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Patient Factors in Bariatric Surgery Choices

Patient Factors in Bariatric Surgery Choices

Gastric bypass surgery and laparoscopic adjustable gastric banding are two commonly performed bariatric procedures, but each has different profiles for risk and effectiveness. Few studies have explored the factors that might lead patients to proceed with one procedure over another. In the Journal of the American College of Surgeons, a study was conducted to investigate the reasons why obese patients choose one type of weight loss operation over another. First author Caroline M. Apovian, MD, FACP, FACN, and colleagues studied 536 adults who had either gastric bypass (297 patients) or gastric banding (239 patients). A Deeper Look According to the results, diabetes status played an important role in decision- making for patients who were choosing between gastric bypass and laparoscopic adjustable gastric banding procedures. Those with diabetes were more likely to proceed with gastric bypass surgery. “This could be the result of patients and their physicians understanding that obesity causes type 2 diabetes, and that gastric bypass surgery can be life-saving and restore normal glucose levels,” says Dr. Apovian. Other patients who were more likely to select gastric bypass over the laparoscopic banding procedure included those who wanted greater weight loss and those willing to assume a higher mortality risk to reach their ideal weight. BMI appeared to play a smaller role in the decision-making process for patients choosing between bariatric surgeries. “Psychological and emotional issues appear to influence surgery decisions,” Dr. Apovian says. “It’s important to consider the patient’s individual preferences and what matters most to them.” In addition, the study found that patients reporting more uncontrolled eating were more likely to undergo laparoscopic banding than gastric bypass....
Clinical Guidelines for Managing Obesity

Clinical Guidelines for Managing Obesity

According to published data, nearly 155 million adults in the United States are classified as being either overweight (having a BMI of 25 to 29.9 kg/m2) or obese (having a BMI of 30 kg/m2 or higher). “Health-care providers are on the front line of the obesity epidemic,” explains Donna H. Ryan, MD. “Greater efforts are needed to identify patients who need to lose weight for cardiovascular reasons. As clinicians, we’re in a prime position to direct successful weight loss efforts.” According to Dr. Ryan, behaviors around food and physical activity and getting patients the help they need to change these behaviors are paramount to weight loss. “Losing weight is a complex issue that goes beyond a person’s willpower,” she says. “We need to do more than simply advise obese and overweight patients to lose weight. We need to be actively involved to help patients reach a healthier body weight, and that’s not necessarily a so-called ‘normal’ body weight.” Helpful Guidance In 2013, the American Heart Association, American College of Cardiology, and Obesity Society released comprehensive treatment recommendations to help healthcare providers tailor weight loss treatments to adults who are overweight or obese. The guidelines address five specific areas of obesity, including:   1)   The identification of who needs to lose weight.   2)   How much weight patients should lose.   3)   Diets to consider for weight loss.   4)   Expected weight loss with lifestyle interventions.   5) Patients who should be considered for bariatric surgery. According to the guidelines, healthcare providers should calculate BMI at annual visits or more frequently and use BMI and waist circumference (WC) cutpoints to identify...
Cardiovascular Disease & Diabetes

Cardiovascular Disease & Diabetes

According to the American Diabetes Association, cardiovascular disease (CVD) is the major cause of morbidity and mortality for people living with diabetes. “The common conditions that coexist with type 2 diabetes, such as hypertension and dyslipidemia, are clearly risk factors for CVD,” explains Robert H. Eckel, MD. “Diabetes itself confers additional risk for CVD, including coronary heart disease, stroke, peripheral vascular disease, and heart failure. Obesity, metabolic syndrome, and inflammation are other key components to the link between diabetes and CVD.” “Large benefits are seen when multiple CVD risk factors are addressed globally.” Published analyses have shown that controlling individual CVD risk factors helps to prevent or slow CVD in people with diabetes. “Large benefits are seen when multiple CVD risk factors are addressed globally,” says Dr. Eckel. “Clinical trials have shown that lowering glucose aggressively can further help reduce CVD risk, but an individualized approach is necessary for most patients with diabetes.” Individualizing Care for Diabetes The American Diabetes Association recommends an A1C of less than 7% for most patients, but Dr. Eckel notes that A1C goals may differ from patient to patient, depending on their individual characteristics (Table 1). “There are several aspects to consider when selecting a target A1C level, including age, duration of diabetes, the extent of diabetes complications, psychosocial support, physical activity limitations, and risks of hypoglycemia. All of these factors—and other cardiometabolic components—will play a role in guiding how aggressively diabetes should be treated.” Blood Pressure & Cholesterol In addition to glycemic control, the management of blood pressure and cholesterol is important to helping prevent or slow CVD in patients with diabetes (Table...
Gastric Bypass Surgery for Mild Obesity in Diabetics

Gastric Bypass Surgery for Mild Obesity in Diabetics

In 2003, a study of more than 1,000 patients who underwent gastric bypass found that one-third of those with diabetes at baseline had normal blood sugars after their surgery and didn’t need medication when they were discharged from their surgical hospitalization. This finding sparked further exploration into the effects of gastric bypass surgery on weight-independent, antidiabetes mechanisms. Testing a New Population In Diabetes Care, my colleagues and I had a study published that explored the use of Roux-en-Y gastric bypass (RYGB) as a primary modality to treat type 2 diabetes in patients for whom weight loss was not the primary objective. When we began the study, clinical observations had suggested that diabetes remits in about 80% of patients who undergo gastric bypass. What we didn’t know was the durability of that effect or what the outcomes would be in patients who weren’t severely obese. In our analysis, we selected 66 consecutive patients with type 2 diabetes who were mildly obese (BMI between 30 kg/m2 and 35 kg/m2) to undergo RYGB. These patients were prospectively studied for up to 6 years. At baseline, they had an average A1C of 9.7% despite being on insulin or at least two diabetes medications. At 6 months after RYGB, the average A1C level decreased to 6.5% and continued to decrease to 6.1% at 6 years, with 100% follow-up in this cohort. At the latest follow-up, 88% of patients had achieved diabetes remission, which was defined as having an A1C of 6.5% or less and being off all diabetes medications. We also found that â-cells were nearly five times more sensitive to blood sugar, on...
AMA: Obesity Is a Disease. Do You Agree?

AMA: Obesity Is a Disease. Do You Agree?

The American Medical Association (AMA) has officially labeled obesity as a disease in hopes that it will help change the way the medical community tackles the complex issue. As it stands, insurance companies generally exclude obesity treatment, which can limit how physicians manage obesity-related conditions like diabetes and high blood pressure.  While the AMA’s decision has no legal authority, some hope that medical therapies and procedures such as the lap-band or gastric bypass surgeries will now be included in insurance coverage. Proponents of the decision contend that treatment for clinically obese patients is not as simple as eating less and exercising more. Physical mechanisms and damage to signaling pathways can make it extremely difficult for people to lose weight. Improving reimbursement for obesity drugs, surgery, and counseling may significantly impact patient outcomes. Those opposing the decision, including the AMA’s own Council on Science and Public Health, consider the measure to define obesity, the body mass index (BMI), too simplistic and flawed.  They argue people with a BMI above the level defining obesity may be perfectly healthy, while others may have dangerous levels of body fat and metabolic problems. Others are concerned that the lack of specific symptoms associated with obesity classify it as more of a risk factor for other conditions than a disease in its own right. Physician’s Weekly wants to know…Will the AMA’s decision influence how you view and manage obesity among your patients? Do you think it will impact insurance...
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