Effect of Metabolic Surgery on diabetes and hypertension

1. Effect of Metabolic Surgeryon diabetes and hypertension

2. Objectives • brief overview of Bariatric surgery • management of bariatric surgery patients and complications • effects of bariatric surgery on diabetes

3. Metabolic Syndrome • Central obesity. (defined as waist circumference ≥ 40 inches for men and ≥ 35cm for women) • raised TG level: ≥ 150 mg/dL • reduced HDL cholesterol: < 40 mg/dL • raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg, or treatment of previously diagnosed hypertension • raised fasting plasma glucose (FPG) ≥ 100 mg/dL or previously diagnosed type 2 diabetes

4. Metabolic Syndrome • 54 Million Americans! • A quarter of the world’s adults have metabolic syndrome • twice as likely to die from, and three times as likely to have a MI or CVA • a five-fold greater risk of developing type 2 diabetes

5. The Metabolic Syndrome:A Network of Atherogenic Factors • Type 2 diabetes and glycemic disorders • Dyslipidemia • - Low HDL • - Small, dense LDL particles • Hypertriglyceridemia • Hypertension • Impaired thrombolysis • - PAI-1 • Endothelial dysfunction/ • inflammation • - CRP, MMP-9 • Microalbuminuria Insulin Resistance  Free Fatty Acids VisceralObesity Atherosclerosis

6. Medical Sequelae of Obesity Hypertension Lipid disorders Diabetes Ischaemic heart disease Cardiomyopathy Pulmonary hypertension Asthma Obstructive sleep apnea Gallstones NASH (Non-alcoholic steatohepatitis) Urinary incontinence GERD Arthritis/back pain Infertility/menstrual problems Obstetric complications DVT and thromboembolism Depression Immobility Breast/bowel/prostate/endometrial cancer Venous stasis ulcers Intertrigo Accident prone

8. Body Mass Index • BMI > 25: Over weight, 2/3rd US • BMI > 30: Obese, 1/3rd US • BMI > 40: Morbid Obese, 6% US (18 million Americans)

9. Criteria • BMI > 40 • BMI > 35 plus 1 or 2 co-morbidities • T2D , Hypertension • OSA, NASH • Hyperlipidemia, Pseudo tumor cerebri • Considerably impaired quality of life

10. Bariatric surgery or weight-loss surgery refers to surgery usually performed in patients with a body mass index (BMI) of 40 kg/m2 or greater and those with a BMI between 35 and 40 kg/m2 and a major medical comorbidity in order to: • Support weight loss • Treat or prevent obesity-related comorbidities (e.g., diabetes, hypertension, cardiovascular disease, obstructive sleep apnea) • The most common types of bariatric surgery include: • Laparoscopic adjustable gastric banding (LAGB) • Roux-en-Y gastric bypass (RYGB) • Sleeve gastrectomy • Biliopancreatic diversion with duodenal switch (BPD/DS)

12. Studies show that bariatric surgery causes significant weight loss and is more effective at improving diabetes in the short term (up to 2 years) than nonsurgical interventions (diet, exercise, other behavioral interventions, and medications). • Diabetes improvement starts rapidly after surgery, before significant weight loss has occurred. • The mechanism for postoperative metabolic improvements has not been fully elucidated and may be, in part, independent of weight loss. • This suggests that bariatric surgery may improve metabolic comorbidities even in patients who are not morbidly obese.

15. The Adipo-insular Axis • Free fatty acids and insulin resistance – Theories • Impaired insulin signaling (muscle) / glucose transport • Increased oxidative stress (reactive oxygen species) • Inhibition of insulin suppression of glycogenolysis in liver • Direct endothelial damage • Impairment of beta cell function • Alterations in blood pressure

16. Outcomes • Non-Surgical management: only 5-10% success • T2D remission: up to 72% at 2 years • RYGB sustained remission of 62% at 6 years • All-cause mortality reduced by 40% 7 years after RYGB • Cause specific mortality reduction: • T2D 92%, Cancer 60%, CAD 56%

17. Pre-op work up • Cardiology, Pulmonary, Psychiatry • Home sleep study • Blood test • Clinical nutrition evaluation • smoking cessation • Pregnancy counseling

18. Thank you