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December 2020

obesity-surgery-diabetes-type-2

Can bariatric surgery cure type 2 diabetes?

By | Obesity surgery - health and diseases

How and why can bariatric surgery cure type 2 diabetes?

In this blog post we will talk about how obesity surgery can cure type 2 diabetes for most patients. But what exactly is type 2 diabetes?

What is type 2 diabetes, what is insulin and how does it relate?

Type 2 diabetes is a chronic disease in which the affected person has a blood sugar level that is not regulated well enough due to partial or complete insulin resistance and excretion. That the disease is chronic means that it is long-lasting[1]. But what is insulin and how does it work?

Insulin is a hormone that plays a crucial role in the absorption of glucose (sugar). Simply explained, when we eat, the carbohydrates in food are converted into glucose which is absorbed into the bloodstream. However, glucose does little good in the bloodstream, we want the glucose into the body’s cells where it functions as fuel. Insulin acts as a key in the cells’ “keyholes” that are found in the surrounding membrane. Insulin (key) opens the door for the glucose do it can enter the cell[2].

If you have type 2 diabetes, as mentioned, you are less sensitive to insulin or maybe you do not secrete enough or no insulin at all. This causes the glucose to stay in the bloodstream and not enter the cells, which results in a too high blood sugar level. This can be measured with a blood glucose meter.

Having an elevated blood sugar level over a longer period of time increases the risk of various other diseases, which is why it is important to lower the blood sugar levels to a normal level.

What is the likelihood of my diabetes being cured?

First of all, we need to define what is meant by cured. When we talk about the patient being cured of type 2 diabetes (sometimes also called diabetes remission), it means that the patient has a normal blood sugar level and no longer needs to take any antidiabetic medication.

It is not possible to predict what the likelihood of diabetes remission is on an individual level before obesity surgery. There are several factors that affect the outcome. Bodies react differently to treatment, just as it does with other medical treatments.

However, it is of course possible to say something about it in general and talk about the average likelihood. Most studies show that 70-89% of patients who have type 2 diabetes prior to surgery are cured after undergoing obesity surgery[3],[4],[5],[6],[7].

In addition, you are more likely to experience complete remission of your diabetes if you have had the disease for a shorter period of time (under 5 years), have a milder degree of diabetes and have a large weight loss after surgery. For example, if you have had diabetes for less than 5 years there is a 95% probability of diabetes remission. Whereas if you have had the disease for 6-10 years, the probability is 75% and if you have had diabetes for more than 10 years, the probability of being cured is 54% [8].

Why can obesity surgery cure type 2 diabetes?

There are several factors that contribute to the fact that an obesity operation can cure type 2 diabetes, but there is not complete agreement on these mechanisms. One of the simple factors is weight loss itself, which increases insulin sensitivity. However, for example, gastric bypass surgery improves diabetes already within days after surgery and thus there are mechanisms other than weight loss that come into play[8].

For example, one hypothesized (the “Hindgut hypothesis”) explains that since food more quickly affects the distal (later) part of the intestines after surgery, there is an increased excretion of the hormones GLP-1 and peptide YY, which causes both increased insulin excretion and sensitivity[9].

Another hypothesis (“Foregut”) related to bypass is that the exclusion of the proximal (first) part of the small intestine on the food’s path through the intestinal system avoids the excretion of a suspected (and not yet clarified) signal that otherwise promotes insulin resistance[10].

In general, calorie restrictions (less than 1100 kcal/day) will result in increased liver insulin sensitivity within 2 days, as there is less insulin in the bloodstream and insulin-producing (beta) cells can rest because they therefore do not have to produce as much insulin [11],[12].

A very small Swedish study with 9 patients has shown that 90% of what affects the insulin mechanisms related to the hormorers GLP-1 and GIP are created by the dietary changes. They believe the same effect is experienced as if the patient had surgery, if the patient is on a powder diet and consumes less than 1000 kcal/day . However, the researchers behind the study find that weight loss is stronger and more permanent in surgery rather than on diet alone [13]. The results are very new and further research on the new findings must be conducted to support the theory.

Summary

In short, obesity surgery fixes the problems you have with insulin that cause elevated blood sugar when you are affected by type 2 diabetes through various mechanisms. These mechanisms are related to weight loss, increased insulin excretion and sensitivity and avoidance of insulin resistance.

Type 1 diabetes cannot be cured as this disease is caused by the destruction of the insulin-producing cells in the pancreas.

 

If you want to know more about overweight surgery, you can read about it here and here. Contact usif you consider that surgery could be beneficial for you!

But. till exempel.

[1] https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/endokrinologi/tilstande-og-sygdomme/diabetes-mellitus/type-2-diabetes/ But. till exempel.

[2] https://endocrinology.dk/nbv/diabetes-melitus/behandling-og-kontrol-af-type-2-diabetes/

[3] https://diabetes.dk/aktuelt/nyheder/nyhedsarkiv/2019/fedmekirurgi-faar-type-2-diabetes-til-at-forsvinde-hos-3-af-4.aspx But. till exempel.

[4] https://pubmed.ncbi.nlm.nih.gov/19272486/

[5] https://pubmed.ncbi.nlm.nih.gov/15479938/ But. till exempel.

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234815/

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360104/

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3102524/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936261/

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856597/ But. till exempel.

[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202361/

[12] https://www.gastrojournal.org/article/S0016-5085(09)00150-4/pdf

[13] https://www.medicin.lu.se/article/strang-diet-forklarar-fetmakirurgins-magi-0

Covid-19 infection in people with obesity -how dangerous is it?

By | News

The Corona virus, or Severe Acute Respiratory Syndrome Coronavirus-2 (Sars-cov-2) as the real term is, is an RNA virus that causes the disease Covid-19 (Corona virus disease 2019). The current epidemic is the third with a coronavirus in the 21st century and by far the most severe.

Society, media, politics, health care and research are now fully focused on covid-19 and the virus Sars-cov-2. From the statistics updated daily from the Swedish Intensive Care Register we see that in Sweden 75% of those admitted to IVA with Coivid-19 are male, the median age is 61 years and 73.9% have a risk factor. Dominant risk factors in the registry are high blood pressure (34.9%), diabetes (25.3%), heart and lung disease (23.6%). Obesity is seen here only to be around 3% -but this is tricky, because the registry here reports only “extreme obesity”, i.e. BMI > 40, and we know that BMI well below 40 often results in high blood pressure, type 2 diabetes and cardiovascular disease (obesity is defined as BMI > 30).

Recent research studies

Furthermore, if you look more specifically for obesity versus Covid-19 (here you have to remember that this field of research is completely new and new studies are published all the time), then you will find a study from France (Simmonet et al). A hospital has studied 124 patients admitted to ICU due to Covid-19. 68.6% of these patients required respiratory care. Patients with BMI > 35 were more than 7 times more likely to need respiratory care compared to those with normal weight (regardless of age, diabetes or high blood pressure).

A recent study from New York (Petrilli et al) has followed more than 4,000 patients with Covid-19. Among other things, risk factors were analysed vs. a/ needing hospital treatment and b/ becoming “critically ill” (critical illness, defined as need for ICU care, discharge to hospice or death). The factors most strongly associated to the need for hospitalization were in descending order age > 75 years, age 65-74 years, BMI > 40, heart failure, BMI 30-40, age 55-64 years, chronic kidney disease, diabetes and male sex.

Risk factors for critical illness in Covid-19 were in descending order age > 75 years, age 65-74 years, BMI > 40 and BMI 30-40. (For those of you in health care: lab-wise CRP > 200, high D-dimer and oxygen saturation < 88% upon arrival at the health care department were the strongest factors related to the risk of developing critical illness).

Obesity as a risk factor in Covid-19

It seems, therefore, that obesity disease is a clear risk factor associated with Covid-19, perhaps BMI > 40 is the main risk factor after increasing age(?). This is something that needs to be researched more, but also highlighted better –the latter ASAP, as the epidemic is already in full swing.

SUPPLEMENT: On Friday, April 17, the National Board of Health and Welfare announced that obesity disease with BMI > 40 is an independent risk factor for Covid-19 disease, read the report here.

In depth reading on corona, ARDS and obesity

The following are things that we don’t know everything about yet, so they are hypotheses rather than proven facts. The research on this has not yet “caught up” with the situation we are in with the epidemic in society. But with this said, if you want to immerse yourself then this is for you: What distinguishes the coronavirus Sars-cov-2 from the common flu or cold virus is that it not only infects the upper respiratory tract (and causes a sore throat, etc.) but in some cases also infects deep into the lungs and at the far end of the alveoli. Here, this infection causes alveolar cells to be destroyed, but also gives a reaction from the body itself: our immune system reacts, sometimes even too much. This gives the risk of acute respiratory distress syndrome (ARDS). ARDS is caused by a hyperactive immune system, sometimes called cytokine storm. The body’s attempts to repair the damage result in fibrosis formation and worsened oxygen saturation. What distinguishes this from a common pneumonia is that the body itself exacerbates the problem because the immune system overreacts.

Where could obesity come into this? Well, research has shown that adipose tissue is much more than just an energy deposit, it is also a hormonally active organ. Fatty tissue produces, among other things, cytokines, hormones, growth factors and prostaglandins, which have effects on organs such as the liver, pancreas, muscles, kidneys, brain and immune system. Obesity has been shown to increase activation of pro-inflammatory substances released from adipose tissue (e.g. interleukins, interferon and TNF-alpha). Thus, many people with obesity have an incorrectly overactivated immune system already normally. If this affects the risk of getting ARDS from the corona virus, future research will show. Other factors that can come into play here are that we know that obesity can contribute to so-called increased coagulability (increased risk of blood clots), other concomitant obesity-related diseases, and the risk of ventilating one’s lungs less effectively at high BMI than at normal weight.

How much risk do you have?

How are we going to deal with all this new information? How “big risk” do you have if you are reading this and living with a large body? I understand if you worry, this is an epidemic that we are not used to.

What can probably be concluded from the study from New York above, is that the combination age >55 years at the same time as BMI > 30 increases the risk of needing hospital care at Covid-19, and that age > 65 years at the same time as BMI > 40 greatly increases the risk. Note that all “risk” is relative, each individual has his or her own unique conditions.

What can you do to reduce your risk?

Follow the recommendations of the authorities including social distancing, hand sanitizing, etc. A general recommendation if you are worried about Covid-19 and are in a probable risk group –test yourself. Hopefully, tests will become more available in Sweden now and people with obesity are very likely a risk group that should be prioritized. (In particular, it applies to those of you who have BMI > 40.) Try to work out even if you are at home -physical activity is positive for the immune system.

I have had bariatric surgery -is that an increased risk?

There is no indication that this in itself would increase the risk. Vitamin or mineral deficiency, on the other hand, is negative for the immune system – so take your vitamins after surgery!

If you need more support or have questions, please contact the National Association HOBS , they are there for you!

ww_dieting

Dieting -warning issued..!

By | About obesity, Best Weight, Body weight regulation, Food and drink, News

Virtually all our patients have tried to lose weight at some point before they eventually come to us. The stricky thing about all the calorie counting/dieting (“just move more and eat less…”) is that it seems to work at the beginning -you lose weight the first 1-2-3 weeks. Then sooner or later there will be a plateau phase, followed by a gradual weight gain, as a rule, to a higher final weight than the one you started at. The biological cause is the body’s internal weight thermostat (“set point”), which we told in more detail about in previous posts (see, for example, this blog from us, this article from Baribuddy or this information film). The result is that the risk of weight gain within five years after a diet is 95-97%. (This risk is something that the dieting industry never tells you about. And for obvious reasons: they have a turnover of 300,000,000 SEK per year in Sweden alone.).

Yo-yo dieting

The end result, weight down and then up again, is what you call “yo-yo-dieting”. But is it that simple? “Yo-yo” indicates that you easily regain your weight after a diet, but also suggests that you may not have very much to lose – the worst thing that can happen is that you are back on “square one”. Or?

… set point up

Unfortunately, it’s not that simple. What typically happens after a failed diet is that the brain’s set point is elevated by 2-5-8 kg (you regain more than what you lost in the beginning). Thus, the dieting triggers the brain to want to weigh even more. Most patients we meet describe how the first half of their gained weight probably came from genes + environment + a trigger (knee injury, smoking cessation, disease, etc.) -but that then the repeated yo-yo diets themselves pushed up the brain set point the remaining extra kilos. A diet risks triggering the body’s defense against starvation, and afterwards the set point is even higher. (It would therefore have been better to avoid the diet and instead accept the original weight.)

Permanently altered biology à la Biggest Loser

The next problem is that several of the mechanisms that counteract weight loss never disappear – even though you regain weight. The most famous study of this was done in the United States on a season of Biggest Loser participants. The study measured the contestants’ metabolism as well as various weight hormones before competition (when they had a large body), at the end of the competition (when they had done massive weight loss) and six years later (when all but one had regained all the weight again). Results: metabolism and the saturation hormone leptin were -as expected -clearly lowered immediately after the competition. What surprised however was that six years later, despite weight regain, the participants still had a lowered metabolism and lowered leptin(!). Dieting had thus permanently impaired the weight physiology of the participants.

Yo-yo dieting causes a change in body composition

For example, if you lose 10 kg with any traditional diet, you have not lost 10 kg of adipose tissue; you have probably broken down 7-8 kg of adipose tissue but at the same time 2-3 kg of muscle mass. Less fat is good, but less musculature is definitely not good. When you then regain the kilos back, let’s say 12 kg up, then in the worst case it is 12 kg of adipose tissue –no muscle mass. Failed dieting thus remodels the body’s composition for the worse. If you imagine that a person living with a large body makes repeated diets maybe 5-10 times in life, then you understand better why muscle pain, fatigue and impaired strength is so common -the person has lost more and more muscle mass.

… and lower self-esteem

In the end, we have the psychological aspect: repeated failure at weight loss is extremely psychologically stressful for the person himself. Most people blame themselves for weight failure (you have “lack of character” and so on) and people around them (often including health care staff) indirectly confirm this by agreeing, or not contradicting.

Dieting -warning issued!

Thus: one can defend the idea of one serious weight loss attempt through changing lifestyle habits or some type of diet program. This is to see what your particular set point for weight in the brain “accepts” regarding weight loss: 3-5% of us have a set point that is more flexible (and one can then imagine that weight loss can persist even in the long run). The other 95-97% will have a fixed set point corresponding to their higher starting weight -thus it will be a yo-yo effect. If you experience this, repeated new dieting attempts are potentially dangerous to your health: set point will be pushed upwards more and more, the body metabolism will be lowered and the level of saturation hormones will be lower, your body will be remodelled to less muscle mass and you will feel worse and worse psychologically. Better if possible to accept the weight you have and instead try to avoid further weight gain (here the concept “Best Weight” can be used, read more about this here). The alternative will be to choose treatment methods that lower the brain’s set point, i.e. medical treatment or obesity surgery.

What we are strongly opposed to is the almost reckless view of diets as something where the customer has “nothing to lose”: weight loss advertising and products are marketed through pharmacies, tabloids, commercial operators online, apps on the phone – but also by the health care system itself. This as a rule without the slightest warning about the risks we reported above, and never ever with information about what set point is. This problem needs to be highlighted and discussed more in society in general. Feel free to share!

Dieting