| Issue | january-february , 2021 | The Health
15
Dangers of diabetes
Three laparoscopic ports inserted for bariatric surgery .
encounter bile acids and other digestive secretions that facilitate the absorption of nutrients . Glucose absorption is dampened in the alimentary limb and rises in the common limb secondary to altered bile acid flow .
Intestinal glucose is consumed by the apical sodium glucose co-transporter 1 ( SGLT1 ), which absorbs sodium and glucose together from the intestinal lumen . Sodium is derived from bile and other digestive fluids .
There is a transition in bile acid trafficking not being exposed to these digestive fluids without the involvement of sodium being co-transported with glucose . In fact , despite SGLT1 expression or function being preserved , bile acids exclusion itself reduces the intestinal sodium-glucose absorption .
Bile acids attenuate the intestinal trafficking of sodium by decreasing the sodium content of the intestine . The inhibition of SGLT1 results in a reduction in postprandial glucose concentrations and improvements in sugar control .
In addition to this , post-RYGB surgery , there is increase in gut mucosa cells caused by sensitivity of the mucosa to undigested nutrients . There is emerging evidence that this causes a reprogramming of glucose metabolism and raises the metabolic rate to satisfy higher energy demand , improving carbohydrate intake .
This improves intestinal glucose utilization , secondary to improved intestinal expression of GLUT1 after RYGB , regardless of weight loss or increases in insulin secretion and sensitivity .
After metabolic surgery , all these outcomes put the gut within the group of organs / peripheral tissues responsible for increasing glucose disposal . With regard to VSG glucose absorption in the small intestine is reduced since part of the stomach is removed . Therefore , leptin- and ghrelin-expressing cells are reduced .
Ghrelin raises appetite , decreases gastric emptying , controls energy intake and reduces glucose-induced insulin release and sensitivity . Gastric leptin is generated in the stomach and secreted to the small intestine , where it is assumed to stimulate glucose absorption by enhancing the glucose transporter-2 ( GLUT2 ) in the jejunum . It has been postulated that after VSG , ghrelin and leptin depletion is one of the main factors contributing to the improvement in glucose homeostasis .
Bariatric surgery performed laparoscopically by lead surgeon Dr Nik Ritza .
Glucose screening
The release of glucose from the small intestine is activated by two main glucose producing enzymes : glucose-6-phosphatase ( Glc6Pase ) and phosphoenolpyruvate carboxykinase ( PEPCK ).
Newly synthesized glucose is detected by the hepato-portal or liver glucose sensing mechanism , modulating the production of liver glucose . This involves glucose transporter ( GLUT-2 ) and is potentiated by GLP-1 . The liver glucose-appearance sensing suppresses liver glucose production but increases peripheral tissue glucose uptake .
In addition , liver glucose sensing causes a decrease in food consumption . These metabolic effects created by the liver nervous system seem to connect to the central control of hormones ie the hypothalamus . Following RYGB surgery , the PEPCK and Glc6Pase enzymes in the intestines have improved expression and activities . This results in increased intestinal glucose release to the liver that in turn suppresses the liver production of glucose and food intake .
Increased intestinal glucose production and activation of the liver glucose sensor through the GLUT-2-dependent pathway is postulated for which RYGB increases insulin sensitivity and decreases the consumption of food .
Fat tissue
Excess of fat or adipose tissue , specifically its central deposition of the abdomen , decreases insulin sensitivity and beta-cell function . It is an independent risk factor for Type 2 diabetes mellitus . Fat is a hormonal organ that releases various hormones , cytokines and molecules that not only affect body weight , food consumption and energy balance , but also controls glucose and lipid metabolism . In the case of cytokines , excess fat deposition is characterized by long term low-grade inflammation implicated in T2DM .
As mentioned above , major weight loss occurs after metabolic surgery . It makes sense to lose both fat mass and fat-free mass as seen in traditional diets . However , following surgical-induced weight loss , the body ’ s structure improves with a lowered body fat content as well as a modest decline in fat-free mass .
In comparison , not only is there a net body fat reduction , but fat surrounding organs and muscles are also reduced . This metabolically advantageous redistribution of fat further adds to the increase in
Laparoscopic surgery is minimally invasive with little scaring post procedure .
The fat tissue itself undergoes a variety of changes in secretory profile , structure , glucose , and lipid metabolism . Both findings confirm the function of adipose tissue as one of the contributors to glycemic recovery observed after metabolic surgery .”
An estimated 463 million people have diabetes worldwide . Type 2 diabetes constitutes 90 per cent of the cases in 2019 with similar rates between male and female . It is likely to continue to rise . Malaysia is no exception with a significant increase in Type 2 diabetes among adults aged 30 years . This should not be ignored as diabetes mellitus is closely related to small and large vessel complications , as well as premature mortality .
If untreated , one is susceptible to acute complications including diabetic ketoacidosis , hyperosmolar hyperglycemic state and even death . Small vessel ( affecting the eye , kidneys and nerves ) and large vessel complications ( angina , heart attack and stroke ) has been seen in patients with long-standing uncontrolled diabetes .
Cost of diabetes
Diabetics require ongoing treatment to manage and keep their condition stable for the long run . This in turn increases healthcare expenditure .
According to the Pharmaceutical Services Division of the Ministry of Health ( MoH ) Malaysia , the cost of a diabetic patient was estimated to be RM466.20 over six months in 2014 . That amount is bound to be higher today !
However , the figure excludes treatment for long term complications such as stroke , heart disease and kidney disease . Kidney dialysis costs between RM150 and RM300 per session , while a heart transplant may cost up to RM100,000 .
Diabetes certainly burns a hole in one ’ s pocket !
glucose metabolism shown following surgical-induced weight loss : there is an improvement in liver insulin sensitivity owing to reduced fat in surrounding organs , decreased muscle mass loss that improved muscle glucose absorption .
The fat tissue itself undergoes a variety of changes in secretory profile , structure , glucose , and lipid metabolism . Both findings confirm the function of adipose tissue as one of the contributors to glycemic recovery observed after metabolic surgery .
Conclusion
Bariatric / metabolic surgery is effective and has a relatively low risk , leading to its acceptance within the algorithm in managing diabetes mellitus . The question of whether it will become a mainstream treatment that most diabetic patients would accept is still at stake .
The advantages of surgery are more perceptible if being done during the early stages rather than waiting for irreversible diabetic complications . Therefore , an honest discussion with the endocrinologist and bariatric / metabolic surgeon is essential for optimum treatment and management of obesity and / or diabetes mellitus . — The Health
Dr Nik Ritza is Professor in Upper Gastrointestinal Surgery , Consultant General Surgeon , Department of Surgery , UKM Medical Centre ( UKMMC ), Dr Hardip is Lecturer and Specialist Otorhinolaryngologist , Head and Neck Surgery , Department of Otorhinolaryngology , Head and Neck Surgery , UKMMC and Dr Mardiana is House Officer , Department of Surgery , UKMMC .