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Laursen TL, Hagemann CA, Wei C, Kazankov K, Thomsen KL, Knop FK, Grønbæk H. Bariatric surgery in patients with non-alcoholic fatty liver disease - from pathophysiology to clinical effects. World J Hepatol 2019; 11:138-149. [PMID: 30820265 PMCID: PMC6393715 DOI: 10.4254/wjh.v11.i2.138] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/01/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is increasingly recognized as a significant liver disease, and it covers the disease spectrum from simple steatosis with a risk of development of non-alcoholic steatohepatitis (NASH) to fibrosis, subsequent cirrhosis, end-stage liver failure, and liver cancer with a potential need for liver transplantation. NAFLD and NASH are closely related to obesity, metabolic syndrome, and type 2 diabetes (T2D). The role of gut hormones, especially glucagon-like peptide 1 (GLP-1), is important in NAFLD. Bariatric surgery has the potential for inducing great weight loss and may improve the symptoms of metabolic syndrome and T2D. Recent data demonstrated significant effects of bariatric surgery on GLP-1 and other gut hormones and important lipid metabolic and inflammatory abnormalities in the pathophysiology of NAFLD. Therefore, bariatric surgery may reverse the pathological liver changes in NAFLD and NASH patients. In the present review, we describe NAFLD and NASH pathophysiology and the primary effects of bariatric surgery on metabolic pathways. We performed a systematic review of the beneficial and harmful effects and focused on changes in liver disease severity in NAFLD and NASH patients. The specific focus was liver histopathology as assessed by the invasive liver biopsy. Additionally, we reviewed several non-invasive methods used for the assessment of liver disease severity following bariatric surgery.
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Affiliation(s)
- Tea L Laursen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N DK-8200, Denmark
| | - Christoffer A Hagemann
- Gubra ApS, Hørsholm 2970, Denmark
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup 2900, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen 2200, Denmark
| | - Chunshan Wei
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N DK-8200, Denmark
- Department of Hepatology, Shenzhen Traditional Chinese Medicine Hospital, the Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen 518033, China
| | - Konstantin Kazankov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N DK-8200, Denmark
| | - Karen L Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N DK-8200, Denmark
| | - Filip K Knop
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup 2900, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen 2200, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen 2200, Denmark
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N DK-8200, Denmark
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Importance of the gastrointestinal tract in type 2 diabetes. Metabolic surgery is more than just incretin effect. Cir Esp 2018; 96:537-545. [PMID: 30337047 DOI: 10.1016/j.ciresp.2018.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 07/25/2018] [Accepted: 09/10/2018] [Indexed: 11/23/2022]
Abstract
Bariatric and metabolic surgery is creating new concepts about how the intestine assimilates food. Recent studies highlight the role of the gastrointestinal tract in the genesis and evolution of type 2 diabetes. This article has been written to answer frequent questions about metabolic surgery results and the mechanisms of action. For this purpose, a non-systematic search of different databases was carried out, identifying articles published in the last decade referring to the mechanisms of action of metabolic techniques. Understanding these mechanisms will help grasp why some surgeries are more effective than others and why the results can be so disparate among patients undergoing the same surgical approach.
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Bächler T, Geary N, Bueter M, Leeners B, Rehfeld JF, Lutz TA, Asarian L. RYGB increases the satiating effect of intrajejunal lipid infusions in female rats. Appetite 2018; 131:94-99. [PMID: 30118785 DOI: 10.1016/j.appet.2018.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/30/2018] [Accepted: 08/13/2018] [Indexed: 11/16/2022]
Abstract
We used a novel rat model to investigate the physiological bases of early satiation after Roux-en-Y gastric bypass surgery (RYGB). Female rats were subjected to RYGB or sham surgery. Chronic infusion catheters were placed in the Roux limb of RYGB rats and the corresponding anatomical locus of the jejuna of sham-RYGB rats. Rats were also ovariectomized and chronically treated with either estradiol (E2; 2 μg each 4th day SC) or the oil vehicle. Testing was begun 10-12 wk after surgery. Intrajejunal lipid infusions (10 min, 4.4 mL, 8.8 kcal) were performed just before test meals of a low-energy artificially sweetened gel diet (0.1 kcal/g) that RYGB rats ingest avidly. Intrajejunal lipid infusions reduced test-meal size more in RYGB rats than sham-operated rats, indicating that, at least after prolonged adaptation to surgery, the satiating actions of lipids acting intra- or post-jejunally are increased by RYGB and that accelerated meal appearance in the intestines after RYGB is not necessary for this effect. The satiating effects of intrajejunal lipid infusions were similar in E2-and oil-treated rats, suggesting that the effect was not dependent on an activational effect of estrogens. In a second experiment, pretreatment with the cholecystokinin A-receptor antagonist devazepide reduced the satiating effect of intrajejunal lipid infusions in E2-treated RYGB rats. Although these data are preliminary due to the smaller numbers of rats than in the first experiment, they suggest that cholecystokinin-mediated jejunal satiation contributes to early satiation after RYGB in ovariectomized rats with peri-ovulatory levels of estradiol. The results of these experiments may be relevant to understanding RYGB outcome in pre- and postmenopausal women.
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Affiliation(s)
- Thomas Bächler
- Institute of Veterinary Physiology, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, 8057, Zurich, Switzerland
| | - Nori Geary
- Department of Psychiatry, Weill Medical College of Cornell University, New York, NY, 10025, USA
| | - Marco Bueter
- Department of Visceral and Transplant Surgery Research, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland; Center for Integrative Human Physiology (ZIHP), University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | - Brigitte Leeners
- Center for Integrative Human Physiology (ZIHP), University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland; Clinic for Reproductive Endocrinology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Jens F Rehfeld
- Department of Clinical Biochemistry (KB3011), Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Thomas A Lutz
- Institute of Veterinary Physiology, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, 8057, Zurich, Switzerland; Center for Integrative Human Physiology (ZIHP), University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | - Lori Asarian
- Institute of Veterinary Physiology, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, 8057, Zurich, Switzerland; Center for Integrative Human Physiology (ZIHP), University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.
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Salehi M, Vella A, McLaughlin T, Patti ME. Hypoglycemia After Gastric Bypass Surgery: Current Concepts and Controversies. J Clin Endocrinol Metab 2018; 103:2815-2826. [PMID: 30101281 PMCID: PMC6692713 DOI: 10.1210/jc.2018-00528] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/01/2018] [Indexed: 12/12/2022]
Abstract
CONTEXT Hypoglycemia, occurring after bariatric and other forms of upper gastrointestinal surgery, is increasingly encountered by clinical endocrinologists. The true frequency of this condition remains uncertain, due, in part, to differences in the diagnostic criteria and in the affected populations, as well as relative lack of patient and physician awareness and understanding of this condition. Postbariatric hypoglycemia can be severe and disabling for some patients, with neuroglycopenia (altered cognition, seizures, and loss of consciousness) leading to falls, motor vehicle accidents, and job and income loss. Moreover, repeated episodes of hypoglycemia can result in hypoglycemia unawareness, further impairing safety and requiring the assistance of others to treat hypoglycemia. OBJECTIVE In this review, we summarize and integrate data from studies of patients affected by hypoglycemia after Roux-en-Y gastric bypass (RYGB) surgery, obtained from PubMed searches (1990 to 2017) and reference searches of relevant retrieved articles. Whereas hypoglycemia can also be observed after sleeve gastrectomy and fundoplication, this review is focused on post-RYGB, given the greater body of published clinical studies at present. OUTCOME MEASURES Data addressing specific aspects of diagnosis, pathophysiology, and treatment were reviewed by the authors; when not available, the authors have provided opinions based on clinical experience with this challenging condition. CONCLUSIONS Hypoglycemia, occurring after gastric bypass surgery, is challenging for patients and physicians alike. This review provides a systematic approach to diagnosis and treatment based on the underlying pathophysiology.
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Affiliation(s)
- Marzieh Salehi
- Diabetes Division, University of Texas Health at San Antonio, San Antonio, Texas
| | | | | | - Mary-Elizabeth Patti
- Research and Clinic Divisions, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Mary-Elizabeth Patti, MD, Research and Clinic Divisions, Joslin Diabetes Center and Harvard Medical School, 1 Joslin Place, Boston, Massachusetts 02215. E-mail:
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Smith EP, Polanco G, Yaqub A, Salehi M. Altered glucose metabolism after bariatric surgery: What's GLP-1 got to do with it? Metabolism 2018; 83:159-166. [PMID: 29113813 DOI: 10.1016/j.metabol.2017.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 10/20/2017] [Accepted: 10/25/2017] [Indexed: 01/20/2023]
Abstract
Bariatric surgery is an effective treatment for obesity. The two widely performed weight-loss procedures, Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG), alter postprandial glucose pattern and enhance gut hormone secretion immediately after surgery before significant weight loss. This weight-loss independent glycemic effects of GB has been attributed to an accelerated nutrient transit from stomach pouch to the gut and enhanced secretion of insulinotropic gut factors; in particular, glucagon-like peptide-1 (GLP-1). Meal-induced GLP-1 secretion is as much as tenfold higher in patients after GB compared to non-surgical individuals and inhibition of GLP-1 action during meals reduces postprandial hyperinsulinemia after GB two to three times more than that in persons without surgery. Moreover, in a subgroup of patients with the late complication of postprandial hyperinsulinemic hypoglycemia after GB, GLP1R blockade reverses hypoglycemia by reducing meal stimulated insulin secretion. The role of enteroinsular axis activity after SG, an increasingly popular alternative to GB, is less understood but, similar to GB, SG accelerates nutrient delivery to the intestine, improves glucose tolerance, and increases postprandial GLP-1 secretion. This review will focus on the current evidence for and against the role of GLP-1 on glycemic effects of GB and will also highlight differences between GB and SG.
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Affiliation(s)
- Eric P Smith
- Division of Endocrinology, Diabetes & Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Georgina Polanco
- Division of Endocrinology, Diabetes & Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Abid Yaqub
- Division of Endocrinology, Diabetes & Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Marzieh Salehi
- Division of Endocrinology, Diabetes & Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Salehi M, Gastaldelli A, D’Alessio DA. Beta-cell sensitivity to glucose is impaired after gastric bypass surgery. Diabetes Obes Metab 2018; 20:872-878. [PMID: 29152839 PMCID: PMC5847451 DOI: 10.1111/dom.13165] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/29/2017] [Accepted: 11/14/2017] [Indexed: 01/15/2023]
Abstract
AIMS Patients who have undergone Roux-en-Y gastric bypass surgery (GB) have exaggerated postprandial insulin secretion, which has been attributed to increased meal glucose appearance and enhanced incretin effect. Here, we sought to determine β-cell glucose sensitivity in the absence of meal stimulation and insulinotropic gut factors. MATERIALS AND METHODS A total of 12 non-diabetic subjects with prior GB, and 7 matched non-surgical control subjects with normal glucose tolerance were studied. Blood glucose and insulin secretion rates were measured during a graded glucose infusion at increasing and then decreasing rates. Insulin sensitivity (SI ) and glucose effectiveness (SG ) were determined by the minimal model. RESULTS GB subjects had SI comparable to that of control subjects. GB subjects had relative hyperglycaemia during the highest dose of glucose infusion associated with significantly reduced β-cell glucose sensitivity throughout both step-up (GB: 34 ± 6, CN: 82 ± 9 pmol min-1 mM-1 L, P < .0001) and step-down (GB: 31 ± 6, CN: 74 ± 9 pmol min-1 mM-1 L, P < .0001) phases of the glucose infusion. GB subjects also had reduced SG (GB: 0.04 ± 0.00, CN: 0.07 ± 0.01 min-1 , P = .004). CONCLUSION In the absence of enteric stimuli, β-cell sensitivity to changes in glycaemia is blunted among individuals with GB, indicating a significant shift in a fundamental property of β-cell function several years after surgery.
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Affiliation(s)
- Marzieh Salehi
- University of Cincinnati College of Medicine, Department of Medicine, Cincinnati, OH
| | - Amalia Gastaldelli
- Cardiometabolic Risk Unit, CNR Institute of Clinical Physiology, Pisa, Italy
| | - David A. D’Alessio
- University of Cincinnati College of Medicine, Department of Medicine, Cincinnati, OH
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Kim KS, Seeley RJ, Sandoval DA. Signalling from the periphery to the brain that regulates energy homeostasis. Nat Rev Neurosci 2018; 19:185-196. [PMID: 29467468 PMCID: PMC9190118 DOI: 10.1038/nrn.2018.8] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The CNS regulates body weight; however, we still lack a clear understanding of what drives decisions about when, how much and what to eat. A vast array of peripheral signals provides information to the CNS regarding fluctuations in energy status. The CNS then integrates this information to influence acute feeding behaviour and long-term energy homeostasis. Previous paradigms have delegated the control of long-term energy homeostasis to the hypothalamus and short-term changes in feeding behaviour to the hindbrain. However, recent studies have identified target hindbrain neurocircuitry that integrates the orchestration of individual bouts of ingestion with the long-term regulation of energy balance.
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Affiliation(s)
- Ki-Suk Kim
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Randy J. Seeley
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Darleen A. Sandoval
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
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Castagneto Gissey L, Casella Mariolo J, Mingrone G. Intestinal peptide changes after bariatric and minimally invasive surgery: Relation to diabetes remission. Peptides 2018; 100:114-122. [PMID: 29412812 DOI: 10.1016/j.peptides.2017.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/09/2017] [Accepted: 12/11/2017] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is very effective in achieving and maintaining weight loss but it is also associated with improvement of obesity metabolic complications, primarily type 2 diabetes (T2D). Remission of T2D or at least a net improvement of glycemic control persists for at least 5 years. The bypass of duodenum and of the first portion of the jejunum up to the Treitz ligament as in Roux-en-Y Gastric Bypass (RYGB), or the bypass of the duodenum, the entire jejunum and the first tract of the ileum, such as in Bilio-Pancreatic Diversion (BPD), achieve different results on insulin sensitivity. Insulin resistance is the major driver of T2D manifesting long before insulin secretion failure. In fact, T2D development can be prevented by treatment with insulin sensitizing agents. Interestingly, RYGB improves hepatic insulin sensitivity while BPD ameliorates whole-body insulin sensitivity. Two major theories have been advocated to explain the early remission of T2D following RYGB or BPD before a meaningful weight loss takes place, the foregut and the hindgut hypotheses. The former holds that the bypass of the proximal intestine, i.e. duodenum and jejunum, prevents the secretion of signals - including nervous transmitters and hormones - promoting insulin resistance, the latter instead states that the delivery of nutrients directly into the ileum stimulates the secretion of hormones improving glucose disposal. The most studied candidate is Glucagon Like Peptide 1 (GLP1). However, while there is unambiguous evidence that GLP-1 stimulates insulin secretion, its direct action in lowering insulin resistance, independently of the effect on weight loss secondary to its satiety action, is utterly controversial. In this review we examine the effects on T2D and gastrointestinal peptide secretion produced by different types of metabolic surgery and by minimally invasive endoscopic surgery, whose utilization for the treatment of obesity and T2D is gaining wider interest and acceptance.
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Affiliation(s)
| | | | - Geltrude Mingrone
- Department of Internal Medicine, Catholic University, Rome, Italy; Diabetes and Nutritional Sciences, Hodgkin Building, Guy's Campus, King's College London, London, United Kingdom.
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Hutch CR, Sandoval D. The Role of GLP-1 in the Metabolic Success of Bariatric Surgery. Endocrinology 2017; 158:4139-4151. [PMID: 29040429 PMCID: PMC5711387 DOI: 10.1210/en.2017-00564] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/04/2017] [Indexed: 12/15/2022]
Abstract
Two of the most popular bariatric procedures, vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB), are commonly considered metabolic surgeries because they are thought to affect metabolism in a weight loss-independent manner. In support of this classification, improvements in glucose homeostasis, insulin sensitivity, and even discontinuation of type 2 diabetes mellitus (T2DM) medication can occur before substantial postoperative weight loss. The mechanisms that underlie this effect are unknown. However, one of the common findings after VSG and RYGB in both animal models and humans is the sharp postprandial rise in several gut peptides, including the incretin and satiety peptide glucagonlike peptide-1 (GLP-1). The increase in endogenous GLP-1 signaling has been considered a primary pathway leading to postsurgical weight loss and improvements in glucose metabolism. However, the degree to which GLP-1 and other gut peptides are responsible for the metabolic successes after bariatric surgery is continually debated. In this review we discuss the mechanisms underlying the increase in GLP-1 and its potential role in the metabolic improvements after bariatric surgery, including remission of T2DM. Understanding the role of changes in gut peptides, or lack thereof, will be crucial in understanding the critical factors necessary for the metabolic success of bariatric surgery.
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Affiliation(s)
- Chelsea R. Hutch
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109
| | - Darleen Sandoval
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109
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Deden LN, Cooiman MI, Aarts EO, Janssen IMC, Gotthardt M, Hendrickx BW, Berends FJ. Gastric pouch emptying of solid food in patients with successful and unsuccessful weight loss after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2017; 13:1840-1846. [PMID: 28935201 DOI: 10.1016/j.soard.2017.07.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/25/2017] [Accepted: 07/25/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), approximately 10% of patients have insufficient weight loss (excess body mass index loss<50%). Gastric pouch emptying may have a role in weight loss. OBJECTIVES To compare pouch emptying of patients with poor weight loss and patients with successful weight loss after RYGB. SETTING A research-intensive nonacademic hospital and center of expertise in bariatric surgery in the Netherlands METHODS: Female patients were included from among patients with the least (poor weight loss group [P-WL]) and the most weight loss (successful weight loss group [S-WL]) in our center 2 years after RYGB. Pouch emptying scintigraphy was performed after ingestion of a radiolabeled solid meal. Emptying curves, intestinal content (IC) at meal completion and after 15, 30, 45, and 60 minutes, half emptying time, and maximal pouch emptying rate were compared. RESULTS Five individuals were included in P-WL and 5 in S-WL, on average 2.5 ± .3 years after RYGB. Total weight loss was 18 ± 4.1% in P-WL and 44 ± 5.7% in S-WL (P<.001). In P-WL, a fast initial pouch emptying and exponential emptying curve was observed, compared with a slower initial emptying and more linear curve in S-WL. Faster emptying in P-WL was also shown by a larger ICmeal (42 ± 18% versus 4.0 ± 3.3%,), IC15 (76 ± 15% versus 35 ± 22%), and IC30 (85 ± 12% versus 54 ± 25%), and a greater maximal pouch emptying rate (17 ± 4.7 versus 5.6 ± 3.4%/min) compared with S-WL (P<.05). A linear correlation was found between total weight loss and maximal pouch emptying rate (Pearson R = .82, P = .004). CONCLUSIONS Pouch emptying for solid food was faster in patients with the least weight loss compared with patients with the most weight loss after RYGB. If pouch emptying is an important mechanism in weight loss, altering the pouch outlet may improve poor weight loss management.
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Affiliation(s)
- Laura N Deden
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands.
| | - Mellody I Cooiman
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Edo O Aarts
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Ignace M C Janssen
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Martin Gotthardt
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Baudewijn W Hendrickx
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frits J Berends
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
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63
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Contribution of Malabsorption to Weight Loss After Roux-en-Y Gastric Bypass: a Systematic Review. Obes Surg 2017; 27:2194-2206. [DOI: 10.1007/s11695-017-2762-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Cavin JB, Bado A, Le Gall M. Intestinal Adaptations after Bariatric Surgery: Consequences on Glucose Homeostasis. Trends Endocrinol Metab 2017; 28:354-364. [PMID: 28209316 DOI: 10.1016/j.tem.2017.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/16/2017] [Accepted: 01/17/2017] [Indexed: 12/25/2022]
Abstract
The gastrointestinal (GI) tract can play a direct role in glucose homeostasis by modulating the digestion and absorption of carbohydrates and by producing the incretin hormones. In recent years, numerous studies have focused on intestinal adaptation following bariatric surgeries. Changes in the number of incretin (glucagon-like peptide 1 and glucose-dependent insulinotropic polypeptide) producing cells have been reported, which could result in the modified hormonal response seen after surgery. In addition, the rate of absorption and the intestinal regions exposed to sugars may affect the time course of appearance of glucose in the blood. This review gives new insights into the direct role of the GI tract in the metabolic outcomes of bariatric surgery, in the context of glucose homeostasis.
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Affiliation(s)
- Jean-Baptiste Cavin
- Inserm UMR 1149, UFR de Médecine Paris Diderot, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, F-75890 Paris, France
| | - André Bado
- Inserm UMR 1149, UFR de Médecine Paris Diderot, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, F-75890 Paris, France
| | - Maude Le Gall
- Inserm UMR 1149, UFR de Médecine Paris Diderot, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, F-75890 Paris, France.
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Cira DK, Sari R, Ozdem S, Yilmaz N, Bozkurt S. GLP-1 and GIP Levels in Patients With Hyperthyroidism: The Effect of Antithyroid Treatment. Ann Pharmacother 2017; 51:663-668. [DOI: 10.1177/1060028017707221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background:Incretin hormones (glucagon-like peptide-1 [GLP-1] and gastric inhibitory polypeptide [GIP]) may play a role in the development of glucose intolerance and hyperglycemia in patients with hyperthyroidism. Objective: We aimed to assess both incretin levels and treatment-induced changes in incretin levels in those with hyperthyroidism. Methods: A total of 24 subjects (12 with hyperthyroidism and 12 healthy) were enrolled in the study. Oral glucose tolerance test was performed and serum glucose, insulin GLP1, and GIP levels were evaluated at 0 (baseline), 30, 60, 90, and 120 minutes using ELISA. Measurements were repeated after euthyroidism was reached in subjects with hyperthyroidism. Results: The baseline glucose level was higher in those with hyperthyroidism compared with controls ( P = 0.03). GLP-1 and GIP responses to oral glucose load did not differ significantly between those with hyperthyroidism and controls. Peak GLP-1 and GIP levels were reached in both groups at 60 and 90 minutes, respectively. Areas under the curve (AUCs) for GLP1 and GIP were similar in those with hyperthyroidism and controls. Although GLP-1 and GIP levels did not change before and after antithyroid treatment in subjects with hyperthyroidism, time to peak GLP-1 and GIP levels were reached at 30 minutes after euthyroid state was achieved. Reversal of hyperthyroid to euthyroid status did not induce significant changes in AUCs for incretins. Conclusion: The findings of the present study suggest that the total incretin response to oral glucose load is preserved in patients with hypertyhroidism, but peak incretin responses may change after achieving euthyroid state.
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Affiliation(s)
| | - Ramazan Sari
- Akdeniz University, School of Medicine, Antalya, Turkey
| | - Sebahat Ozdem
- Akdeniz University, School of Medicine, Antalya, Turkey
| | - Nusret Yilmaz
- Akdeniz University, School of Medicine, Antalya, Turkey
| | - Selen Bozkurt
- Akdeniz University, School of Medicine, Antalya, Turkey
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Evers SS, Sandoval DA, Seeley RJ. The Physiology and Molecular Underpinnings of the Effects of Bariatric Surgery on Obesity and Diabetes. Annu Rev Physiol 2017; 79:313-334. [DOI: 10.1146/annurev-physiol-022516-034423] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Simon S. Evers
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109;
| | - Darleen A. Sandoval
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109;
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Randy J. Seeley
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109;
- Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan 48109
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67
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Steinert RE, Feinle-Bisset C, Asarian L, Horowitz M, Beglinger C, Geary N. Ghrelin, CCK, GLP-1, and PYY(3-36): Secretory Controls and Physiological Roles in Eating and Glycemia in Health, Obesity, and After RYGB. Physiol Rev 2017; 97:411-463. [PMID: 28003328 PMCID: PMC6151490 DOI: 10.1152/physrev.00031.2014] [Citation(s) in RCA: 367] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The efficacy of Roux-en-Y gastric-bypass (RYGB) and other bariatric surgeries in the management of obesity and type 2 diabetes mellitus and novel developments in gastrointestinal (GI) endocrinology have renewed interest in the roles of GI hormones in the control of eating, meal-related glycemia, and obesity. Here we review the nutrient-sensing mechanisms that control the secretion of four of these hormones, ghrelin, cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1), and peptide tyrosine tyrosine [PYY(3-36)], and their contributions to the controls of GI motor function, food intake, and meal-related increases in glycemia in healthy-weight and obese persons, as well as in RYGB patients. Their physiological roles as classical endocrine and as locally acting signals are discussed. Gastric emptying, the detection of specific digestive products by small intestinal enteroendocrine cells, and synergistic interactions among different GI loci all contribute to the secretion of ghrelin, CCK, GLP-1, and PYY(3-36). While CCK has been fully established as an endogenous endocrine control of eating in healthy-weight persons, the roles of all four hormones in eating in obese persons and following RYGB are uncertain. Similarly, only GLP-1 clearly contributes to the endocrine control of meal-related glycemia. It is likely that local signaling is involved in these hormones' actions, but methods to determine the physiological status of local signaling effects are lacking. Further research and fresh approaches are required to better understand ghrelin, CCK, GLP-1, and PYY(3-36) physiology; their roles in obesity and bariatric surgery; and their therapeutic potentials.
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Affiliation(s)
- Robert E Steinert
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Christine Feinle-Bisset
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Lori Asarian
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Michael Horowitz
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Christoph Beglinger
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Nori Geary
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
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68
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Sachdev S, Wang Q, Billington C, Connett J, Ahmed L, Inabnet W, Chua S, Ikramuddin S, Korner J. FGF 19 and Bile Acids Increase Following Roux-en-Y Gastric Bypass but Not After Medical Management in Patients with Type 2 Diabetes. Obes Surg 2016; 26:957-65. [PMID: 26259981 DOI: 10.1007/s11695-015-1834-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study aims to quantify changes in fibroblast growth factor 19 (FGF19) and bile acids (BAs) in patients with uncontrolled type 2 diabetes randomized to Roux-en-Y gastric bypass (RYGB) vs intensive medical management (IMM) and matched for similar reduction in HbA1c after 1 year of treatment. METHODS Blood samples were drawn from patients who underwent a test meal challenge before and 1 year after IMM (n = 15) or RYGB (n = 15). RESULTS Mean HbA1c decreased from 9.7 to 6.4% after RYGB and from 9.1 to 6.1% in the IMM group. At 12 months, the number of diabetes medications used per subject in the RYGB group (2.5 ± 0.5) was less than in the IMM group (4.6 ± 0.3). After RYGB, FGF19 increased in the fasted (93 ± 15 to 152 ± 19 pg/ml; P = 0.008) and postprandial states (area under the curve (AUC), 10.8 ± 1.9 to 23.4 ± 4.1 pg × h/ml × 10(3); P = 0.006) but remained unchanged following IMM. BAs increased after RYGB (AUC ×10(3), 6.63 ± 1.3 to 15.16 ± 2.56 μM × h; P = 0.003) and decreased after IMM (AUC ×10(3), 8.22 ± 1.24 to 5.70 ± 0.70; P = 0.01). No changes were observed in the ratio of 12α-hydroxylated/non-12α-hyroxylated BAs. Following RYGB, FGF19 AUC correlated with BAs (r = 0.54, P = 0.04) and trended negatively with HbA1c (r = -0.44; P = 0.09); these associations were not observed after IMM. CONCLUSIONS BA and FGF19 levels increased after RYGB but not after IMM in subjects who achieved similar improvement in glycemic control. Further studies are necessary to determine whether these hormonal changes facilitate improved glucose homeostasis.
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Affiliation(s)
- Saachi Sachdev
- Department of Medicine, Columbia University Medical Center, 650 West 168th St, Black Building, Room 905, New York, NY, 10032, USA
| | - Qi Wang
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | | | - John Connett
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Leaque Ahmed
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - William Inabnet
- Department of Surgery, Mount Sinai Medical Center, New York, NY, USA
| | - Streamson Chua
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sayeed Ikramuddin
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Judith Korner
- Department of Medicine, Columbia University Medical Center, 650 West 168th St, Black Building, Room 905, New York, NY, 10032, USA.
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69
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Rigda RS, Trahair LG, Little TJ, Wu T, Standfield S, Feinle-Bisset C, Rayner CK, Horowitz M, Jones KL. Regional specificity of the gut-incretin response to small intestinal glucose infusion in healthy older subjects. Peptides 2016; 86:126-132. [PMID: 27780735 DOI: 10.1016/j.peptides.2016.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/20/2016] [Accepted: 10/21/2016] [Indexed: 02/07/2023]
Abstract
The importance of the region, as opposed to the length, of small intestine exposed to glucose in determining the secretion of the incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) remains unclear. We sought to compare the glycemic, insulinemic and incretin responses to glucose administered to the proximal (12-60cm beyond the pylorus), or more distal (>70cm beyond the pylorus) small intestine, or both. 10 healthy subjects (9M,1F; aged 70.3±1.4years) underwent infusion of glucose via a catheter into the proximal (glucose proximally; GP), or distal (glucose distally; GD) small intestine, or both (GPD), on three separate days in a randomised fashion. Blood glucose, serum insulin and plasma GLP-1, GIP and CCK responses were assessed. The iAUC for blood glucose was greater in response to GPD than GP (P<0.05), with no difference between GD and GP. GP was associated with minimal GLP-1 response (P=0.05), but substantial increases in GIP, CCK and insulin (P<0.001 for all). GPD and GD both stimulated GLP-1, GIP, CCK and insulin (P<0.001 for all). Compared to GP, GPD induced greater GLP-1, GIP and CCK responses (P<0.05 for all). Compared with GPD, GD was associated with greater GLP-1 (P<0.05), but reduced GIP and CCK (P<0.05 for both), responses. We conclude that exposure of glucose to the distal small intestine appears necessary for substantial GLP-1 secretion, while exposure of both the proximal and distal small intestine result in substantial secretion of GIP.
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Affiliation(s)
- Rachael S Rigda
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia
| | - Laurence G Trahair
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia
| | - Tanya J Little
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia
| | - Tongzhi Wu
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia
| | - Scott Standfield
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia
| | - Christine Feinle-Bisset
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia
| | - Christopher K Rayner
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia
| | - Michael Horowitz
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia
| | - Karen L Jones
- Discipline of Medicine, The University of Adelaide, South Australia, 5000, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, 5000, Australia.
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70
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Chondronikola M, Harris LLS, Klein S. Bariatric surgery and type 2 diabetes: are there weight loss-independent therapeutic effects of upper gastrointestinal bypass? J Intern Med 2016; 280:476-486. [PMID: 27739136 PMCID: PMC5117433 DOI: 10.1111/joim.12527] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Type 2 diabetes (T2D) is a major worldwide public health concern. Despite a large armamentarium of T2D medications, a large proportion of patients fail to achieve recommended treatment goals for glycemic control. Weight loss has profound beneficial effects on the metabolic abnormalities involved in the pathogenesis of T2D. Accordingly, bariatric surgery, which is the most effective available weight loss therapy, is also the most effective therapy for treating patients with T2D. Surgical procedures that bypass the upper gastrointestinal (UGI) tract are particularly effective in achieving partial and even complete remission of T2D, suggesting that UGI bypass has weight loss-independent effects on glycemic control. Although a number of hypotheses (e.g. a role for multiorgan insulin sensitivity, β-cell function, incretin response, the gut microbiome, bile acid metabolism, intestinal glucose metabolism and browning of adipose tissue) have been proposed to explain the potential unique effects of UGI tract bypass surgery, none has yet been adequately evaluated to determine therapeutic importance in patients with T2D. Here, we review the efficacy of UGI bypass surgery in treating T2D and the mechanisms that have been proposed to explain its potential weight loss-independent therapeutic effects.
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Affiliation(s)
- M Chondronikola
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St Louis, MO, USA.,Department of Nutritional Sciences and Dietetics, Harokopio University of Athens, Athens, Greece
| | - L L S Harris
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - S Klein
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St Louis, MO, USA.
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71
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Rao R, Roche A, Febres G, Bessler M, Tso P, Korner J. Circulating Apolipoprotein A-IV presurgical levels are associated with improvement in insulin sensitivity after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2016; 13:468-473. [PMID: 27986588 DOI: 10.1016/j.soard.2016.10.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/08/2016] [Accepted: 10/23/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Apolipoprotein A-IV (ApoA-IV) has been shown to be involved in obesity and diabetes pathogenesis in animal studies, but its role in humans is uncertain. OBJECTIVES The objective of this study was to determine the relation of ApoA-IV with changes in glucose metabolism and weight after bariatric surgery. SETTING University Hospital. METHODS The patients (n = 49) included lean controls (n = 8) and patients before and after a mean of 7 months after laparoscopic adjustable gastric banding (LAGB, n = 12), laparoscopic Roux-en-Y gastric bypass (RYGB, n = 22), or laparoscopic sleeve gastrectomy (SG, n = 11). ApoA-IV and other hormone assays were performed in the fasting and the postprandial state. Pearson's correlation analyses controlled for baseline BMI and percent excess weight loss (EWL) were used to determine relationships between ApoA-IV levels and insulin resistance (HOMA-IR). RESULTS With all bariatric procedures combined, the change in ApoA-IV [533 versus 518 microg/L, P = .813] or ApoA-IV area under the curve (AUC - 1072 versus 1042, P = .939) was not significant. None of the surgeries individually affected levels of fasting or ApoA-IV AUC. Bariatric surgery resulted in a decrease in HOMA-IR (5.3 versus 2.0, P<.001). In the RYGB group, higher baseline ApoA-IV levels correlated with decrease in HOMA-IR [r = -.6, P = .008]. This relationship was independent of EWL and was not observed in the LAGB or SG group. There was no association of ApoA-IV levels with EWL, insulin secretion, Peptide-YY, or leptin levels. CONCLUSION Preoperative ApoA-IV levels, rather than changes in levels, positively correlate with improvements in insulin sensitivity independent of weight loss after RYGB.
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Affiliation(s)
- Raghavendra Rao
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Gerardo Febres
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Marc Bessler
- Department of Surgery , Columbia University Medical Center, New York, NY
| | - Patrick Tso
- Department of Pathology and Laboratory Medicine, Metabolic Diseases Institute, University of Cincinnati, Cincinnati, OH
| | - Judith Korner
- Department of Medicine, Columbia University Medical Center, New York, NY.
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72
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Kulkarni BV, LaSance K, Sorrell JE, Lemen L, Woods SC, Seeley RJ, Sandoval D. The role of proximal versus distal stomach resection in the weight loss seen after vertical sleeve gastrectomy. Am J Physiol Regul Integr Comp Physiol 2016; 311:R979-R987. [PMID: 27581811 DOI: 10.1152/ajpregu.00125.2016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 08/26/2016] [Accepted: 08/27/2016] [Indexed: 12/16/2022]
Abstract
The mechanisms involved in the weight loss seen after vertical sleeve gastrectomy (VSG) are not clear. The rat stomach has two morphologically and functionally distinct proximal and distal parts. The rat model for VSG involves complete removal of the proximal part and 80% removal of the distal part along the greater curvature. The purpose of this study was to understand the potential independent contributions of removal of these distinct gastric sections to VSG outcomes. We prepared four surgical groups of male Long-Evans rats: VSG, sham surgery (control), selective proximal section removal (PR), and selective distal section removal (DR). Gastric emptying rate (GER) was highest after VSG compared with all other groups. However, PR, in turn, had significantly greater GER compared with both DR and sham groups. The surgery-induced weight loss followed the same pattern with VSG causing the greatest weight loss and PR having greater weight loss compared with DR and sham groups. The results were robust for rats fed regular chow or a high-fat diet. Body mass analysis revealed that the weight loss was due to the loss of fat mass, and there was no change in lean mass after the surgeries. In conclusion, removal of the proximal stomach contributes to most, but not all, of the physiological impact of VSG.
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Affiliation(s)
- Bhushan V Kulkarni
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Kathleen LaSance
- Department of Radiology, Vontz Core Imaging Laboratory, University of Cincinnati, Cincinnati, Ohio
| | - Joyce E Sorrell
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Lisa Lemen
- Department of Radiology, Vontz Core Imaging Laboratory, University of Cincinnati, Cincinnati, Ohio
| | - Stephen C Woods
- Department of Psychiatry, University of Cincinnati, Cincinnati, Ohio
| | - Randy J Seeley
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Darleen Sandoval
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; .,Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio; and
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73
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Tamboli RA, Sidani RM, Garcia AE, Antoun J, Isbell JM, Albaugh VL, Abumrad NN. Jejunal administration of glucose enhances acyl ghrelin suppression in obese humans. Am J Physiol Endocrinol Metab 2016; 311:E252-9. [PMID: 27279247 PMCID: PMC4967145 DOI: 10.1152/ajpendo.00082.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/26/2016] [Indexed: 01/03/2023]
Abstract
Ghrelin is a gastric hormone that stimulates hunger and worsens glucose metabolism. Circulating ghrelin is decreased after Roux-en-Y gastric bypass (RYGB) surgery; however, the mechanism(s) underlying this change is unknown. We tested the hypothesis that jejunal nutrient exposure plays a significant role in ghrelin suppression after RYGB. Feeding tubes were placed in the stomach or jejunum in 13 obese subjects to simulate pre-RYGB or post-RYGB glucose exposure to the gastrointestinal (GI) tract, respectively, without the confounding effects of caloric restriction, weight loss, and surgical stress. On separate study days, the plasma glucose curves obtained with either gastric or jejunal administration of glucose were replicated with intravenous (iv) infusions of glucose. These "isoglycemic clamps" enabled us to determine the contribution of the GI tract and postabsorptive plasma glucose to acyl ghrelin suppression. Plasma acyl ghrelin levels were suppressed to a greater degree with jejunal glucose administration compared with gastric glucose administration (P < 0.05). Jejunal administration of glucose also resulted in a greater suppression of acyl ghrelin than the corresponding isoglycemic glucose infusion (P ≤ 0.01). However, gastric and isoglycemic iv glucose infusions resulted in similar degrees of acyl ghrelin suppression (P > 0.05). Direct exposure of the proximal jejunum to glucose increases acyl ghrelin suppression independent of circulating glucose levels. The enhanced suppression of acyl ghrelin after RYGB may be due to a nutrient-initiated signal in the jejunum that regulates ghrelin secretion.
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Affiliation(s)
- Robyn A Tamboli
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reem M Sidani
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna E Garcia
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph Antoun
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James M Isbell
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vance L Albaugh
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Naji N Abumrad
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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74
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Salehi M, D'Alessio DA. Mechanisms of surgical control of type 2 diabetes: GLP-1 is the key factor-Maybe. Surg Obes Relat Dis 2016; 12:1230-5. [PMID: 27568473 PMCID: PMC5002889 DOI: 10.1016/j.soard.2016.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 05/07/2016] [Accepted: 05/09/2016] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is the most effective treatment for obesity and diabetes. The 2 most commonly performed weight-loss procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy, improve glycemic control in patients with type 2 diabetes independent of weight loss. One of the early hypotheses raised to explain the immediate antidiabetic effect of RYGB was that rapid delivery of nutrients from the stomach pouch into the distal small intestine enhances enteroinsular signaling to promote insulin signaling. Given the tenfold increase in postmeal glucagon-like peptide-1 (GLP-1) response compared to unchanged integrated levels of postprandial glucose-dependent insulinotropic peptide after RYGB, enhanced meal-induced insulin secretion after this procedure was thought to be the result of elevated glucose and GLP-1 levels. In this contribution to the larger point-counterpoint debate about the role of GLP-1 after bariatric surgery, most of the focus will be on RYGB.
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Affiliation(s)
- Marzieh Salehi
- Department of Biomedical Science, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California.
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75
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Holst JJ, Gribble F, Horowitz M, Rayner CK. Roles of the Gut in Glucose Homeostasis. Diabetes Care 2016; 39:884-92. [PMID: 27222546 DOI: 10.2337/dc16-0351] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/22/2016] [Indexed: 02/05/2023]
Abstract
The gastrointestinal tract plays a major role in the regulation of postprandial glucose profiles. Gastric emptying is a highly regulated process, which normally ensures a limited and fairly constant delivery of nutrients and glucose to the proximal gut. The subsequent digestion and absorption of nutrients are associated with the release of a set of hormones that feeds back to regulate subsequent gastric emptying and regulates the release of insulin, resulting in downregulation of hepatic glucose production and deposition of glucose in insulin-sensitive tissues. These remarkable mechanisms normally keep postprandial glucose excursions low, regardless of the load of glucose ingested. When the regulation of emptying is perturbed (e.g., pyloroplasty, gastric sleeve or gastric bypass operation), postprandial glycemia may reach high levels, sometimes followed by profound hypoglycemia. This article discusses the underlying mechanisms.
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Affiliation(s)
- Jens Juul Holst
- The Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Fiona Gribble
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, U.K
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Chris K Rayner
- Discipline of Medicine, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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76
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Surowska A, De Giorgi S, Theytaz F, Campos V, Hodson L, Stefanoni N, Rey V, Schneiter P, Laville M, Giusti V, Gabert L, Tappy L. Effects of roux-en-Y gastric bypass surgery on postprandial fructose metabolism. Obesity (Silver Spring) 2016; 24:589-96. [PMID: 26916239 DOI: 10.1002/oby.21410] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/24/2015] [Accepted: 10/26/2015] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Fructose is partly metabolized in small bowel enterocytes, where it can be converted into glucose or fatty acids. It was therefore hypothesized that Roux-en-Y gastric bypass (RYGB) may significantly alter fructose metabolism. METHODS We performed a randomized clinical study in eight patients 12-17 months after RYGB and eight control (Ctrl) subjects. Each participant was studied after ingestion of a protein and lipid meal (PL) and after ingestion of a protein+lipid+fructose+glucose meal labeled with (13) C-fructose (PLFG). Postprandial blood glucose, fructose, lactate, apolipoprotein B48 (apoB48), and triglyceride (TG) concentrations, (13) C-palmitate concentrations in chylomicron-TG and VLDL-TG, fructose oxidation ((13) CO2 production), and gluconeogenesis from fructose (GNGf) were measured over 6 hours. RESULTS After ingestion of PLFG, postprandial plasma fructose, glucose, insulin, and lactate concentrations increased earlier and reached higher peak values in RYGB than in Ctrl. GNGf was 33% lower in RYGB than Ctrl (P = 0.041), while fructose oxidation was unchanged. Postprandial incremental areas under the curves for total TG and chylomicrons-TG were 72% and 91% lower in RYGB than Ctrl (P = 0.064 and P = 0.024, respectively). ApoB48 and (13) C-palmitate concentrations were not significantly different. CONCLUSIONS Postprandial fructose metabolism was not grossly altered, but postprandial lipid concentrations were markedly decreased in subjects having had RYGB surgery.
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Affiliation(s)
- Anna Surowska
- Department of Physiology, University of Lausanne, Lausanne, Switzerland
| | - Sara De Giorgi
- Department of Physiology, University of Lausanne, Lausanne, Switzerland
| | - Fanny Theytaz
- Department of Physiology, University of Lausanne, Lausanne, Switzerland
| | - Vanessa Campos
- Department of Physiology, University of Lausanne, Lausanne, Switzerland
| | - Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | | | - Valentine Rey
- Department of Physiology, University of Lausanne, Lausanne, Switzerland
| | | | - Martine Laville
- Centre De Recherche En Nutrition Humaine Rhône Alpes, Centre Européen De Nutrition Pour La Santé, Hospices Civils De Lyon, Université Lyon 1, Pierre Bénite, France
| | - Vittorio Giusti
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
| | - Laure Gabert
- Centre De Recherche En Nutrition Humaine Rhône Alpes, Centre Européen De Nutrition Pour La Santé, Hospices Civils De Lyon, Université Lyon 1, Pierre Bénite, France
| | - Luc Tappy
- Department of Physiology, University of Lausanne, Lausanne, Switzerland
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
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Sandoval D. Roux-en-Y Gastric Bypass and Vertical Sleeve Gastrectomy: Divergent Pathways to Improved Glucose Homeostasis. Gastroenterology 2016; 150:309-12. [PMID: 26710990 DOI: 10.1053/j.gastro.2015.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Darleen Sandoval
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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78
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Nguyen NQ, Debreceni TL, Burgstad CM, Neo M, Bellon M, Wishart JM, Standfield S, Bartholomeusz D, Rayner CK, Wittert G, Horowitz M. Effects of Fat and Protein Preloads on Pouch Emptying, Intestinal Transit, Glycaemia, Gut Hormones, Glucose Absorption, Blood Pressure and Gastrointestinal Symptoms After Roux-en-Y Gastric Bypass. Obes Surg 2016; 26:77-84. [PMID: 25986427 DOI: 10.1007/s11695-015-1722-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim was to determine the effects of fat and protein preloads on pouch emptying (PE), caecal arrival time (CAT), glucose absorption, blood glucose (BSL), gut hormones, haemodynamics and gastrointestinal (GI) symptoms in subjects who had undergone Roux-en-Y gastric bypass (RYGB) >12 months previously. METHODS Ten RYGB subjects were studied on three occasions, in randomised order, receiving 200-ml preloads of either water, fat (30 ml olive oil) or whey protein (55 g), 30 min before a mixed meal. PE, CAT, BSL, plasma 3-O-methyl-D-glucopyranose (3-OMG), insulin, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide 1 (GLP-1) and glucagon, blood pressure (BP), heart rate (HR) and GI symptoms were assessed over 270 min. RESULTS Although fat and protein preloads did not alter PE of either solids or liquids, the CAT of solids, but not liquids, was longer than that after the water preload (fat 68 ± 5 min and protein 71 ± 6 min vs. water 46 ± 5 min; P = 0.02). BSL elevated promptly after the meal on all days (P < 0.001), but after protein, the magnitude and integrated increases in the first 75 min were less than fat and water preloads (area under the curve (AUC(0-75 min)), 18.7 ± 18.2 vs. 107.2 ± 30.4 and 76.1 ± 19.3 mmol/L/min; P < 0.05). Compared to water preload, the protein and fat preloads were associated with greater increases in plasma insulin, GLP-1 and glucagon concentrations, a reduction in BP, and greater increases in HR, fullness, bloating and nausea. Plasma 3-OMG levels were lower after the protein than after the water and fat preloads (P < 0.001). CONCLUSIONS Given its effects to attenuate post-prandial glycaemia, reduce intestinal glucose absorption and potentiate the "incretin response", without inducing more adverse post-prandial GI symptom, protein preload may prove clinically useful in RYGB patients and warrant further evaluation, particularly in those with type 2 diabetes (T2DM) and/or dumping syndrome.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
- Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia.
| | - Tamara L Debreceni
- Department of Gastroenterology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
| | - Carly M Burgstad
- Department of Gastroenterology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
| | - Melissa Neo
- Department of Gastroenterology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
| | - Max Bellon
- Department of Nuclear Medicine, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Judith M Wishart
- Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Scott Standfield
- Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Dylan Bartholomeusz
- Department of Gastroenterology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
- Department of Nuclear Medicine, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Chris K Rayner
- Department of Gastroenterology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Gary Wittert
- Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
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le Roux CW, Engström M, Björnfot N, Fändriks L, Docherty NG. Equivalent Increases in Circulating GLP-1 Following Jejunal Delivery of Intact and Hydrolysed Casein: Relevance to Satiety Induction Following Bariatric Surgery. Obes Surg 2015; 26:1851-8. [DOI: 10.1007/s11695-015-2005-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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80
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Gut Hormone Suppression Increases Food Intake After Esophagectomy With Gastric Conduit Reconstruction. Ann Surg 2015; 262:824-29; discussion 829-30. [DOI: 10.1097/sla.0000000000001465] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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81
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Breath Hydrogen as a Biomarker for Glucose Malabsorption after Roux-en-Y Gastric Bypass Surgery. DISEASE MARKERS 2015; 2015:102760. [PMID: 26538792 PMCID: PMC4619887 DOI: 10.1155/2015/102760] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/08/2015] [Accepted: 09/17/2015] [Indexed: 12/13/2022]
Abstract
Objective. Abdominal symptoms are common after bariatric surgery, and these individuals commonly have upper gut bacterial overgrowth, a known cause of malabsorption. Breath hydrogen determination after oral glucose is a safe and inexpensive test for malabsorption. This study is designed to investigate breath hydrogen levels after oral glucose in symptomatic individuals who had undergone Roux-en-Y gastric bypass surgery. Methods. This is a retrospective study of individuals (n = 63; 60 females; 3 males; mean age 49 years) who had gastric bypass surgery and then glucose breath testing to evaluate abdominal symptoms. Results. Among 63 postoperative individuals, 51 (81%) had a late rise (≥45 minutes) in breath hydrogen or methane, supporting glucose malabsorption; 46 (90%) of these 51 subjects also had an early rise (≤30 minutes) in breath hydrogen or methane supporting upper gut bacterial overgrowth. Glucose malabsorption was more frequent in subjects with upper gut bacterial overgrowth compared to subjects with no evidence for bacterial overgrowth (P < 0.001). Conclusion. These data support the presence of intestinal glucose malabsorption associated with upper gut bacterial overgrowth in individuals with abdominal symptoms after gastric bypass surgery. Breath hydrogen testing after oral glucose should be considered to evaluate potential malabsorption in symptomatic, postoperative individuals.
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82
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Bojsen-Møller KN, Jacobsen SH, Dirksen C, Jørgensen NB, Reitelseder S, Jensen JEB, Kristiansen VB, Holst JJ, van Hall G, Madsbad S. Accelerated protein digestion and amino acid absorption after Roux-en-Y gastric bypass. Am J Clin Nutr 2015; 102:600-7. [PMID: 26245808 DOI: 10.3945/ajcn.115.109298] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 07/02/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) involves exclusion of major parts of the stomach and changes in admixture of gastro-pancreatic enzymes, which could have a major impact on protein digestion and amino acid absorption. OBJECTIVE We investigated the effect of RYGB on amino acid appearance in the systemic circulation from orally ingested protein and from endogenous release. DESIGN Nine obese glucose-tolerant subjects, with a mean body mass index (in kg/m(2)) of 39.2 (95% CI: 35.2, 43.3) and mean glycated hemoglobin of 5.3% (95% CI: 4.9%, 5.6%), were studied before and 3 mo after RYGB. Leucine and phenylalanine kinetics were determined under basal conditions and during 4 postprandial hours by intravenous infusions of [3,3,3-(2)H3]-leucine and [ring-(2)D5]-phenylalanine combined with ingestion of [1-(13)C]-leucine intrinsically labeled caseinate as the sole protein source of the meal. Changes in body composition were assessed by dual-energy X-ray absorptiometry. RESULTS After RYGB, basal plasma leucine concentration did not change, but marked changes were seen postprandially with 1.7-fold increased peak concentrations (before—mean: 217 μmol/L; 95% CI: 191, 243 μmol/L; 3 mo—mean: 377 μmol/L; 95% CI: 252, 502 μmol/L; P = 0.012) and 2-fold increased incremental AUC (before-mean: 4.1 mmol ∙ min/L; 95% CI: 2.7, 5.5 mmol ∙ min/L; 3 mo-mean: 9.5 mmol ∙ min/L; 95% CI: 4.9, 14.2 mmol ∙ min/L; P = 0.032). However, the postprandial hyperleucinemia was transient, and concentrations were below basal concentrations in the fourth postprandial hour. These concentration differences were mainly caused by changes in leucine appearance rate from orally ingested caseinate: peak rate increased nearly 3-fold [before—mean: 0.5 μmol/(kg fat-free mass ∙ min); 95% CI: 0.4, 0.5 μmol/(kg fat-free mass ∙ min); 3 mo—mean 1.4 μmol/(kg fat-free mass ∙ min); 95% CI: 0.8, 1.9 μmol/(kg fat-free mass ∙ min); P = 0.002], and time to peak was much shorter (before—mean: 173 min; 95% CI: 137, 209 min; 3 mo—mean: 65 min; 95% CI: 46, 84 min; P < 0.001). Only minor changes were seen in endogenous leucine release after RYGB. CONCLUSIONS RYGB accelerates caseinate digestion and amino acid absorption, resulting in faster and higher but more transient postprandial elevation of plasma amino acids. Changes are likely mediated by accelerated intestinal nutrient entry and clearly demonstrate that protein digestion is not impaired after RYGB. This trial was registered at clinicaltrials.gov as NCT01559792.
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Affiliation(s)
| | - Siv H Jacobsen
- Department of Endocrinology and Novo Nordisk Foundation Centre for Basic Metabolic Research and
| | - Carsten Dirksen
- Department of Endocrinology and Novo Nordisk Foundation Centre for Basic Metabolic Research and
| | - Nils B Jørgensen
- Department of Endocrinology and Novo Nordisk Foundation Centre for Basic Metabolic Research and
| | - Søren Reitelseder
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Viggo B Kristiansen
- Department of Surgical Gastroenterology, Hvidovre Hospital, Copenhagen, Denmark
| | - Jens J Holst
- Novo Nordisk Foundation Centre for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gerrit van Hall
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Metabolomics, Rigshospitalet, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology and Novo Nordisk Foundation Centre for Basic Metabolic Research and
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Nguyen KT, Billington CJ, Vella A, Wang Q, Ahmed L, Bantle JP, Bessler M, Connett JE, Inabnet WB, Thomas A, Ikramuddin S, Korner J. Preserved Insulin Secretory Capacity and Weight Loss Are the Predominant Predictors of Glycemic Control in Patients With Type 2 Diabetes Randomized to Roux-en-Y Gastric Bypass. Diabetes 2015; 64:3104-10. [PMID: 25901097 PMCID: PMC4542441 DOI: 10.2337/db14-1870] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 04/16/2015] [Indexed: 12/12/2022]
Abstract
Improvement in type 2 diabetes after Roux-en-Y gastric bypass (RYGB) has been attributed partly to weight loss, but mechanisms beyond weight loss remain unclear. We performed an ancillary study to the Diabetes Surgery Study to assess changes in incretins, insulin sensitivity, and secretion 1 year after randomization to lifestyle modification and intensive medical management (LS/IMM) alone (n = 34) or in conjunction with RYGB (n = 34). The RYGB group lost more weight and had greater improvement in HbA1c. Fasting glucose was lower after RYGB than after LS/IMM, although the glucose area under the curve decreased comparably for both groups. Insulin sensitivity increased in both groups. Insulin secretion was unchanged after LS/IMM but decreased after RYGB, except for a rapid increase during the first 30 min after meal ingestion. Glucagon-like peptide 1 (GLP-1) was substantially increased after RYGB, while gastric inhibitory polypeptide and glucagon decreased. Lower HbA1c was most strongly correlated with the percentage of weight loss for both groups. At baseline, a greater C-peptide index and 90-min postprandial C-peptide level were predictive of lower HbA1c at 1 year after RYGB. β-Cell glucose sensitivity, which improved only after RYGB, and improved disposition index were associated with lower HbA1c in both groups, independent of weight loss. Weight loss and preserved β-cell function both predominantly determine the greatest glycemic benefit after RYGB.
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Affiliation(s)
- Kim T Nguyen
- Division of Endocrinology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Charles J Billington
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Adrian Vella
- Division of Endocrinology and Diabetes, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Qi Wang
- Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | - Leaque Ahmed
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - John P Bantle
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Marc Bessler
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - John E Connett
- Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | | | - Avis Thomas
- Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | | | - Judith Korner
- Division of Endocrinology, Department of Medicine, Columbia University Medical Center, New York, NY
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84
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Nguyen NQ, Debreceni TL, Burgstad CM, Wishart JM, Bellon M, Rayner CK, Wittert GA, Horowitz M. Effects of Posture and Meal Volume on Gastric Emptying, Intestinal Transit, Oral Glucose Tolerance, Blood Pressure and Gastrointestinal Symptoms After Roux-en-Y Gastric Bypass. Obes Surg 2015; 25:1392-400. [PMID: 25502436 DOI: 10.1007/s11695-014-1531-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study is to determine the effects of posture and drink volume on gastric/pouch emptying (G/PE), intestinal transit, hormones, absorption, glycaemia, blood pressure and gastrointestinal (GI) symptoms after gastric bypass (Roux-en-Y gastric bypass (RYGB)). METHODS Ten RYGB subjects were studied on four occasions in randomized order (sitting vs. supine posture; 50 vs. 150 ml of labelled water mixed with 3 g 3-O-methyl-D-glucose (3-OMG) and 50 g glucose). G/PE, caecal arrival time (CAT), blood glucose, plasma insulin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), peptide YY (PYY), 3-OMG, blood pressure, heart rate and GI symptoms were assessed over 240 min. Controls were ten volunteers with no medical condition or previous abdominal surgery, who were studied with the 150-ml drink in the sitting position. RESULTS Compared to controls, PE (P < 0.001) and CAT (P < 0.001) were substantially more rapid in RYGB subjects. In RYGB, PE was more rapid in the sitting position (2.5 ± 0.7 vs. 16.6 ± 5.3 min, P = 0.02) and tends to be faster after 150 ml than the 50-ml drinks (9.5 ± 2.9 vs. 14.0 ± 3.5 min, P = 0.16). The sitting position and larger volume drinks were associated with greater releases of insulin, GLP-1 and PYY, as well as more hypotension (P < 0.01), tachycardia (P < 0.01) and postprandial symptoms (P < 0.001). CONCLUSIONS Pouch emptying, blood pressure and GI symptoms after RYGB are dependent on both posture and meal volume.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia,
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85
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Hankir MK, Ashrafian H, Hesse S, Horstmann A, Fenske WK. Distinctive striatal dopamine signaling after dieting and gastric bypass. Trends Endocrinol Metab 2015; 26:223-30. [PMID: 25887491 DOI: 10.1016/j.tem.2015.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 03/10/2015] [Accepted: 03/15/2015] [Indexed: 12/25/2022]
Abstract
Highly palatable and/or calorically dense foods, such as those rich in fat, engage the striatum to govern and set complex behaviors. Striatal dopamine signaling has been implicated in hedonic feeding and the development of obesity. Dieting and bariatric surgery have markedly different outcomes on weight loss, yet how these interventions affect central homeostatic and food reward processing remains poorly understood. Here, we propose that dieting and gastric bypass produce distinct changes in peripheral factors with known roles in regulating energy homeostasis, resulting in differential modulation of nigrostriatal and mesolimbic dopaminergic reward circuits. Enhancement of intestinal fat metabolism after gastric bypass may also modify striatal dopamine signaling contributing to its unique long-term effects on feeding behavior and body weight in obese individuals.
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Affiliation(s)
- Mohammed K Hankir
- Leipzig University Medical Center, IFB Adiposity Diseases, Leipzig, Germany
| | - Hutan Ashrafian
- Department of Surgery & Cancer, Imperial College London, London, UK.
| | - Swen Hesse
- Leipzig University Medical Center, IFB Adiposity Diseases, Leipzig, Germany; Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Annette Horstmann
- Leipzig University Medical Center, IFB Adiposity Diseases, Leipzig, Germany; Max-Planck-Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Wiebke K Fenske
- Leipzig University Medical Center, IFB Adiposity Diseases, Leipzig, Germany
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86
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Dutia R, Embrey M, O’Brien S, Haeusler RA, Agénor KK, Homel P, McGinty J, Vincent RP, Alaghband-Zadeh J, Staels B, le Roux CW, Yu J, Laferrère B. Temporal changes in bile acid levels and 12α-hydroxylation after Roux-en-Y gastric bypass surgery in type 2 diabetes. Int J Obes (Lond) 2015; 39:806-13. [PMID: 25599611 PMCID: PMC4422767 DOI: 10.1038/ijo.2015.1] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 11/26/2014] [Accepted: 12/25/2014] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Gastric bypass surgery (GBP) leads to sustained weight loss and significant improvement in type 2 diabetes (T2DM). Bile acids (BAs), signaling molecules which influence glucose metabolism, are a potential mediator for the improvement in T2DM after GBP. This study sought to investigate the effect of GBP on BA levels and composition in individuals with T2DM. METHODS Plasma BA levels and composition and fibroblast growth factor (FGF)-19 levels were measured during fasting and in response to an oral glucose load before and at 1 month and 2 years post GBP in 13 severely obese women with T2DM. RESULTS A striking temporal change in BA levels and composition was observed after GBP. During the fasted state, BA concentrations were generally reduced at 1 month, but increased 2 years post GBP. Postprandial BA levels were unchanged 1 month post GBP, but an exaggerated postprandial peak was observed 2 years after the surgery. A significant increase in the 12α-hydroxylated/non12α-hydroxylated BA ratio during fasting and postprandially at 2 years, but not 1 month, post GBP was observed. Significant correlations between BAs vs FGF-19, body weight, the incretin effect and peptide YY (PYY) were also found. CONCLUSIONS This study provides evidence that GBP temporally modifies the concentration and composition of circulating BAs in individuals with T2DM, and suggests that BAs may be linked to the improvement in T2DM after GBP.
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Affiliation(s)
- R Dutia
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - M Embrey
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - S O’Brien
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - RA Haeusler
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - KK Agénor
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - P Homel
- Department of Medicine, Albert Einstein School of Medicine, New York, NY, USA
| | - J McGinty
- Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Mount Sinai, St. Luke’s Roosevelt Hospitals, New York, NY, USA
| | - RP Vincent
- Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust Denmark Hill, London, UK
| | - J Alaghband-Zadeh
- Department of Clinical Biochemistry, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - B Staels
- European Genomic Institute for Diabetes (EGID), Université Lille 2, Inserm UMR 1011, Institut Pasteur de Lille, Lille, France
| | - CW le Roux
- Diabetes Complications Research Center, Conway Institute, University College, Dublin, Ireland
| | - J Yu
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - B Laferrère
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Seeley RJ, Chambers AP, Sandoval DA. The role of gut adaptation in the potent effects of multiple bariatric surgeries on obesity and diabetes. Cell Metab 2015; 21:369-78. [PMID: 25662404 PMCID: PMC4351155 DOI: 10.1016/j.cmet.2015.01.001] [Citation(s) in RCA: 155] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bariatric surgical procedures such as vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) are the most potent treatments available to produce sustained reductions in body weight and improvements in glucose regulation. While traditionally these effects are attributed to mechanical aspects of these procedures, such as restriction and malabsorption, a growing body of evidence from mouse models of these procedures points to physiological changes that mediate the potent effects of these surgeries. In particular, there are similar changes in gut hormone secretion, bile acid levels, and composition after both of these procedures. Moreover, loss of function of the nuclear bile acid receptor (FXR) greatly diminishes the effects of VSG. Both VSG and RYGB are linked to profound changes in the gut microbiome that also mediate at least some of these surgical effects. We hypothesize that surgical rearrangement of the gastrointestinal tract results in enteroplasticity caused by the high rate of nutrient presentation and altered pH in the small intestine that contribute to these physiological effects. Identifying the molecular underpinnings of these procedures provides new opportunities to understand the relationship of the gastrointestinal tract to obesity and diabetes as well as new therapeutic strategies to harness the effectiveness of surgery with less-invasive approaches.
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Affiliation(s)
- Randy J Seeley
- Departments of Surgery and Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Adam P Chambers
- Department of Diabetes Pharmacology, Novo Nordisk, Copenhagen 2760 MÅLØV, Denmark
| | - Darleen A Sandoval
- Departments of Surgery and Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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Svane MS, Bojsen-Møller KN, Madsbad S, Holst JJ. Updates in weight loss surgery and gastrointestinal peptides. Curr Opin Endocrinol Diabetes Obes 2015; 22:21-8. [PMID: 25517025 DOI: 10.1097/med.0000000000000131] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are referred to as 'metabolic surgery' due to hormonal shifts with impacts on diabetes remission and weight loss. The purpose of this review is to summarize recent findings in mechanisms underlying beneficial effects of weight loss surgery. RECENT FINDINGS Importantly, gut hormone secretion is altered after RYGB and sleeve gastrectomy due to accelerated transit of nutrients to distal parts of the small intestine, leading to excessive release of L-cell peptide hormones [e.g. glucagon-like peptide-1 (GLP-1), peptide YY].Improved glucose metabolism after RYGB and sleeve gastrectomy involves several mechanisms: early increased hepatic insulin sensitivity, resulting from reduced liver fat content in response to the postoperative caloric restriction, improved beta-cell function mediated by exaggerated postprandial GLP-1 secretion; as demonstrated by relapse of impaired glucose tolerance in studies blocking the GLP-1 receptor by exendin 9-39, and later after major weight loss increased peripheral insulin sensitivity. Gut hormone secretion changes towards a more anorectic profile and is likely important for less caloric intake and weight loss. SUMMARY Changes in gut hormone secretion after RYGB and sleeve gastrectomy surgery induce the beneficial effects on weight and glycemic control through the influence on appetite regulation and insulin secretion.
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Affiliation(s)
- Maria Saur Svane
- aDepartment of Endocrinology, Hvidovre University Hospital, Hvidovre bDepartment of Biomedical Sciences and NNF Center for Basic Metabolic Research, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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