Dr Arutchelvam Consultant in Diabetes, Endocrinology and Metabolic medicine

1. Dr Arutchelvam Consultant in Diabetes, Endocrinology and Metabolic medicine James Cook university hospital

2. Case History-1 • 30 year old man • Weight 228 kg, BMI 72 • Generalised Edema • Can it be constrictive pericarditis? • Difficult to investigate • Non- concordant with investigations • Died of sudden cardiac arrest after 4weeks in hospital

3. Case history-2 • 56 year old Mr JC • BMI 74 • Walked like a ‘pregnant penguin’ • Stopped mobility since December • Admitted in March

4. Case history-2 • Bed bound • 8 people to mobilise him in bed • No mobility in 2 months • Impossible to scan • Died after 12 weeks in hospital

5. Case History-3 • 62 year old lady • Type 2 Diabetes for 12 years • Best HbA1c 97 (11%) on 12.5.2012, on Metformin, Insulin, Liraglutide • HbA1c 11.11.12 39 ( 5.7%) • Not on any medication • Lost 32 Kg in weight • RYGB September 2012 • Hypertension resolved • Returned CPAP

6. Next few minutes… • Obesity - an epidemic • Medical treatment • Bariatric surgery and co-morbidities • Type 2 Diabetes- Progressive or reversible? • Summary

8. Obesity - an epidemic • Obesity is driving diabetes to epidemic proportions

9. WHO facts • Worldwide obesity has nearly doubled since 1980. • In 2008, more than 1.4 billion adults overweight. • Of these over 200 million men and nearly 300 million women were obese. • 65% of the world's population live in countries where overweight and obesity kills more people than underweight. • More than 40 million children under the age of five were overweight in 2011. • Obesity is preventable.

10. Obesity- Mortality • 279000 deaths in Europe related to obesity (7.7%) • 8.7% in UK • 70% related to cardiovascular • 20% related to cancer • Second most common cause of preventable deaths in USA • Estimated 300000 deaths / year

11. World sponsors … Coco colonisation

14. Physical activity …?

15. Weight reduction benefits • For every 1 kg weight reduction , the risk of diabetes development reduced by 16% • DPP-Lancet 2009:374:1677-86 • 30% reduction in all cause mortality after bariatric surgery • Sjostorm NEJM 2007:367:741-752

16. Weight reduction options

17. Weight reduction options • Diet, Exercise 5-10% • Pharmacotherapy 5-10% • Diet, Exercise, medications 5-10% • Bariatric surgery 25-30%

18. Physical activity…?

19. Physical activity…?

20. Nice… guidance…

21. Specialist weight management Multi disciplinary team Medical assessment Structured programme All NICE guided best practices Robust audit arrangements

22. Medications • Orlistat • Rimonobant • Sibutramine

23. Medications • Metreleptin Leptin agonist • Pramlintide Approved in type1 DM • Liraglutide GLP-1 Analogue • Lorcaserein Serotonin agonist • Testofensine CB1 Antagoniost,2nd gen. • MTP inhibitors Gut selective • Injectable peptides

24. Who is this?

25. Injectable peptides • Exenatide • Liraglutide • Taspoglutide • Albiglutide • Lixiglutide • Pramlintide

26. Group exercise

27. Incidence of co-morbidities in obese patients % • Osteoarthritis 50-65 • Hypertension 25-60 • Diabetes 10-20 • OSA/OSH 5-40 • Reflux 30-50 • Depression 20-50 • Asthma 10-20 • Heart failure 7-12

28. Bariatric surgery Secondary causes ruled out Co-morbidities optimised Life style modified Target weight reduction achieved Smoking stopped Mental health assessed Long term commitment ascertained No plastic surgery

29. Referral Criteria BMI > 35 without co-morbidities B,I >40 With co-morbidities

30. Bariatric procedures • Restrictive • Malabsorbtive

31. Adjustable Silastic Gastric Banding (ASGB): LapBandTM GENERAL FEATURES Inflatable balloon within the band orifice can be adjusted via a reservoir under the skin Average Weight loss 50% of excess weight

32. Sleeve Gastrectomy • Part of stomuch removed • Restrictive • Close results as RYGB

33. Roux-en-Y Gastric Bypass (RYGBP) • General Features • Pouch size: 1 oz • Pouch opening: 0.5 in • Roux-en-Y limb • Standard: 2 ft • Average Weight Loss • 70 % of excess weight

34. Weight Maintenance after Bariatric Surgery Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

35. Effect on co morbidities following bariatric surgery

36. Hypertension • 50-60% resolved with improvement in others following RYGB • Loss of diurnal variation is restored • Improvement in BP, even before weight reduction- Hormonal effect • Buchwald H :2004 ;JAMA; :292(14):1724-37 • Czupriniak L: 2005: Am J of Hypertension 18:446-51 • Bennett JC : 2007:Surg obes Relat Dis 3(3) 387-391 • Ahmed AR: 2009:Obes surg 19(7): 845-849

37. Type 2 diabetes • More than 80% type 2 diabetes are obese • More than 9% morbidly obese(>40)

38. Buchwald meta analysis • Complete resolution 76.8% • Improvement 86% • RYGB- Complete resolution 83.7% • Sustained • Independent of weight loss • Further review of 621 studies • 888 treatment arms, 135,246 patients • 78.1% resolution, improvement in 86.6% • Buchwald H 2004: JAMA 292(14): 1724-1737

39. High Quality (Level I & II-1,2) Studies on Bariatric / Metabolic Surgery in Diabetic Patients 39

40. STAMPEDE Results: Significantly More Diabetic Patients at Glycemic Control with Bariatric / Metabolic Surgery * ** Medical Therapy + Gastric Bypass *p=0.002 Medical Therapy + Sleeve Gastrectomy **p=0.008 Medical Therapy Glycemic control: HbA1c < 6.0% with or without diabetes medications, 12 mo after randomization. Figures adapted from study data. page 40

41. Mingrone Study Glycated Hemoglobin Levels during 2 Years of Follow-up 41

42. Type 2 Diabetes ADA classified remission: 2011 • Complete remission • FBG <100mg/dl( 5.5mmol/l) • Hba1c <5.5% (<37) • With no drug treatment for 1 year • Partial remission • FBG 100-125( 5.5- 7mmol/l) • HbA1c <6.5% (<47) • With no drug treatment for 1 year • Prolonged resolution • More than 5 years

43. Diabetes remission • Remission rates are high in RYGB • Hormonal effect: Ghrelin, GLP-1… • Recurrence rate higher in • Insulin users • High HbA1c • Weight re gainers • Type1 Diabetes: Control improves

44. Complications of diabetes • Macro vascular complications improved significantly • All cause mortality, diabetes related mortality and Cardiovascular mortality reduced • Pontirolli AE: Ann of surgery 2011 • Adams TD : NEJM: 2007

45. ADA Algorithm • Bariatric surgery to be considered if diabetes or associated co-morbidities are difficult to control in persons with BMI >35 ADA 2007 • Bariatric surgery : For people not responding adequately to life style measures and Metformin in persons with BMI> 35 ADA 2011

46. Bariatric surgery in diabetes • May need to be considered early in people with diabetes early in the algorithm, than as a last resort

47. Obstructive sleep apnoea • OSA resolution in 85.7% patients in the meta analysis of 22,094 patients • Buchwald H:2004: JAMA 292(14): 1724-1737 • Improvement of OSA symptoms : as early as 1 month post operative • Varela :2007: obes surg 17 (10) 1279- 1282

48. Dyslipidaemia • All lipid parameters improve • Fewer patients took anti-lipid medications after suergery • As early as 3 months post-operative • Sustained over 5 years • Zlabek :2005: Sur Obes relat dis 1(6): 537-542 • Nguyen NT: 2006: J Am Coll Surg 203(1):24-29

49. Other co-morbidities • Benign intracranial hypertension • Improvement demonstrated • Sugarman HJ ; Ann surg 1999: 229(5) 634-650 • Polycystic ovary syndrome • Restoration of cycles • Resolution hyperandrogenaemia • Improvement in hirsutism scores • Eid : Surg obes rel dis 2005 : 1(2): 77-80

50. Quality of Life Nguyen et al. Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs. Ann Surg. 234, 2004. 279-91.