by gestational diabetes mellitus, after adjustment for age, race, study center, time-dependent parity, baseline body mass index, components of the metabolic syndrome, education, smoking, and physical activity.

Of 704 parous women, 84 had gestational diabetes and 620 did not. During 9993 person-years, there were 120 incident cases of metabolic syndrome, yielding an overall crude incidence rate of 12.0 per 1000 person-years (10.8 for nongestational diabetes and 22.1 for gestational diabetes). Increasing duration of lactation was associated with lower crude incidence rates of metabolic syndrome from 0 to 1 month through 9 months or more of breast-feeding (P < .001).

“The findings indicate that breastfeeding a child may have lasting favorable effects on a woman’s risk factors for later developing diabetes or heart disease,” Dr. Gunderson said.

Risk reductions associated with longer duration of lactation were greater among women with gestational diabetes (fully adjusted relative hazards range, 0.14 – 0.56; P = .03) vs those without gestational diabetes (fully adjusted relative hazards range, 0.44 – 0.61; P = .03).

Limitations of this study include observational design and possible residual confounding.

“Longer duration of lactation was associated with lower incidence of the metabolic syndrome years post-weaning among women with a history of GDM [gestational diabetes mellitus] and without GDM controlling for preconception measurements, BMI [body mass index], socio-demographic and lifestyle traits,” the study authors conclude. “Further investigation is needed to elucidate the mechanisms through which lactation may influence women’s cardiometabolic risk profiles, and whether lifestyle modifications, including lactation duration, may affect development of coronary heart disease and type 2 diabetes, particularly among high-risk groups such as women with a history of GDM.”

The National Institutes of Health (the National Heart, Lung, and Blood Institute; the National Institute of Diabetes, Digestive and Kidney Diseases) and the American Diabetes Association supported this study. The study authors have disclosed no relevant financial relationships.

Diabetes. Published online December 3, 2009. Abstract

Positive Outcomes from Gastric Banding

On December 15, 2009, in Uncategorized, by Andrea

From Medscape:

ASMBS 2009: Gastric Banding Achieves Sustained Weight Loss, Improvement of Diabetes

Louise Gagnon

June 29, 2009 (Dallas, Texas) — Laparoscopic adjustable gastric banding has a sustained and substantial positive effect on metabolic parameters in morbidly obese patients with type 2 diabetes, according to data presented here at the annual meeting of the American Society of Metabolic and Bariatric Surgery.

Investigators assessed the 5-year outcomes of 95 morbidly obese patients with type 2 diabetes, recording age, sex, race, body mass index (BMI), diabetes history, fasting glucose level, hemoglobin A1c (HbA1c), and use of medications. The patients underwent laparoscopic adjustable gastric banding between January 2002 and June 2004.

Morbid obesity was defined as a BMI of 40 kg/m2 or more or a BMI of 35 kg/m2 with an obesity-related illness. The mean age of patients before surgery was 49.3 years, and mean duration of diabetes was 6.5 years. The mean preoperative BMI was 46.3 kg/m2 (range, 35.1 – 71.9 kg/m2), which fell to 35.0 kg/m2 (range, 21.1 – 53.7 kg/m2) at 5-year follow-up. Mean excess weight loss was 48.3%.

The mean fasting glucose level fell from 146 mg/dL to 118.5 mg/dL (P = .004). The mean HbA1c decreased from 7.53% to 6.58% at 5 years after banding (P < .0001).

Diabetes resolution was defined as the patient being medication-free with an HbA1c of less than 6% and/or a glucose level less than 100 mg/dL. Resolution occurred in 23 (39.7%) of 58 patients. Improvement, defined as fewer medications required and fasting glucose levels between 100 and 125 mg/dL, was seen in 41 (71.9%) of 57 patients.

The overall combined improvement/resolution rate was 80% (64 of 80 patients).

“Our study shows that for the vast majority of diabetic, morbidly obese patients, they will have improvement in their diabetes and often times a resolution of their diabetes, which extends out to 5 years,” said Christine Ren, MD, FACS, an associate professor of surgery at New York University School of Medicine in New York City, and one of the study’s senior authors.

“We saw [that] the only difference between those who had complete resolution of diabetes vs those who did not was their weight loss,” said Dr. Ren.

“It appears that in gastric banding, the probability of a patient having improvement or resolution of diabetes depends on how much weight you lose and keep off.”

Investigators did not find a statistically significant difference in remission of diabetes based on the duration of diagnosis prebanding. A total of 83 (88.3%) of 94 patients were on oral medications before gastric banding, and 14.9% were on insulin. Five years after gastric banding surgery, 33 (46.5%) of 71 patients were on oral medications and 8.5% were on insulin.

Evidence has been available on the efficacy of gastric bypass surgery on resolution of diabetes, but these results point to the efficacy of laparoscopic adjustable gastric banding in resolving diabetes and in controlling metabolic parameters in the morbidly obese patient with diabetes, said Alan Wittgrove, MD, FACS, a member of the executive council of the American Society of Metabolic and Bariatric Surgery and medical director of the Bariatric Surgical Program at Scripps Memorial Hospital in La Jolla, California.

“It’s important because the study follows the patients for at least 5 years,” said Dr. Wittgrove. “It shows the longevity of the procedure in resolving diabetes through weight loss and [its] impact on the metabolic syndrome.”

Although the study did not reveal the duration of diagnosis to be a factor that influenced whether or not patients experienced improvement in their diabetes, duration of diagnosis may have emerged as a variable that affected outcomes in a larger study, according to Dr. Wittgrove.

“That is probably a function of the power of the study,” he said, noting that several studies have found that the timing of surgery has an effect on resolving diabetes in this type of patient. Surgery performed earlier results in more durable resolution, he pointed out.

“Since [duration of disease] has been shown to be a factor in other studies, I would extrapolate that if [the researchers] get more numbers, it would reach [statistical] significance,” Dr. Wittgrove said.

The study was independently conducted. Dr. Ren is a member of the Speaker’s Bureau, sits on an advisory board, and receives research and educational grants from Allergan Inc. She receives research and educational grants from Ethicon Endo-Surgery Inc and is a consultant for Explora Med Development, LLC. Dr. Wittgrove is a consultant for Ethicon Endo-Surgery Inc and receives research funding from Stryker Corporation.

American Society of Metabolic and Bariatric Surgery 2009 Annual Meeting: Abstract PL-104. Presented June 24, 2009.

Recommendations for WLS as treatment for WLS

On December 15, 2009, in Uncategorized, by Andrea

From Medscape:

Recommendations Issued for Use of Gastrointestinal Surgery to Treat Type 2 Diabetes

Laurie Barclay, MD

December 1, 2009 — The Diabetes Surgery Summit (DSS) Consensus Conference reviewed pertinent research and made clinical recommendations regarding gastric surgery as a treatment of type 2 diabetes mellitus (T2DM). The new position statement, which consists of recommendations for clinical and research issues, as well as overall concepts and definitions in diabetes surgery, is published in the November 19 Online First issue of Annals of Surgery.

“Increasing evidence demonstrates that bariatric surgery can dramatically ameliorate type 2 diabetes,” write Francesco Rubino, MD, from Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, and colleagues from the DSS Delegates. “Not surprisingly, gastrointestinal operations are now being used throughout the world to treat diabetes in association with obesity, and increasingly, for diabetes alone. However, the role for surgery in diabetes treatment is not clearly defined and there are neither clear guidelines for these practices nor sufficient plans for clinical trials to evaluate the risks and benefits of such ‘diabetes surgery.’”

Development of Position Statement

The goal of this consensus conference was to issue guidelines for the use of gastrointestinal surgery for treatment of patients with T2DM and to develop a plan for further research. The DSS consensus document aimed to include the foundations underlying “diabetes surgery” and to present the opinions of leading scholars and evidence base supporting better access to surgical options, while preventing harm from unwarranted use of unproven procedures.

At the first International Conference on Gastrointestinal Surgery to Treat Type 2 Diabetes (the DSS), a multidisciplinary group of 50 voting delegates from around the world were convened in Rome, Italy, to review available scientific evidence. These data were evaluated and critiqued by the entire group to determine the strength of evidence and to draft consensus statements.

Draft statements from this meeting were reviewed, debated, edited, reevaluated, and presented for formal voting. Those statements that achieved consensus were summarized and distributed to all voting delegates for further input and final approval. At the 1st World Congress on Interventional Therapies for T2DM held in New York in September 2008, the final consensus statements were reviewed and discussed by representatives of several scientific societies to generate the current position statement.

The DSS acknowledged that in carefully selected patients, surgical approaches to treat T2DM are appropriate. In patients with poorly controlled diabetes and a body mass index (BMI) of 30 kg/m2 or more, for example, gastric bypass was recognized to be a reasonable treatment option.

Specific procedures may include Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding, or biliopancreatic diversion.

The DSS recommended further clinical trials to determine the precise role of surgery in patients who have less severe obesity and diabetes. Also strongly needed is further research on the mechanisms underlying surgical control of diabetes, which may further elucidate the pathophysiology of diabetes.

Recommendations

Specific recommendations in the DSS position statement, and their accompanying level of evidence rating, include the following:

  • In acceptable surgical candidates with a BMI of 35 kg/m2 or more whose disease is inadequately controlled by lifestyle and medical therapy, gastrointestinal surgery, such as RYGB, laparoscopic adjustable gastric banding, or biliopancreatic diversion, should be considered for the treatment of T2DM (level of evidence, A).
  • In suitable surgical candidates with mild to moderate obesity (BMI 30 – 35 kg/m2), a surgical approach may also be appropriate as a nonprimary option to treat inadequately controlled T2DM (level of evidence, B). RYGB may be an appropriate surgical option to treat diabetes in these patients (level of evidence, C).
  • In early clinical studies, novel gastrointestinal surgical techniques (eg, duodenal-jejunal bypass, ileal interposition, sleeve gastrectomy, and endoluminal sleeves) have shown promising results for the treatment of T2DM. At present, however, they should be used only in the context of institutional review board–approved and registered trials (level of evidence, A).
  • Establishing standards to measure clinical and physiologic outcomes of surgical treatment for T2DM is a high priority to obtain better-quality medical evidence (level of evidence, A).
  • To evaluate the usefulness of gastrointestinal surgery to treat T2DM, the DSS strongly encourages more randomized controlled trials (level of evidence, A).
  • Another important research priority is to identify the appropriate use of gastrointestinal surgery to treat T2DM in patients with a BMI of less than 35 kg/m2 (level of evidence, A). This should be accomplished with controlled clinical trials to assess the safety and efficacy of gastrointestinal metabolic surgery (level of evidence, A) and to identify parameters other than BMI to help guide selection of suitable patients (level of evidence, A).
  • Defining the optimal use of gastrointestinal surgery for treatment of T2DM in patients with a BMI of less than 35 kg/m2 would also be greatly facilitated by development of a standard registry/database (level of evidence, A).
  • Animal models can also offer helpful insights regarding the efficacy and mechanisms of gastrointestinal metabolic surgery used to treat T2DM (level of evidence, A).
  • Research on gastrointestinal metabolic surgery offers valuable, novel opportunities to investigate contributions of the gastrointestinal tract to glucose homeostasis and to clarify the pathophysiologic mechanisms of T2DM (level of evidence, A).
  • After laparoscopic adjustable gastric banding, weight loss alone accounts for diabetes control, based on available evidence from animal and clinical studies (level of evidence, A). However, mechanisms beyond those related to lowered food intake and body weight seem to be involved in intestinal bypass procedures such as RYGB, biliopancreatic diversion, and duodenal-jejunal bypass (level of evidence, A). In addition, distinct physiologic mechanisms that ameliorate T2DM are activated by anatomic changes in different regions of the gastrointestinal tract (level of evidence, B).
  • To improve understanding of gastrointestinal mechanisms of metabolic regulation and to use these insights to improve T2DM treatment, collaboration should be encouraged among endocrinologists, surgeons, and basic scientists (level of evidence, A).
  • To oversee the study and development of diabetes surgery, a multidisciplinary task force should be established, including endocrinologists, surgeons, clinical and basic investigators, bioethicists, and other appropriate experts (level of evidence, A).

“Delegates unanimously agreed that patients with inadequately controlled diabetes and BMI >35 kg/m2 should be considered for GI [gastrointestinal] surgery,” the DSS authors conclude. “This concurs with existing NIH [National Institutes of Health] guidelines and with the 2009 American Diabetes Association standards of care position statement, and it further emphasizes the role of GI surgery in severely obese patients, where mounting evidence shows that surgery improves overall survival.”

DSS was supported by Covidien, Ethicon, Allergan, Storz, GI Dynamics, Roche, Amylin, and Power Medical Interventions.

Ann Surg. Published online November 19, 2009. Abstract

Yet another reason to get WLS..

On November 27, 2009, in Uncategorized, by Andrea

Via CNN.com

(CNN) — The number of Americans with diabetes will nearly double in the next 25 years, and the costs of treating them will triple, according to a new report.

The figures, in a University of Chicago report released Friday, add fuel to the congressional debate regarding reining in the cost of health care.

By 2034, 44.1 million Americans will be living with diabetes — nearly twice the current number of 23.7 million, according to the report, published in the December issue of the journal Diabetes Care. About 90 percent of those with diabetes have type 2, a version of the condition that develops over time.

Accounting for inflation, the direct medical cost of treating them will rise from $113 billion annually to $336 billion, the report says.

Keep in mind that the number one cause — the number one cause of Type 2 diabetes is obesity.  Even modest changes in diet and exercise can stave off diabetes.

Also keep in mind that the DS has a 98% CURE rate — not remission, but CURE rate — of diabetes.  RNY can pretty much throw it into remission immediately for most folks, and the band and sleeve can throw it into remission after enough weight loss.  All forms of WLS are helpful for diabetes.

Chalk it up for the home team, folks.

CNN gives the DS a shoutout

On November 16, 2009, in Uncategorized, by Andrea

Finally.

In a quick Q&A, a CNN.com doc answers a question about resolution of diabetes with weight loss surgery:

Does roux-en-Y gastric bypass cure diabetes?

Asked by Rick Shetron, Troy, New York

“60 Minutes” had a story several months ago about a type of weight-loss surgery that seemed to also cure type 2 diabetes in many people. Has more research been done on this? Do you need the full bypass of about one-third of the small intestine or just the duodenum and jejunum? My weight problem came about with/after diabetes, not before.

Expert answer

Hi, Rick. I’m not a surgeon, so to answer your question more thoroughly, I consulted with a very well-respected bariatric surgeon in San Francisco, John Rabkin, M.D. He explained that the roux-en-Y gastric bypass (RGB) improves type 2 diabetes via at least three different mechanisms:

1. The surgery decreases caloric intake immediately after the procedure because food intake is restricted by the small volume of the created stomach pouch, which holds only 1 ounce. The decrease in food intake, particularly refined carbohydrates, which are not well-tolerated after this procedure, can help stabilize blood sugar levels and immediately improves control of diabetes.

2. The significant amount of weight loss that results from the surgery improves insulin resistance over time.

3. There are changes in hormones and caloric processing because the food ingested bypasses the segment of the small intestine closest to where it attaches to the stomach (the duodenum and proximal jejunum), but not quite as much as you mentioned (not one-third of the small intestine). Because of the anatomical changes resulting from the surgery, it appears that these hormonal changes are greater than would be seen with weight loss via diet and exercise, but no research has yet to compare the two directly and evaluate hormonal changes.

The overall outcome is complete resolution of type 2 diabetes in greater than 70 percent of patients with diabetes before the procedure.

Unfortunately, as many RGB patients regain weight over time, the durability of the cure isn’t as high as with a newer procedure called the duodenal switch.

In this procedure, there is a much larger pouch created (4 to 5 ounces), and the complete stomach anatomy is preserved, which helps preserve more normal stomach function. In this procedure, the rearrangement of the intestines leads not only to some restriction of food, but also causes your body to absorb significantly fewer calories, which has a more lasting effect.

Rabkin, a leader in this procedure, reports that he has had a 96 percent cure of type 2 diabetes at one year after surgery, which has persisted for five and 10 years post -op and seems to be similarly durable out past 15 years post-op.

Hope this helps. I strongly recommend spending a considerable amount of time with your surgeon if you are considering either of these procedures, as both have important lifestyle-related issues that should be discussed to determine the best procedure for you for the long term.

Answered by Dr. Melina Jampolis Physician Nutrition Specialist

Bout time this is really hitting the mainstream.  I would take some exception with the assumption that all RNY’ers regain their weight, but many do.  I get that.  I only wish they had qualified this a bit better, but glad the DS got some mainstream attention.

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