Morbid Obesity: No longer just a hopeless disease

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Morbid ObesityNo longer just a hopeless disease

• Walter J. Pories, MD, FACS
• Departments of Surgery and Biochemistry
• The Brody School of Medicine
• East Carolina University

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Youve heard it all..

• I hate fat people, theyre just gluttons
• You can get some weight loss but it wont last.
• Surgery? Youve got to be kidding. Those fat
  ladies are just awful risks.
• Diabetes? Now there is a disease! Nothing works
  and folks just keep getting worse.

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But the pessimism is not warrented. The truth is
that

• Morbid obesity is a disease, not a moral failing
• Morbid obesity can be treated successfully and
  safely with surgery
• Diabetes can be placed into long-term remission
  with a reduction in morbidity and mortality

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What is Morbid Obesity?

• ?100 lbs. over normal weight
• BMI (Kg/M2) ? 35
• body fat ? 25

Our average patient weighed 317 lbs Equal to
carrying three 60 lb. bags of feed 24 hrs/day
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Obesity is a chronic, lifelong,
genetically-related, life-threatening disease
with highly significant medical, psychological,
social, physical, and economic co-morbidities
Statement on morbid obesity and its treatment.
Obesity Surgery 1997 740-41
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Health Problems Associated with Morbid Obesity

• Diabetes
• Sleep Apnea
• Pulmonary Failure
• Hypertension
• Cardiovascular Disease
• Hernias
• Pseudotumor cerebri

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Health Problems Associated with Morbid Obesity

• Musculoskeletal Problems
• Psychological Problems
• Gastroesophageal Reflux
• Infertility
• Cancers of colon, stomach, breast

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The Emotional Side of Morbid Obesity

• In the 16 year cohort
• Of the 17 deaths
• 5 were alcohol related
• 2 were suicides
• And others required treatment
• 1 (1) was hospitalized for depression
• 2 (2) had suicide attempts
• 1 (1) became addicted to alcohol

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In 1991, the National Institutes of Health
concluded in its Consensus Conference that diets,
exercise programs, appetite suppressants and
behavior modifications are not effective
therapies
Report of the Consensus Conference on Surgery of
Morbid Obesity, National Institutes of Health,
Washington, DC 1991
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The Greenville Gastric Bypass
10 - 20 ml gastric pouch 8 - 10 mm.
anastomosis 40 - 60 cm alimentary loop
Total group 1980-1998 831 16 year cohort
147
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Bariatric Surgery at East Carolina University
1980 -1997

• Primary Gastric Bypass 831
• Revisions 180
• Other
• Vertical Banded Gastroplasty 19
• Adjustable Gastric Banding 35
• Total 1,065

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Follow-up Was Rigorous

• 147 patients underwent the gastric bypass between
  Jan. 1980 - 1982
• 8 were lost ( 95 16 year follow-up)
• 17 (12) patients died
• 122 (83) had a 16 year followup

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16 Yr. Gastric Bypass Follow-up Study Population

• 93 (76) White Females
• 14 (12) Black Females
• 15 (12) White Males

Ages 31-72 years Average age at
follow-up 52 years
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Weight Loss After Bariatric Surgery _at_ 16 Years
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The weight loss is sustained
300
250
LB
200
150
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5
0
1
2
10
Years
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The improvement was sustained
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Initial Conclusions

• The Greenville gastric bypass provides
• better control of weight than any other therapy
• even after 16 years
• The gastric bypass is safe with a 1 mortality
  And a 10 perioperative complication rate.
• The operation also controls diabetes,
• hypertension, arthritis, sleep apnea, and
• infertility in many of the patients

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Hey?Did you say thatthe operation controls
diabetes?
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Yes, the gastric bypass

• Restores euglycemia in 83 of diabetics
• Restores euglycemia in 99 of IGT
• Prevents progression of occult diabetes
• Improves the mortality rate from 4.5 to 1 per
  year

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In fact, the diabetes is usually gonebefore the
patient leaves the hospital
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Why does it work?
Some clues

• Patients eat less after the operation
• In most patients, the diet changes
• The operation excludes much of the foregut from
  food
• The hyperglycemia and excessive insulin disappear
  within days

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It doesnt make senseAre we wrong about diabetes?

• The current textbook explanation?
• Type 2 diabetes is an intracellular disease due
  to increased insulin resistance.

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Yes, the return to euglycemia is very rapid,a
matter of days!
Before there is significant loss of weight or
fat!
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Is Weight Loss the Critical Factor?
Two groups of 6 weight stable women
Surgical Group Had the gastric bypass and were
now weight stable
Control Group Also weight stable No surgery but
matched to the other group in adiposity fat,
age, waist size, weight, aerobic capacity
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The groups were well matched

• Control Bypass
• Age (yrs) 40.4 41.2
• fat 40.7 40.2
• BMI 39.6 43.7
• Waist (cm) 122.3 114.7
• VO2max 20.5 20.1
• VO2maxmlkg-1min-1

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The gastric bypass produced remarkable changes

• control
  bypass
• fasting glucose (mM) 5.70 4.82
• fasting insulin (pM) 95.3 23.0
• leptin (ng/ml) 35.8 22.3
• insulin sensitivity 1.75 3.90
• ? intake (Kcal/day) 2252 1156

all significant at p
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Exclusion of food from the foregutproduces
profoundalterations of glucose
metabolismindependent of weight
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Nor is the change in glucose metabolism just of
academic interest
The operation reduces mortality And morbidity
from diabetes
NIDDM with gastric bypass 1/yr NIDDM controls
no surgery 4.5/yr
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If changingthe plumbing of the gutprovides full
remissionof diabetescould it be that
diabetesis a disease of the gut?
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And other clues to the role of the gut in the
etiology of diabetes

• Surgical observations The obese gut is
  different thicker walls, more vascular, ? longer
• Tumors Patients with insulinomas have a high
  insulin resistance
• Incretins insulin-stimulating intestinal
  hormones have been identified

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CHO
incretins
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CHO
Insulin Resistance
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CHO
Insulin Resistance
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Diabetes may be an Endocrine disease of the
gut Diabetes may be due to hyperincretinism
and Insulin resistance may be a Protective
mechanism of the gut
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Conclusions

• The gastric bypass provides safe and effective
  control of morbid obesity and many of
  complications of that disease.
• The gastric bypass provides long-term control of
  diabetes a phenomenon that is
• Still poorly understood.