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Month: June 2009

Gastric Bypass Linked to Abnormal Glucose Tolerance

June 29, 2009 12:45 am

By Charles Bankhead, Staff Writer, MedPage Today
Published: June 26, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

DALLAS, June 26 — Patients who undergo gastric bypass surgery often have undiagnosed glucose abnormalities that can lead to bad eating habits and regained weight, a small clinical study suggests.

Almost 80% of the patients had glucose abnormalities, including hyperglycemia, hypoglycemia, or both, Mitchell Roslin, MD, of Lenox Hill Hospital in New York, reported here at the American Society of Metabolic and Bariatric Surgery meeting. Patients were alarmed by the weight regain, but at the same time, they often had a ravenous appetite soon after a meal, accompanied by an almost uncontrollable urge to eat.” Our hypothesis is that . . . patients may have an enhanced insulin response,” said Dr. Roslin. “They have rapid emptying of the pouch that leads to reactive hypoglycemia. The combination of an empty pouch and low blood sugar leads to hunger.” The findings have led him to question whether gastric bypass surgery should remain the gold standard procedure for treating obesity, he added. At the very least, surgeons should consider the possible need to include a valve in gastric bypass.

The study evolved from clinical observations during patients’ periodic postoperative visits. A growing number of patients complained of weight regain and loss of restriction. The complaints often had a common ring.” Patients were saying that one or two hours after eating, they were ravenously hungry,” said Dr. Roslin. “It sounded a lot like hypoglycemia to me.” To investigate the origin of the symptoms, Dr. Roslin and colleagues studied 63 patients who had undergone gastric bypass procedures. All the patients had a 100-g glucose tolerance test, wherein the maximum/minimum glucose ratio was assessed one to two hours after the glucose challenge.The investigators defined reactive hypoglycemia as a glucose value <60 mg/ dL, or a decrease of 100 mg/dL or more within two hours and no glucose value exceeding 200 mg/dL. They defined hyperglycemia as any value >200 mg/dL and no value <80 mg/dL. Follow-up from surgery averaged about four years. The mean age of the group was 48.5, and 81% were women. The patients’ average preoperative weight was 138 kg, with an average body mass index of 49. One-third had preoperative diabetes. The percentage of excess BMI lost averaged 55%, and the patients had regained an average of 12 kg. Glucose tolerance tests showed six patients with hyperglycemia, including five who had normal fasting blood glucose levels. In addition, 35 patients had reactive hypoglycemia, while eight had hyper- and hypoglycemia. “The hyperglycemic cohort was characterized by a rapid rise to high sugar levels,” said Dr. Roslin. “The fact that most of these patients had normal fasting glucose means we need to be very careful of what we call cure or control of diabetes.” Reactive hypoglycemia manifested as a rapid upsurge of glucose levels that correlated with a rise in insulin and then a rapid decline during the second hour after the glucose challenge. Patients with both hyper- and hypoglycemia had even more pronounced swings in glucose and insulin levels, said Dr. Roslin.

The most dramatic rises and falls in blood glucose have been associated with small pouches and wide anastomoses, he added. The findings suggest a need to consider alterations in the standard gastric bypass procedure, such as use of valves, or possibly abandonment of the procedure in favor of another approach. “I believe that vertical-sleeve gastrectomy and duodenal switches that are not severely malabsorptive will be the best options in the future,” said Dr. Roslin.

A Few Extra Pounds Might Bring Extra Years

June 25, 2009 10:19 am

June 23 (HealthDay News) — A new study finds that being overweight — but not obese — might help you live longer.

In the study of more than 11,000 Canadian adults, overweight people lived longer than normal-weight people, while those who were either extremely obese or underweight died at an earlier age than normal-weight people.

The findings do not mean that normalweight people should try to pack on extra pounds, the researchers said. “It may be that a few extra pounds actually protect older people as their health declines, but that doesn’t mean that people in the normal weight range should try to put on a few pounds,” said study co-author Mark Kaplan, a professor of community health at Portland State University.

The study followed 11,326 adults in Canada for 12 years. Compared to normal-weight people, those who were underweight were 70% more likely to die and those who were extremely obese were 36% more likely to die, the researchers found.

On the other hand, overweight people were 17% less likely to die than those of normal weight. The risk for obese people was the same as for people of normal weight, the study authors noted.

Overweight was defined as a body mass index (BMI) between 25 and 30, and obesity was defined as BMI of 30 and above. BMI is a measurement based on weight and height. For example, a 5-foot 10-inch man weighing 181 pounds has a BMI of 26; a 5-foot 6-inch woman weighing 210 pounds has a BMI of about 34.

The study was published online June 18 in the journal Obesity.

“It’s not surprising that extreme underweight and extreme obesity increase the risk of dying, but it is surprising that carrying a little extra weight may give people a longevity advantage,” co-author David Feeny, a senior investigator at the Kaiser Permanente Center for Health Research in Portland, Ore., said in a Kaiser news release.

But Kaplan noted that there’s more to health than just living longer. “Our study only looked at mortality, not at quality of life,” he pointed out, “and there are many negative health consequences associated with obesity, including high blood pressure, high cholesterol, and diabetes.

Being healthy involves more than body mass index (BMI) or the number on a bathroom scale, said Dr. Keith Bachman, a weight management specialist with Kaiser Permanente’s Care Management Institute.

“We know that people who choose a healthy lifestyle enjoy better health: good food choices, being physically active every day, managing stress, and keeping blood pressure, cholesterol and blood sugar levels in check,” Bachman said in the news release.

Robert Preidt
SOURCE: Kaiser Permanente, news release, June 23, 2009

Editorial:
The above information is nothing new. This is one of the issues that I most frequently discuss in our group meetings. “….it is healthier to be a10-15 lbs over weight that 10-15 lbs underweight…” I realize that almost all patients who have weight loss surgery, are afraid of the continuos weight gain after heating a low point on the scale. After all every single diet and exercise plan and diet pill has resulted in a transient weight loss followed by the weight regain. I emphasize that it would be very very unlikely for patient to gain substantial amount of weight after duodenal switch operation. This is not however the case for patient’s that have had the Gastric bypass, adjustable gastric banding or other procedures.
Ara Keshishian, MD, FACS