Reflux, obesity, diabetes – recognising connections
At the 4th Helvetius Holding AG symposium, Dr. med. Jörg Zehetner, Professor (USC), dealt with the connection between reflux diseases, obesity and diabetes in a detailed lecture. In most cases, there are causal relationships between the different clinical pictures, which must also be taken into account in medical therapy. While a large proportion of overweight patients also complain of reflux, the links between obesity and diabetes are even more apparent. Both diseases are reciprocal consequences and triggers of the other disease. This also affects the professional approach to therapy. The full article on the lecture, a video stream of the lecture and further information can be found here.
In his highly acclaimed lecture at the 4th Helvetius Holding AG symposium at the Talent Campus Bodensee in Kreuzlingen, Dr. med. Jörg Zehetner, Professor (USC), revealed the connections between belching, obesity and diabetes. Based on the latest scientific findings and from his own medical clinic, Dr. med. Jörg Zehetner has developed a model from this that makes it clear how the connections are to be seen, which health restrictions and experiences result from this and which medical interventions are indicated.
Dr. med. Jörg Zehetner is considered THE specialist in visceral and obesity surgery in Switzerland. His comprehensive training and specialisation also make him a sought-after specialist abroad, for example as a supporting luminary to his professional colleagues in the United Arab Emirates. The extended training in the USA and his own scientific research have made Dr. med. Jörg Zehetner a proven specialist in his field. As the head of one of the largest private practices in Switzerland, he is the head of Swiss1Chirurgie and offers patients, their relatives and specialist colleagues a wide range of modern treatment methods and expanded options for therapy in the association of companies that operate under the umbrella of Helvetius Holding AG.
Individual clinical pictures, diagnoses and complaints are often closely linked and not infrequently form a kind of causal reaction chain in which one abnormality causes the other or is a consequence of previous illnesses. Therefore, it is important to look for and find the possible connections between different symptoms.
The clinics in the Helvetius Holding AG network
First, a few introductory words about Swiss1Chirurgie. The Swiss1Chirurgie is a visceral surgery clinic in which Dr. med. Steffen, Dr. med. Anita Scheiwiller, Dr. med. Metzger, Dr. med. Flückiger, Dr. med. Fringeli and Dr. med. Jörg Zehetner provide highly specialised medical services for patients. The Swiss1Chirurgie sites are in Bern, in Solothurn and in Valais, where patients are treated primarily in the specialties of bariatrics, reflux diseases, oesophageal and stomach cancer, colon, thyroid diseases, liver diseases and hernias.
The Centre for Bariatric Surgery ZfbC has established itself as a specialised pre- and post-operative care centre for bariatric surgery in conjunction with Swiss1Chirurgie. Here, patients are cared for holistically by the specialists before a necessary operation and after the surgical procedure.
The Gastroenterology Group Practice Bern GGP is the centre for endoscopic examinations and functional diagnostics. Chronic diseases of the gastrointestinal tract are also treated here.
An internal medicine clinic has established itself in the Bern PZBE clinic and offers services here not only in the field of internal medicine, but also in the special field of psychosomatics.
All specialist practices under the umbrella of Helvetius Holding AG are staffed with experienced medical specialists, work closely with each other and thus provide holistic and professional healthcare and necessary medical interventions in the overall concert of specialist medical services for the benefit of patients.
Reflux – Acid regurgitation
Everyone is certainly familiar with acid regurgitation, for example after a sumptuous and very fatty meal or after excessive alcohol consumption. An occasional belching with clearly defined temporary symptoms is not a problem at first.
Acid reflux only becomes a problem if it occurs chronically, i.e. more or less repeatedly, and if it is actually disturbing or even annoying to the body. Then we are talking about reflux. By reflux we mean that gastric juice rises from the stomach into the oesophagus. The stomach acid not only leads to the familiar unpleasant sour sensation, but in its chronic form can also lead to serious burns of the oesophagus and even to the development of oesophageal cancer.
The whole thing is referred to in medical parlance as Gastroesophageal Reflux Disease, or GERD for short, and is a serious disorder with disease value. This is a disease of the sphincter and/or diaphragm, but is favoured by other factors. One of the factors that cause gastric juice to be expelled into the oesophagus is a valve at the junction between the oesophagus and the stomach that does not function normally. Normally, this valve prevents acidic gastric juice from being pushed up into the oesophagus. If the function of this valve is disturbed, reflux can occur. This valve is located at the transition from the thorax to the abdominal cavity, which is practically formed by the diaphragm. The oesophagus runs through the diaphragm.
A normal function of the valve requires that this valve itself is organically completely without findings. Furthermore, a normal weight is a good prerequisite for the undisturbed functioning of the valve. If you are overweight, the increased pressure on the abdomen and diaphragm alone means that the function of the valve can be restricted. The mechanism works in such a way that the lungs pull in normal function, while an overfull abdomen pushes against it, so that the function of the valve is affected in only one direction, upwards. As a result, a defective or weak valve at the transition from the oesophagus to the stomach allows gastric juice to flow back.
It should be noted that the stomach does not only contain gastric acid. Pepsin, bile, pancreatic juice and of course food components in variously decomposed forms are found in the stomach. If the pumping function of the oesophagus is disturbed and the valve is not fully functional, all these components are pressed into the oesophagus, which is not only unpleasant but can also become really dangerous in the long term.
Treatment of reflux disease
Reflux can be treated conservatively in many cases. A change in lifestyle is just as helpful as a diet. Avoid spicy foods, coffee, greasy and fried foods, onions, garlic and tomatoes, fruits and fruit juices. Furthermore, dark chocolate with a high cocoa content, alcohol, carbonated drinks, large food portions and, in individual cases, certain medicines should be avoided.
Often, avoiding such factors already helps to reduce reflux. It is remarkable that smokers complain more about reflux, as smoking also has a loosening effect on the function of the valve described above. The same applies to other stimulants, which we have described here before with dark chocolate and alcohol.
When changing our lifestyle, the most important thing is that we don’t always eat the really big portions, but rather smaller portions more often. Opulent food right before going to bed should also be avoided. There are a number of medications that affect the function of the oesophago-gastric valve. A whole industry has grown up around acid reflux, which often sells its medicines without a prescription, virtually at discount stores.
The function of such medicines is usually only oriented towards the symptom, but not the cause. Such medicines do not stop the actual reflux, but reduce the production of stomach acid. They are nothing more than so-called acid blockers, but have no effect on the production of bile, pepsin or pancreatic juices and have no effect whatsoever on the defective or weakened valve at the junction between the oesophagus and the stomach. Therefore, the mode of action always remains limited and ultimately does not change the causes of reflux.
This means that only a part of the whole symptomatology, i.e. the stomach acid, is removed or reduced, but the problem as such remains.
Until ten years ago, only two procedures were actually established for reflux. On the one hand the Nissen fundoplication and on the other hand the Toupet fundoplication. While good oesophageal function is a prerequisite for the Nissen fundoplication, the Toupet fundoplication can also be used in cases of poor oesophageal function.
At Swiss1Chirurgie, we have been using the LINX system in the therapeutic treatment of reflux in Switzerland since 2015. In simple terms, this LINX system is a magnetic ring made up of individual parts on a kind of belt. This magnetic band closes the transition between the oesophagus and the stomach, but opens under a certain pressure so that, on the one hand, normal food intake into the stomach but, on the other hand, vomiting remains possible. However, the relatively light pressure of reflux is stopped so that no gastric juices can push up into the oesophagus.
Another advantage of this system is that a normal diet is possible postoperatively and air can also be expelled, which is not to be expected with the older procedures. Furthermore, when using the LINX system, there is significantly less of the feeling of fullness known from the other methods and no increased flatulence.
As part of a medical study, we have also been using RefluxStopTM in Swiss1Chirurgie since 2020. This involves fixing the stomach to the oesophagus in order to maintain the lower sphincter in the abdomen. A small silicone ball holds the prepared area in position, allowing an almost natural situation to be restored. In all such operations, the existing diaphragmatic hernia must also be treated surgically.
Jörg Zehetner, MD, is the only surgeon in Switzerland to offer his patients all of the procedures listed here. He always makes his decisions individually and on the basis of the situation found in the individual case. The important starting point for the decision is the function of the oesophagus. With normal oesophageal function, the LINX system and the Nissen fundoplication can be used well. In cases of moderately to severely reduced oesophageal function, the Toupet fundoplication, the RefluxStopTM system or, in exceptional cases, a Dor fundoplication are more likely to be used. In the clear majority of cases, the proven LINX system can be used.
Problems due to reflux
In addition to the actually already unpleasant appearance of reflux due to the repeated acid regurgitation, reflux also hides clearly dangerous constellations. The constant acid attack on the inner oesophagus often leads to infectious processes. These infections can lead to changes in the oesophageal mucosa. As a result, the mucous membrane changes in such a way that at some point it also shows tissue changes that are visually very reminiscent of stomach tissue. Such tissue then also has the potential to develop cancer. So oesophageal cancer cannot be ruled out and is always on the cards as it progresses. This is not something to be taken lightly. Adequate treatment is urgently needed.
The statistical evaluation shows that oesophageal cancers have increased significantly since 1975. Here, an increase of 700 percent can be observed in the last 30 to 40 years. For men, it is the cancer that has increased the most worldwide.
If we look at the correlations between reflux, obesity and diabetes in the following, some correlations become clear even in the statistical analysis.
Connection between overweight and reflux
In general, it can already be stated here that the probability of suffering from reflux increases significantly with the presence of severe overweight. For example, the body mass index BMI was compared and correlated with acid exposure. A BMI of 30 or more is referred to as obesity, which is expressed in various classifications. A BMI of 35 or more can be considered pathologically overweight.
Being morbidly overweight is not just a matter of external symptoms such as a colloquial “beer belly” and the inevitable fat deposits. With a BMI over 40, we already speak of a metabolic syndrome, which can be defined by diabetes, high blood pressure, elevated cholesterol levels, fatty liver, high blood fat levels as well as arthritis and gout.
These symptoms also increase the risk factors for cardiovascular disease, stroke, sleep apnoea, cancer, abdominal wall hernias and reflux disease. The risk of oesophageal cancer then increases again with the reflux diseases. This observation already shows that the connections and transitions between reflux, obesity and diabetes must be considered causally.
When assessing the development of obesity, the tendency is that obesity is increasingly observed worldwide, especially in the developed industrialised countries but even in the developing countries. And this is happening at a breathtaking rate of progression in close connection with a food oversupply with virtually unlimited availability of food.
As body weight increases, it is not only the outwardly visible fat deposits that occur. The liver is always particularly affected, which develops from a healthy liver to a fatty liver and even cirrhosis with increasing obesity. On the topic of fatty liver, we have provided a separate contribution and lecture by Dr. med. Michaela Neagu from the Gastroenterological Group Practice Bern GGP. A contribution and lecture by Dr. Hardy Walle on liver fasting is also available.
If you look at the phenomena of obesity with a close look at the metabolic processes in the body, then a concrete connection to diabetes can also be established. If you bring together the statistical data on obesity and diabetes, the interaction becomes more than clear.
It should also be clearly assessed that a fatty liver is often the cause of diabetes, but diabetes can also be the cause of a fatty liver. Here, a kind of vicious circle closes that can only be broken by appropriate medical interventions.
The function of the pancreas is clearly related to diabetes. The pancreas lies anatomically behind the stomach and fulfils two essential functions. On the one hand, it supports the digestive function, on the other hand, it produces insulin, which is required for the metabolisation of sugar, more precisely glucose. Insulin affects the sugar balance in the liver, fatty tissue and muscles. In overweight people, this metabolism is disturbed. The fatty cells show resistance to insulin uptake, which significantly disturbs the metabolisation of glucose. As a result, blood glucose levels deviate from normal. Progressive diabetes mellitus develops.
Diabetes mellitus is divided into two types. Type 1 with subgroups 1a and 1b. Diabetes mellitus type 1a is mostly observed as a congenital form in childhood and manifests after viral infections.
Type 1b is seen up to about 35 years of age and is associated with islet cell antibodies and autoimmune system disorders.
Diabetes mellitus type 2 used to be called adult-onset diabetes and occurs mainly in overweight people with a disturbed metabolism. In the meantime, we are increasingly observing diabetes mellitus type 2 also in children and adolescents who are very overweight. Type 2 diabetes mellitus is even more common in children and adolescents than type 1.
The problem with diabetes is not only the damaged metabolism. The blood vessels, liver and heart function are also affected. Arteriosclerosis often occurs, leading to narrowing or blockage of blood vessels. The risk of heart attack increases fivefold and the risk of stroke triples.
The course of diabetes is a progressive process that initially appears to be easily manageable, but as it progresses, it requires more and more specialist medical intervention. In the context of diabetes and obesity, it has been shown that surgically treated obesity patients often experience a better and faster improvement in diabetes than those with only drug treatment. Of course, if the obesity surgery is done after many years of an existing diabetes, the likelihood that the diabetes will also improve again is reduced.
Accordingly, it is important not to put off obesity surgery for a long time in patients with a BMI of 40 or more when diabetes is just beginning. The sooner action is taken, the greater the effects both on body weight and on preventing the progression of diabetes.
It is important to understand that obesity is a disease and must be treated as such. Different studies clearly show that in cases of severe obesity, obesity surgery is always the better solution compared to other medical interventions, also with an effect on diabetes.
Effects of metabolic surgery
If all experiences from metabolic surgery are considered in the context of reflux, obesity and diabetes mellitus, the following effects can be demonstrated in patients with a BMI over 40:
- generally improved quality of life
- greater improvement in blood glucose levels
- Reduced consumption of diabetes medication
- fewer vascular diseases
- fewer strokes
- reduced cancer risk
- Less overall mortality
- Higher weight loss than with conservative therapies
Only two to three percent of patients with a BMI over 40 achieve significant weight reduction in conservative therapies. Only patients with a BMI between 30 and 35 often show good results with conservative therapies.
View bariatric surgery as a whole
Bariatric surgery presents itself as a triad that does not stop at one surgical procedure. The operation alone does not solve the problem. Important is the interaction of
- Lifestyle change
- Change in dietary habits and
- surgical intervention with good pre- and aftercare
Modern surgical procedures have long since bid farewell to the gastric banding that has been used for many years. In the USA and Germany, the preferred outcome of the operation is the formation of a tube stomach. This affects up to 60 percent of patients. In Switzerland, the current level here is around 30 percent. Partial removal of the stomach also achieves hormonal effects, as the passage of food through the stomach is accelerated and the small intestine is much more likely to be activated with corresponding hormone release.
Another option is gastric bypass, which is performed laparoscopically. This technique is preferably used in patients with pre-existing diabetes or pre-existing reflux. With a share of about 70 per cent, this is the most frequently performed bariatric operation in Switzerland. A small gastric pouch is formed and connected directly to the small intestine.
You can watch the entire lecture in its original wording, with additional questions and answers as well as interesting statistics here in the stream.
In addition, we recommend further articles and videos that were produced as part of the Helvetius Holding AG symposia.