I recently had the pleasure of speaking at a medical conference devoted to diabetes. Mine was the talk focused on the association between weight gain and diabetes. While there are a great many interesting discoveries occurring all the time in the field of diabetes, it remains the case that the disease itself marches on, increasingly affecting more and more people around the country and around the world.

What strikes me as the most stunning statistic is the one which describes the close relationship between obesity and type 2 diabetes mellitus. The relationship is truly stunning. Even modest weight gain leads to dramatic increases in the development of type 2 diabetes.

We think of a normal body mass index as being 18-25, but really when one goes from a healthy body mass index to a body mass index of 25, the risk of type 2 diabetes more than doubles. Then when the body mass index climbs even higher, hold onto your hats because the risk of diabetes climbs through the roof. What does this mean? How are we to treat this runaway epidemic?

While there are new drugs that come out every year and better insulin management regimens hold promise for steadier regulation of the blood sugar, these treatments do nothing to reverse the growth of the disease around the country among men and women, young and old and people of all races. What is needed is really a prevention solution or a solution aimed at the root cause.

The only real solution at this point in time that reverses and eliminates the disease is weight loss. Weight loss takes a person back down curve and below the threshold at which their body can no longer handle the blood sugar. So while the treatment must involve controlling the blood sugar, and must involve medications, attacking the root cause by losing weight, must become the top priority for most people with type 2 diabetes.

Medically supervised weight loss holds the best promise for producing sustained weight loss in moderately overweight people. Weight loss surgery provides the best results for people with type 2 diabetes with body mass index over 30. There may even be a role for gastric bypass surgery as a type of “metabolic surgery” as the treatment for type 2 diabetes in normal weight individuals.

In our practice, we developed a sense that all problems resolve after weight loss surgery. I bet if you polled the nurses, the nurse practitioners, office staff, physician assistants and the doctors at Western Bariatric Institute, you would find that through the experience of thousands of patient having undergone weight loss surgery, our clinical staff has come to believe that most health problems fade away and disappear.

This is not hubris; it is just the impression one gets from seeing people in follow up who gradually reduce the number of medications they are on and show up years later looking like an entirely new, and healthier, person. It is very common for people to have been on eight or twelve medications plus CPAP machines for their obstructive sleep apnea, only to return a year or two or three later not only looking like an entirely different person, but also having stopped all their medications and their CPAP.

This impression may be accurate for many people. However, there is some concern among the sleep specialists that obstructive sleep apnea may be a bit more complex disease than we have imagined. In the world of medically supervised weight loss and in bariatric surgery, we tend to view all diseases as being purely weight-related or obesity-related. But that of course is not entirely true.

Around 25% of people with obstructive sleep apnea are not obese. Their risk factors may be more of an anatomic one, having to do with the shape of their mouth and jaw and pharynx. So if a normal weight person has obstructive sleep apnea and then goes on to gain weight, you can imagine that the sleep apnea becomes more severe. Once the weight is lost through bariatric surgery or medically supervised weight loss, the structure of the face and throat has not really changed, so it stands to reason that some degree of obstructive sleep apnea would continue.

As weight loss doctors, we have not taken a highly sophisticated approach to the long-term follow up of obstructive sleep apnea. We probably thought that if the patient reported they were sleeping better and feeling better, and they had lost weight, then what would be the reason for more studies of their sleep?

Well, although there is not much long-term data out there on this question, it may be the case that people with obstructive sleep apnea do need long-term follow up and many of them do need ongoing CPAP. Most of the people who lost weight and kept it off do not need the same level of CPAP. For example, they do not need the pressure settings to be as high as 15 or 18 cm, but rather they can use CPAP more comfortably at 7 or 8 cm. But the big reason to continue with CPAP and to continue visiting the sleep doctors is that independent data shows that untreated sleep apnea carries its own risks of mortality and contributes to other health problems including hypertension and daytime sleepiness.

We see such dramatic resolution of patient’s health conditions like high blood pressure, diabetes and high cholesterol that we naturally lump in obstructive sleep apnea in the same categories and expect its complete and total resolution after weight loss surgery. The truth is probably a bit more complicated. Patients with obstructive sleep apnea undergo weight loss surgery, lose weight and markedly improve or resolve their sleep apnea, but many patients will benefit from ongoing CPAP at lower pressures to avoid the long-term risks and adverse effects of untreated obstructive sleep apnea.

One future study we may undertake at Western Bariatric Institute will be a long-term observation of obstructive sleep apnea over the course of ten years and beyond after their weight loss surgery. This would provide really meaningful data on the need for ongoing sleep studies and titration of CPAP.

With so many people around the world gaining weight, the Metabolic Syndrome has taken on greater importance as a cause of individual heart attacks and strokes, and as a public health problem.

The clinical definition of the metabolic syndrome is as follows:

Metabolic syndrome is diagnosed when a person has three or more of these conditions:
1. Elevated blood pressure. Blood pressure of 130/85 or higher is a component of metabolic syndrome. If only one of your two blood pressure numbers is over the limit, it’s still a risk factor for metabolic syndrome.
2. Elevated triglyceride level in the blood of 150 mg/dL or higher (or you are taking medicine to treat high triglycerides).
3. A lower than normal level of HDL cholesterol, less than 50 mg/dL for women and less than 40 mg/dL for men (or you’re on medicine to treat low HDL).
4. A large waistline. A waist measurement of 35 inches or more for women and 40 inches or more for men.
5. Higher than normal fasting blood sugar (glucose) (or you’re on medicine to treat high blood sugar). Fasting blood sugar of 126 mg/dL or higher is considered diabetes. A fasting blood sugar of 100 mg/dL or higher (prediabetes or diabetes) is a component of metabolic syndrome.
The more of these risk factors, the greater the chances of developing heart disease, diabetes, or stroke. Someone with metabolic syndrome is twice as likely to develop heart disease and five times as likely to develop diabetes as someone without metabolic syndrome.

The treatment for the metabolic syndrome is really based on two concepts: Historically, doctors tried to treat all of these diseases or problems independently. For example, we would treat diabetes with blood sugar lowering pills or insulin shots. We would then treat the high blood pressure with blood pressure lowering medication and lastly, we would prescribe lipid-lowering drugs for the hyperlipidemia. While this still remains a necessary part of the treatment, some of these drugs can have adverse effects also including weight gain. And since weight gain is such a powerful factor in the development of metabolic syndrome, it really makes sense to focus efforts on losing weight.

So the more modern and forward-thinking approach to the metabolic syndrome is to emphasize weight loss as a primary treatment. It is very common to see that people with full-blown metabolic syndrome resolve one, two or three diseases entirely as a result of a successfully medically supervised weight loss program. And while losing weight successfully and keeping it off for the long-term is definitely harder than just taking a pill to treat the high cholesterol level, the results are worth it.

Increasingly, I am seeing patients who were told by their primary doctors that they had a form of something called “Metabolic Syndrome”. In the past, many people were told they had a collection of independent problems including elevated blood pressure, elevated cholesterol, triglycerides or hyperlipidemia, adult onset diabetes, and were overweight. Increasingly, it is recognized that these health problems are all interrelated and are, in fact, part of a syndrome that is related to weight gain.

Amazingly, over 45 million adults in the United States have Metabolic Syndrome. It is responsible for a significant part of the reduced life expectancy we are seeing in the United States.

Heart attacks and strokes occur much earlier in life in people who have hyperlipidemia, hypertension or diabetes. When a person has all of these health problems together, then the risks of early heart attacks and strokes go up considerably.

The primary unifying factor in Metabolic Syndrome is weight gain. It appears that weight gain changes the cells in our body so that they become more resistant to circulating hormones, especially insulin and leptin. This leads to many unhealthy changes in the body that result in higher blood sugar levels and higher circulating lipids. Blood pressure also rises with weight gain. You can think of elevated blood pressure as the body’s way of pumping blood through all of those extra tissues.

Other Names for Metabolic Syndrome
Syndrome X
Insulin resistance syndrome
Dysmetabolic syndrome
Hypertriglyceridemic waist
Obesity syndrome

Doctors have struggled with how to define the Metabolic Syndrome, and in recent years have settled on a definition that requires that 3 out of 5 conditions be present (large waist, increased triglycerides, low HDL, increased blood pressure, and increased blood sugar). I will explore these in more detail in the next post on the Metabolic Syndrome.