RNY, insulin, carbs, weight regain - Articles
Abnormal glucose tolerance testing following gastric bypass demonstrates reactive hypoglycemia.
Roslin M, Damani T, Oren J, Andrews R, Yatco E, Shah P.Source
Department of Surgery, Lenox Hill Hospital, 186 East 76th Street, New York, NY, 10021, USA.
Abstract
BACKGROUND:
Symptoms of reactive hypoglycemia have been reported by patients after Roux-en-Y gastric bypass (RYGB) surgery who experience maladaptive eating behavior and weight regain. A 4-h glucose tolerance test (GTT) was used to assess the incidence and extent of hypoglycemia.
METHODS:
Thirty-six patients who were at least 6 months postoperative from RYGB were administered a 4-h GTT with measurement of insulin levels. Mean age was 49.4 ± 11.4 years, mean preoperative body mass index (BMI) was 48.8 ± 6.6 kg/m(2), percent excess BMI lost (%EBL) was 62.6 ± 21.6%, mean weight change from nadir weight was 8.2 ± 8.6 kg, and mean follow-up time was 40.5 ± 26.7 months. Twelve patients had diabetes preoperatively.
RESULTS:
Thirty-two of 36 patients (89%) had abnormal GTT. Six patients (17%) were identified as diabetic based on GTT. All six of these patients were diabetic preoperatively. Twenty-six patients (72%) had evidence of reactive hypoglycemia at 2 h post glucose load. Within this cohort of 26 patients, 14 had maximum to minimum glucose ratio (MMGR) > 3:1, 5 with a ratio > 4:1. Eleven patients had weight regain greater than 10% of initial weight loss (range 4.9-25.6 kg). Ten of these 11 patients (91%) with weight recidivism showed reactive hypoglycemia.
CONCLUSIONS:
Abnormal GTT is a common finding post RYGB. Persistence of diabetes was noted in 50% of patients with diabetes preoperatively. Amongst the nondiabetic patients, reactive hypoglycemia was found to be more common and pronounced than expected. Absence of abnormally high insulin levels does not support nesidioblastosis as an etiology of this hypoglycemia. More than 50% of patients with reactive hypoglycemia had significantly exaggerated MMGR. We believe this may be due to the nonphysiologic transit of food to the small intestine due to lack of a pyloric valve after RYGB. This reactive hypoglycemia may contribute to maladaptive eating behaviors leading to weight regain long term. Our data suggest that GTT is an important part of post-RYGB follow-up and should be incorporated into the routine postoperative screening protocol. Further studies on the impact of pylorus preservation are necessary.
- PMID:
- 21184112
- [PubMed - in process]
Weight regain after Roux-en-Y: a significant 20% complication related to PYY.
Meguid MM, Glade MJ, Middleton FA.Source
Surgical Metabolism and Nutrition Laboratory, Department Surgery, Neuroscience and Physiology Program, SUNY Upstate Medical University, Syracuse, New York, USA. [email protected]
Abstract
OBJECTIVE:
Roux-en-Y gastric bypass (RYGB) produces rapid and dramatic weight loss in very heavy obese patients. Up to 20% cannot sustain their weight loss beyond 2 to 3 y after surgery.
METHODS:
To identify putative etiologic factors producing post-RYGB weight regain, a literature survey of metabolic changes in very obese and a review of our diet-induced obese RYGB rat model data was done.
RESULTS:
Weight regain suggests an imbalance in physiologic mechanisms regulating appetite and metabolic rate. Weight regain occurred in 25% of our rats, produced by return to presurgical energy intake levels. The 75% of rats that sustained weight loss secreted a significantly larger amount of peptide YY (PYY) while suppressing leptin secretion; those that failed were unable to develop or sustain a sufficiently large plasma PYY:leptin ratio. Metabolic consequences of this failure included reversal of initial postsurgical increases in peripheral fatty acid oxidation, anorexigenic activity in the hypothalamic arcuate nucleus and paraventricular nucleus, and the expression of uncoupling protein-2 in adipose tissues, and decreases in hepatic lipogenesis, free tri-iodothyronine secretion, expression of orexigenic activity in the arcuate nucleus and paraventricular nucleus, expression of adenosine monophosphate kinase in adipose tissues, skeletal muscle mitochondrial mass, and endocannabinoid content and appetite.
CONCLUSION:
Weight regain after RYGB occurs in approximately 20% of patients and constitutes a serious complication. Weight regain-promoting consequences are attributed to a failure to sustain elevated plasma PYY concentrations, indicating that combining RYGB with pharmacologic stimulation of PYY secretion in patients after RYGB who exhibit inadequate PYY concentration may increase long-term success of surgical weight reduction in morbidly obese adults.
Endoscopic findings and outcomes of revisional procedures for patients with weight recidivism after gastric bypass.
Yimcharoen P, Heneghan HM, Singh M, Brethauer S, Schauer P, Rogula T, Kroh M, Chand B.Source
Bariatric and Metabolic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA, [email protected].
Abstract
BACKGROUND:
Significant weight regain occurs for 10% to 20% of patients after Roux-en-Y gastric bypass (RYGB). Potential causative factors include anatomic abnormalities such as enlargement of the gastric pouch and gastrojejunostomy (GJ). This report describes endoscopic findings for patients referred for investigation of weight regain and presents the outcomes of revisional therapy for patients with abnormal anatomy.
METHODS:
To evaluate gastric pouch and stoma size, RYGB patients referred for weight regain underwent upper endoscopy. A GJ was defined as enlarged if it had a diameter greater than 2 cm in any dimension, and a pouch was defined as enlarged if its length exceeded 6 cm long or its width exceeded 5 cm. Patients with abnormal anatomy who subsequently underwent revisional procedures were arbitrarily categorized into three groups based on the interval from RYGB to endoscopic evaluation: less than 5 years (group 1), 5 to 10 years (group 2), longer than 10 years (group 3). The percentage of regained weight lost (%RWL) after revision was compared between the groups.
RESULTS:
In this study, 205 RYGB patients (176 women with a mean age of 47 ± 10 years and a current body mass index [BMI] of 43.4 ± 8.4 kg/m(2)) were evaluated. The mean time from primary RYGB was 6.9 ± 3.7 years, and the increase in BMI from its nadir was 9.78 ± 5.80 kg/m(2). Abnormal endoscopic findings (n = 146, 71.2%) included large GJ (n = 86, 58.9%), large pouch (n = 42, 28.8%), or both (n = 18, 12.3%). Of the 205 patients, 51 (24.9%) underwent a revisional surgical or endoluminal procedure. At a mean follow-up assessment 13 months after revision, group 1 (n = 12) had a mean %RWL of 103% ± 89.3%, and 62% of these patients lost all their regained weight. The mean %RWL was 45% ± 12.6% in group 2 (n = 30) and 40% ± 13.6% in group 3 (n = 9).
CONCLUSION:
Endoscopy is a valuable tool for evaluating weight regain after bariatric surgery that can identify abnormal post-RYGB anatomy in a majority of patients. Revisional procedures to restore normal RYGB anatomy appear to be most successful if performed within 5 years after the primary procedure.
Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up.
DiGiorgi M, Rosen DJ, Choi JJ, Milone L, Schrope B, Olivero-Rivera L, Restuccia N, Yuen S, Fisk M, Inabnet WB, Bessler M.Source
Columbia University Center for Metabolic and Weight Loss Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York 10032, USA. [email protected]
Abstract
BACKGROUND:
Studies have shown that type 2 diabetes (T2DM) improves or resolves shortly after Roux-en-Y gastric bypass (RYGB). Few data are available on T2DM recurrence or the effect of weight regain on T2DM status.
METHODS:
A review of 42 RYGB patients with T2DM and >or=3 years of follow-up and laboratory data was performed. Postoperative weight loss and T2DM status was assessed. Recurrence or worsening was defined as hemoglobin A1c >6.0% and fasting glucose >124 mg/dL and/or medication required after remission or improvement. Patients whose T2DM recurred or worsened were compared with those whose did not, and patients whose T2DM improved were compared with those whose T2DM resolved.
RESULTS:
T2DM had either resolved or improved in all patients (64% and 36%, respectively); 24% (10) recurred or worsened. The patients with recurrence or worsening had had a lower preoperative body mass index than those without recurrence or worsening (47.9 versus 52.9 kg/m2; P = .05), regained a greater percentage of their lost weight (37.7% versus 15.4%; P = .002), had a greater weight loss failure rate (63% versus 14%; P = .03), and had greater postoperative glucose levels (138 versus 102 mg/dL; P = .0002). Patients *****quired insulin or oral medication before RYGB were more likely to experience improvement rather than resolution (92% versus 8%, P
Kim
Melting Mama's post from the other day made me curious, so I started doing some research. My goal weight is 150 and my maintenance goal has been to remain within 5 pounds of it. HOWEVER, the scale has been inching upward since February and hovering around 160-161. I tried Zumba and also cutting back, but still I'd not been able to get it back down. I looked down at my wrists and forearms one day last week and they looked FAT, like before I lost weight. The definition was gone.
After reading Beth's article, I wondered if carbohydrates were the culprit so I decided to try the Atkins plan. I started Monday and I've already dropped 4 pounds of fluid. I feel so much better. I can even see my wrist bones again.
Something in my body has changed. At first I thought it was related to aging and menopause, but now I'm thinking it's that carb connection.
EDITED TO ADD: I started having reactive hypoglycemic episodes a couple of years ago. I'm 6 1/2 years post op.
KimThe DS has already been proven to have the highest percent resolution of type 2 diabetes with about a 99% cure rate as reported in the JAMA publication....Are you sure you're not experiencing dumping syndrome?
