Post on 19-Apr-2022
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
• 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
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)
RYGB Skewed Right Band Skewed Left
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
2017
2015
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
Dia
be
tes
Ob
esi
ty
Complex Mechanistic Pathways
Obe
sity
Complex Mechanistic Pathways
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
Restrictive
Malabsorption
•>90% searches were for weight loss surgery or bariatrics
•Only 2% searches were for metabolic surgery
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
Set Point or Set Range
http://ethiconinstitute.com/node/1426/asset
• 2 Models of Energy Balance Equation• Purposeful behavior (how much
you eat and exercise drives) the physiology
• The physiology drives the behaviors
WHO defines obesity as abnormal or excessive fat
accumulation that may impair health
Fat is the Bodies Fuel
Thermostat
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
Homeostasis
Homeostasis
•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
Set Range
Energy ExpenditureEnergy Intake
(+) Energy Balance (-) Energy Balance
3000
2500
2000
20 25 30 35
BMIWeigle DS FASEB Journal 1994, 8:302-310.
2200 kcal/day - Average calories we consume daily1300 kcal/day - Average calories we need daily
900 kcal/day - Excess daily
2200 kcal/day - Average calories we consume daily1300 kcal/day - Average calories we need daily
900 kcal/day - Excess daily
•CNS regulates set range•Receives Signals from hormones•Signals sent from fat, muscle, bone, GI track….
•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
•Chronic Exposure:•Unhealthy Foods•Stress •Lack of Sleep•Medications that cause weight gain
Genetic Influences on Set Range
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)
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)
20 22 24 26 28 30 33 36 39 42 46 50 55 60
BMI
EveryOne Responds Differently due to differences in Genetics
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
Energy ExpenditureEnergy Intake
(+) Energy Balance (-) Energy Balance
3000
2500
2000
20 25 30 35
BMIWeigle DS FASEB Journal 1994, 8:302-310.
Aging and Environmental Influences (No Intervention)
SurgeryAging and Environmental Influences (Post Intervention)
Fat MassSet Point
Time (years)
Lower Set Point with Surgery
BMI40
Expect Lifelong:•Need for optimization of
modifiable environmental Factors •Need for Medications•Need for Revisional Surgery•Avoid medications causing weight gain
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
260270280290300310320330340350360370380390400410420430440450
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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
260270280290300310320330340350360370380390400410420430440450
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Mar-16
Apr-16
May-16
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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
.. .
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.