Dear Colleagues:

I am contacting you sooner than planned due to slight change in program of our first

meeting.

This meeting will take place on Thursday 8th October 2015 at 1pm at Wolverhampton

Goldthorn Hotel, 126 Penn Road WV3 0ER.

Meeting Agenda is as follows:

Buffet Lunch 1 pm

First Session 1.45 pm

Presenter: Lyndsey Richards (Diabetes specialist dietician)

Practical dietary advice in 10 minutes consultation-understanding basics of nutrition and

impact of various foods on weight and diabetes control.

Second Session 3 pm

Presenter: Dr Ananth Viswanath (Consultant Physician)

Obesity in Diabetes- Evidence base on treatment options for obesity in diabetes. Local

weight management services/pathways and vision for the future.

Meeting Close 4.15 pm

Many Thanks

Dr Syed Gillani

Syed.gillani@nhs.net

GP Wolverhampton

Clinical Research Fellow Diabetes

Senior Lecturer University of Wolverhampton

Clinical Champion DUK

1

Obesity & Diabetes

Lynsey Richards

Ananth Viswanath

Diabesity

Lynsey Richards

Ananth Viswanath

Health Survey of England 2010-2012

Adult BMI

status by

gender

Adult waist

circumference

by gender

National, Regional and Local BMI in Adults and Children

Active People

Survey 2012

National child

weight

measurement

programme

Type 2 diabetes is closely linked to obesity

Chan JM et al. Diabetes Care 1994; 17: 961–969. 27,983 men followed for 5 years

BMI

Ag

e-a

dju

ste

d r

ela

tive

ris

k

of T

ype

2 d

iab

ete

s

60

23–

23.9

< 23 24–

24.9

25–

26.9

27–

28.9

29–

30.9

31–

32.9

33–

34.9

> 35

0

50

40

30

20

10

OVERWEIGHT OBESE

2

Diabetes in Wolverhampton

AcrossEnglandappro ximatelyathirdoftheprojectedriseindiabetesprevalenc ecanbeattributedtothe

increasingprevalenceofobesity .IfobesitylevelsinWolverhamptonMDcouldbemaintainedattherates

foundin2010therewouldbe700fewerpeoplew ithdiabetesin2020(equvilentto3.3%ofpeoplep rojected

tohavediabetes.By2030astat icprevalenceofobesitywouldmeananest imated1900fewerpeo plewith

diabetes(equivalentto 7.5%ofpeopleprojectedtohavediabetesin2030) .

DiabetesprevalenceinWolverhamptonMD

Itisest im atedthatin20129.4%ofpeopleaged16yearsando lderinWolverhamp tonMD.Ifcurrenttrends in

po pulat ionchangeandobesitypersisttheto talprevalenceofd iabetesisexpec tedtoriseto10.8%by2020and

12.3%by2030

Estimatedtotal(d iagnosedandu ndiagnosed)diabetesprevalenceinadults

Estimatedimpactoftheinc reasingp revalenc eofo bes ityond iabetesp revalenc e

TheDiabetesPrevalenceModelestimatesthetotal(diagnosedandundiagnosed)numberofpeoplewith

diabetes.Est imatesareadjustedfo rtheage,sex,ethnicgroupanddeprivationpatternofthelocalpopulat io n.

Forfurtherinformationseehttp://www.yhpho.org .uk/default .aspx?RID=81090

-

5,000

10,000

15,000

20,000

25,000

30,000

2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030

Numbe

rofadultsestimatedtohav

e

diabe

tes

2010obesitylevelsmaintained Obesitycontinuestoriseatcurrentrate

9.4% 9.9%10.8% 11.5% 12.3%

7.3% 7.6% 8.2% 8.6% 8.8%

0%

2%

4%

6%

8%

10%

12%

14%

2012 2015 2020 2025 2030

WolverhamptonMD England

AcrossEnglandapproximatelyathirdoftheprojectedriseindiabetesprevalencecanbeattributedtothe

increasingprevalenceofobesity.IfobesitylevelsinWolverhamptonMDcouldbemaintainedattherates

foundin2010therewouldbe700fewerpeoplewithdiabetesin2020(equvilentto3.3%ofpeopleprojected

tohavediabetes.By2030astaticprevalenceofobesitywouldmeananestimated1900fewerpeoplewith

diabetes(equivalentto7.5%ofpeopleprojectedtohavediabetesin2030).

DiabetesprevalenceinWolverhamptonMD

Itisestimatedthatin20129.4%ofpeopleaged16yearsandolderinWolverhamptonMD.Ifcurrenttrendsin

populationchangeandobesitypersistthetotalprevalenceofdiabetesisexpectedtoriseto10.8%by2020and

12.3%by2030

Estimatedtotal(diagnosedandundiagnosed)diabetesprevalenceinadults

Estimatedimpactoftheincreasingprevalenceofobesityondiabetesprevalence

TheDiabetesPrevalenceModelestimatesthetotal(diagnosedandundiagnosed)numberofpeoplewith

diabetes.Estimatesareadjustedfortheage,sex,ethnicgroupanddeprivationpatternofthelocalpopulation.

Forfurtherinformationseehttp://www.yhpho.org.uk/default.aspx?RID=81090

-

5,000

10,000

15,000

20,000

25,000

30,000

2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030

Numberofadultsestim

atedtohave

diabetes

2010obesitylevelsmaintained Obesitycontinuestoriseatcurrentrate

9.4% 9.9% 10.8% 11.5% 12.3%

7.3% 7.6% 8.2% 8.6% 8.8%

0%

2%

4%

6%

8%

10%

12%

14%

2012 2015 2020 2025 2030

WolverhamptonMD England

Estimated Prevalence of Diabetes - Impact of obesity

Outline

• NICE Obesity guidance

• Case based discussion

• Lifestyle intervention- does it work?

• Medical therapy- what are our options?

• Bariatric surgery - what is the evidence?

• Obesity strategy

Mostly it is easy to identify! The ‘Y’ Files

Mr. Yudkin

Aged 60 yrs

Caucassian

Obesity expert

Healthy diet

Active

Runs

marathon

BMI 22.3

Mr. Yagnik

Aged 52 yrs

Asian

Endocrine

specialist

Vegetarian

diet

Minimal

activity

BMI 22.3

Body Fat

9.1% 22.2%

NICE Obesity Guideline 2014

• Identification and

classification of

overweight and

obesity

• Lifestyle

interventions

• Pharmacological

interventions

• Surgical

interventions

• Follow-up care

Obesity: Identification and classification (NICE)

Classification BMI (kg/m2)

Healthy weight 18.5-24.9

Overweight 25-29.9

Obesity I 30-34.9

Obesity II 35-39.9

Obesity III 40 or more

Risk thresholds are

Lower for adults of Asian

family origin

BMI

classification

Waist circumference (if BMI <35)

Low High Very high

Overweight No increased risk Increased risk High risk

Obesity I Increased risk High risk Very high risk

Men <94 cm 94-102 cm >102 cm

Women <80 cm 80-88 cm >88 cm

3

Level of intervention (NICE)

BMI

classification

Waist circumference Comorbidities

present

Low High Very high

Overweight LS DPA DPA DPA, Rx

Obesity I DPA DPA DPA DPA, Rx

Obesity II DPA, Rx DPA, Rx DPA, Rx DPA, Rx, Sx

Obesity III DPA, Rx,

Sx

DPA, Rx,

Sx

DPA, Rx,

Sx

DPA, Rx, Sx

LS Lifestyle advice

DPA Diet and physical activity

Rx Consider drugs

Sx Consider surgery

Comorbidities, e.g. T2DM, HTN, CVD, OA, dyslipidaemia, sleep apnoea

Case discussion

54 year old gentleman

Presentation with tiredness

Random blood glucose 12 mmol/L

• Urine analysis: glycosuria

• BP: 149/90, Weight 89Kg; BMI 32

• HbA1c: 8.2%, Crt 91, T.Chol: 5.6, HDL 0.9, Trigs 3.9

Initial consideration

Life style intervention:

• Dietary advise

• Increasing physical activity

• Encourage weight loss

CV Risk assessment:

• Smoking cessation

• BP & Lipids

Hypoglycaemic therapy:

Started on Metformin

• Does it work?

• Is it sustainable?

• What are the barriers?

Practical d ietary advice in a 10

minute consultation: Understanding the basics of nutrition and

impact of various foods on weight and

diabetes control

Lynsey Richards

Diabetes Dietitian

Traditional vs current advice

Quality vs quantity of carbohydrate

“New” options for weight loss

Low fat d iet

Physical activity

Energy balance model

4

Between 80-90% of people with type 2 d iabetes are

overweight (1)

20kcal more than we need every day for one year

= +1kg

Effect of medications:

Sulphonylurea and glitazones: +3kg (2)

Insulin initiation: +5kg (3)

Provide information and support to allow person

with d iabetes to make informed food choices

(Promote self-management)

Promote quality of life and healthy lifestyle

Provide flexibility and meet needs of all

ind ividuals

Prevent short and long term complications

Insulin is anabolic: promotes lipogenesis and

prevents lipolysis

So, insulin resistant ind ividuals often struggle

to lose weight

There is no “right” way to lose weight - ind ividual approach based on current lifestyle / preferences / metabolic goals (4)

Key points:

Unprocessed foods

Avoid trans-fats

Limit high GI carbs

5

5 – 9 portions 5 – 14 portions

2 - 3 portions 0 - 4 portions 2 - 3 portions

What is a portion?

Starchy carbohydrate 5-14 portions (Average 80kcal per portion)

• 2 – 4 tbsp breakfast cereal • Medium slice of bread / toast • ½ small pitta bread / chapati • 1 – 2 tbsp cooked rice / pasta / noodles • 2 crackers / 4 – 6 chips • 2 egg sized new potatoes • ½ baked potato • 1 – 2 tbsp mashed potato • 2 – 3 crispbread or crackers

Fruit & vegetables 5-9 portions (Average 50kcal

per portion) • 2 – 3 heaped tbsp veg • Cereal bowl of salad • 1 medium fruit (e.g. banana / apple) • 2 small fruit (e.g. satsumas / plums) • 1 slice melon • 150ml glass juice • Small cup grapes / berries • 1 tbsp dried fruit

Meat / fish / alternatives 2-3 portions (Average 150kcal per portion)

• 85g red meat / chicken • 120 – 140g fish • 2 eggs • 3-4 tbsp pulses / lentils / dhal • 2 tbsp nuts

Dairy foods 2-3 portions (Average 100kcal per portion)

• 1/3 pint (190mls) milk • Small yoghurt (125ml) • 2 tbsp cottage cheese • 40-45g cheese (matchbox size)

Fatty / sugary 0-4 portions (Average 100kcal per portion)

• 2 tsp margarine / 10ml oil • 2 tsp mayonnaise • ½ sausage / 1 rasher bacon • 1 scoop ice cream / 1tbsp cream • 1 mini chocolate bar • 1 chocolate biscuit • ½ packet of crisps • 2 tsp sugar / jam / honey

Has the greatest effect on blood glucose

Portion size is the most important factor

Type of carbohydrate also important (GI)

Low carbohydrate d iets are becoming more popular

Moderate carbohydrate: 130 to 225g of carbs

Low carbohydrate: under 130g of carbs

Very low carbohydrate: under 30g of carbs (20g/ day to start Atkins!)

100ml

Breakfast = 29g

Lunch = 15g

Evening meal =

51g

Total = 95g

The ranking of carbohydrate food based on how quickly it affects blood glucose level

Can be usefu l in managing type 2 d iabetes and weight

Can prevent spikes in blood glucose level and therefore insu lin response

Can aid satiety

Can reduce HbA1c by ~0.5% (5)

More weight loss and improved lipid profile (6)

Source: glycemicindex.com

6

Affected by a number of factors:

Cooking / preparation / storage of food

Ripeness

Other food / d rink taken at the same time

Based on a 50g portion of food

Incorporates the GI plus the portion of the

food eaten

A more useful measure of the impact of food

on BGL

What is the glycaemic index? (High / medium / low)

What is the glycaemic index? 74

74 40 51

78 87

36

32 48

50

50

73

75 42

21

87

92

59 32

103 32

43 21

55

97 47 41

Quick wins…

7

Current choice Exchange for: Calorie saving

280ml orange ju ice

100kcal

150ml tomato ju ice

21kcal

79kcal

½ pint whole milk

187kcal

½ pint skimmed milk

90kcal

97kcal

330ml fizzy drink

135kcal

330ml d iet fizzy drink

0kcal

135kcal

280ml fru it smoothie

150kcal

280ml no added sugar

squash 3kcal

147kcal

Total saving: 458kcal

Current choice Exchange for: Calorie saving

3 x choc hobnobs

280kcal

3 x ginger biscuits

131kcal

149kcal

28g bombay mix

141kcal

22g dried fru it & nuts

97kcal

44kcal

38g pkt crisps 201kcal 3 x rice cakes 89kcal 112kcal

2 x scoops ice cream

142kcal

2 x scoops sorbet 85kcal 57kcal

Average portion of fru it = < 50kcal Total saving: 362kcal

Options for weight loss… if

all else has failed

E.g. Optifast / Slimfast

2 x replacements (e.g. shakes / bars) which is

fortified with vitamins and minerals

one low calorie meal

Removes the need for decision making / food

choice / temptation

e.g. LighterLife

<800kcal/ day for max 12 weeks

Usually involves shakes / bars

BMI >30kg/ m2 and have been unsuccessful with trad itional methods

Side effects: fatigue, d iarrhoea / constipation, nausea

8

2500/ 2000kcal for 5 days

600/ 500kcal for 2 days (not consecutive days)

Side effects (anecdotal): d ifficu lties sleeping, bad breath

(a known problem with low carbohydrate d iets),

irritability, anxiety, dehydration, daytime sleepiness

Research is continuing regarding efficacy of the d iet

X-PERT diabetes course (Wolves Community

Trust)

Healthy Minds service

Weightwatchers

Health trainers (including fit for a fiver)

1. Diabetes UK (2011) Evidence-based nutrition guidelines for the prevention and management of

d iabetes.

2. Bolen, S., Feldman, L., Vassy J. et al (2007) Systematic review: comparative effectiveness and

safety of oral medications for type 2 d iabetes mellitus. Ann Intern Med, 147(6): 386-99.

3. Holman, R.R., Thorne, K.I., Farmer, A.J. et al (2007) Addition of biphasic, p randial, or basal

insu lin to oral therapy in type 2 d iabetes, New England Journal of Medicine, 357 (17): 1716-30.

4. Johnston BC, Kanters S, Bandayrel K, et al. Comparison of Weight Loss Among Named Diet Programs in

Overweight and Obese Adults: A Meta-analysis. JAMA. 2014;312(9):923-933.

doi:10.1001/ jama.2014.10397.

5. Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, d iets for d iabetes mellitus. Cochrane

Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006296. DOI:

10.1002/ 14651858.CD006296.pub2

6. Thomas D, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight and

obesity. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005105. DOI:

10.1002/ 14651858.CD005105.pub2.

Question 1

• 3500 excess calories = 1 pound gained

• An imbalance of 100 calories per day = 36,500 calories in 1 year

• 36,500 calories = 10.4 lbs

• Extra 100 calories per day caloric excess each day for a year is 10 lbs

Doctor I hardly eat anything but my weight keeps

going up!

Small changes can make a REAL difference

Question 2: How much should I exercise?

• Average person burns about 70

Calories/hour at rest

• In one day = 1700 Calories/day

• Assuming energy consumption

around 2000 calories/day

• Expend ~ 300 calories to

maintain weight

Walking:

Walking at a moderate or brisk pace of 3 to 4.5 mph on a level surface

Calorie consumption 5 – 7 Kcal/min

30 minutes of walking 130-200 Kcal

NICE recommendation: Physical activity

• Encourage adults to increase physical activity levels even if they

don’t loose weight

• Activity type:

Brisk walking, gardening or cycling

Supervised exercise programmes

Swimming, Stair climbing

• Minimum: At least 30 min of moderate or greater intensity

physical activity on 5 or more days a week

• To maintain weight: 45-60 minutes of moderate activity /day

• To avoid weight regain: 60-90 min of activity per day

9

• RCT involved 5,145 obese adults with type 2 DM

• Randomized to intensive lifestyle intervention

– Goal >7% initial weight loss

– 175 minutes per week physical activity

• Mean age 58.7 years, mean BMI 36, duration of DM-5

years, HbA1c-7.3%

• Primary endpoint: composite cardiovascular outcome

• Median FU 9.6 years

Look AHEAD: Diabetes Care 2007. 30(6):1374-1383

Results

Look AHEAD: Diabetes Care 2007. 30(6):1374-1383

Cumulative Hazard Curves for the primary composite end

point

Phases of Obesity Treatment

Phase I (Weight Loss)

3-6 months

Phase II (Weight-Loss Maintenance)

Indefinitely

When you stop intervention,

the weight comes back!

Weig

ht

Back to our case: 2 years on…….

• Initial improvement in A1c is not sustained

• No significant weight loss despite life style

intervention!

• Weight: 90 kg, BMI 33, BP 134/78

• HbA1c now 8.9%

• T Chol 4.2, Trigs 2.9, HDL 0.9

Second line agents: What after METFORMIN?

Established therapies

Sulphonylurea

Glitazones (TZD)

Insulin

New agents

GLP-1 agonist

DPPIV inhibitor:

Gliptins

SGLT-2 inhibitors

Barriers:

Hypoglycaemia

Weight gain

Any better?

Anti-obesity

Rimonabant

Orlistat

Sibutramine

Effective?

Durable?

Orlistat (Xenical)

• Effectiveness in Clinical studies: 35-50 % of subjects achieved a

5% or greater decrease in body mass and 15- 24.8% achieved

at least a 10% decrease in body fat in a year.

• Initiation criteria:

• BMI 28 kg/m2 or more + associated risk factors (T2 DM)

• BMI 30 kg/m2 or more

• Continue beyond 3 months only if at least 5% weight loss

• T2DM patients may have slower weight loss rate – less strict goals

may be appropriate

• Continue beyond 12 months (for weight maintenance) only after

benefits/limitations have been discussed

• Can be sued in conjunction with other glucose lowering agents

10

SGLT-2 inhibitors

(Dapagliflozin, Cannagliflozin, Empagliflozin)

Promotes Glycosuria, glucose lowering and weight loss

DAPAGLIFLOZIN: Effective as mono or add-on therapy

*Statistically significant versus placebo using Dunnett’s correction (p<0.0001); †Statistically significant versus placebo (p<0.0001); ‡ Statistically significant versus placebo (p<0.001).

OAD, oral antidiabetic drug.

Clinical trials are conducted under varying conditions and results from individual trials cannot be directly compared

1. Ferrannini E, et al. Diabetes Care 2010;33:2217–24; 2. Bailey CJ, et al. Lancet 2010;375:2223–33; 3. Strojek K, et al. Diabetes Obes Metab 2011;13:928–38; 4. Jabbour SA, et al. Diabetes Care 2014;37:740–50; 5. Wilding JPH, et al. Ann Intern Med 2012;156:405–15.

FORXIGA

Placebo

(24 weeks)

FORXIGA as add-on to metformin versus SU: Additional benefit of weight loss sustained over 4 years1

1. Del Prato S, et al. Presented at the 73rd American Diabetes Association Scientific Sessions, Chicago, USA.

21–25 June 2013. Abstract 62-LB; 2. Nauck MA, et al. Diabetes Care 2011;34:

3. Bailey CJ, et al. Lancet 2010;375:2223–33; 4. FORXIGA®. Summary of product characteristics, 2014.

At 52 weeks, dapagliflozin was associated with weight loss of –3.2 kg versus weight gain of +1.4 kg with glipizide (p<0.0001)2

SGLT-2 inhibitors

(Cannaglipflozin, Dapagliflozin Empagliflozin)

• Oral agent taken once daily

• HbA1c reduction 0.8-1%

• Weight loss

• Can be used in combination with OHA and

insulin

• Caution: Elderly, Renal impairment, Heart

failure

• Concerns: Polyuria, electrolyte disturbances,

urinary tract infections and genital infections

Physiological effects of GLP-1 (Exenatide, Liraglutide, Lixexenatide)

Gastric emptying1,2

Stomach

Insulin secretion1 Glucagon secretion1,2

Insulin biosynthesis1

Beta-cell proliferation*1

Beta-cell apoptosis*1

Preserved hypoglycaemic counter-regulation3

*In animal models Muscle (indirect effect)

Glucose uptake1 Food intake2

Brain

Pancreas

Glucose production1

Liver (indirect effect)

GLP-1 from intestinal

L cells

1. Baggio LL, Drucker DJ. Gastroenterology 2007;132:2131–2157

2. Drucker DJ. Diabetes Care 2003;26:2929–2940

3. Drucker DJ, Nauck MA. Lancet

2006;368:1696−1705 Figure adapted from reference 1

DURATION Studies: GLP-1 agonist and

Glucose lowering

11

DURATION Studies: GLP-1 agonist and weight

loss

SCALE Diabetes study: Liraglutide

• 56 weeks RCT 3700

non-diabetics

• Intervention group:

3 mg Liraglutide

• Control group:

lifestyle intervention

• Not currently

licenced in the UK

DDP-IV is responsible for degradation of incretin hormones GLP-1 and GIP DPP-IV inhibitors prolong the action of incretins Oral agent, well tolerated and no weight loss

Dipeptidyl peptidase IV antagonists

(Sitagliptin, Linagliptin, Alogliptin)

Guidance: Second Line Agent

Sulphonylurea

<25

Body Mass Index

25-30

Hypo a concern?

Sulphonylurea

Gliptins

SGLT 2 inhb

Glitazone

30-35 >35

Avoid SOU

SGLT-2 inhb

GLP-1 agonist

Gliptins

GLP-1 Agonist

SGLT-2 inhb

Gliptins

3 years on….

• On Metformin 850 mg BD and Glimepiride 4

mg/day

• HbA1c 8.6 %

• Weight 100 Kg (BMI 40)

• BP 150/85 (despite 4 agents)

• Osteoarthritis and limited physical activity

12

Next Option

• Gliptins

• SGLT 2 inhibitor

• GLP-1Agonist

• Insulin

Surgical Treatment for Diabetes: A shifting Paradigm

Diabetes ?Still diabetic

NICE Guidance Bariatric surgery

• Bariatric surgery is a

treatment option for

people with obesity if:

• They have a BMI of 40

kg/m2 or more, or

between 35 kg/m2 and

40 kg/m2 and other

significant disease (for

example, type 2 diabetes

or high blood pressure)

that could be improved if

they lost weight

Recommendation for new onset T2 Diabetes

• Offer an expedited assessment for bariatric

surgery to people with a BMI of 35 or over

who have recent-onset type 2 diabetes as

long as they are also receiving or will receive

assessment in a tier 3 service (or equivalent).

• Consider an assessment for bariatric surgery

for people of Asian family origin who have

recent-onset type 2 diabetes at a lower BMI

than other populations

Bariatric surgery and Diabetes

• How effective is bariatric surgery in patients

with diabetes?

• Which procedure is better?

• How long do the benefits last?

• Are there any additional benefits?

• Are the benefits solely related to weight loss?

• Is it cost effective?

Lap Band Gastric By-pass

Sleeve Gastrectomy

13

• Meta-analysis of Bariatric surgery Vs Conventional

medical therapy

• 16 studies (5 RCT) which included DM endpoints

• 6131 patients with a mean FU of 17.3 months

• 3076 underwent bariatric surgery (mean BMI 40.9;

age 47; 72% female)

• 3055 had medical treatment (mean BMI 39.4; age

48.6; 69% female)

Ribaric G, Buchwald JN, McGlennon TW. Diabetes and weight in comparative

studies of bariatric surgery vs conventional medical therapy: a

systematic review and meta-analysis. Obes Surg. 2014; 24: 437-55.

A comparison of the mean changes in BMI and HbA1c achieved with individual procedures

Bariatric

procedure

Body mass index (Kg/ M2) HbA1c (%)

Pre-

surgery

Post-

surgery

Mean reduction

(95%CI)

Pre-

surgery

Post-

surgery

Mean reduction

(95% CI)

AGB 37 29.5 7.5 (5.9 – 9.1) 7.8 6.0 1.8 (1.3 – 2.3)

SG 41.3 28.3 13.0 (10 – 15.9) 7.9 6.0 1.9 (1.0 – 2.8)

RYGB 34.6 25.8 11.8 (9 – 16.4) 8.2 6.1 2.1 (1.3 – 2.9)

BPD 50.5 34.6 15.9 (11 – 20) 8.0 5.2 2.8 (2.1 – 3.5)

Ribaric G, Buchwald JN, McGlennon TW. Diabetes and weight in comparative

studies of bariatric surgery vs conventional medical therapy: a

systematic review and meta-analysis. Obes Surg. 2014; 24: 437-55.

Bariatric surgery Vs Conventional therapy

Excessive weight loss

Ribaric G, Buchwald JN, McGlennon TW. Diabetes and weight in comparative

studies of bariatric surgery vs conventional medical therapy: a

systematic review and meta-analysis. Obes Surg. 2014; 24: 437-55.

Diabetes Remission

Study limitations

• Many observational studies with limited RCT

evidence

• Study duration less than 2 years

• Definition of diabetes remission?

• Surgery not compared directly with more vigorous

medical weight-loss strategies

UK Experience: National Bariatric Surgery Register

• 161 surgeons from 137 hospitals recorded 32,073 operations

2011-2013:

• 18,283 operations

• 76.2% operations were funded by NHS

• 22.6% were independently funded

• 9,526 RYGB, 4,705 GB operations and 3,797 SG operations

• 95.4% of all primary operations were performed laparoscopically

National Bariatric Surgery Registry -UK

• The average BMI was 48.8 kg

• 53.9% of men & 41.4% of women

had a high level of co-existing

disease

Number of Bariatric surgeries done in the UK

Published December 2014

14

Excess Weight Loss after Surgery

Gastric Bypass>> Sleeve Gastrectomy >> Lap band

Timing of Bariatric surgery

• Effective weight loss

independent of BMI at

baseline

• Diabetes remission

rates higher in

patients:

- on OHA

- lesser duration

of diabetes

NBSR December 2014

Long term study: Swedish Obesity Study

Weight loss over 10 years

Prospective case control

study

Follow-up over 10 years

Surgical group: 1,703

patients, of whom 118 had

type 2 diabetes

RYGB 13%, vertical

banded gastroplasty 68%

Control group received

medical therapy of whom

77 patients had type 2

diabetes

Remission from diabetes and hypertension

Diabetes remission based on FBS <7 and not on diabetes medications

Remission rate: 72% at 2 years

37% at 10 years

Bariatric surgery: complications

• Mortality (NBSR): The observed in-hospital mortality rate

after primary surgery was 0.07% overall

• The estimated mortality for primary bariatric surgery for

April 2009 to February 2013 was 0.11% (25 / 23,760)

(Quality Outcomes Research Unit in Birmingham

Surgeon-Level Outcomes Publication (2013))

• Complication rate: 2%

• Re-operation rate: 6-7%

• The average post-operative stay was 2.7 days, indicating

efficient use of resources

How does bariatric surgery improve DM control?

• Weight Loss

• Calorie restriction improves hyperglycaemia

• Alteration in gut hormones and impact on

pancreatic function ( GLP-1 and Gherelin)

• Increased insulin sensitivity: hepatic insulin

sensitivity improves within a few days post surgery

• Bile acids and changes in gut flora

15

Long Term Follow-up

• At risk of developing Vitamin and mineral

deficiencies:

- Iron deficiency anemia (155 of cases)

- Fat soluble Vitamin A, E K, D

- Vitamin B12, Folate, Iron

- Zinc, Copper, Selenium

• Impact on microvascular disease

• Post-prandial hypoglycaemia

Bariatric surgery and Diabetes

How effective is bariatric surgery?

Which procedure is better?

Are there any additional benefits?

Are the benefits solely related to weight loss?

• Is it cost effective?

• Is it safe?

Short term data impressive, but long term studies needed

Bypass is more effective in diabetes

Risk and benefit should be evaluated for individual patients

Other mechanisms identified

Reduction in all cause mortality

Yes

Obesity Pathway (NOF)

Bariatric

assessment,

Surgery and Post-

op follow-up

Centrally Funded

National commissioning

board

Weight

assessments and

Management

clinics- MDT

Commissioned

locally by CCG

Tier 2 - Primary Care with Community Interventions

Tier 1 – Public health intervention

No shortage of guidelines!! • Obesity: identification, assessment and management of overweight and obesity in children, young people and adults (2014)

NICE guideline CG189

• Exercise referral schemes to promote physical activity (2014) NICE guideline PH54

• Overweight and obesity in adults: lifestyle weight management (2014) NICE guideline PH53

• Behaviour change – individual approaches (2014) NICE guideline PH49

• Overweight and obese children and young people: lifestyle weight management services (2013) NICE guideline PH47

• BMI and waist circumference – black, Asian and minority ethnic groups (2013) NICE guideline PH46

• Physical activity: brief advice for adults in primary care (2013) NICE guideline PH44

• Obesity: working with local communities (2012) NICE guideline PH42

• Walking and cycling (2012) NICE guideline PH41

• Preventing type 2 diabetes: risk identification and interventions for individuals at high risk (2012) NICE guideline PH38

• Preventing type 2 diabetes: population and community interventions (2011) NICE guideline PH35

• Looked after children and young people (2010) NICE guideline PH28

• Weight management before, during and after pregnancy (2010) NICE guideline PH27

• Promoting physical activity for children and young people (2009) NICE guideline PH17

• Occupational therapy and physical activity interventions to promote the mental wellbeing of older people in primary care and

residential care (2008) NICE guideline PH16

• Promoting physical activity in the workplace (2008) NICE guideline PH13

• Maternal and child nutrition (2008) NICE guideline PH11

• Physical activity and the environment (2008) NICE guideline PH8

• Behaviour change: the principles for effective interventions (2007) NICE guideline PH6

• Obesity (2006) NICE guideline CG43

• Eating disorders (2004) NICE guideline CG9

Tier-1 Health Promotion

Wolverhampton

• Strategy

developed by

Public health

department

• Focus on health

promotion and

increasing

physical activity

Tier-2 services

• Lifestyle weight management programmes

• Lifestyle weight management programmes for overweight or

obese adults are multi-component programmes that aim to

reduce a person's energy intake and help them to be more

physically active by changing their behaviour.

• They may include weight management programmes, courses or

clubs that:

- accept adults through self-referral or referral from a health or

social care practitioner

- are provided by the public, private or voluntary sector

- are based in the community, workplaces, primary care or

online.

16

Tier-3 service

• Commissioned locally by CCG

• Consider referral if:

• surgery is being considered

• the underlying causes of being overweight or obese need to be

assessed

• the person has complex disease states or needs that cannot be

managed adequately in tier 2 conventional treatment has been

unsuccessful

• drug treatment is being considered for a person with a BMI of more

than 50 kg/m2

• specialist interventions (such as a very-low-calorie diet) may be

needed

Referral for Bariatric Surgery

Surgery &

Post- operative care

Bariatric unit UHNS

Tier 3 Weight assessment &

Management service

Post Bariatric surgery Follow-

up @ New Cross Hospital

(Specialist MDT)

Tier 4 Bariatric Assessment

@ New Cross Hospital

(Specialist MDT)

Discharge to Primary care

team/Tier 3 service

After 2 years

Satisfies criteria for surgery

Proposed Joint Tier 4 service in Wolverhampton

Includes: Assessment for bariatric

surgery, and Post –op follow-up

Commissioned: Centrally by the

National commissioning board (NCB)

Location: Diabetes centre (1-2

clinics per month)

Multi-disciplinary team:

Endocrinologist (Bariatric Physician)

Bariatric surgeon (From UHNS)

Dietician (New Cross)

Clinical Psychologist service

Post-op Follow-up: 6-8

appointments over 2 years

Discussion

Delegate’s Feedback

Session Name: Practical dietary advice in 10 minutes consultation

Questions

1 The content was at an appropriate level

2 The presenter appeared well informed about the subject

3 The presenter appeared enthusiastic about the subject

4 Audience participation and interaction was encouraged

5 There was effective use of audio visual aids/hand-outs

6 The presentation was given at the right pace

7 The presentation was of a reasonable length

8 Overall, this teaching session was of a high quality

Question Number

Nu

mb

er o

f R

esp

on

ses

Session Name: Obesity in Diabetes

Questions

1 The content was at an appropriate level

2 The presenter appeared well informed about the subject

3 The presenter appeared enthusiastic about the subject

4 Audience participation and interaction was encouraged

5 There was effective use of audio visual aids/hand-outs

6 The presentation was given at the right pace

7 The presentation was of a reasonable length

8 Overall, this teaching session was of a high quality

General Comments

Excellent, Primary care focused, very informative, enthusiastic speakers, interactive, pitched at right

level, want more such sessions.

Question Number

Nu

mb

er o

f R

esp

on

ses