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

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

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

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

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.