Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations

Perceptions of bariatric surgery in patients with type 2 diabetes: data from a self-administered questionnaire

BACKGROUND

Although bariatric surgery (BS) is recommended for patients with type 2 diabetes (T2D) and moderate to severe obesity, only approximately 2% of patients undergo surgery.

OBJECTIVE

To compare the knowledge and perception of BS with that of other treatments for diabetes among patients with diabetes.

SETTING

French social media platforms.

METHODS

A self-administered questionnaire was distributed from May 13 to June 3, 2020, via different French social media, including patients with T2D (main target), and patients with type 1 diabetes (control population). Different profiles of reluctance to BS were identified using a factorial analysis.

RESULTS

Of the 4481 responders (50.4% women, 33.9% aged over 65), 60% had T2D. Of the 1736 patients who had heard of BS (38.7%), 1493 declared they never addressed it with their physician. Among T2D patients, BS is the treatment that elicits the most negative response, with more than 10% showing reluctance. Four reluctance profiles were identified: (1) cluster 1 (43.4%), fear of consequences on their eating habits and irreversibility of the procedure; (2) cluster 2 (34.9%), fear of poorer diabetes control; (3) cluster 3 (9.3%), fear of surgical risk; and (4) cluster 4 (12.4%), fear of side effects. In all clusters, the opinion of their physician would be the most important factor to change their mind.

CONCLUSION

Bariatric surgery for T2D is rarely addressed in routine medical visits. Fear of operative risks and irreversibility of the procedure largely explains the reluctance to BS. Information and education campaigns on the benefit of metabolic surgery for patients with T2D remain necessary.

Global research trends of diabetes remission: a bibliometric study

Background

Research on diabetes remission has garnered prominence in recent years. However, to date, no pertinent bibliometric study has been published. This study sought to elucidate the current landscape and pinpoint potential new research directions through a bibliometric analysis of diabetes remission.

Methods

We perused relevant articles on diabetes remission from January 1, 2000, to April 16, 2023, in the Web of Science. We utilized CiteSpace software and VOSviewer software to construct knowledge maps and undertake analysis of countries, institutional affiliations, author contributions, journals, and keywords. This analysis facilitated the identification of current research foci and forecasting future trends.

Results

A total of 970 English articles were procured, and the annual publication volume manifested a steady growth trend. Most of the articles originated from America (n=342, 35.26%), succeeded by China and England. Pertaining to institutions, the University of Newcastle in England proliferated the most articles (n=36, 3.71%). Taylor R authored the most articles (n=35, 3.61%), and his articles were also the most co-cited (n=1756 times). Obesity Surgery dominated in terms of published articles (n=81, 8.35%). "Bariatric surgery" was the most prevalently used keyword. The keyword-clustering map revealed that the research predominantly centered on diabetes remission, type 1 diabetes, bariatric surgery, and lifestyle interventions. The keyword emergence and keyword time-zone maps depicted hotspots and shifts in the domain of diabetes remission. Initially, the hotspots were primarily fundamental experiments probing the feasibilities and mechanisms of diabetes remission, such as transplantation. Over the course, the research trajectory transitioned from basic to clinical concerning diabetes remission through bariatric surgery, lifestyle interventions, and alternative strategies.

Conclusion

Over the preceding 20 years, the domain of diabetes remission has flourished globally. Bariatric surgery and lifestyle interventions bestow unique advantages for diabetes remission. Via the maps, the developmental milieu, research foci, and avant-garde trends in this domain are cogently portrayed, offering guidance for scholars.

Diabetes Remission After LRYGBP With and Without Fundus Resection: a Randomized Clinical Trial

BACKGROUND

Glycemic control, after metabolic surgery, is achieved in two stages, initially with neuroendocrine alterations and in the long-term with sustainable weight loss. The resection of the gastric fundus, as the major site of ghrelin production, is probably related with optimized glucose regulation. The aim of the present study is to investigate whether the modification of laparoscopic Roux-en-Y gastric bypass (LRYGBP) with fundus resection offers superior glycemic control, compared to typical LRYGBP.

MATERIALS AND METHODS

Participants were 24 patients with body mass index (BMI) ≥40kg/m2 and type II diabetes mellitus (T2DM), who were randomly assigned to undergo LRYGBP and LRYGBP with fundus resection (LRYGBP+FR). Gastrointestinal (GI) hormones [ghrelin, glucagon-like-peptide-1 (GLP-1), peptide-YY (PYY)] and glycemic parameters (glucose, insulin, HbA1c, C-peptide, insulinogenic index, HOMA-IR) were measured preoperatively, at 6 and 12 months during an oral glucose tolerance test (OGTT).

RESULTS

Ninety-five percent of patients showed complete remission of T2DM after 12 months. LRYGBP+FR was not related with improved glycemic control, compared to LRYGBP. Ghrelin levels were not significantly reduced at 6 and 12 months after LRYGBP+FR. GLP-1 and PYY levels were remarkably increased postprandially in both groups at 6 and 12 months postoperatively (p<0.01). Patients who underwent LRYGBP+FR achieved a significantly lower BMI at 12 months in comparison to LRYGBP (p<0.05).

CONCLUSION

Fundus resection is not associated with improved glycemic regulation, compared to typical LRYGBP and the significant decrease in BMI after LRYGBP+FR has to be further confirmed with longer follow-up.

National usage of bariatric surgery for class I obesity: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program

BACKGROUND

National and international consensus statements, as well as the National Institutes of Health (NIH), support the use of bariatric surgery for the treatment of class I obesity. Despite this, most payors within the United States limit reimbursement to the outdated 1991 NIH guidelines or a similar adaptation.

OBJECTIVES

This study aimed to determine the safety of bariatric surgery in patients with lower BMI compared with standard patients, as well as determine U.S. utilization of bariatric surgery in class I obesity in 2015-2019.

SETTING

A retrospective analysis was performed of the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass patients were divided into body mass index cohorts: class I obesity (<35 kg/m2) and severe obesity (≥35 kg/m2). Differences in preoperative patient selection and postoperative outcomes were established, and frequency trends were delineated.

RESULTS

Analysis included 760,192 surgeries with 8129 (1%) for patients with class I obesity. The patients with class I obesity were older, more commonly female, and with lower American Society of Anesthesiologists (ASA) class, but with higher rates of type 2 diabetes, hyperlipidemia, and gastroesophageal reflux disease (P < .05). Variation was found for operative time, length of stay, 30-day readmission, and composite morbidity. Minimal annual variation was found for bariatric surgeries performed for patients with class I obesity.

CONCLUSIONS

The short-term safety of bariatric surgery in patients with class I obesity was corroborated by this study. Despite consensus statements and robust support, rates of bariatric surgery in patients with class I obesity have failed to increase and remain limited to 1%. This demonstrates the impact of the outdated 1991 NIH guidelines regarding access to care for these potentially life-saving surgeries.

Transforming Medical Paradigms: A Cutting-Edge Review of Genomic and Robotic Medical and Surgical Approaches in the Battle Against Diabetes, Hypertension, and Cardiovascular Issues

This article provides an in-depth review of the current state of management for diabetes, hypertension, and cardiovascular disease, focusing on advancements from genomics to robotics. It explores the role of genomic markers in personalized medicine, offering tailored treatment options for these chronic conditions. The article also examines the efficacy of various pharmacological and surgical interventions, including bariatric surgery for diabetes and device-based treatments for hypertension. A comparative analysis is presented to evaluate the cost-effectiveness and patient outcomes between medical and surgical approaches. The review concludes that while personalized medicine and minimally invasive surgical techniques show promise, more high-quality comparative research is needed. The ultimate goal is to integrate these emerging technologies within a framework of evidence-based medicine to improve patient outcomes and health equity.

Impact of Robotic Assistance on Complications in Bariatric Surgery at Expert Laparoscopic Surgery Centers: A Retrospective Comparative Study With Propensity Score

OBJECTIVE

To investigate the way robotic assistance affected rate of complications in bariatric surgery at expert robotic and laparoscopic surgery facilities.

BACKGROUND

While the benefits of robotic assistance were established at the beginning of surgical training, there is limited data on the robot's influence on experienced bariatric laparoscopic surgeons.

METHODS

We conducted a retrospective study using the BRO clinical database (2008-2022) collecting data of patients operated on in expert centers. We compared the serious complication rate (defined as a Clavien score≥3) in patients undergoing metabolic bariatric surgery with or without robotic assistance. We used a directed acyclic graph to identify the variables adjustment set used in a multivariable linear regression, and a propensity score matching to calculate the average treatment effect (ATE) of robotic assistance.

RESULTS

The study included 35,043 patients [24,428 sleeve gastrectomy (SG); 10,452 Roux-en-Y gastric bypass (RYGB); 163 single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S)], with 938 operated on with robotic assistance (801 SG; 134 RYGB; 3 SADI-S), among 142 centers. Overall, we found no benefit of robotic assistance regarding the risk of complications (average treatment effect=-0.05, P =0.794), with no difference in the RYGB+SADI group ( P =0.322) but a negative trend in the SG group (more complications, P =0.060). Length of hospital stay was decreased in the robot group (3.7±11.1 vs 4.0±9.0 days, P <0.001).

CONCLUSIONS

Robotic assistance reduced the length of stay but did not statistically significantly reduce postoperative complications (Clavien score≥3) following either GBP or SG. A tendency toward an elevated risk of complications following SG requires more supporting studies.

Laparoscopic Sleeve Gastrectomy With Transit Loop Bipartition and Transit Bipartition in Type 2 Diabetic Patients With Obesity: A Retrospective Analysis

AIM

We aimed to compare 1-year postoperative results of patients with obesity and type 2 diabetes mellitus (T2DM) who underwent laparoscopic sleeve gastrectomy with transit bipartition (LSG-TB) and transit loop bipartition (LSG-TLB) and mini gastric bypass (MGB).

PATIENTS AND METHODS

This is a retrospective comparison of 2 novel bariatric surgery techniques with MGB. Primary outcome measure of the study was a rate of T2DM remission. Secondary outcomes included excess body mass index (BMI) loss, improvement in hepatosteatosis, and duration of operation. Revision surgery needs were also assessed.

RESULTS

Overall, 32 patients underwent the LSG-TLB, 15 underwent LSG-TB, and 50 underwent MGB. Mean age and sex distribution were comparable for all groups. Presurgical BMI was similar in MGB and LSG + TB groups, whereas LSG + TLB group had significantly lower BMI values compared with the MGB group. In both groups, BMI values reduced significantly compared with respective baseline values. Excess BMI loss was significantly higher in patients who underwent LSG-TLB compared with patients treated with LSG-TB and MGB. Bariatric surgery procedures lasted shorter in LSG-TLB than in LSG-TB. However, the shortest of all was MGB. The remission of T2DM rates were 71% and 73.3% in LSG-TLB and LSG-TB groups, respectively ( P > 9.999). The rate of revision surgeries was comparable in both groups.

CONCLUSION

In conclusion, LSG-TLB took less time and provided significantly higher excess BMI loss compared with LSG-TB. T2DM remission and improvement rates were similar in both groups. LSG-TLB seemed like a promising bariatric surgery technique in patients with obesity and T2DM.

Benefits of bariatric surgery on microvascular outcomes in adult patients with type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Microvascular diabetes complications impair patients' health-related quality of life. Bariatric surgery (BS) emerged as a compelling treatment that demonstrated to have beneficial effects on patients with diabetes and obesity.

OBJECTIVE

We aimed to synthesize the benefit of bariatric surgery on microvascular outcomes in adult patients with type 2 diabetes.

SETTING

2011-2021.

METHODS

We included both cohort studies and randomized trials that evaluated bariatric surgery added to medical therapy compared with medical therapy alone in the treatment of adult patients with type 2 diabetes. Studies must have evaluated the incidence of any microvascular complication of the disease for a period of at least 6 months. We performed our search using PubMed, Scopus, EMBASE, Web of Science, and COCHRANE Central database which was performed from inception date until March 2021. PROSPERO (CRD42021243739).

RESULTS

A total of 25 studies (160,072 participants) were included. Pooled analysis revealed bariatric surgery to reduce the incidence of any stage of retinopathy by 71% (odds ratio [OR] .29; 95% confidence interval [CI] .10-.91), nephropathy incidence by 59% (OR .41; 95% CI 17-96), and hemodialysis/end-stage renal disease by 69% (OR .31 95% CI .20-.48). Neuropathy incidence revealed no difference between groups (OR .11; 95% CI .01-1.37). Bariatric surgery increased the odds of albuminuria regression by 15.15 (95% CI 5.96-38.52); higher odds of retinopathy regression were not observed (OR 3.73; 95% CI .29-47.71). There were no statistically significant differences between groups regarding the change in surrogate outcomes.

CONCLUSIONS

Bariatric surgery in adult patients with diabetes reduced the odds of any stage of retinopathy, hemodialysis/end-stage renal disease, and nephropathy composite outcome. However, its effect on many individual outcomes, both surrogates, and clinically significant, remains uncertain.

["Treatment of obesity - State of the art"]

According to WHO, overweight and obesity are responsible for more than 1,2 million deaths in Europe each year, representing >13% of the Region's total mortality. According to the 2022 Obesity Report, it will take significant effort to get people to adopt healthier lifestyles and be more physically active. Therapeutic measures in the context of an escalating stepwise approach should include strategies for a targeted weight reduction and long-term weight maintenance. An important health policy goal should be better access to these therapy options with an additional focus on primary prevention.

Mid-Long-Term Effect of Metabolic Surgery on Type 2 Diabetes in Nonobese Patients: a Meta-analysis

BACKGROUND

This study aimed to perform a meta-analysis regarding the mid-long-term effect (≥ 2-year follow-up) of metabolic surgery on T2DM in non-obese patients.

METHODS

PubMed, EMBASE and CENTRAL databases were searched for clinical studies from inception to March 2023. Stata 12.0 was used for data aggregation. Sensitivity, subgroup, and meta-regression analyses were performed when feasible.

RESULTS

This meta-analysis included 18 articles involving 548 patients. A pooled rate of 47.5% of T2DM remission was found after metabolic surgery. To be more specific, 83.5% was obtained for hemoglobin A1c (HbA1c) < 7.0%, 45.1% for HbA1c < 6.5%, and 40.4% for HbA1c < 6.0%. Subgroup analysis showed that one-anastomosis gastric bypass (OAGB) had a higher remission rate (93.9%) than other surgeries. Studies conducted in America had a higher remission rate (61.4%) than in Asia (43.6%). Meta-regression analysis displayed that publication year, number of patients, study design, preoperative age, BMI, and quality assessment score were not significantly associated with T2DM remission rate. Additionally, metabolic surgery could result in significant reductions in BMI (-4.133 kg/m2), weight (-9.874 kg), HbA1c (-1.939%), fasting blood glucose, fasting C-peptide, and fasting insulin. However, metabolic surgery seemed to have poorer glycemic control in non-obese than obese T2DM patients.

CONCLUSION

A moderate mid-long-term effect of T2DM remission was observed after metabolic surgery in non-obese patients. However, we still need more prospective multi-institutional studies using the same definitions for diabetes and the same surgical technique for the surgery. Without this, the exact role of bariatric surgery in non-obese patients is unanswered.

Incidence of Asymptomatic Gallstones in Obese Patients Who Underwent Bariatric Surgery in Qassim Region at King Fahad Specialist Hospital

BACKGROUND

Gallstone is a significant health issue in the KSA and other developing countries. Multiple important risk factors have been identified as being associated with gallstones. Obesity is one of the risk factors for gallstone formation. Therefore, this study intends to determine the incidence of asymptomatic gallstone disease among the obese population in the Qassim region. The purpose of this study is to determine the incidence of asymptomatic gallstone in obese patients and the risk factors that contribute to its development in the Qassim region. As well as to compare the prevalence of gallstone disease between age groups and genders.

METHODOLOGY

A retrospective study of all patients who underwent bariatric surgery and had gallstones between January 2018 and January 2022 at King Fahad Specialist Hospital in Qassim Region, Saudi Arabia. The data, including age, gender, body mass index (BMI), and co-morbidities, will be collected from their charts.  Results: The current study included 295 patients with a mean age of 34.83 years (SD = 11.7) and 126 (42.7%) male participants. The most common comorbidity was diabetes mellitus, which was present in 54 (18.4%) participants, followed by hypertension in 42 (14.3%) participants. Of the 295 participants, 232 (78.6%) had asymptomatic gallstones, while 63 (14.3%) patients were symptomatic. The results showed that younger people (16-25 years) had the highest odds ratio of having asymptomatic gallstones compared to the reference group (>55 years). Gender was also significantly associated with asymptomatic gallstones, with males having higher odds of having asymptomatic gallstones than females. Participants with comorbidities other than diabetes mellitus had lower odds of having asymptomatic gallstones.

CONCLUSION

The present study's main finding is that obese patients receiving bariatric surgery had a significant prevalence of comorbidities and asymptomatic gallstones. According to the results, diabetes mellitus, male gender, and younger age may all be risk factors for the occurrence of asymptomatic gallstones in this population.

Late Diabetes Relapse After Sleeve Gastrectomy Compared with Long-Term Remission: Characteristics and Cardiometabolic Outcomes

Background: Studies of the relapse of type 2 diabetes mellitus (T2D) after laparoscopic sleeve gastrectomy (LSG) are scarce. We assessed the rate of relapse 5 years after LSG, compared relapsed patients to their baseline and to those with remission, and explored the independent predictors of relapse. Methods: Retrospective analysis of 103 adults who underwent primary LSG at our institution between 2011 and 2015. Data retrieved comprised 23 pre-/postoperative demographic, anthropometric, biochemical, and clinical characteristics. Univariate and multivariate analyses assessed the predictors of relapse. Results: In total, 54% of our patients experienced relapse. Nevertheless, their anthropometric and metabolic profiles significantly improved compared to the values before surgery, reflecting better weight, glycemic, clinical, and biochemical control (P values ranged from 0.012 to <0.0001). These improvements were mirrored by significant increase in the proportion of relapsed patients meeting the American Diabetes Association treatment goals of hemoglobin A1c (HbA1c), blood pressure, high-density lipoprotein, and triglyceride at 5 years compared with the proportion before surgery (P = 0.027-0.008). In addition, the anthropometric and metabolic profiles of relapsed patients were not different compared to those of patients with long-term remission (P = 0.075-0.686), except for a significantly higher prevalence of dyslipidemia and number of diabetes medications among the relapsed group (P = 0.008 and <0.0001, respectively). Multivariate analysis showed that most of the predictors tested operated in the appropriate direction but fell short of statistical significance. Weight regain at 3 years did not predict relapse at 5 years. Conclusions: Relapse of T2D per se should not undervalue the overall long-term health benefits of LSG. Long-term monitoring of glycemic status after LSG is recommended.

Predictors of T2DM Remission after Bariatric Surgery in Patients with a BMI < 35 kg/m2: a Meta-Analysis

PURPOSE

Although a few studies have reported the predictors of postoperative diabetes remission in patients with body mass index (BMI) < 35 kg/m2, the conclusions are still inconsistent. This meta-analysis aimed to evaluate the preoperative clinical factors of type 2 diabetes mellitus (T2DM) remission after bariatric surgery.

MATERIALS AND METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched until April 2022. The Newcastle-Ottawa Scale was used for quality assessment. Statistical heterogeneity was assessed with the I2 statistic, followed by subgroup and sensitivity analyses.

RESULTS

16 studies involving 932 patients were selected. T2DM remission was negatively correlated with age, duration, insulin use, fasting plasma glucose, fasting insulin, and glycosylated hemoglobin levels. While BMI, body weight, waist circumference, and C-peptide levels were positive predictors of T2DM remission in patients with a BMI < 35 kg/m2. However, there was no significant association between gender, oral hypoglycemic agent, homeostasis model assessment, high-density lipoprotein, low-density lipoprotein, total cholesterol, triglycerides, systolic blood pressure, diastolic blood pressure, and remission rate.

CONCLUSION

Patients with younger age, short diabetes duration, more obesity, better glucose control, and better β cell function were more likely to achieve T2DM remission in patients with a BMI < 35 kg/m2 after bariatric surgery.

Use of SGLT2 inhibitors after bariatric/metabolic surgery: Risk/benefit balance

Bariatric/metabolic surgery and sodium-glucose cotransporter 2 inhibitors (SGLT2is) are becoming increasingly popular for the management of overweight/obese patients with type 2 diabetes mellitus (T2DM). Consequently, the chance that a patient undergoing bariatric/metabolic surgery is also treated with an SGLT2i would be rather common in clinical practice. Both risks and benefits have been reported. On the one hand, several cases of euglycemic diabetic ketoacidosis have been reported within the few days/weeks after bariatric/metabolic surgery. The causes are diverse but a drastic reduction in caloric (carbohydrate) intake most probably plays a crucial role. Thus, SGLT2is should be stopped a few days (and even more if a pre-operative restricted diet is prescribed to reduce liver volume) before the intervention and reintroduced only when the caloric (carbohydrate) intake is sufficient. On the other hand, SGLT2is may exert a favorable effect to reduce the risk of postprandial hypoglycemia, a complication reported among patients who have been treated with bariatric/metabolic surgery. An increased hepatic glucose production and a reduced production of interleukin-1β have been proposed as possible underlying mechanisms for this protective effect. Finally, whether SGLT2is could prolong diabetes remission following surgery and improve the prognosis of patients with T2DM who benefit from bariatric/metabolic surgery remains to be investigated.

Major Adverse Cardiovascular Events Among Obese Patients with Diabetes After Metabolic and Bariatric Surgery: a Meta-analysis of Matched Cohort and Prospective Controlled Studies with 122,361 Participates

PURPOSE

Metabolic and bariatric surgery (MBS) can exert effective function on glycemic control. The present study aimed to estimate the risk of MACE among obese patients with diabetes after MBS.

MATERIALS AND METHODS

Systematic search of PubMed, Embase, Medline, and Web of Science was performed for studies published before 20th February 2023. The odds ratio (OR) corresponding to the 95% confidence interval (95% CI) was used to assess the outcome. The statistical heterogeneity among studies was assessed with the Q-test and I2 statistics.

RESULTS

Fifteen cohort studies with 122,361 obese patients with diabetes were available for analysis. Our meta-analysis found significantly decreased morbidity and mortality of MACE (OR = 0.65, 95% CI = 0.59-0.72, I2 = 62.8% for morbidity, OR = 0.49, 95% CI = 0.36-0.67, I2 = 68.7% for mortality). Subgroup analysis revealed MBS decreased cerebrovascular disease, coronary artery disease, atrial fibrillation, heart failure, myocardial infarction, and stroke risk.

CONCLUSION

Our meta-analysis indicated that MBS for obese patients with diabetes is beneficial to decreasing MACE risk. Moreover, further studies estimating the functional effect may eventually provide a better and comprehensive understanding of the effect on different populations.

Induction of remission in diabetes by lowering blood glucose

As diabetes continues to grow as major health problem, there has been great progress in understanding the important role of pancreatic beta-cells in its pathogenesis. Diabetes develops when the normal interplay between insulin secretion and the insulin sensitivity of target tissues is disrupted. With type 2 diabetes (T2D), glucose levels start to rise when beta-cells are unable to meet the demands of insulin resistance. For type 1 diabetes (T1D) glucose levels rise as beta-cells are killed off by autoimmunity. In both cases the increased glucose levels have a toxic effect on beta-cells. This process, called glucose toxicity, has a major inhibitory effect on insulin secretion. This beta-cell dysfunction can be reversed by therapies that reduce glucose levels. Thus, it is becoming increasingly apparent that an opportunity exists to produce a complete or partial remission for T2D, both of which will provide health benefit.

Comprehensive Cardiovascular and Renal Protection in Patients with Type 2 Diabetes

Type 2 diabetes (T2DM) is one of the main public health care problems worldwide. It is associated with a marked increased risk of developing atherosclerotic vascular disease, heart failure, chronic kidney disease and death. It is essential to act during the early phases of the disease, through the intensification of lifestyle changes and the prescription of those drugs that have been shown to reduce these complications, with the aim not only of achieving an adequate metabolic control, but also a comprehensive vascular risk control. In this consensus document, developed by the different specialists that treat these patients (endocrinologists, primary care physicians, internists, nephrologists and cardiologists), a more appropriate approach in the management of patients with T2DM or its complications is provided. A particular focus is given to the global control of cardiovascular risk factors, the inclusion of weight within the therapeutic objectives, the education of patients, the deprescription of those drugs without cardiovascular benefit, and the inclusion of GLP-1 receptor agonists and SGLT2 inhibitors as cardiovascular protective drugs, at the same level as statins, acetylsalicylic acid, or renin angiotensin system inhibitors.

The role of the gastric fundus in glycemic control

PURPOSE

Ghrelin, one of the most studied gut hormones, is mainly produced by the gastric fundus. Abundant evidence exists from preclinical and clinical studies underlining its contribution to glucose regulation. In the following narrative review, the role of the gastric fundus in glucose regulation is summarized and we investigate whether its resection enhances glycemic control.

METHODS

An electronic search was conducted in the PubMed® database and in Google Scholar® using a combination of medical subject headings (MeSH). We examined types of metabolic surgery, including, in particular, gastric fundus resection, either as part of laparoscopic sleeve gastrectomy (LSG) or modified laparoscopic gastric bypass with fundus resection (LRYGBP + FR), and the contribution of ghrelin reduction to glucose regulation.

RESULTS

Fourteen human studies were judged to be eligible and included in this narrative review. Reduction of ghrelin levels after fundus resection might be related to early glycemic improvement before significant weight loss is achieved. Long-term data regarding the role of ghrelin reduction in glucose homeostasis are sparse.

CONCLUSION

The exact role of ghrelin in achieving glycemic control is still ambiguous. Data from human studies reveal a potential contribution of ghrelin reduction to early glycemic improvement, although further well-designed studies are needed.

What is Obesity?: Definition as a Disease, with Implications for Care

Advances in the understanding of weight regulation provide the framework for the recognition of obesity as a chronic disease. Lifestyle approaches are foundational in the prevention of obesity and should be continued while weight management interventions, including antiobesity medications and metabolic-bariatric procedures, are offered to eligible patients. Clinical challenges remain, however, including overcoming obesity stigma and bias within the medical community toward medical and surgical approaches, ensuring insurance coverage for obesity management (including medications and surgery), and promoting policies that reverse the upward worldwide trend in obesity and adiposity complications in populations.

Cost-effectiveness of metabolic surgery for the treatment of type 2 diabetes and obesity: a systematic review of economic evaluations

AIM

To systematically identify and appraise the international literature on the cost-effectiveness of metabolic surgery for the treatment of comorbid type 2 diabetes (T2D) and obesity.

METHODS

A systematic search was conducted in electronic databases and grey literature sources up to 20 January 2021. Economic evaluations in a T2D population or a subpopulation with T2D were eligible for inclusion. Screening, data extraction, critical appraisal of methodological quality (Consensus Health Economic Criteria list) and assessment of transferability (International Society for Pharmacoeconomics and Outcomes Research questionnaire) were undertaken in duplicate. The incremental cost-effectiveness ratio (ICER) was the main outcome. Costs were reported in 2020 Irish Euro. Cost-effectiveness was interpreted using willingness-to-pay (WTP) thresholds of €20,000 and €45,000/quality-adjusted life year (QALY). Due to heterogeneity arising from various sources, a narrative synthesis was undertaken.

RESULTS

Thirty studies across seventeen jurisdictions met the inclusion criteria; 16 specifically in a T2D population and 14 in a subpopulation with T2D. Overall, metabolic surgery was found to be cost-effective or cost-saving. Where undertaken, the results were robust to sensitivity and scenario analyses. Of the 30 studies included, 15 were considered high quality. Identified limitations included limited long-term follow-up data and uncertainty regarding the utility associated with T2D remission.

CONCLUSION

Published high-quality studies suggest metabolic surgery is a cost-effective or cost-saving intervention. As the prevalence of obesity and obesity-related diseases increases worldwide, significant investment and careful consideration of the resource requirements needed for metabolic surgery programmes will be necessary to ensure that service provision is adequate to meet demand.

Percentage of maximum weight lost as an optimal parameter of weight regain after bariatric surgery in Chinese patients with diabetes

OBJECTIVE

The goal of this study was to compare measures of weight regain (WR) and their association with the glucose metabolism deterioration within 3 years following bariatric surgery among Chinese patients with obesity and type 2 diabetes mellitus (T2DM).

METHODS

Among a retrospective cohort of 249 patients with obesity and T2DM who underwent bariatric surgery and were followed up to 3 years, WR was assessed by weight changes, BMI changes, percentage of presurgery weight, percentage of nadir weight, and percentage of maximum weight lost (%MWL). Glucose metabolism deterioration was defined as a change from an absence of antidiabetic medication use to use, or absence of insulin use to use, or an increase in glycated hemoglobin by at least 0.5% to 5.7% or greater.

RESULTS

A comparison of C-index of glucose metabolism deterioration indicated %MWL had better discriminatory ability versus weight change, BMI change, percentage of presurgery weight, or percentage of nadir weight (all p < 0.01). The %MWL also had the highest prediction accuracy. The optimal %MWL cutoff point was 20%.

CONCLUSIONS

Among Chinese patients with obesity and T2DM who underwent bariatric surgery, WR quantified as %MWL predicted 3-year postoperative glucose metabolism deterioration better than the alternatives; 20% MWL was the optimal cutoff point.

Future of bariatric surgery beyond simple weight loss: Metabolic surgery

Anatomical modifications implemented during bariatric surgery not only result in weight loss, but also lead to metabolic corrections that translate into better glycemia stability and improvement in cardiovascular and liver disorders. The logical extension of surgical indications beyond mere reduction of the body mass index (BMI) (i.e. patients with<35kg/m2) is a hot topic today in France and worldwide. Metabolic surgeries make use of multiple modalities (endoscopic, mini-invasive, invasive) that should be carried out by trained physicians and within the same type of multidisciplinary formation as that for bariatric surgery. The aim of this update is to describe the physiological mechanisms that result in the benefits of bariatric surgery, the various procedures currently available and the perspectives for this new field in visceral and digestive surgery.

Contemporary medical, device, and surgical therapies for obesity in adults

The goal of obesity management is to improve health. Sustained weight loss of more than 10% overall bodyweight improves many of the complications associated with obesity (eg, prevention and control of type 2 diabetes, hypertension, fatty liver disease, and obstructive sleep apnoea), as well as quality of life. Maintenance of weight loss is the major challenge of obesity management. Like all chronic diseases, managing obesity requires a long-term, multimodal approach, taking into account each individual's treatment goals, and the benefit and risk of different therapies. In conjunction with lifestyle interventions, anti-obesity medications and bariatric surgery improve the maintenance of weight loss and associated health gains. Most available anti-obesity medications act on central appetite pathways to reduce hunger and food reward. In the past 5 years, therapeutic advances have seen the development of targeted treatments for monogenic obesities and a new generation of anti-obesity medications. These highly effective anti-obesity medications are associated with weight losses of more than 10% of overall bodyweight in more than two-thirds of clinical trial participants. Long-term data on safety, efficacy, and cardiovascular outcomes are awaited. Long-term studies have shown that bariatric surgical procedures typically lead to a durable weight loss of 25% and rapid, sustained improvements in complications of obesity, although they have not yet been compared with new-generation highly effective anti-obesity medications. Further work is required to determine optimal patient-specific treatment strategies, including combinations of lifestyle interventions, anti-obesity medications, endoscopic and bariatric surgical procedures, and to ensure equitable access to effective treatments.

[Pharmacotherapy of obesity-Competition to bariatric surgery or a meaningful supplement?]

Obesity is a complex chronic disease and requires a long-term multimodal approach. The current treatment algorithm for treatment of obesity mainly consists of a stepwise approach, which starts with a lifestyle intervention followed by or combined with medication treatment, whereas bariatric surgery is often reserved for the last option. This article provides an overview of the currently available conservative medicinal treatment regimens and the currently approved medications as well as medications currently undergoing approval studies with respect to the efficacy and possible side effects. Special attention is paid to the importance of combination treatment of pharmacotherapy and surgery in the sense of a multimodal treatment. The data so far show that using a multimodal approach an improvement in the long-term weight loss and metabolic benefits can be achieved for the patients.

Current treatment landscape for obesity in Singapore

The rising prevalence of obesity in Singapore is a harbinger for a corresponding increase in obesity-related complications such as type 2 diabetes mellitus (T2DM) and coronary heart disease. Obesity is a complex disease driven by multiple factors, and hence, treatment cannot follow a 'one-size-fits-all' approach. Lifestyle modifications involving dietary interventions, physical activity and behavioural changes remain the cornerstone of obesity management. However, similar to other chronic diseases such as T2DM and hypertension, lifestyle modifications are often insufficient on their own, hence the importance of other treatment modalities including pharmacotherapy, endoscopic bariatric therapy and metabolic-bariatric surgery. Weight loss medications currently approved in Singapore include phentermine, orlistat, liraglutide and naltrexone-bupropion. In recent years, endoscopic bariatric therapies have evolved as an effective, minimally invasive and durable therapeutic option for obesity. Metabolic-bariatric surgery remains the most effective and durable treatment for patients with severe obesity, with an average weight loss of 25%-30% after one year.

Remission with an Intervention: Is Metabolic Surgery the Ultimate Solution?

Long-term remission of type 2 diabetes following lifestyle intervention or pharmacotherapy, even in patients with mild disease, is rare. Long-term remission following metabolic surgery however, is common and occurs in 23% to 98% depending on disease severity and type of surgery. Remission after surgery is associated with excellent glycemic control without reliance on pharmacotherapy, improvements in quality of life, and major reductions in microvascular and macrovascular complications. For patients with type 2 diabetes, early intervention with metabolic surgery, when beta cell function still remains intact, provides the greatest probability of long-term remission as high as 90% or more.

Precision Bariatric/Metabolic Medicine and Surgery

Indications and techniques of bariatric surgery (BS) have constantly evolved in recent decades and now face new challenges [...].

Health outcomes of patients with type 2 diabetes following bariatric surgery: Results from a publicly funded initiative

OBJECTIVE

Bariatric surgery is an effective treatment for type 2 diabetes and morbid obesity. This paper analyses the clinical and patient-reported outcomes of patients treated through the Bariatric Surgery Initiative, a health system collaboration providing bariatric surgery as a state-wide public service in Queensland, Australia.

RESEARCH DESIGN AND METHODS

A longitudinal prospective cohort study was undertaken. Eligible patients had type 2 diabetes and morbid obesity (BMI ≥ 35 kg/m2). Following referral by specialist outpatient clinics, 212 patients underwent Roux-en-Y gastric bypass or sleeve gastrectomy. Outcomes were tracked for a follow-up of 12-months and included body weight, BMI, HbA1c, comorbidities, health-related quality of life, eating behaviour, and patient satisfaction.

RESULTS

Following surgery, patients' average body weight decreased by 23.6%. Average HbA1c improved by 24.4% and 48.8% of patients were able to discontinue diabetes-related treatment. The incidence of hypertension, non-alcoholic steatohepatitis, and renal impairment decreased by 37.1%, 66.4%, and 62.3%, respectively. Patients' emotional eating scores, uncontrolled eating and cognitive restraint improved by 32.5%, 20.7%, and 6.9%, respectively. Quality of life increased by 18.8% and patients' overall satisfaction with the treatment remained above 97.5% throughout the recovery period.

CONCLUSIONS

This study confirmed previous work demonstrating the efficacy of publicly funded bariatric surgery in treating obesity, type 2 diabetes and related comorbidities, and improving patients' quality of life and eating behaviour. Despite the short follow-up period, the results bode well for future weight maintenance in this cohort.

Obesity in South and Southeast Asia-A new consensus on care and management

Obesity is a chronic disease in which the abnormal or excessive accumulation of body fat leads to impaired health and increased risk of mortality and chronic health complications. Prevalence of obesity is rising rapidly in South and Southeast Asia, with potentially serious consequences for local economies, healthcare systems, and quality of life. Our group of obesity specialists from Bangladesh, Brunei Darussalam, India, Indonesia, Malaysia, Philippines, Singapore, Sri Lanka, Thailand, and Viet Nam undertook to develop consensus recommendations for management and care of adults and children with obesity in South and Southeast Asia. To this end, we identified and researched 12 clinical questions related to obesity. These questions address the optimal approaches for identifying and staging obesity, treatment (lifestyle, behavioral, pharmacologic, and surgical options) and maintenance of reduced weight, as well as issues related to weight stigma and patient engagement in the clinical setting. We achieved consensus on 42 clinical recommendations that address these questions. An algorithm describing obesity care is presented, keyed to the various consensus recommendations.

Ghost Fat: Altered Female Body Perception After Bariatric Surgery

Body perception is an individual's ability to recognize their body in attitudinal and/or dimensional aspects. We investigated women's body perceptions before and after bariatric surgery. Participants were 31 women (M age = 36.23, SD = 7.95 years old) with an average pre-operative body mass index of 44.58 (SD = 4.65) kg/m². We collected anthropometric and body perception measures (attitudinal body image [ABI] and dimensional body image [DBI]) before bariatric surgery and 30, 60, 90, and 120 days after it. There was an average decrease of 21.09% in participants' body weight over the 120 days. Regarding ABI, 51.61% of participants had high body dissatisfaction before surgery, and this proportion of dissatisfied participants decreased to 3.23% 120 days after surgery. We observed no statistically significant differences in DBI perceptions. Fast weight loss caused by bariatric surgery appeared to generate a perception of ghost fat. Somatosensory interventions and/or a longer follow-up are needed to alter this persistent distortion of body dimensions.

Clinical pathways in the management of the obese: Pre- and postoperative aspects

INTRODUCTION

Bariatric surgery (BS) leads to substantial weight loss accompanied by reversal of several obesity-related co-morbidities and reduced mortality. However, surgery is associated with risks and its nearly irreversible characteristic requires a clearly established pre- and postoperative clinical pathway. In France, this pathway relies on recommendations made by the High Authority of Health (Haute Autorité de santé (HAS)) in 2009; an update is awaited in 2023.

PREOPERATIVE ASPECTS

BS should be proposed only after failure of well-conducted medical treatment and is intended for patients whose body mass index (BMI) is ≥40kg/m² or for those with BMI ≥35kg/m² who also have co-morbidities amenable to improvement, and in whom there are no contra-indications, particularly, those related to general anesthesia or psychological factors. The success and safety of surgical management requires preparation of the patient with regard to dietetic and nutritional counseling, and physical activity. The possibility of complications must be recognized and communicated, including, in view of the large variability of outcomes between individuals, the risk of failure and regain of weight.

POSTOPERATIVE ASPECTS

Prior to the operation, patients should be informed of and accept the program of postoperative clinical and laboratory follow-up, as well as the need for lifelong supplementation in micronutrients and the financial implications including what patients may have to pay out of their own pocket.

CONCLUSION

Surgical management of obesity cannot replace the multidisciplinary medical management of severe obesity. The results obtained by BS are sustainable only if the patient adheres to the proposed modalities. New drugs such a GLP-1 analogues have opened encouraging perspectives as possible alternatives to BS in certain indications.

Long-term impact of weight loss for people with overweight but not obesity, and with type 2 diabetes: 10-year outcomes of a randomized trial of gastric band surgery

AIM

Randomized trials reporting 5-year outcomes have shown bariatric surgery  to induce diabetes remission and improve cardiovascular risk. However, the longer-term effects of surgery are uncertain, with only one randomized trial reporting 10-year diabetes outcomes in people with obesity. We aimed to compare 10-year diabetes outcomes of people who are overweight but not obese, randomly assigned to receive either multidisciplinary diabetes care, or multidisciplinary diabetes care combined with gastric band (GB) surgery.

METHODS

Between 2009 and 2011, 51 adults were randomized. After 5 years, they were discharged to receive community care and reassessed after 10 years. The primary outcome was diabetes remission, defined as glycated haemoglobin (HbA1c) <6.5% (48 mmol/mol) without glucose-lowering medication.

RESULTS

Forty-one participants (20 medical and 21 GB) completed the 10-year assessment. The median (Q1, Q3) weight loss in the GB group was 9.8 (6.7, 16.3)% at 10 years compared with 5.6 (3.4, 7.6)% in the medical group (median difference 4.2%; p = .008). Diabetes remission occurred in five GB participants and no medical participants (relative risk 0.76, 95% CI: 0.55-0.93, p = .048). GB participants used fewer glucose-lowering medications at 10 years but HbA1c, fasting glucose, calculated cardiovascular risk, quality-of-life and incident diabetes complications did not differ significantly between the groups.

CONCLUSION

When compared with medical care, GB surgery achieved greater weight loss and modestly increased the likelihood of diabetes remission. However, it did not improve HbA1c, cardiovascular risk or quality of life.

Effect of Triglyceride-Glucose Indices and Circulating PCSK9-Associated Cardiovascular Risk in STEMI Patients with Primary Percutaneous Coronary Artery Disease: A Prospective Cohort Study

Background and Aims

This study aimed to determine whether convertase subtilisin/kexin type 9 (PCSK9)-associated cardiovascular risk is modulated by triglyceride-glucose (TyG) in ST-segment elevation myocardial infarction (STEMI) patients with primary percutaneous coronary disease (PCI).

Methods

A total of 1541 patients with STEMI (aged ≥18 years) undergoing primary PCI were consecutively enrolled between March 2017 and March 2019.

Outcomes

When stratifying the overall population according to TyG indices less than or greater than the median (TyG median = 9.07) as well as according to quartiles of PCSK9 levels, higher TyG index levels were significantly associated with all-cause mortality only when TyG levels were 9.07 or higher (ie, relative to quartile 1 [Q1], the adjusted HR for all-cause mortality was 3.20 [95% CI, 0.54-18.80] for Q2, p = 0.199; 7.89 [95% CI, 1.56-40.89] for Q3, p = 0.013; and 5.61 [95% CI, 1.04-30.30] for Q4, p = 0.045. During a median follow-up period of 1.96 years, the HR for all-cause mortality was higher in the subset of patients with TyG ≥median and PCSK9 ≥median (p for trend = 0.023) among those with type 2 diabetes mellitus (T2DM). However, there were no statistically significant differences among the subgroups. Among T2DM patients with a TyG index greater than the median, the Kaplan-Meier curve showed that patients with the highest PCSK9 levels had an increased risk of all-cause mortality (log-rank p = 0.017) and cardiac-cause mortality (log-rank p = 0.037) compared with lower PCSK9 quartile levels.

Conclusion

Elevated PCSK9 levels are related to all-cause mortality and cardiac-related mortality when TyG levels are greater than the median, but not when levels are less than the median. This suggests a potential benefit of lowering circulating PCSK9 levels in STEMI patients with insulin resistance.

Bariatric-metabolic surgery for NHS patients with type 2 diabetes in the United Kingdom National Bariatric Surgery Registry

AIM

Bariatric-metabolic surgery is approved by the National Institute of Health and Care Excellence (NICE) for people with severe obesity and type 2 diabetes (T2DM) (including class 1 obesity after 2014). This study analysed baseline characteristics, disease severity and operations undertaken in people with obesity and T2DM undergoing bariatric-metabolic surgery in the UK National Health Service (NHS) compared to those without T2DM.

METHODS

Baseline characteristics, trends over time and operations undertaken were analysed for people undergoing primary bariatric-metabolic surgery in the NHS using the National Bariatric Surgical Registry (NBSR) for 11 years from 2009 to 2019. Clinical practice before and after the publication of the NICE guidance (2014) was examined. Multivariate logistic regression was used to determine associations with T2DM status and the procedure undertaken.

RESULTS

14,948/51,715 (28.9%) participants had T2DM, with 10,626 (71.1%) on oral hypoglycaemics, 4322 (28.9%) on insulin/other injectables, and with T2DM diagnosed 10+ years before surgery in 3876 (25.9%). Participants with T2DM, compared to those without T2DM, were associated with older age (p < 0.001), male sex (p < 0.001), poorer functional status (p < 0.001), dyslipidaemia (OR: 3.58 (CI: 3.39-3.79); p < 0.001), hypertension (OR: 2.32 (2.19-2.45); p < 0.001) and liver disease (OR: 1.73 (1.58-1.90); p < 0.001), but no difference in body mass index was noted. Fewer people receiving bariatric-metabolic surgery after 2015 had T2DM (p < 0.001), although a very small percentage increase of those with class I obesity and T2DM was noted. Gastric bypass was the commonest operation overall. T2DM status was associated with selection for gastric bypass compared to sleeve gastrectomy (p < 0.001).

CONCLUSION

NHS bariatric-metabolic surgery is used for people with T2DM much later in the disease process when it is less effective. National guidance on bariatric-metabolic surgery and data from multiple RCTs have had little impact on clinical practice.

Changes in Eating Behaviors and Their Associations with Weight Loss in Japanese Patients Who Underwent Laparoscopic Sleeve Gastrectomy

BACKGROUND

Metabolic and bariatric surgery (MBS) has been established to provide long-term weight loss in severe obesity. In this study, we investigated the factors that affect post-operative weight loss, with a particular focus on changes in eating behaviors.

METHODS

Time-course changes in body weight and eating behaviors were examined in 49 Japanese patients who underwent laparoscopic sleeve gastrectomy from the first visit to 12 months after surgery. Each eating behavior was evaluated via the questionnaire of the Japan Society for the Study of Obesity.

RESULTS

Pre-operative weight reduction mediated by dietary and lifestyle interventions showed significant positive correlations with weight loss outcomes at 12 months after surgery. We observed significant decreases in scores for most of the eating behaviors 12 months after surgery. However, "emotional eating behavior" scores declined temporarily in the early post-operative period of one month but thereafter returned to the pre-operative level at 12 months. Furthermore, increases in the scores for "emotional eating behavior" and "sense of hunger" from 1 to 12 months post-operatively were significantly associated with poor weight loss.

CONCLUSIONS

Our results demonstrate the beneficial effects of MBS on obesity-related eating behaviors, as well as highlighting "emotional eating behavior" as requiring particular attention.

The development of machine learning in bariatric surgery

Background

Machine learning (ML), is an approach to data analysis that makes the process of analytical model building automatic. The significance of ML stems from its potential to evaluate big data and achieve quicker and more accurate outcomes. ML has recently witnessed increased adoption in the medical domain. Bariatric surgery, otherwise referred to as weight loss surgery, reflects the series of procedures performed on people demonstrating obesity. This systematic scoping review aims to explore the development of ML in bariatric surgery.

Methods

The study used the Preferred Reporting Items for Systematic and Meta-analyses for Scoping Review (PRISMA-ScR). A comprehensive literature search was performed of several databases including PubMed, Cochrane, and IEEE, and search engines namely Google Scholar. Eligible studies included journals published from 2016 to the current date. The PRESS checklist was used to evaluate the consistency demonstrated during the process.

Results

A total of seventeen articles qualified for inclusion in the study. Out of the included studies, sixteen concentrated on the role of ML algorithms in prediction, while one addressed ML's diagnostic capacity. Most articles (n = 15) were journal publications, whereas the rest (n = 2) were papers from conference proceedings. Most included reports were from the United States (n = 6). Most studies addressed neural networks, with convolutional neural networks as the most prevalent. Also, the data type used in most articles (n = 13) was derived from hospital databases, with very few articles (n = 4) collecting original data via observation.

Conclusions

This study indicates that ML has numerous benefits in bariatric surgery, however its current application is limited. The evidence suggests that bariatric surgeons can benefit from ML algorithms since they will facilitate the prediction and evaluation of patient outcomes. Also, ML approaches to enhance work processes by making data categorization and analysis easier. However, further large multicenter studies are required to validate results internally and externally as well as explore and address limitations of ML application in bariatric surgery.

14. Children and Adolescents: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

[Obesity and type 2 diabetes (Update 2023)]

The body mass index (BMI) is a very crude measure of body fatness in individuals. Even normal weight persons can have too much body fat in cases of a lack of muscle mass (sarcopenia), which is why additional measurements of waist circumference and body fatness, e.g. bioimpedance analysis (BIA), are recommended. Lifestyle management including nutrition modification and increase in physical activity are important measures for the prevention and treatment of diabetes. Regarding the treatment of type 2 diabetes, body weight is increasingly used as a secondary target parameter. The choice of anti-diabetic treatment and additional concomitant therapies is increasingly influenced by body weight. The importance of modern GLP‑1 agonists and dual GLP‑1 GIP agonists increases since these drugs target obesity and type 2 diabetes. Bariatric surgery is at present indicated with a BMI > 35 kg/m² with concomitant risk factors, such as diabetes and can lead at least to partial diabetes remission but has to be incorporated into an appropriate lifelong care concept.

Efficacy and Safety of One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass for Obesity: a Meta-analysis and Systematic Review

The objective of this review is to systematically review the efficacy and safety outcomes of one anastomosis gastric bypass (OAGB) with Roux-en-Y gastric bypass (RYGB). From inception to July 4, 2022, a systematic literature search was performed using PubMed, Embase, and Cochrane Library for randomized clinical trials comparing OAGB with RYGB in obesity. A meta-analysis performed using the RevMan 5.4.1 software evaluations was completed. We identified 1217 reports; after exclusions, eight trials with a total of 931 patients were eligible for analysis. Compared with RYGB, OAGB had multiple advantageous indexes. Examples include percent of excess weight loss (%EWL) at 12 months (P = 0.009), body mass index (BMI) at 2 years (P < 0.00001), early postoperative complication (P = 0.04), remission of dyslipidemia (P < 0.0001), and operative time (P < 0.00001). No significant statistical difference was observed in BMI at 6 months, %EWL at 6 months, BMI at 12 months, percent of excess body mass index loss (%EBMIL) at 2 years, BMI at 5 years, intraoperative complications, late postoperative complications, remission of type 2 diabetes mellitus, and dyslipidemia or gastroesophageal reflux disease remission between OAGB and RYGB. OAGB is no less effective than RYGB; no significant differences in weight loss efficacy were observed, and more large and long-term randomized controlled trials are needed to verify this. In addition, studies have shown that OAGB has a shorter operation time, fewer early postoperative complications, and a shorter learning curve, making it easier for young surgeons to perform.

Bariatric Surgery in Kidney Transplant Candidates and Recipients: Experience at an Asian Center

Background

Kidney transplant (KT) candidates and recipients with obesity experience more frequent complications such as infection, poorer allograft outcomes, diabetes, and mortality, limiting their eligibility for transplantation. Bariatric surgery (BS) is not commonly performed among KT patients given concerns about immunosuppression absorption, wound healing, infections, and graft outcomes. Its role has not been described before in an Asian KT patient setting.

Methods

A retrospective review of patients who underwent BS at the largest KT center in Singapore from 2008 to 2020 was conducted. Metabolic outcomes, immunosuppression doses, graft outcomes, and mortality were studied.

Results

Seven patients underwent BS and KT (4 underwent BS before KT, 3 underwent BS after KT; 4 underwent sleeve gastrectomy, 3 underwent gastric bypass). Mean total weight losses of 23.8% at 1 year and 18.6% at 5 years post-BS were achieved. Among the five patients with diabetes, glycemic control improved after BS. There were no deaths in the first 90 days or graft loss in the first year after KT and BS. Patients who underwent BS after KT had no significant changes in immunosuppression dose.

Conclusion

BS can be safely performed in KT recipients and candidates and results in sustainable weight losses and improvements in metabolic comorbidities. Although no major complications were observed in our study, close monitoring of this complex group of patients is imperative.

Higher magnesium levels are associated with better glycaemic control and diabetes remission post-bariatric surgery

BACKGROUND

Low Magnesium (Mg) dietary intake has been associated with increased risk of type 2 diabetes mellitus (T2DM). Furthermore, in patients with T2DM, hypomagnesemia is associated with worst glycaemic control. Bariatric surgery (BS) remains the most effective treatment in severe obesity and also provides resolution/improvement of T2DM. Our aim is to evaluate the association between Mg supplementation post-BS and Mg serum levels with diabetes status after BS.

METHODS

We performed an observational study on patients with obesity and T2DM who underwent BS. Data was assessed pre-BS and one-year post-BS.

RESULTS

We included a total of 403 patients with T2DM. At baseline, 43.4% of the patients had Mg deficiency. Pre-BS, patients with Mg deficiency had poorer glycaemic control - HbA1c 7.2 ± 1.6% vs 6.4 ± 1.0% (p < 0.001), fasting plasma glucose 146.2 ± 58.8 mg/dL vs 117.5 ± 36.6 mg/dL (p < 0.001) and were under a greater number of anti-diabetic drugs 1.0 (IQR 0-2.0) vs 1.0 (IQR 0-1.0) (p = 0.002). These findings persisted at one-year post-BS. At the first-year post-BS, 58.4% of the patients had total remission of T2DM and 4.1% had partial remission. Patients without Mg deficiency at one-year post-BS had higher rates of total and partial remission. Higher serum Mg levels at baseline is an independent predictor of total T2DM remission (p < 0.0001). The optimal cut-off of baseline Mg to predict total T2DM remission was 1.50 mg/dL with a sensitivity of 73% and a specificity of 58% (area under ROC = 0.65). Patients that were under Mg supplementation post-BS had serum Mg values, glycaemic control and total remission of T2DM similar to patients non-supplemented.

CONCLUSION

In patients with T2DM submitted to BS, higher Mg serum levels at baseline and 1-year after BS were associated with better glycaemic control and higher rates of total T2DM remission at the first year post-BS.

Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycaemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional healthcare team providing diabetes care in the USA and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the healthcare system and physical activity behaviours including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Changes of Guidelines in the Management of Obese Patients With Diabetes in the Metabolic Surgery Perspective

Recently, metabolic surgery was recommended for patients with a BMI of 30 or higher and 27.5 or higher for Asians, as evidence level A. Until 2008, bariatric surgery was not introduced for the treatment of diabetes. Bariatric surgery was first recommended for adults with body mass index ≥35 kg/m² and type 2 diabetes in the American Diabetes Association (ADA) guidelines as evidence level B in 2009. In 2017, the terminology was changed from bariatric surgery to metabolic surgery. How such large changes could have occurred in the ADA guidelines? Because many patients have reached diabetes remission through metabolic surgery, and the long-term benefit and cost-effectiveness have been strongly proven by historical randomized controlled trials and high-quality studies. This review demonstrates how the recommendations for the treatment of obesity in patients with diabetes have changed in diabetes treatment guidelines and summarizes the evidence behind this change.

Data assimilation on mechanistic models of glucose metabolism predicts glycemic states in adolescents following bariatric surgery

Type 2 diabetes mellitus is a complex and under-treated disorder closely intertwined with obesity. Adolescents with severe obesity and type 2 diabetes have a more aggressive disease compared to adults, with a rapid decline in pancreatic β cell function and increased incidence of comorbidities. Given the relative paucity of pharmacotherapies, bariatric surgery has become increasingly used as a therapeutic option. However, subsets of this population have sub-optimal outcomes with either inadequate weight loss or little improvement in disease. Predicting which patients will benefit from surgery is a difficult task and detailed physiological characteristics of patients who do not respond to treatment are generally unknown. Identifying physiological predictors of surgical response therefore has the potential to reveal both novel phenotypes of disease as well as therapeutic targets. We leverage data assimilation paired with mechanistic models of glucose metabolism to estimate pre-operative physiological states of bariatric surgery patients, thereby identifying latent phenotypes of impaired glucose metabolism. Specifically, maximal insulin secretion capacity, σ, and insulin sensitivity, SI, differentiate aberrations in glucose metabolism underlying an individual's disease. Using multivariable logistic regression, we combine clinical data with data assimilation to predict post-operative glycemic outcomes at 12 months. Models using data assimilation sans insulin had comparable performance to models using oral glucose tolerance test glucose and insulin. Our best performing models used data assimilation and had an area under the receiver operating characteristic curve of 0.77 (95% confidence interval 0.7665, 0.7734) and mean average precision of 0.6258 (0.6206, 0.6311). We show that data assimilation extracts knowledge from mechanistic models of glucose metabolism to infer future glycemic states from limited clinical data. This method can provide a pathway to predict long-term, post-surgical glycemic states by estimating the contributions of insulin resistance and limitations of insulin secretion to pre-operative glucose metabolism.

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional health care team providing diabetes care in the U.S. and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.