Clinician-to-Clinician Update Clinician-to-Clinician Update

Patient’s Gastrectomy Helps Control Type 2 Diabetes and Provides Sustained Weight Loss

September 2017

Contributed by Daniel B. Leslie, MD

Adding surgery to a medical approach to obesity reinforces food intake behaviors by limiting volume of food eaten and increases a patient’s probability of maintaining at least 10% weight loss, an amount proven to be beneficial for improving diabetes management. In this case, a woman who had pursued various weight-management strategies finds sustained weight loss with bariatric surgery combined with medical and lifestyle management.

Patient

A 41-year old woman who was 5’6” and weighed 279 pounds (body mass index [BMI], 45 kg/m2) presented to physicians in the bariatric clinic. She had attempted to lose weight numerous times using calorie counting, high-protein diets, and several commercial weight-loss programs. She lost as much as 20 pounds through pursuing any 1 method but typically regained all and more weight.

Her medical history included type 2 diabetes, diagnosed 5 years earlier. At diagnosis, her hemoglobin A1C (HbA1C) was 6.5%, and at that point, she began taking metformin. She had also received lifestyle counseling and diabetes education. Her LDL cholesterol level was controlled with simvastatin and hypertension addressed with lisinopril.

After her diabetes diagnosis, HbA1C normalized with metformin alone, but within 2 years, it rose to 7.9% in association with a weight gain to 292 pounds, her highest lifetime weight. Glimepiride was added for glucose control. She was diagnosed with minimal-change kidney disease that required prednisone. She also was found to have nonalcoholic fatty liver disease.

Consultation and Management

At the time of her bariatric consultation, she was also using Lantus and Humalog insulin, and her HbA1C was 8.1%. Our physician assistant met with her to discuss a comprehensive approach to weight management, and bariatric dietician counseling focused on food intake and food choice behaviors.

One month later, the patient’s weight was unchanged, and the physician assistant prescribed topiramate to reduce hunger signals. Her primary care provider was asked to consider prescribing liraglutide or exenatide, which have weight loss as a side effect.

The patient lost 10 pounds and decided to have vertical sleeve gastrectomy for assistance with long-term weight control. She underwent an uneventful operation. She had an overnight stay and was discharged without complication.

At her 3-month follow-up appointment, her weight was 215 pounds, HbA1C was 5.2%, and fasting plasma glucose was 84 mg/dL. She no longer required any antihyperglycemic medications. Her blood pressure was under control without medication, but her LDL levels required continuance of simvastatin.

Twelve months after surgery, she weighed 200 pounds with a BMI of 32 kg/m2. HbA1C was 5.0%; fasting plasma glucose, 79 mg/dL; and blood pressure was 118/75 without medications. Liver transaminase testing remains normal and urinalysis demonstrates no protein.

Postintervention Weight Management

She has been involved in group fitness classes and is trying to stay active. She eats three small meals daily and typically avoids liquid calories. She redeveloped sugar cravings and topiramate was renewed. Her overall weight loss is 72 pounds, about 27.6% of her original weight, and her health has improved markedly.

The patient wants to lose an additional 20 pounds and has been counseled how to do this safely. She realizes that with diabetes control and an improved life, her focus is on health and wellness goals rather than on any specific weight target. Staff have also discussed control of medical problems rather than focusing on cure, and she recognizes that diabetes would return if she regains weight.

This patient was particularly interested in the sleeve gastrectomy because it is a less complex operation with fewer long-term side effects and complications. She understood the potential for diabetes recidivism after surgery and the long-term need to continue monitoring for hyperglycemia. The acceptance of topiramate use again after surgery recognizes our team’s understanding that surgery is just a tool and that we will use all available options to mitigate weight regain risk.

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