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Patients who attend follow-up have better outcomes

8 November 2016

Patients who attend follow-up have better outcomes

Hi All,

This study proves what I have anecdotally noticed about my own patient group.  The patients who are more reliable at attending follow up appointments, either to see me, my Nutritionist (Nicola Page) or my Bariatric Nurse Specialist (Kate Berridge) are more likely to stay on track with their weight loss in the long term.  It is interesting to see that this also translates into improvements in their medical conditions associated with being overweight ie Hypertension, Hypercholesterolemia and Type 2 diabetes.  It probably follows that if you are more conscientious about attending appointments you are probably going to be more strictly adhering to nutritional and eating habit guidelines that we suggest for post-bariatric surgery life.  It is true that everything changes around eating and drinking immediately after having Bariatric surgery and these new habits should become a 'new normal' from then on to ensure the long term outcomes are good.  The better patients are at practicing their new habits, the better the outcomes they will achieve.  Anyway, plenty more to talk about when we meet in person.  An appointment to see me for a chat is the first step to take and we can take it from there!

Kind regards,

Steph Ulmer

 

 

Bariatric patients who stick to a schedule of three-, six- and 12-month follow-up visits with their doctors see greater improvements or remission of their diabetes, high blood pressure and high cholesterol than patients who skip their visits, according to research presented at ObesityWeek 2016. The paper, “The effect of close postoperative follow-up on comorbidity improvement after bariatric surgery,” was presented by researchers from the Brody School of Medicine at East Carolina University in Greenville, NC.

The study assessed the relationship between complete follow-up and improvement or remission of comorbid conditions at 12-months after surgery. The investigators obtained data from the Bariatric Outcomes Longitudinal Database (BOLD) from 2007 to 2012 and reviewed the results of 38,613 patients who had the three follow-up visits (complete follow-up) and compared them to the results of 12,468 patients who only had one or two follow-ups (incomplete follow-up). Improvement and remission of comorbid conditions were compared between the two cohorts. Specifically, changes in diabetes (T2D), hypertension, and dyslipidemia were evaluated at 12-month postoperatively.

After one year, 62.3 percent of patients with complete follow-up saw their type 2 diabetes go into remission, while those who missed a visit or two had a remission rate of 57.5 percent. The rate of improvement in diabetes was also better for those who made all three visits (74.6% vs. 68.9%). The differences between the two groups also held for high blood pressure and lipid abnormalities including high cholesterol.

“This study shows there is great value in seeing patients at routine intervals after surgery in terms of health outcomes,” said Dr Andrea Schwoerer, study co-author, currently at Carolinas Medical Center. “Unfortunately, many patients, reportedly as many as 50 percent, are lost to follow-up and therefore may not benefit as much as they can from weight-loss surgery, no matter how well it was performed.”

Hypertension improved in 63.2 percent of the patients in the complete follow-up group and 58.1 percent in the incomplete follow-up group. The difference in resolution rates in the groups was less, but still statistically significant (46.1% vs. 42%). The trend also held for lipid abnormalities, with these improving for 55 percent of patients completing follow up versus 51.1 percent for those who did not. Remission rates were,42.8% vs. 41.1% respectively, a small, but still statistically significant difference. After adjusting for baseline characteristics, complete postoperative follow-up in the first year after surgery was independently associated with a higher rate of improvement or remission of comorbid conditions.

We cannot stress enough the importance of follow-up visits and post-operative care,” said Dr Stacy Brethauer, President-elect, ASMBS and bariatric surgeon at the Cleveland Clinic in Ohio, who was not involved in the study. “It could mean the difference between a good and a great result. The most committed patients do best, and we need to find ways to keep all patients engaged for the long-term.”

 

Gestational Diabetes and the risk of developing subsequent Type 2 diabetes

16 August 2016

Gestational Diabetes and the risk of developing subsequent Type 2 diabetes

Hi All,  

This study is a longitudinal look at not only what happens to women who have been diagnosed with Gestational Diabetes and whether they go on to develop Type 2 diabetes within 10 years of diagnosis, but also the effect of non-surgical interventions on the risk of going on to develop Type 2 diabetes.  The positive news is that lifestyle changes alone can decrease this risk!! That is very encouraging.  It also holds true for my patients who have chosen to have Bariatric surgery to improve their health and minimise medical issues associated with obesity.  The message for my patients who undergo bariatric surgery is that the focus in the first post-operative year is to make lifestyle changes that can last a lifetime. This improves the chances of maintaining the weight loss that they have achieved with Bariatric Surgery (Bypass, Sleeve or Banding).  And life long weight maintenance is what we all want!!

Cheers, 

Steph Ulmer

 

 

Women with a history of gestational diabetes (GD) face a heightened risk of developing yype 2 diabetes for years after giving birth, but intensive lifestyle intervention or a medication regimen can have a protective effect in this population, according to a study published in the Endocrine Society's Journal of Clinical Endocrinology & Metabolism.

"Our long-term follow-up study found the elevated risk of developing type 2 diabetes persisted for years in women who had been diagnosed with gestational diabetes, and this long-term risk can be reduced with either intensive lifestyle intervention or the medication metformin," said one of the study's authors, Dr Vanita Aroda of the MedStar Health Research Institute in Hyattsville, MD.

The Diabetes Prevention Program Outcomes Study (DPPOS) analysed long-term metabolic health in 288 women who had a previous diagnosis of GD and 1,226 mothers who did not have a history of the condition. The women all participated in the initial Diabetes Prevention Program study, a randomised clinical trial where they were assigned to intensive lifestyle intervention, the diabetes medication metformin or a placebo. The intensive lifestyle intervention was aimed at reducing body weight by 7 percent and participating in moderate cardio exercise for 150 minutes a week.

During the DPPOS, the women continued to have their blood glucose levels measured twice a year for six years. The study looked at long-term health outcomes in Diabetes Prevention Program participants for about a decade after the women first enrolled in the study.

Over 10 years, women with a history of GD assigned to placebo had a 48% higher risk of developing diabetes compared with women without a history of GD. In women with a history of GD, lifestyle intervention and metformin reduced progression to diabetes compared with placebo by 35% and 40%, respectively. Among women without a history of GD, lifestyle intervention reduced the progression to diabetes by 30%, and metformin did not reduce the progression to diabetes.

"Medical and lifestyle interventions were remarkably effective at slowing the progression of Type 2 diabetes in this at-risk population in both the short and long term," said Aroda. 

The Invention That Could End Obesity

14 June 2016

The Invention That Could End Obesity

Love the enthusiasm..! This does seem too good to be true, and... But it does show how keen the world is to finding a solution to the Obesity epidemic that doesn't mean subjecting people to major surgery.  However, this, I suspect is not it.  Gastric surgery for obesity is still the best (and currently only) way of giving patients significant weight loss experiences with the chance of excellent long term results as well.  That sounds too good to be true also, but in my experience it isn't!  It does require some guidance regarding the right option for Bariatric Surgery (Gastric Banding, Gastric Sleeve and Gastric Bypass) for you and the right support pre-, during and post- surgery.  Don't look any further - we should talk!

Steph Ulmer

A Michigan surgeon invented an apparatus that he believes tricks the brain into thinking the stomach is full. His Full Sense Device could be a lifesaver for millions of obese Americans and raises questions about how hunger — our most basic human impulse — even works.

Bonnie Lauria was miserable. She was subsisting on liquids and a handful of foods her stomach could handle. Ever since she’d undergone gastric bypass surgery in the ’80s, foods like meat and bread that went down her throat in a lump would come right back up. “I knew where every bathroom was in every restaurant in the state,” Lauria says from her home in West Branch, Michigan. “It was horrendous.”

During gastric bypass surgery, the stomach is reduced to about the size of a walnut and attached to the middle of the small intestine. Lauria’s complications from the surgery weren’t normal, so she went under the knife a second time. Still, her condition didn’t change. She switched doctors several times, but no one could help. Eventually, someone recommended bariatric surgeon Dr. Randy Baker in Grand Rapids in 2004.

Baker ran some tests and saw that the spot where Lauria’s walnut-size pouch met her small bowel was tightening. Previous doctors had tried to widen the passage so that food could pass through, but the stricture had returned. Complicating Lauria’s condition were those multiple surgeries, which left so much scar tissue that operating again would be too difficult and too dangerous.

Baker was at a loss. Then he started thinking about esophageal stents. Just like a coronary stent keeps an artery open, an esophageal stent holds the esophagus open and is often used in patients who have difficulty swallowing. What if one of those could prop open the small bowel too?

As far as Baker knew, no one had ever attempted a procedure like that before. But Lauria was out of options, so Baker told her his strategy. She agreed; he inserted the stent and hoped for the best.

“She came back to my office two weeks later and said, ‘Dr. Baker, I’m feeling great. I can eat sloppy Joes!’” Baker says. “Here’s a lady who could only do liquids, and now she can eat solids. And she’s losing weight.”

Lauria didn’t have an explanation; she told Baker she simply wasn’t hungry anymore. Baker wondered if he and other bariatric surgeons had been going at it all wrong. The stent, he theorized, was putting pressure at the top of Lauria’s pouch and sending signals to her brain saying, “I’m full.” It was doing what food does, but without actual food. Which raised some questions: What if we don’t need invasive surgeries that cut away portions of the stomach and rearrange the digestive tract and intestines? What if all we need is a device that puts pressure near the top of the stomach?

Baker set out to test his hypothesis, teaming up with a former product specialist from W.L. Gore (creators of Gore-Tex) and two surgeons at his Grand Rapids practice to create the Full Sense Device — a nitinol wire-mesh funnel coated in silicone that can be inserted through the mouth and placed in less than 10 minutes. Current plans would allow the device to remain for up to six months before removal, though in the future that time may be longer. In the company’s trials, every patient implanted with the device lost weight and continued to lose weight until the device was removed. Baker calls the phenomenon “implied satiety.” At six months, average patients lost 75% of their excess body weight — significantly more and at a faster rate than any bariatric procedure, and all, Baker says, with no “severe adverse side effects.”

The Institute for Health Metrics and Evaluation estimates that 160 million Americans — nearly half — are overweight as indicated by their body mass index, which is calculated from a person’s height and weight. (A BMI between 25 and 29.9 is considered overweight; 30-plus is obese.) Of those people, 24 million are estimated to be morbidly obese, meaning they have a BMI over 40 and are at higher risk for serious, life-threatening illnesses, including heart disease, diabetes, degenerative arthritis, and cancer. Bariatric surgeries can and often do lead to impressive weight loss, yet only 1% of obese Americans opts for the invasive and costly procedure — usually $20,000 to $30,000. (Rex Ryan, Roseanne Barr, Carnie Wilson, Al Roker, Chris Christie, Randy Jackson, and Star Jones are reported to be among the 1%.)

“There are a bunch of things that contribute to that,” says Randy Seeley, an obesity researcher and professor of surgery at the University of Michigan. “One is the ick factor — ‘someone is going to chop up my GI tract.’ Some of it is cost — it’s still not universally covered. Third is stigma. The implication is that it’s the easy way out — you’re cheating somehow by taking that option — which goes to our societal biases about obesity.”

Dr. Baker has come up with a nonsurgical device that he says will enable obese patients to lose substantial weight, and at a fraction of the cost of surgery — in the neighborhood of $5,000 at an outpatient center. A company claiming to have found a simple solution to drastic, easy weight loss is, of course, nothing new; in fact, it’s big business. (See: late-night infomercials.) Some surgeons and researchers are skeptical of Baker’s pressure theory, and at least one patient experienced chronic acid reflux after the device was inserted. But more than 10 years after the eureka moment, Baker is hopeful that doctors in Europe could begin using the Full Sense Device this year and in Canada and Mexico soon after. Americans will have to wait longer; Food and Drug Administration approval is unpredictable and likely still years away. Baker’s concern, though, is that the Full Sense Device might work too well. If it’s effective, easy, and cheap, what’s to stop people from abusing it?

“When this hits the market, there’s not going to be just 10,000 to 15,000 people having it,” says Fred Walburn, president and sole employee of Full Sense Device’s parent company, BFKW. “There’s going to be hundreds of thousands. Millions per year.”

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