Bariatric Surgery Dramatically Outperforms Standard Treatment for Type 2 Diabetes

Patient Events Calendar

Volume 1, Issue 3 Christine L. Frissora, MD,

FACP, FACG Medical Editor Associate Attending Physician

Pamela E. Kline Editor Patient Navigator Georgia A. Giannopoulos, RD, CDN, CNSC Contributor Senior Dietitian

Inside this issue:

Bariatric Surgery Dramatically Outperforms Standard Treatment

for Type 2 Diabetes Message from the Medical Editor

Make No Bones About It: Inflammatory Bowel Disease &

Bone Health Nutrition Corner: Protect Your Body from Vitamin B12 Deficiency Colonoscopy Sweepstakes Update

THE #1 HOSPITAL IN NEW YORK. 12 YEARS RUNNING.

Bariatric Surgery Dramatically

Outperforms Standard Treatment

for Type 2 Diabetes

NEJM Study Shows Two-Year Results of a Randomized Trial

Comparing Bariatric Surgery to Traditional Medical Treatment

Authors Find Effects of Bariatric Surgery on Type 2 Diabetes

Are Independent of Weight Loss

In the first published study of its kind, researchers from the Catholic University/ Policlinico Gemelli in Rome, Italy, and NewYork-Presbyterian/Weill Cornell Medical Center found that bariatric surgery dramatically outperforms standard medical treatment of severe type 2 diabetes.

The study’s authors report that most bariatric surgery patients were able to discontinue all diabetes medications and maintain disease remission for the two-year study period, while none of those randomly assigned to receive standard medical treatment did.

“Although bariatric surgery was initially conceived as a treatment for weight loss, it is now clear that surgery is an excellent approach for the treatment of diabetes and metabolic disease,” says senior author Dr. Francesco Rubino, chief of Gastro-intestinal Metabolic Surgery and director of the Metabolic and Diabetes Surgery Center at NewYork-Presbyterian/Weill Cornell and associate professor of surgery at Weill Cornell Medical College.

(continues on page 2) Alfons Pomp, MD, FACS, FRCSC Francesco Rubino, MD

Message from the

Medical Editor

Christine L. Frissora, MD, FACP, FACG

(Continued from cover: Bariatric Surgery Dramatically Outperforms Standard Treatment for Type 2 Diabetes)

It is particularly challenging to treat obese patients who have type 2 diabetes, because insulin therapy and other hypoglycemic medications often cause additional weight gain. In this study, most surgery patients experienced improvements in blood sugar levels, decreased total cholesterol and triglyc-erides, and improved HDL-cholesterol concentrations. This suggests that bariatric surgery for the treatment of diabetes may reduce a patient’s cardiovascular risk.

“The unique ability of surgery to improve blood sugar levels and cholesterol levels as well as reduce weight makes it an ideal approach for obese patients with type 2 diabetes,” says lead author Dr. Geltrude Mingrone, chief of the Division of Obesity and Metabolic Diseases and professor of medicine at Catholic University in Rome. The current study is part of a broader, ongoing research collaboration between the Catholic University of Rome and Weill Cornell Medical College in New York. In March 2007, the Catholic University hosted the “Diabetes Surgery Summit” where a group of leading inter-national scholars first recommended consideration of gastrointestinal surgery to intentionally treat type 2 diabetes (“diabetes surgery”). In the same year, NewYork-Presbyterian/Weill Cornell

Medical Center established the Diabetes Surgery Center, the first academic program of its kind, as an effort to model clinical practice, education and research around the specific aim of surgically treating diabetes. The Center has since organized the first two editions of the “World Congress on Interventional Therapies for Type 2 Diabetes,” which raised global awareness of diabetes surgery.

An estimated 8.3 percent of the global population has type 2 diabetes, according to World Health Organization 2010 statistics, and that number is projected to increase to 9.9 percent by 2030. As many as 23 percent of patients with morbid obesity also have type 2 diabetes. The costs associated with diabetes pose a huge burden on health care systems. Previous studies have suggested that bariatric surgery may be a cost-effective approach for obese patients with diabetes. In spite of the potential gains, however, access to surgery for those eligible is very limited, and barriers are substantial. Less than 2 percent of eligible patients have access to bariatric/metabolic surgery in the U.S., and the figure is even lower in the rest of the world. The authors hope their study will help change the way bariatric surgery is perceived and that based on these findings, physicians will consider surgery in the treatment of diabetes.

The research was funded by the Catholic University of Rome, Italy.

As patients take certain courses of antibiotics, the good and pathogenic bacteria are often killed simultaneously. As these pathogens, such as Clostridium difficle, grow back at a faster rate without a balance of good bacteria, the overabundance of toxins can cause fever, diarrhea and a high white blood count. Some patients that contract C. diff will recover with little issue, while others can become life-threateningly ill. Those at high risk include the immunocompromised and elderly, as well as hospitalized patients.

C. diff is typically identified by a stool

sample and can be treated with Flagyl (Metronidazole) or second line Vancomycin.

There are several strategies that can be implemented to help reduce your risk of developing C. diff. Antibiotics should only be utilized when absolutely necessary. Taking a probiotic, such as

Saccharomyces boulardii, has been

shown to decrease the development of antibiotic associated C. diff. Talk to your physician about your antibiotic usage and if probiotics are a viable option (Immunocompromised patients can develop fungi or bacteria in the blood after taking probiotics). If you come in contact with a patient with

C. diff, carefully wash your hands

with soap and water. Do not leave toothbrushes exposed in the bathroom if someone in the house has C. diff. The brush can become contaminated with spores when the toilet flushes. If possible, patients with C. diff should attempt to use their own bathroom.

N

Why are people with IBD at increased risk of osteoporosis?

• Problems absorbing calcium and vitamin D

Health conditions affecting the gastrointestinal tract can make it difficult to absorb enough nutrients. This is especially true if you have Crohn’s disease, which commonly affects the small intestine where calcium and vitamin D are absorbed. If you have inflammation or have had surgery to bypass or remove parts of your small intestine then you may be at increased risk of calcium and vitamin D deficiencies. If you have ulcerative colitis, which primarily occurs in the large intestine, calcium and vitamin D absorption may be less of a problem. • Elevated cytokine levels

Again, this is more likely an issue if you have Crohn’s disease. Cytokines are proteins that increase inflammation in your body and also appear to slow the rate at which old bone is removed and new bone is formed.

• Corticosteroid drugs

If you take corticosteroid drugs (like prednisone) to treat IBD, you are at an increased risk of osteoporosis because corticosteroids interfere with calcium absorption. They also

cause bone breakdown while preventing new bone from being formed. An estimated 30% to 50% of people who take corticosteroids for an extended period of time develop osteoporosis.

• Lactose intolerance or sensitivity

Some people with IBD can’t tolerate dairy products because of lactose intolerance or sensitivity. This means that they cannot break down lactose, the main carbohydrate in milk. Since milk and other dairy products are good sources of calcium, this can contribute to a deficiency. Note that IBD does not increase your risk for lactose intolerance.

Why is calcium important?

Bone may seem lifeless and inert, but it’s actually living tissue. Your body is constantly breaking down old bone and creating new bone. Without adequate calcium intake and absorption, your body will take calcium from your bones, decreasing their mass and leading to osteoporosis. Since our bodies don’t produce calcium, it’s important to get enough from calcium-rich foods and/or supplements. Calcium is also critical for healthy teeth, proper nerve and muscle function, blood clotting, and hormone secretion.

What about vitamin D?

It’s also important to maintain adequate vitamin D levels. Vitamin D plays a key role in calcium absorption. A study of people with IBD found that those with low bone density also had a significantly higher rate of vitamin D deficiency, and those who increased their vitamin D levels also increased their bone density. Vitamin D may also play a role in regulating and strengthening your immune system and protecting against a number of chronic autoimmune diseases, including IBD.

Make No Bones About It:

Inflammatory Bowel Disease & Bone Health

What can I eat to help prevent and treat osteoporosis?

Research within the past decade has shown that increasing calcium and vitamin D intake can improve bone health in patients with IBD.

• Calcium

To increase your calcium intake, try low-fat dairy products or calcium-fortified foods and beverages, including soy, almond, and rice milk, as well as calcium-fortified juices and tofu made with calcium sulfate. If you have lactose intolerance, try aged cheeses and yogurt, which are usually well tolerated. Other good sources of calcium are canned sardines and salmon with bones, as well as green, leafy vegetables. Check out the recipes for Banana Oatmeal Parfait and Broccoli, Cannellini Bean, and Cheddar Soup. Both are great ways to boost your calcium. • Vitamin D

Our bodies make vitamin D when our skin is directly exposed to the sun, and most people get at least some of the vitamin D they need this way. However, it may be difficult to get enough sun exposure if you have dark-colored skin, always wear sunscreen, are age 70 or older, or live in the northern part of the United States where the sun is not strong enough during the winter months. If that is the case, you can increase your intake by eating foods that contain significant amounts of

vitamin D, such as fortified dairy products and orange juice; fatty fish like herring, mackerel, salmon, sardines, and tuna; and shitake mushrooms.

What else can I do to decrease my osteoporosis risk?

There are a number of other risk factors for developing osteoporosis, some of which you can’t control (frame size, family history, being postmenopausal, and age) and some of which you can.

• If you smoke, quit.

• If you drink alcohol, do so in moderation.

• If you are sedentary, increase your physical activity. • If you take medication that is associated with bone loss,

talk to your doctor about other options. The bottom line

When you have IBD, it’s important to be an active participant in maintaining your bone health. Be sure to discuss any concerns with your physician or nutritionist, and remember that early intervention can help you reverse bone loss before osteoporosis becomes a problem.

Make No Bones About It:

Inflammatory Bowel Disease & Bone Health

Colleen D. Webb, MS, RD, CDN and Ellen J. Scherl, MD, AGAF, FACG, FACP, FASGE

Dr. Ellen Scherl was recently honored with the Women of Distinction in

Medicine award at the annual Crohn’s and Colitis Foundation of America

(CCFA) Women of Distinction luncheon.

Nutrition Corner:

Protect Your Body from

Vitamin B12 Deficiency

Georgia A. Giannopoulos, RD, CDN, CNSC

Vitamin B12 is an essential vitamin that has various roles throughout the body, including developing and maintaining a healthy nervous system, forming red blood cells, and producing DNA. Its absorption involves a specialized series of steps throughout the gastrointestinal tract.

Vitamin B12 deficiency is serious; if left untreated, it may lead to irreversible nerve damage. Signs and symptoms of deficiency include, but are not limited to weakness, paleness, numbing or tingling in fingers or toes, poor memory, loss of balance, and dementia.

Vitamin B12 is naturally found in many animal foods, including fish, meat, milk, milk products, and eggs. Most plant foods do not have vitamin B12, but some packaged foods, such as breakfast cereals, are fortified with the vitamin. To find out if a food is fortified with vitamin B12, check the Nutrition

Facts label.

The Recommended Dietary Allowance (RDA) of vitamin B12 is 2.4 micrograms per day (mcg/d)

for adults, 2.6 mcg/d for pregnancy and 2.8 mcg/d for lactation. While studies show that most

people in the United States meet the RDAs, those who eat mostly plant-based foods (vegetarians, vegans, and their breastfed infants) are at risk for deficiency and may need to consume fortified foods and/or supplements to meet their needs.

Even when eating enough vitamin B12 to meet one’s needs, it is possible to develop a deficiency due to malabsorption. Individuals with digestive diseases and/or a history of gastro-intestinal surgeries are at increased risk of deficiency. Some older adults have difficulty absorbing the vitamin B12 naturally found in animal foods and need to consume fortified foods and/or supplements to prevent deficiency. Those with pernicious anemia may rely on vitamin B12 injections to meet their needs. Certain medications, including aspirin, antacids, and proton-pump inhibitors, may interfere with vitamin B12 absorption and increase one’s risk of developing a deficiency. Taking large doses of folic acid can mask a vitamin B12 deficiency and may lead to irreversible nerve damage if the vitamin B12 deficiency goes undetected and untreated. Tell your healthcare provider about all medications you are taking, including over-the-counter supplements, to prevent this.

If you are concerned that you or a loved one may have vitamin B12 deficiency, speak with your healthcare provider to get tested. If needed, vitamin B12 supplements are available in pill, sublingual, and injectable forms; your healthcare provider can discuss the options that best fit your needs.

A Registered Dietitian (RD) can help you meet your individu-alized nutrition needs; if you would like to meet with a RD, contact NewYork-Presbyterian Hospital’s Nutrition Wellness Center at 212.746.0838 to schedule an appointment. For more information about our Department of Food & Nutrition, visit us at nyp.org/nutrition.

Patient Events Calendar

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For more information please contact 877-902-2232 (877-902-CADC) nyp.org/cadc

Earlier this year CBS and NewYork-Presbyterian Hospital joined forces to increase awareness for colon cancer and promote early screening to help save lives by launching the second CBS Cares Colonoscopy Sweepstakes.

Anthony Matuszky, the winner of the 2012 CBS Cares Colonoscopy Sweepstakes, met with Paul Miskovitz, M.D. of NewYork-Presbyterian Hospital/Weill Cornell Medical Center for an examination the day before he claims his grand prize - a colonoscopy performed by Dr. Miskovitz, a leading gastroenterologist and colon cancer expert. Matuszky, who was randomly selected from nearly 70,000 other sweepstakes entrants, hails from Latrobe, Pennsylvania and is a 26-year-veteran of the Westmoreland County Department of Public Safety where he works as a 911 Supervisor. As part of the grand prize, Matuszky won a three night trip for two to New York City. Matuszky was accompanied by his son, Joshua.

COLONOSCOPY SWEEPSTAKES UPDATE

Visit http://nyp.org/cadc/information-for-patients/events for more information about patient events.

CADC Patient Seminar Series

Location: 1305 York Avenue, 2nd Floor

Conference Room C Time: 5:30 – 6:30 pm No RSVP required Tuesday, October 2, 2012 Tuesday, November 13, 2012 Tuesday, December 4, 2012

CADC Outpatient Ostomy Support Group

Location: 1305 York Avenue, 2nd Floor

Conference Room C Time: 6:00 – 7:00 pm No RSVP required Tuesday, September 11, 2012 Tuesday, October 9, 2012 Tuesday, November 13, 2012 Tuesday, December 11, 2012

Inflammatory Bowel Disorder Support Group

Location: Jill Roberts Center for IBD;

1315 York Avenue, Mezzanine

Time: 5:30 – 6:30 pm

No RSVP required

Thursday, September 6, 2012

Contact 212-746-5077 for future dates.

Hepatitis C Support Group

Location: 1305 York Avenue, 2nd Floor,

Myra Mahon Patient Resource Center

Time: 4:00 – 5:00 pm No RSVP Required Wednesday, September 5, 2012 Wednesday, October 3, 2012 Wednesday, November 7, 2012 Wednesday, December 5, 2012