National multispecialty centers needed to combat metabolic diseases
LAS VEGAS — Multispecialty metabolic centers, based on the cancer center model, should be established at the national level to address metabolic syndrome-related diseases, particularly with bariatric surgery, according to a keynote speaker at ObesityWeek.
Bariatric surgery provides benefits for those with obesity, diabetes, hypertension, dyslipidemia, nonalcoholic steatohepatitis, heart disease, polycystic ovary syndrome and even cancer, according to Walter J. Pories, MD, FACS, professor and founding chair of the department of surgery at the Brody School of Medicine at East Carolina University in Greenville, North Carolina. Metabolic centers would support basic research into the commonalities among these diseases, provide interventions, and support care before and after bariatric procedures.
“My proposal is a national network of metabolic centers,” Pories said during his presentation. “Bariatric surgery reverses the metabolic syndrome with full, durable remission of diabetes, obesity and related diseases, with sharp reductions in complications and mortality, but the selection and preparation for surgery are complex. The early and late complications are challenging and require expertise, and we need to address this challenge ... with a nationwide network of metabolic centers.”
Barriers to care
Treating metabolic diseases begins with nonsurgical therapies, such as weight loss and glucose-lowering drugs. Unfortunately, these are most often ineffective, Pories said.
Surgery can be a better option; however, health insurance companies erect barriers to these interventions.
For example, patients must meet stringent BMI thresholds for coverage. According to Pories, using BMI can be ineffective for assessing adiposity and can also discriminate against patients of certain ethnicities. Furthermore, patients do not necessarily have to have obesity or overweight to benefit from bariatric surgery, he said.
Beyond BMI, other hurdles are a 12-month dietary trial and mental health provider and nutritionist approval.
“While I think that can be very helpful in many cases, just remember that it’s not required for any other kind of surgery,” Pories said, while also combatting the notion that these procedures are more dangerous than other surgeries. “The real problem is because of all of these measures by carriers, less than 1% of those who would benefit from surgery have undergone the procedures.”
Dealing with negative effects
Metabolic centers would also provide postoperative care and address any complications of bariatric procedures, such as anastomotic leaks, internal hernias, episodic hypoglycemia, malnutrition and mental health issues, Pories said.
Pories emphasized that these conditions are not always immediately apparent.
For anastomotic leaks and internal hernias, health care providers should pay attention to complaints of pain in the abdomen.
Episodic hypoglycemia, which can “sneak up,” should be tested for with a 24-hour glucose monitor. If present, Pories first recommends ensuring proper vitamin and mineral intake. Diets low in carbohydrates and medications, such as diazoxide, acarbose and GLP-1 receptor agonists, might also be effective.
Patients presenting with neuropathy, pain, weakness and headaches may have micronutrient malnutrition, which often has a “confusing presentation,” Pories said. He recommends that health care providers err on the side of caution and treat these patients for malnutrition.
“If your patient comes in having had metabolic surgery, and you don’t know what’s going on ... the first thing to ask is ‘are you taking your vitamins and minerals?’ and I can assure you, almost always the answer will be no,” Pories said.
Pories also outlined potential post-surgery problems, such as emotional distress, complications of mental illness, and alcohol and substance abuse.
“The bottom line is bariatric surgery needs careful pre- and postoperative psychiatric assessment so they can fully cope with challenges,” Pories said, even if these assessments should not necessarily be used to qualify for these surgeries.
Blueprint for metabolic centers
“The only way this is going to work is if all these problems [are] faced together,” Pories said. “We need metabolic centers for treating patients, for education and for research.”
Pories argued that there is already a blueprint for these types of centers.
“The challenge requires multiple disciplinary resources from every possible specialty, and we need it now,” Pories said. “You might say that’s overwhelming and impossible, but not at all because the country is filled with successful models. We just call them cancer centers. That’s exactly what happens at cancer centers. Multiple disciplines working together. One-stop shopping. Much lower expense and much better outcomes.” – by Phil Neuffer
Pories W. We can do better! A call for interdisciplinary diabetes centers. Presented at: ObesityWeek 2019; Nov. 3-7, 2019; Las Vegas.
Disclosure: Pories reports no relevant financial disclosures.