set point and bariatric surgery
TRANSCRIPT
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Set Point and
Bariatric SurgeryDana Portenier, MD, FACS, FASMBS
Division Chief, Duke Center For Metabolic and Weight Loss SurgeryCo-Program Director, Duke Minimally Invasive and Bariatric Surgery Fellowship
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• Medtronic - Speaker/Research Grant/Robotics Advisory Board
• Gore - Education Grant/Speaker
• Teleflex - Consultant• Da Vinci - Proctor• Mederi - Speaker• Novadaq - Advisory
Board• Levita Magnetics -
Advisory Board
Disclosure
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Weight Loss Variation among Patients
0
5
10
15
20
25
30
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Device (Duodenal Liner)
0
5
10
15
20
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Diet (Low Carbohydrate)
0
5
10
15
20
25
30
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Drug (Liraglutide)
0
5
10
15
20
25
>5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Surgery (Gastric Bypass)
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RYGB Skewed Right Band Skewed Left
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Sleeve Gastrectomy
Gastric Bypass
Duodenal Switch 6%
20%
unknown unknown
94%
80%*( 34% if BMI >50)
*(higher than gastric bypass after 1 year)
50% EWL
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2017
2015
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Drive Growth in Bariatrics
•Risk Reduction
•Expand Access to care
•Push Metabolic Syndrome with obesity just one of the co-morbidities improved
•Change our messaging around obesity
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Dia
be
tes
Ob
esi
ty
Complex Mechanistic Pathways
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Obe
sity
Complex Mechanistic Pathways
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Saber Obes Surg 2008;18:121-128
Dr. Viktor Henrikson (1952) credited with first operation to
induce weight loss
Resected a 105 cm segment of small intestine
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Restrictive
Malabsorption
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•>90% searches were for weight loss surgery or bariatrics
•Only 2% searches were for metabolic surgery
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Drive Growth in Bariatrics
•Risk Reduction
•Expand Access to care
•Push Metabolic Syndrome with obesity just one of the co-morbidities improved
•Change our messaging around obesity
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Set Point or Set Range
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http://ethiconinstitute.com/node/1426/asset
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• 2 Models of Energy Balance Equation• Purposeful behavior (how much
you eat and exercise drives) the physiology
• The physiology drives the behaviors
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WHO defines obesity as abnormal or excessive fat
accumulation that may impair health
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Fat is the Bodies Fuel
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Thermostat
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Set Point
200
250
300
350Food Restricted
Control
2001751501251007550250Bernstein, IL. Proc Soc Exp Biol Med; 1975 Nov; 150(2):546-8
Days
Influences on Set Point•Genetics•Environment•Developmental
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Homeostasis
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Homeostasis
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•CNS regulates set range•Receives Signals from hormones•Signals sent from fat, muscle, bone, GI track….
4k of our 22k genes are involved in body composition and metabolism
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Set Range
Energy ExpenditureEnergy Intake
(+) Energy Balance (-) Energy Balance
3000
2500
2000
20 25 30 35
BMIWeigle DS FASEB Journal 1994, 8:302-310.
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2200 kcal/day - Average calories we consume daily1300 kcal/day - Average calories we need daily
900 kcal/day - Excess daily
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2200 kcal/day - Average calories we consume daily1300 kcal/day - Average calories we need daily
900 kcal/day - Excess daily
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•CNS regulates set range•Receives Signals from hormones•Signals sent from fat, muscle, bone, GI track….
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•CNS regulates set range•Receives Signals from hormones•Signals sent from fat, muscle, bone, GI track….
Less Calories wont work Altering what you eat might
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•Chronic Exposure:•Unhealthy Foods•Stress •Lack of Sleep•Medications that cause weight gain
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Genetic Influences on Set Range
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Weight Loss Variation among Patients
0
5
10
15
20
25
30
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Device (Duodenal Liner)
0
5
10
15
20
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Diet (Low Carbohydrate)
0
5
10
15
20
25
30
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Drug (Liraglutide)
0
5
10
15
20
25
>5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Surgery (Gastric Bypass)
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Weight Loss Variation among Patients
0
5
10
15
20
25
30
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Device (Duodenal Liner)
0
5
10
15
20
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Diet (Low Carbohydrate)
0
5
10
15
20
25
30
45-5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Drug (Liraglutide)
0
5
10
15
20
25
>5040-4535-4025-3020-2515-2010-155-100-5 Loss0-5 Gain5-10 Gain10-15 Gain
Patients (%)
Surgery (Gastric Bypass)
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20 22 24 26 28 30 33 36 39 42 46 50 55 60
BMI
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EveryOne Responds Differently due to differences in Genetics
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20 22 24 26 28 30 33 36 39 42 46 50 55 60
BMI
• Baseline• Healthy Lifestyle• Weight Regain• Restrictive Dieting• Rebound Weight Gain• Recurrent Dieting• Rebound Weight Gain
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Energy ExpenditureEnergy Intake
(+) Energy Balance (-) Energy Balance
3000
2500
2000
20 25 30 35
BMIWeigle DS FASEB Journal 1994, 8:302-310.
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Aging and Environmental Influences (No Intervention)
SurgeryAging and Environmental Influences (Post Intervention)
Fat MassSet Point
Time (years)
Lower Set Point with Surgery
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BMI40
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Expect Lifelong:•Need for optimization of
modifiable environmental Factors •Need for Medications•Need for Revisional Surgery•Avoid medications causing weight gain
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Time After Surgery
Weight (lbs)
Surgery
Rx1
Rx2
Lifelong Multi-Modal TherapyTreatment
• Unhealthy Foods• Stress • Lack of Sleep• Medications that
cause weight gain• Exercise
Medication #1
Medication #2
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260270280290300310320330340350360370380390400410420430440450
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
WeightLossCurve
PreopWeight Loss
Regular Followup
No Follow UpDx Fibromyalgia
Several Courses of Steroids
Med
icat
ions
• 3/2015 Phentermine• 5/2015 Added
Topiramate• 8/2015 Stopped and
started Contrave• Back on Track Program
Regular FollowupOff Meds
RevisionSurgery
Nadir
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260270280290300310320330340350360370380390400410420430440450
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
WeightLossCurve
PreopWeight Loss
Regular Followup
No Follow UpDx Fibromyalgia
Several Courses of Steroids
Med
icat
ions
Regular FollowupOff Meds
RevisionSurgery
Nadir
.. .
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Conclusion
• Obesity is effectively treated by lowering the set point
• For Bariatric Surgery to continue to grow likely needs to focus on metabolic syndrome of which weight is valued no more than other co-morbidities
• We need to change the expectation that surgery will finally fix the obesity problem. Aligning patients and primary care doctors to the chronic nature of the disease.