Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Type 2 Diabetes and Obesity

Compared with Controls, Bariatric Surgery Prevents Long-Term Mortality in Persons with Obesity Only Above Median Age of Cohorts: a Systematic Review and Meta-Analysis

PURPOSE

Compared to medical treatment, bariatric surgery reduces long-term mortality in persons with obesity. Some studies indicate that the effect only applies to patients above median age of cohorts, not to younger patients. Our objective was to assess the role of age in the reduction of mortality (global mortality and mortality for specific causes) through bariatric surgery.

MATERIALS AND METHODS

Data sources: PubMed, Cochrane Library, MEDLINE, and Embase.

STUDY SELECTION

studies reporting mortality in relation to median age of patients.

DATA EXTRACTION AND SYNTHESIS

pooled random effects of estimates of the risk of mortality in participants undergoing surgery compared with controls, as function of median age.

RESULTS

Mortality was lower in patients undergoing surgery than in controls (OR = 0.29, 95% CI 0.17-0.49). Below median age, the difference between surgery patients and controls was nonsignificant (OR = 0.78, 95% CI 0.57-1.06). Above median age, the difference was significant (OR = 0.23, 95% CI 0.12-0.44). In a subset of 5 studies, deaths due to various causes were less, and external causes-related deaths were more frequent in surgery than in controls. Below median age, deaths due to CVD were less frequent in surgery than in controls. Above median age, total deaths and deaths due to various causes (cardiovascular, diabetes, cancer, and other causes) were less in surgery than in controls. Publication bias was absent.

CONCLUSION

Compared with controls, bariatric surgery reduces long-term global mortality only above median age, not below median age. Also mortality due to specific causes is mainly reduced in persons above median age.

Transient postprandial increase in intact circulating fibroblast growth factor-21 levels after Roux-en-Y gastric bypass: a randomized controlled clinical trial

Background

Despite a consistent link between obesity and increased circulating levels of fibroblast growth factor-21 (FGF21), the effect of weight-loss interventions on FGF21 is not clear. We aimed to determine the short- and long-term effects of Roux-en-Y gastric bypass (RYGB) on intact plasma FGF21 levels and to test the hypothesis that RYGB, but not diet-induced weight loss, increases fasting and postprandial responses of FGF21.

Method

Twenty-eight participants with obesity followed a low-calorie diet for 11 weeks. The 28 participants were randomized to undergo RYGB surgery at week 8 (RYGB group, n = 14), or to a control group scheduled for surgery at week 12 (n = 14). Fasting levels of intact, biologically active FGF21 (amino acids 1-181) and its postprandial responses to a mixed meal were assessed at week 7 and 11, and 78 weeks (18 months) after RYGB.

Results

At week 11 (3 weeks after RYGB), postprandial responses of intact FGF21 were enhanced in participants undergoing surgery at week 8 (change from week 7 to 11: P = 0.02), whereas no change was found in non-operated control participants in similar negative energy balance (change from week 7 to 11: P = 0.81). However, no between-group difference was found (P = 0.27 for the group-week-time interaction). Fasting, as well as postprandial responses in intact FGF21, were unchanged 18 months after RYGB when both the RYGB and control group were collapsed together (change from week 7 to 78 weeks after RYGB: P = 0.17).

Conclusion

Postprandial intact FGF21 levels were enhanced acutely after RYGB whereas no signs of sustained changes were found 18 months after surgery. When comparing the acute effect of RYGB with controls in similar negative energy balance, we failed to detect any significant differences between groups, probably due to the small sample size and large inter-individual variations, especially in response to surgery.

Ockham's razor and the metabolic syndrome

The broad effects of bariatric/metabolic surgery on virtually every tissue and organ system remain unexplained. Weight loss, although a major factor, does not fully account for the rapid, full, and durable remission of type 2 diabetes, return of islet function, reduction of the prevalence of cancers, increase in gray matter of the brain, and decrease in all-cause mortality. This review supports the thesis that the metabolic syndrome is not a group of separate diseases but rather multiple expressions of a shared defect in the utilization of carbohydrates and lipids. That error is probably caused by a dysmetabolic signal from the foregut, stimulated by food, that limits entry of 2-carbon fragments into the tricarboxylic acid cycle, the accumulation of lactate and, in turn, increases in glucose and insulin. Surgery limits that signal by reducing contact between food and foregut mucosa. Speciation of that signal(s) may offer a new pathway for drug development.

Bariatric Surgery and Cardiovascular Outcomes in Patients With Obesity and Cardiovascular Disease:: A Population-Based Retrospective Cohort Study

BACKGROUND

Bariatric surgery has been shown to significantly reduce cardiovascular risk factors. However, whether surgery can reduce major adverse cardiovascular events (MACE), especially in patients with established cardiovascular disease, remains poorly understood. The present study aims to determine the association between bariatric surgery and MACE among patients with cardiovascular disease and severe obesity.

METHODS

This was a propensity score-matched cohort study using province-wide multiple-linked administrative databases in Ontario, Canada. Patients with previous ischemic heart disease or heart failure who received bariatric surgery were matched on age, sex, heart failure history, and a propensity score to similar controls from a primary care medical record database in a 1:1 ratio. The primary outcome was the incidence of extended MACE (first occurrence of all-cause mortality, myocardial infarction, coronary revascularization, cerebrovascular events, and heart failure hospitalization). Secondary outcome included 3-component MACE (myocardial infarction, ischemic stroke, and all-cause mortality). Outcomes were evaluated through a combination of matching via propensity score and subsequent multivariable adjustment.

RESULTS

A total of 2638 patients (n=1319 in each group) were included, with a median follow-up time of 4.6 years. The primary outcome occurred in 11.5% (151/1319) of the surgery group and 19.6% (259/1319) of the controls (adjusted hazard ratio [HR], 0.58 [95% CI, 0.48-0.71]; P<0.001). The association was notable for those with heart failure (HR, 0.44 [95% CI, 0.31-0.62]; P<0.001; absolute risk difference, 19.3% [95% CI, 12.0%-26.7%]) and in those with ischemic heart disease (HR, 0.60 [95% CI, 0.48-0.74]; P<0.001; absolute risk difference, 7.5% [95% CI, 4.7%-10.5%]). Surgery was also associated with a lower incidence of the secondary outcome (HR, 0.66 [95% CI, 0.52-0.84]; P=0.001) and cardiovascular mortality (HR, 0.35 [95% CI, 0.15-0.80]; P=0.001).

CONCLUSIONS

Bariatric surgery was associated with a lower incidence of MACE in patients with cardiovascular disease and obesity. These findings require confirmation by a large-scale randomized trial.

Association Between Bariatric Surgery and Major Adverse Diabetes Outcomes in Patients With Diabetes and Obesity

IMPORTANCE

There are high-quality randomized clinical trial data demonstrating the effect of bariatric surgery on type 2 diabetes remission, but these studies are not powered to study mortality in this patient group. Large observational studies are warranted to study the association of bariatric surgery with mortality in patients with type 2 diabetes.

OBJECTIVE

To determine the association between bariatric surgery and all-cause mortality among patients with type 2 diabetes and severe obesity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based matched cohort study included patients with type 2 diabetes and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) 35 or greater who underwent bariatric surgery from January 2010 to December 2016 in Ontario, Canada. Multiple linked administrative databases were used to define confounders, including age, baseline BMI, sex, comorbidities, duration of diabetes diagnosis, health care utilization, socioeconomic status, smoking status, substance abuse, cancer screening, and psychiatric history. Potential controls were identified from a primary care electronic medical record database. Data were analyzed in 2020.

EXPOSURE

Bariatric surgery (gastric bypass and sleeve gastrectomy) and nonsurgical management of obesity provided by the primary care physician.

MAIN OUTCOMES AND MEASURES

The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality and nonfatal morbidities. Groups were compared through a multivariable Cox proportional Hazards model.

RESULTS

A total of 6910 patients (mean [SD] age at baseline, 52.04 [9.45] years; 4950 [71.6%] women) were included, with 3455 patients who underwent bariatric surgery and 3455 match controls and a median (interquartile range) follow-up time of 4.6 (3.22-6.35) years. In the surgery group, 83 patients (2.4%) died, compared with 178 individuals (5.2%) in the control group (hazard ratio [HR] 0.53 [95% CI, 0.41-0.69]; P < .001). Bariatric surgery was associated with a 68% lower cardiovascular mortality (HR, 0.32 [95% CI, 0.15-0.66]; P = .002) and a 34% lower rate of composite cardiac events (HR, 0.68 [95% CI, 0.55-0.85]; P < .001). Risk of nonfatal renal events was also 42% lower in the surgical group compared with the control group (HR, 0.58 [95% CI, 0.35-0.95], P = .03). Of the groups that had the highest absolute benefit associated with bariatric surgery, men had an absolute risk reduction (ARR) of 3.7% (95% CI, 1.7%-5.7%), individuals with more than 15 years of diabetes had an ARR of 4.3% (95% CI, 0.8%-7.8%), and individuals aged 55 years or older had an ARR of 4.7% (95% CI, 3.0%-6.4%).

CONCLUSIONS AND RELEVANCE

These findings suggest that bariatric surgery was associated with reduced all-cause mortality and diabetes-specific cardiac and renal outcomes in patients with type 2 diabetes and severe obesity.

Management of Obesity in Adults with CKD

Obesity is a leading public health problem that currently affects over 650 million individuals worldwide. Although interest in the adverse effects of obesity has grown exponentially in recent years, less attention has been given to studying its management in individuals with CKD. This relatively unexplored area should be considered a high priority because of the rapid growth and high prevalence of obesity in the CKD population, its broad impact on health and outcomes, and its modifiable nature. This article begins to lay the groundwork in this field by providing a comprehensive overview that critically evaluates the available evidence related to obesity and kidney disease, identifies important gaps in our knowledge base, and integrates recent insights in the pathophysiology of obesity to help provide a way forward in establishing guidelines as a basis for managing obesity in CKD. Finally, the article includes a kidney-centric algorithm for management of obesity that can be used in clinical practice.

Relation of Bariatric Surgery to Inpatient Cardiovascular Outcomes (from the National Inpatient Sample)

Approximately one in 3 patients in the United States are obese. There is a strong association between obesity and an increased rate of cardiovascular disease (CVD)-related mortality. Bariatric surgery (BS) has emerged as an effective strategy to achieve reduction of excess weight. Our study aims to explore the relationship between BS and major adverse cardiovascular events (MACE) among obese hospitalized patients in the United States. This is a retrospective study of all obese adult patients with BMI ≥35 kg/m² (n= 1,700,943) in the National Inpatient Sample between 2012 and 2016. Differences in the clinical characteristics of obese patients with a history of BS versus obese patients without a history of BS were analyzed as well as the association between BS and MACE after adjusting for CVD risk factors. Among 50,296 obese patients with a history of BS (2.96%), the mean age was 53 ± 12 years with the majority being female (75.32%) and Caucasian (71.85%). Multivariate analysis revealed that obese patients with a history of BS had a1.6-fold decrease odds of MACE compared with patients without BS (OR 0.62; 95% CI, 0.60 to 0.65; p <0.001). In conclusion, this study illustrates that among obese patients with BMI ≥35 kg/m², history of BS was associated with a significantly lower odds of inpatient MACE, after adjusting for CVD risk factors.

Type 2 diabetes and metabolic surgery guidelines and recommendations should urgently be unified

Metabolic surgery has been studied in the last decades as an effective and safe treatment for type 2 diabetes (T2D), and randomized controlled trials generally found surgery superior when compared with medical treatment. In 2016, the DSS-II Joint Statement recognized the importance of metabolic surgery in the treatment of T2D and urged clinicians to discuss, recommend, or at least consider this procedure for their patients. Diabetes societies also cogitate metabolic surgery as an option for T2D patients in their guidelines. However, there are some differences in recommendations that could lead a careful reader to some confusion. This was potentialized in a recent document published by the same DSS-II group concerning prioritization for surgery after the COVID-19 pandemic, in which the criteria suggested for an expedited recommendation that is not exactly evidence-based, and collided substantially with several clinical guidelines worldwide, especially with regard to secondary prevention of cardiovascular disease. A more harmonious discussion and unified guidelines between clinicians and surgeons are needed in order to provide the same message for those who read different articles.

Cardiovascular Risk Reduction Following Metabolic and Bariatric Surgery

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality in developed countries, with worsening pandemics of type 2 diabetes mellitus and obesity as major cardiovascular (CV) risk factors. Clinical trials of nonsurgical obesity treatments have not shown benefits in CVD, although recent diabetes trials have demonstrated major CV benefits. In many retrospective and prospective cohort studies, however, metabolic (bariatric) surgery is associated with substantial and reproducible CVD benefits. Despite a lack of prospective, randomized clinical trials, data suggest metabolic surgery may be the most effective modality for CVD risk reduction, likely through weight loss and weight loss-independent mechanisms.

Sex Differences of Kidney Stone Urine Risk Factors after Roux-en-Y Gastric Bypass

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is a bariatric surgical procedure that is associated with higher risk of kidney stones after surgery. We examined urine composition in 18 men and women before and after RYGB to examine differences in kidney stone risk.

METHODS

Three 24-h urine collections were performed before and 1 year after RYGB. We analyzed mean urinary values for pre- and post-RYGB collections and compared men and women.

RESULTS

Seven men and eleven women completed pre- and post-RYGB urine collections. Pre-RYGB, men had higher calcium oxalate supersaturation (CaOx SS) (7.0 vs. 5.0, p = 0.04) compared with women. Post-RYGB, women had higher urine CaOx SS (13.1 vs. 4.6, p = 0.002), calcium phosphate supersaturation (1.04 vs. 0.59, p = 0.05), and lower urine volumes (1.7 vs. 2.7L, p < 0.001) compared with men.

DISCUSSION/CONCLUSION

There are important differences in urine composition by sex that may contribute to higher kidney stone risk in women after RYGB compared with men.

Potential Effects of Bariatric Surgery on the Incidence of Heart Failure and Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus and Obesity and on Mortality in Patients With Preexisting Heart Failure: A Nationwide, Matched, Observational Cohort Study

Background

Obesity and diabetes mellitus are strongly associated with heart failure (HF) and atrial fibrillation (AF). The benefits of bariatric surgery on cardiovascular outcomes are known in people with or without diabetes mellitus. Surgical treatment of obesity might also reduce the incidence of HF and AF in individuals with obesity and type 2 diabetes mellitus (T2DM).

Methods and Results

In this register‐based nationwide cohort study we compared individuals with T2DM and obesity who underwent Roux‐en‐Y gastric bypass surgery with matched individuals not treated with surgery. The main outcome measures were hospitalization for HF and/or AF and mortality in patients with preexisting HF. We identified 5321 individuals with T2DM and obesity who had undergone Roux‐en‐Y gastric bypass surgery between January 2007 and December 2013 and 5321 matched controls. The individuals included were 18 to 65 years old and had a body mass index >27.5 kg/m². The follow‐up time for hospitalization was until the end of 2015 (mean 4.5 years) and the end of 2016 for death. Our results show a 73% lower risk for HF (hazard ratio [HR], 0.27; CI, 0.19–0.38), 41% for AF (HR, 0.59; CI, 0.44–0.78), and 77% for concomitant AF and HF (HR, 0.23; CI, 0.12–0.46) in the surgically treated group. In patients with preexisting HF we observed significantly lower mortality in the group who underwent surgery (HR, 0.23; 95% CI, 0.12–0.43).

Conclusions

Bariatric surgery may reduce risk for HF and AF in patients with T2DM and obesity, speculatively via positive cardiovascular and renal effects. Obesity treatment with surgery may also be a valuable alternative in selected patients with T2DM and HF.

Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients

BACKGROUND

Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases.

OBJECTIVES

To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG.

SETTING

Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center.

METHODS

EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)-guided deployment of DPS or lumen apposing metal stents.

RESULTS

A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818).

CONCLUSION

Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.

Prevention and treatment of nutritional complications after bariatric surgery

Obesity and the corresponding burden of related diseases is a major public health issue worldwide that is reaching pandemic proportions. Bariatric surgery is the only intervention that has been shown to result in substantial and lasting weight loss, and a decrease in overall mortality for patients with severe obesity. Consequently, the population of patients having undergone this procedure is increasing. Multifactorial weight-dependent and independent mechanisms underlying metabolic diseases could also drive preventable, but potentially life-threatening, long-term nutritional complications. However, given post-bariatric patients are prone to functional gastrointestinal symptoms and substantial weight loss, nutritional complications might be challenging. This Review is focused on the prevention and treatment of nutritional complications after bariatric surgery in the clinical setting.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Bariatric Surgery and Long-term Survival in Patients With Obesity and End-stage Kidney Disease

Importance

Obesity rates in patients with end-stage kidney disease are rising, contribute to excess morbidity, and limit access to kidney transplant. Despite this, there continues to be controversy around the use of bariatric surgery in this patient population.

Objective

To determine whether bariatric surgery is associated with improvement in long-term survival among patients with obesity and end-stage kidney disease.

Design, Setting, and Participants

Retrospective cohort study and secondary analysis of previously collected data from the United States Renal Data System registry (2006-2015). We used Cox proportional hazards analysis to evaluate differences in outcomes for patients receiving bariatric surgery (n = 1597) compared with a matched cohort of nonsurgical patients (n = 4750) receiving usual care. Data were analyzed between September 3, 2019, and November 13, 2019.

Exposure

Receipt of bariatric surgery.

Main Outcomes and Measures

All-cause mortality at 5 years. Secondary outcomes included disease-specific mortality and incidence of kidney transplant.

Results

Surgical and nonsurgical control patients had similar age, demographics, and comorbid disease burden. The mean (SD) age was 49.8 (11.2) years for surgical patients vs 51.7 (11.1) years for nonsurgical patients. Six hundred fifteen surgical patients (38.5%) were black vs 1833 nonsurgical patients (38.6%). Surgery was associated with lower all-cause mortality at 5 years compared with usual care (cumulative incidence, 25.6% vs 39.8%; hazard ratio, 0.69, 95% CI, 0.60-0.78). This was driven by lower mortality from cardiovascular causes at 5 years for patients undergoing bariatric surgery compared with nonsurgical control patients (cumulative incidence, 8.4% vs 17.2%; hazard ratio, 0.51; 95% CI, 0.41-0.65). Bariatric surgery was also associated with an increase in kidney transplant at 5 years (cumulative incidence, 33.0% vs 20.4%; hazard ratio, 1.82; 95% CI, 1.58-2.09). However, at 1 year, bariatric surgery was associated with higher all-cause mortality compared with usual care (cumulative incidence, 8.6% vs 7.7%; hazard ratio, 1.45; 95% CI, 1.13-1.85).

Conclusions and Relevance

Among patients with obesity and end-stage kidney disease, bariatric surgery was associated with lower all-cause mortality compared with usual care. Bariatric surgery was also associated with an increase in kidney transplant. Bariatric surgery may warrant further consideration in the treatment of patients with obesity and end-stage kidney disease.

Metabolic surgery: A clinical update

Metabolic and bariatric surgery has grown beyond 'experimental' weight-loss surgery. As techniques have advanced over the last few decades, so has the growing body of research and evidence, proving that both weight-loss and metabolic health improvement are induced. Metabolic surgery has become the more appropriate term for weight-loss surgery because of the altered gastrointestinal anatomy and subsequent beneficial metabolic effects. Although the tool of metabolic surgery has been well refined, a large portion of the global population does not have adequate access to it. This clinical update aims to (a) inform healthcare providers from all disciplines about the myriad of benefits of metabolic surgery and (b) equip them with the necessary knowledge to bridge the gap between patients in need of metabolic treatment and the therapies in metabolic surgery available to them.

Obesity as a multisystem disease: Trends in obesity rates and obesity-related complications

Obesity is a chronic multisystem disease associated with increased morbidity and mortality. The increasing prevalence of obesity makes it a major healthcare challenge across both developed and developing countries. Traditional measures such as body mass index do not always identify individuals at increased risk of comorbidities, yet continue to be used in deciding who qualifies for weight loss treatment. A better understanding of how obesity is associated with comorbidities, in particular non-metabolic conditions, is needed to identify individuals at risk in order to prioritize treatment. For metabolic disorders such as type 2 diabetes (T2D), weight loss can prevent T2D in individuals with prediabetes. It can improve and reverse T2D if weight loss is achieved early in the course of the disease. However, access to effective weight loss treatments is a significant barrier to improved health for people with obesity. In the present paper, we review the rising prevalence of obesity and why it should be classed as a multisystem disease. We will discuss potential mechanisms underlying its association with various comorbidities and how these respond to treatment, with a particular focus on cardiometabolic disease, malignancy and mental health.

Association of Bariatric Surgery with Clinical Outcomes of SARS-CoV-2 Infection: a Systematic Review and Meta-analysis in the Initial Phase of COVID-19 Pandemic

Introduction

Obesity worsens clinical outcomes of coronavirus disease 2019 (COVID-19). The aim of this study was to measure the association between history of bariatric surgery and the severity of COVID-19.

Methods

Data source included PubMed/MEDLINE, Scopus, Google Scholar, and pre-print servers between January and November 1, 2020. Literature was screened and selected to extract the relevant data. The two outcomes of this meta-analysis were the difference in mortality and hospitalization rates in patients with SARS-CoV-2 infection with and without history of bariatric surgery. Random-effect models were used to estimate the pooled effects.

Results

The systematic review yielded 3 retrospective studies on 9022 patients. The risk of mortality without previous bariatric surgery was 133 per 1000 cases and its risk with previous bariatric surgery was 33 per 1000 (summary OR 0.22, 95% CI 0.19–0.26). No heterogeneity was observed between the included studies (I² = 0%, P = 0.98 for heterogeneity). In the pooled analysis, the hospitalization rate in patients without previous bariatric surgery was 412 per 1000 cases and its rate in patients with previous bariatric surgery was 164 per 1000 (summary OR 0.28, 95% CI 0.12–0.65). No heterogeneity was observed between the included studies (I² = 0%, P = 0.71 for heterogeneity). There was a substantial risk of bias across the studies for confounding and selection bias.

Conclusion

Findings of this meta-analysis of observational studies suggest that prior bariatric surgery is associated with a lower rate of mortality and hospital admission in patients with obesity who become infected with SARS-CoV-2. Confirmation of these findings will require larger studies with better quality data.

Predictors of change in cardiovascular disease risk and events following gastric bypass: a 7-year prospective multicenter study

BACKGROUND

Change in short-term (i.e., 10-year) and lifetime risk of cardiovascular disease (CVD) following Roux-en-Y gastric bypass (RYGB) has significant heterogeneity.

OBJECTIVE

To identify predictors of change in CVD risk and cardiovascular events following RYGB.

METHODS

Between 2006-2009, 1625 adults without a history of CVD enrolled in a prospective cohort study and underwent RYGB at 1 of 10 U.S. hospitals. Participants were followed annually for a maximum of 7 years. Associations between presurgery characteristics (anthropometric, sociodemographic, physical and mental health, alcohol/drug use, eating behaviors) and 1) pre to postsurgery change in 10 year and lifetime atherosclerotic CVD (ASCVD) risk scores, respectively, and 2) having a CVD event (nonfatal myocardial infarction, stroke, ischemic heart disease, congestive heart failure, angina, percutaneous coronary intervention, coronary artery bypass grafting, or CVD-attributed death) as repeated measures (yr 1-7) were evaluated.

SETTING

Observational cohort study at ten hospitals throughout the United States.

RESULTS

Presurgery factors independently associated with decreases in both 10-year and lifetime risk scores 1-7 years post-RYGB were higher CVD risk score, female sex, higher household income, and normal kidney function. Additionally, Black race and having diabetes were independently associated with decreases in 10-year risk, while not having diabetes and a higher (better) composite mental health score were independently related to decreases in lifetime risk. A lower (worse) presurgery composite physical health score was associated with a higher CVD event risk (RR = 1.68, per 10 points).

CONCLUSION

This study identified multiple presurgery factors that characterize patients who may have more cardiovascular benefit from RYGB, and patients who might require additional support to improve their cardiovascular health.

8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical 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 (https://doi.org/10.2337/dc21-SPPC), 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, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Sex and ethnic differences in the cardiovascular complications of type 2 diabetes

Diabetes mellitus represents a global health concern affecting 463 million adults and is projected to rapidly rise to 700 million people by 2045. Amongst those with type 2 diabetes (T2D), there are recognised differences in the impact of the disease on different sex and ethnic groups. The relative risk of cardiovascular complications between individuals with and without T2D is higher in females than males. People of South Asian heritage are two to four times more likely to develop T2D than white people, but conversely not more likely to experience cardiovascular complications. Differences in the pathophysiological responses in these groups may identify potential areas for intervention beyond glycaemic control. In this review, we highlight key differences of diabetes-associated cardiovascular complications by sex and ethnic background, with a particular emphasis on South Asians. Evidence assessing therapeutic efficacy of new glucose lowering drugs in minority groups is limited and many major cardiovascular outcomes trials do not report ethnic specific data. Conversely, lifestyle intervention and bariatric surgery appear to have similar benefits regardless of sex and ethnic groups. We encourage future studies with better representation of women and ethnic minorities that will provide valuable data to allow better risk stratification and tailored prevention and management strategies to improve cardiovascular outcomes in T2D.

The COVID-19 Pandemic Did Not Affect Target Weight Loss 1 Year Post Bariatric Surgery

BACKGROUND

Bariatric surgery is one of the most effective treatments for patients with severe and complex obesity. Lifestyle modifications in diet and exercise habits have long been important adjunct to the long-term success after bariatric surgery. The effect of the COVID-19 pandemic on the postoperative bariatric patient is not well understood. We sought to evaluate the impact the COVID-19 pandemic on postoperative weight loss at 1 year in a bariatric cohort.

METHODS

All patients who underwent bariatric surgery from January 1, 2020, to March 12, 2020, were included. Patients who underwent bariatric surgery during the same period of the two preceding years (2018 and 2019) were included as control groups. Primary end point was %EBMIL at 1 year. A telephone survey was administered to all patients from 2020 to assess for their perception on the effects of the COVID-19 pandemic on weight loss.

RESULTS

A total of 596 patients were included: 181 from 2020, 199 from 2019, and 216 from 2018. The response rate was 97% and 53.4% of patients reported that the lockdown affected their ability to lose weight. The %EBMIL at 1 year was 64.1%, 63.7%, and 68.1% for 2020, 2019, and 2018, respectively. There was no difference in weight loss at 1 year (p = 0.77) despite a decrease in exercise activity in those who had surgery just before the pandemic.

CONCLUSION

There was no difference in target weight loss at 1 year in a cohort who underwent bariatric surgery before the pandemic.

Risk Factors for Kidney Stone Formation following Bariatric Surgery

Kidney stones are painful, common, and increasing in incidence. Obesity and bariatric surgery rates are also on the rise in the United States. Although bariatric surgery is associated with improvements in metabolic outcomes, malabsorptive bariatric surgery procedures are also associated with increased risk of kidney stones. Restrictive bariatric surgeries have not been associated with kidney-stone risk. Higher risk of kidney stones after malabsorptive procedures is associated with postsurgical changes in urine composition, including high urine oxalate, low urine citrate, and low urine volume. Certain dietary recommendations after surgery may help mitigate these urine changes and reduce risk of kidney stones. Understanding risk of kidney stones after surgery is essential to improving patient outcomes after bariatric surgery.

Sleeve gastrectomy enables simultaneous pancreas and kidney transplantation in severely obese recipients

BACKGROUND

Obesity adversely affects wait-listing and precludes patients with concomitant end-stage renal disease and type 1 diabetes mellitus from getting a simultaneous pancreas and kidney transplantation (SPK).

OBJECTIVE

To analyze safety and efficacy of laparoscopic sleeve gastrectomy (LSG) before SPK in severely obese type I diabetics.

METHODS

We assessed weight curve, complications, and graft function of three patients who underwent LSG before SPK.

RESULTS

LSG was uneventful in all patients. Body mass index dropped from 38.4 (range 35.7 - 39.9) before LSG to 28.5 (26.8 - 30.9) until SPK, with a mean loss of 25.8% (22.4 - 32.3). Interval between LSG and SPK was 364.3 (173 - 587) days. Pancreas and kidney graft function was excellent, with 100% insulin-free and dialysis-free survival over a mean follow-up of 3.6 (2.9 - 4.5) years. A1C dropped from 7% (6.3 - 8.2) before LSG to 4.9% (4.7 - 5.3) and 4.8% (4.5 - 5.1) 1 and 2 years after SPK, respectively.

CONCLUSION

LSG before SPK is safe and effective to enable severely obese type I diabetics to receive a lifesaving transplant. This is the first study analyzing the role of bariatric surgery before simultaneous pancreas and kidney transplantation.

Lower Mortality and Morbidity with Low-Molecular-Weight Heparin for Venous Thromboembolism Prophylaxis in Spine Trauma

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

The objective of this study was to evaluate outcomes between patients receiving LMWH versus UH in a retrospective cohort of patients with spine trauma.

SUMMARY OF BACKGROUND DATA

Although multiple clinical trials have been conducted, current guidelines do not have enough evidence to suggest low-molecular-weight heparin (LMWH) or unfractionated heparin (UH) for venous thromboembolism (VTE) prophylaxis in spine trauma.

METHODS

Patients with spine trauma in the Trauma Quality Improvement Program datasets were identified. Those who died, were transferred within 72 hours, were deemed to have a fatal injury, were discharged within 24 hours, suffered from polytrauma, or were missing data for VTE prophylaxis were excluded. A propensity score was created using age, sex, severity of injury, time to prophylaxis, presence of a cord injury, and altered mental status or hypotension upon arrival, and inverse probability weighted logistic regression modeling was used to evaluate mortality, venous thromboembolic, return to operating room, and total complication rates. E values were used to calculate the likelihood of unmeasured confounders.

RESULTS

Those receiving UH (n = 7172) were more severely injured (P < 0.0001), with higher rates of spinal cord injury (32.26% vs. 25.32%, P < 0.0001) and surgical stabilization (29.52% vs. 22.94%, P < 0.0001) compared to those receiving LMWH (n = 20,341). Patients receiving LMWH had lower mortality (odds ratio [OR]: 0.47; 95% CI: 0.42-0.53; P < 0.001; E = 3.68), total complication (OR: 0.92; 95% CI: 0.88-0.95; P < 0.001; E = 1.39), and VTE event (OR: 0.80; 95% CI: 0.72-0.88; P < 0.001; E = 1.81) rates than patients receiving UH. There were no differences in rates of unplanned return to the operating room (OR: 1.01; 95% CI: 0.80-1.27; P = 0.93; E = 1.11).

CONCLUSION

There is an association between lower mortality and receiving LMWH for VTE prophylaxis in patients with spine trauma. A large randomized clinical trial is necessary to confirm these findings.

LEVEL OF EVIDENCE

3.

Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

This guideline will provide the practicing endocrinologist with an approach to the assessment and treatment of dyslipidemia in patients with endocrine diseases, with the objective of preventing cardiovascular (CV) events and triglyceride-induced pancreatitis. The guideline reviews data on dyslipidemia and atherosclerotic cardiovascular disease (ASCVD) risk in patients with endocrine disorders and discusses the evidence for the correction of dyslipidemia by treatment of the endocrine disease. The guideline also addresses whether treatment of the endocrine disease reduces ASCVD risk.

CONCLUSION

This guideline focuses on lipid and lipoprotein abnormalities associated with endocrine diseases, including diabetes mellitus, and whether treatment of the endocrine disorder improves not only the lipid abnormalities, but also CV outcomes. Based on the available evidence, recommendations are made for the assessment and management of dyslipidemia in patients with endocrine diseases.

Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity

Background

Obesity is a risk factor for poor clinical outcomes in patients with coronavirus disease 2019 (COVID-19).

Objectives

To investigate the relationship between prior metabolic surgery and the severity of COVID-19 in patients with severe obesity.

Setting

Cleveland Clinic Health System in the United States.

Methods

Among 4365 patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 8, 2020 and July 22, 2020 in the Cleveland Clinic Health System, 33 patients were identified who had a prior history of metabolic surgery. The surgical patients were propensity matched 1:10 to nonsurgical patients to assemble a cohort of control patients (n = 330) with a body mass index (BMI) ≥ 40 kg/m² at the time of SARS-CoV-2 testing. The primary endpoint was the rate of hospital admission. The exploratory endpoints included admission to the intensive care unit (ICU), need for mechanical ventilation and dialysis during index hospitalization, and mortality. After propensity score matching, outcomes were compared in univariate and multivariate regression models.

Results

The average BMI of the surgical group was 49.1 ± 8.8 kg/m² before metabolic surgery and was down to 37.2 ± 7.1 at the time of SARS-CoV-2 testing, compared with the control group’s BMI of 46.7 ± 6.4 kg/m². In the univariate analysis, 6 (18.2%) patients in the metabolic surgery group and 139 (42.1%) patients in the control group were admitted to the hospital (P = .013). In the multivariate analysis, a prior history of metabolic surgery was associated with a lower hospital admission rate compared with control patients with obesity (odds ratio, 0.31; 95% confidence interval, 0.11−0.88; P = .028). While none of the 4 exploratory outcomes occurred in the metabolic surgery group, 43 (13.0%) patients in the control group required ICU admission (P = .021), 22 (6.7%) required mechanical ventilation, 5 (1.5%) required dialysis, and 8 (2.4%) patients died.

Conclusion

Prior metabolic surgery with subsequent weight loss and improvement of metabolic abnormalities was associated with lower rates of hospital and ICU admission in patients with obesity who became infected with SARS-CoV-2. Confirmation of these findings will require larger studies.

•

Is there an association between prior metabolic surgery and severity of COVID-19 in patients with obesity?

•

In this matched cohort study of 363 patients with COVID-19 (including 33 patients who underwent metabolic surgery and 330 matched controls with obesity), metabolic surgery was significantly associated with near three times lower odds of hospital admission (odds ratio 0.31, P=0.028).

•

While none of the 4 exploratory outcomes occurred in the metabolic surgery group, 43 (13.0%) patients in the control group required ICU admission (P=0.021), 22 (6.7%) required mechanical ventilation, 5 (1.5%) required dialysis, and 8 (2.4%) patients died.

•

Among patients with obesity, metabolic surgery was significantly associated with a lower risk of hospital and intensive care unit admission.

The relationship between kidney function and body mass index before and after bariatric surgery in patients with chronic kidney disease

BACKGROUND

Improvements in kidney function post-bariatric surgery may be related to weight loss-independent effects.

OBJECTIVES

To characterize the dynamic relationship between body mass index (BMI) and estimated glomerular filtration rate (eGFR) before and after bariatric surgery in patients with chronic kidney disease (CKD).

SETTING

Kaiser Permanente Southern California (KPSC) health system.

METHODS

We conducted an observational, retrospective cohort study of patients with CKD stage 3 or higher who received bariatric surgery at the KPSC health system between 2007-2015. Bariatric surgery procedures included primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) procedures. Outcomes consisted of mean trajectory estimates and correlations of BMI and eGFR taken between 2 years before and 3 years after surgery. Multivariate functional mixed models were used to estimate how BMI and eGFR trajectories evolved jointly.

RESULTS

A total of 619 RYGB and 474 SG patients were included in the final analytic sample. The measurements were available before surgery for a median time of 1.9 years for SG and 1.8 years for RYGB patients. Median follow-up times after surgery were 2.8 years for both SG and RYGB patients. The mean age at the time of surgery was 58 years; 77% of patients were women; 56% of patients were non-Hispanic White; the mean BMI was 44 kg/m²; 60% of patients had diabetes mellitus; and 84% of patients had hypertension. Compared to the presurgery eGFR declines, the postsurgery declines in eGFR were 57% slower (95% credible interval [CrI], 33%-81%) for RYGB patients and 55% slower (95% CrI, 25%-75%) for SG patients. The mean correlation between BMI and eGFR was negligible at all time points.

CONCLUSION

Though bariatric surgery slowed declines in eGFR up to 3 years after surgery, changes in eGFR tracked poorly with changes in BMI. This study provides evidence that the kidney-related benefits of bariatric surgery may be at least partly independent of weight loss. Confirming this hypothesis could lead to mechanistic insights and new treatment options for CKD.

How Much Weight Loss is Required for Cardiovascular Benefits? Insights From a Metabolic Surgery Matched-cohort Study

OBJECTIVE

The aim of this study was to determine the minimum amount of weight loss required to see a reduction in major adverse cardiovascular events (MACE).

BACKGROUND

Although obesity is an established risk factor for morbidity and mortality, the minimum amount of weight loss to have a meaningful impact on cardiovascular health and survival is unknown.

METHODS

Patients with obesity (body mass index ≥30 kg/m) and type 2 diabetes who underwent metabolic surgery in an academic center (1998-2017) were propensity-matched 1:5 to nonsurgical patients who received usual care. The adjusted linear and nonlinear effects of weight loss (achieved in the first 18 months after the index date) were studied to identify cut-offs for the minimum weight loss to achieve decreased risk of all-cause mortality and MACE (composite of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation).

RESULTS

A total of 7201 patients (1223 surgical and 5978 nonsurgical) with a median follow-up time of 4.9 years (interquartile range, 3.5-7) were included. The positive effect of metabolic surgery was still present after adjusting for weight loss amounts, suggesting that there are weight loss-independent factors contributing to a reduction in risk of MACE and all-cause mortality in the surgical cohort. After considering the weighted estimates from a diverse set of models, the risk of MACE decreases after approximately 10% of weight is lost in the surgical group and approximately 20% in the nonsurgical group. For all-cause mortality, the threshold for benefit appeared to be approximately 5% weight loss after metabolic surgery and 20% in the nonsurgical group.

CONCLUSIONS

This large matched-cohort study identified the minimum weight loss thresholds for reduction in risk of MACE and all-cause mortality in patients with obesity and diabetes. Furthermore, in our analysis, the effect of surgery was still present after accounting for weight loss, which may suggest the presence of weight-independent beneficial effects of metabolic surgery on MACE and survival.

Association of Baseline and Longitudinal Changes in Body Composition Measures With Risk of Heart Failure and Myocardial Infarction in Type 2 Diabetes: Findings From the Look AHEAD Trial

BACKGROUND

Intentional weight loss is associated with lower risk of heart failure (HF) and atherosclerotic cardiovascular disease among patients with type 2 diabetes. However, the contribution of baseline measures and longitudinal changes in fat mass (FM), lean mass (LM), and waist circumference (WC) to the risk of HF and myocardial infarction (MI) in type 2 diabetes is not well established.

METHODS

Adults from the Look AHEAD trial (Action for Health in Diabetes) without prevalent HF were included. FM and LM were predicted using validated equations and compared with dual-energy x-ray absorptiometry measurements in a subgroup. Adjusted Cox models were used to evaluate the associations of baseline and longitudinal changes in FM, LM, and WC over 1- and 4-year follow-up with risk of overall HF, HF with preserved ejection fraction (EF; EF ≥50%), HF with reduced EF (EF <50%), and MI.

RESULTS

Among 5103 participants, there were 257 incident HF events over 12.4 years of follow-up. Predicted and measured FM/LM were highly correlated (R²=0.87-0.90; n=1369). FM and LM decreased over 4-year follow-up with greater declines in the intensive lifestyle intervention arm. In adjusted analysis, baseline body composition measures were not significantly associated with HF risk. Decline in FM and WC, but not LM, over 1 year were each significantly associated with lower risk of overall HF (adjusted hazard ratio per 10% decrease in FM, 0.80 [95% CI, 0.68-0.95]; adjusted hazard ratio per 10% decrease in WC, 0.77 [95% CI, 0.62-0.95]). Decline in FM was significantly associated with lower risk of both HF subtypes. In contrast, decline in WC was significantly associated with lower risk of HF with preserved EF but not HF with reduced EF. Similar patterns of association were observed for 4-year changes in body composition and HF risk. Longitudinal changes in body composition were not significantly associated with risk of MI.

CONCLUSIONS

In adults with type 2 diabetes, a lifestyle intervention is associated with significant loss of FM and LM. Declines in FM and WC, but not LM, were each significantly associated with lower risk of HF but not MI. Furthermore, decline in WC was significantly associated with lower risk of HF with preserved EF but not HF with reduced EF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00017953.

Weight Loss After Sleeve Gastrectomy: Does Type 2 Diabetes Status Impact Weight and Body Composition Trajectories?

INTRODUCTION/ PURPOSE

Sleeve gastrectomy (SG), the most frequently performed bariatric procedure, induces marked weight-loss, but with high inter-individual variability. Since type 2 diabetes (T2D) negatively impacts weight-loss outcomes after Roux-en-Y gastric bypass (RYGB), we herein aimed to evaluate whether and how T2D status may influence weight-loss and body composition changes in individuals with or without T2D after SG.

MATERIAL AND METHODS

We retrospectively included individuals with obesity operated from SG and prospectively followed at our center: 373 patients including 152 with T2D (40%). All subjects' clinical characteristics were collected before and during 4 years of follow-up post-SG. Linear mixed models were applied to analyze weight-loss trajectories post-surgery.

RESULTS

Compared to individuals with obesity but no T2D, those with T2D before SG displayed lower weight-loss at 1 year (21 vs. 27% from baseline, p < 10^-3). This difference was accentuated in patients with poorer glucose control (HbA1c > 7%) at baseline. Furthermore, patients with T2D underwent less favorable body composition changes at 1-year post-SG compared to individuals without T2D (% fat mass reduction: 28 vs. 37%, p < 10^-3 respectively).

CONCLUSION

When undergoing SG, subjects with obesity and T2D who have poor pre-operative glycemic control display reduced weight-loss and less improvement in body composition compared to patients with obesity but without T2D. This result suggests that glycemic control prior to surgery is important to take into account for the outcome of bariatric surgery.

Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Severe Obesity: A Nationwide Cohort Study

BACKGROUND

The number of patients with myocardial infarction and severe obesity is increasing and there is a lack of evidence how these patients should be treated. The aim of this study was to investigate the association between metabolic surgery (Roux-en-Y gastric bypass and sleeve gastrectomy) and major adverse cardiovascular events in patients with previous myocardial infarction (MI) and severe obesity.

METHODS

Of 566 patients with previous MI registered in the SWEDEHEART registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) undergoing metabolic surgery and registered in the nationwide Scandinavian Obesity Surgery Registry, 509 patients (Roux-en-Y gastric bypass n=465; sleeve gastrectomy n=44) could be matched 1:1 to a control with MI from SWEDEHEART, but no subsequent metabolic surgery regarding sex, age (±3 years), year of MI (±3 years), and body mass index (±3). The 2 groups were well matched, except for a lower proportion of reduced ejection fraction after MI (7% versus 12%), previous heart failure (10% versus 19%), atrial fibrillation (6% versus 10%), and chronic obstructive pulmonary disease (4% versus 7%) in patients undergoing metabolic surgery.

RESULTS

The median (interquartile range) follow-up time was 4.6 (2.7-7.1) years. The 8-year cumulative probability of major adverse cardiovascular events was lower in patients undergoing metabolic surgery (18.7% [95% CI, 15.9-21.5%] versus 36.2% [33.2-39.3%], adjusted hazard ratio, 0.44 [95% CI, 0.32-0.61]). Patients undergoing metabolic surgery had also a lower risk of death (adjusted HR, 0.45 [95% CI, 0.29-0.70]; MI, 0.24 [0.14-0.41]) and new onset heart failure, but there were no significant differences regarding stroke (0.91 [0.38-2.20]) and new onset atrial fibrillation (0.56 [0.31-1.01]).

CONCLUSIONS

In severely obese patients with previous MI, metabolic surgery is associated with a low risk for serious complications, lower risk of major adverse cardiovascular events, death, new MI, and new onset heart failure. These findings need to be confirmed in a randomized, controlled trial.

A New Endemic of Concomitant Nonalcoholic Fatty Liver Disease and Chronic Hepatitis B

Hepatitis B virus (HBV) infection remains a global public problem despite the availability of an effective vaccine. In the past decades, nonalcoholic fatty liver disease (NAFLD) has surpassed HBV as the most common cause of chronic liver disease worldwide. The prevalence of concomitant chronic hepatitis B (CHB) and NAFLD thus reaches endemic proportions in geographic regions where both conditions are common. Patients with CHB and NAFLD are at increased risk of liver disease progression to cirrhosis and hepatocellular carcinoma. Due to the complexity of the pathogenesis, accurate diagnosis of NAFLD in CHB patients can be challenging. Liver biopsy is considered the gold standard for diagnosing and determining disease severity, but it is an invasive procedure with potential complications. There is a growing body of literature on the application of novel noninvasive serum biomarkers and advanced radiological modalities to diagnose and evaluate NAFLD, but most have not been adequately validated, especially for patients with CHB. Currently, there is no approved therapy for NAFLD, although many new agents are in different phases of development. This review provides a summary of the epidemiology, clinical features, diagnosis, and management of the NAFLD and highlights the unmet needs in the areas of CHB and NAFLD coexistence.

Dysregulated lipid metabolism links NAFLD to cardiovascular disease

Background

Non-alcoholic fatty liver disease (NAFLD) is rapidly becoming a global health problem. Cardiovascular diseases (CVD) are the most common cause of mortality in NAFLD patients. NAFLD and CVD share several common risk factors including obesity, insulin resistance, and type 2 diabetes (T2D). Atherogenic dyslipidemia, characterized by plasma hypertriglyceridemia, increased small dense low-density lipoprotein (LDL) particles, and decreased high-density lipoprotein cholesterol (HDL-C) levels, is often observed in NAFLD patients.

Scope of review

In this review, we highlight recent epidemiological studies evaluating the link between NAFLD and CVD risk. We further focus on recent mechanistic insights into the links between NAFLD and altered lipoprotein metabolism. We also discuss current therapeutic strategies for NAFLD and their potential impact on NAFLD-associated CVD risk.

Major conclusions

Alterations in hepatic lipid and lipoprotein metabolism are major contributing factors to the increased CVD risk in NAFLD patients, and many promising NASH therapies in development also improve dyslipidemia in clinical trials.

A Review of the Current Evidence: Impact of Metabolic Surgery on Diabetes Outcomes and Obesity-Associated Macrovascular Complications

PURPOSE OF REVIEW

Type 2 diabetes (T2D) and obesity are comorbidities that generally progress with time even when non-invasive therapies are prescribed. Indeed, weight loss that is achieved with behavioral modification alone is generally inconsistent and often short-lived. In contrast, although patients do experience weight regain with metabolic surgery, they still benefit from a significant net decrease in weight. As a result, T2D remission can be achieved in up to 60% of patients within 2 years after surgery. However, it is unknown if the positive effects of metabolic surgery extend to macrovascular disease risk reduction.

RECENT FINDINGS

As noted in four randomized controlled trials (RCTs), Roux-en-Y gastric bypass (RYGB) facilitates partial remission of T2D in about 30% of volunteers 5 years after surgery. Of the four RCTs, only one investigated the effects of sleeve gastrectomy (SG) at 5 years; that study found that the rate of partial relapse was slightly lower with SG (23%). However, observational studies indicate that the gap between RYGB and SG may be larger than that observed in RCTs. In contrast, the rate of full remission is noted infrequently 5 years after SG or RYGB. Metabolic surgery also mitigates macrovascular disease risk as indicated by multiple observational studies. The effects of metabolic surgery on cardiometabolic parameters are clinically meaningful. The weight loss that is facilitated by metabolic surgery reduces the metabolic and inflammatory stress caused by T2D and obesity. In turn, metabolic surgery likely mitigates macrovascular disease risk. Additional evidence from RCTs is needed to substantiate the effects of metabolic surgery on macrovascular disease risk.

Glucagon-Like Peptide 1 Receptor Agonists and Heart Failure

With worsening epidemiological trends for both the incidence and prevalence of type 2 diabetes mellitus (T2DM) and heart failure (HF) worldwide, it is critical to implement optimal prevention and treatment strategies for patients with these comorbidities, either alone or concomitantly. Several guidelines and consensus statements have recommended glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter type 2 inhibitors as add-ons to lifestyle interventions with or without metformin in those at high atherosclerotic cardiovascular disease risk. However, these recommendations are either silent about HF or fail to differentiate between the prevention of HF in those at risk versus the treatment of individuals with manifest HF. Furthermore, these documents do not differentiate among those with different HF phenotypes. This distinction, even though important, may not be critical for sodium-glucose cotransporter type 2 inhibitors in view of the consistent data for benefit for both atherosclerotic cardiovascular disease– and HF-related outcomes that have emerged from the regulatory-mandated cardiovascular outcome trials for all sodium-glucose cotransporter type 2 inhibitors and the recent DAPA-HF trial (Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction)demonstrating the benefit of dapagliflozin on HF-related outcomes in patients with HF with reduced ejection fraction with or without T2DM. However, the distinction may be crucial for glucagon-like peptide-1 receptor agonists and other antihyperglycemic agents. Indeed, in several of the new statements, glucagon-like peptide-1 receptor agonists are suggested treatment not only for patients with T2DM and atherosclerotic cardiovascular disease, but also in those with manifest HF, despite a lack of evidence for the latter recommendation. Although glucagon-like peptide-1 receptor agonists may be appropriate to use in patients at risk for HF, mechanistic insights and observations from randomized trials suggest no clear benefit on HF-related outcomes and even uncertainty regarding the safety in those with HF with reduced ejection fraction. Conversely, theoretical rationales suggest that these agents may benefit patients with HF with preserved ejection fraction. Considering that millions of patients with T2DM have HF, these concerns have public health implications that necessitate the thoughtful use of these therapies. Achieving this aim will require dedicated trials with these drugs in both patients who have HF with reduced ejection fraction and HF with preserved ejection fraction with T2DM to assess their efficacy, safety, and risk-benefit profile.

A Structured Approach for Safely Reintroducing Bariatric Surgery in a COVID-19 Environment

Due to the profound effect of novel coronavirus disease 2019 (COVID-19) on healthcare systems, surgical programs across the country have paused surgical operations and have been utilizing virtual visits to help maintain public safety. For those who treat obesity, the importance of bariatric surgery has never been more clear. Emerging studies continue to identify obesity and several other obesity-related comorbid conditions as major risk factors for a more severe COVID-19 disease course. However, this also suggests that patients seeking bariatric surgery are inherently at risk of suffering severe complications if they were to contract COVID-19 in the perioperative period. The aim of this protocol is to utilize careful analysis of existing risk stratification for bariatric patients, novel COVID-19-related data, and consensus opinion from multiple academic bariatric centers within our organization to help guide the reanimation of our programs when appropriate and to use this template to prospectively study this risk-stratified population in real time. The core principles of this protocol can be applied to any surgical specialty.

Predictors of normalized HbA1c after gastric bypass surgery in subjects with abnormal glucose levels, a 2-year follow-up study

Clinical biomarkers can predict normalization of HbA1c after Roux-en-Y gastric bypass (RYGB) surgery, but it is unclear which are the most predictive.The aim of this study was to compare biomarkers for insulin sensitivity and other clinical parameters in the prediction of normalization of HbA1c after RYGB surgery. This study included 99 (23 men) obese subjects (BMI > 35 kg/m²) undergoing a laparoscopic RYGB. Clinical and biochemical examinations were performed pre-operatively and up to 2 years after surgery. Pre-operatively, normal fasting glucose levels were found in 25 individuals (NG), prediabetes in 46 and type 2 diabetes (T2DM) in 28. At baseline IGF-I (SD), IGFBP-1 and adiponectin levels were low while leptin was high. Weight loss was observed in all three groups, most in the prediabetes group. After 2 years HbA1c was decreased in prediabetes and T2DM. In all three groups insulin, HOMA-IR, lipids and blood pressure improved, IGFBP-1 and adiponectin increased and leptin decreased. IGF-I (SD) increased only in T2DM. In those with prediabetes or T2DM (n = 74), HbA1c at 2 years correlated to baseline BMI (r = -0.27, p = 0.028), age (r = 0.43, p < 0.001), HbA1c (r = 0.37, p = 0.001) and IGFBP-1 (r = 0.25, p = 0.038), and was normalized in 45/74 (61%) at 1 year and in 36 subjects (49%) at 2 years. These responders were younger, had higher BMI, larger waist circumference, lower HbA1c and lower IGFBP-1 levels at baseline. In a multiple regression model age (negative, p = 0.021) and waist circumference (positive, p = 0.047) were the only predictors for normalized HbA1c. RYGB normalized HbA1c in 49% at two years follow-up, which was predicted by low baseline IGFBP-1 level, a marker of hepatic insulin sensitivty and insulin secretion. However,. younger age and larger waist circumference were the only predictors of normalized HbA1c in multivariate analysis.

Effects of gastric bypass surgery on expression of glucose transporters and fibrotic biomarkers in kidney of diabetic fatty rats

BACKGROUND

Diabetic nephropathy is the leading cause of chronic kidney disease. Observational studies suggest Roux-en-Y gastric bypass (RYGB) reduces progression of diabetic nephropathy.

OBJECTIVES

To unravel the mechanisms by which RYGB is beneficial and protective for diabetic nephropathy.

SETTING

Academic laboratories.

METHODS

Forty-eight Zucker diabetic fatty rats were randomized to RYGB, sham surgery (SHAM), or pair-fed (PF) groups. An oral glucose tolerance test was performed at 25 days post intervention and kidneys were harvested at 30 days. Primary outcome measures included expression of key genes and proteins in the glucose transport, oxidative stress, inflammation, and fibrosis pathways.

RESULTS

Thirty days post intervention, RYGB rats weighed 349 ± 8 g, which was lower than SHAM (436 ± 14 g, P < .001), but not PF (374 ± 18 g) rats. RYGB rats had lower fasting glucose than PF animals and improved homeostatic model assessment of insulin resistance compared with PF and SHAM groups. These enhanced metabolic outcomes were accompanied by reduced sodium-glucose co-transporter 1 (Sglt1) gene expression (-23% versus PF, P = .01) in the kidney of RYGB rats. Expression of Sglt2, Glut1, or Glut2 mRNA, or oxidative stress and inflammation markers did not differ significantly. However, RYGB surgery induced a 19% lower expression of transforming growth factor (Tgfβ) mRNA (P = .004) compared with SHAM treated animals. Notably, adenosine monophosphate-activated protein kinase phosphorylation was increased (P = .04) in kidneys of the RYGB surgery animals.

CONCLUSIONS

Improvement of hyperglycemia after RYGB may reduce the glucose load on the kidney leading to a downregulation of specific glucose transporters. RYGB surgery may also attenuate kidney fibrosis through the adenosine monophosphate-activated protein kinase/TGFβ pathway.

Outcomes in Bariatric and Metabolic Surgery: an Updated 5-Year Review

PURPOSE OF REVIEW

Knowledge regarding postoperative outcomes after bariatric and metabolic surgery continues to evolve. This review highlights key findings in outcomes research over the last 5 years related to weight loss, remission of obesity-related disease, reflux, revisional surgery, robotic-assisted surgical platforms, and adolescent populations.

RECENT FINDINGS

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) produce similar weight loss patterns at 5 years, while duodenal switch (BPD/DS) and related procedures are associated with maximal weight loss overall and optimal resolution of obesity-related comorbidities. Remission of type 2 diabetes mellitus (T2DM) following surgery is more likely in patients who are not insulin dependent prior to surgery. Bariatric and metabolic surgery offers a significant protective effect against coronary artery disease (CAD) and associated interventions in both diabetic and nondiabetic patients, as well as heart failure (HF). Gastroesophageal reflux disease (GERD) and dysphagia following SG are common, and routine endoscopic surveillance for Barrett's esophagus may be of significant utility. Robotic-assisted laparoscopic platforms concur similar outcomes to laparoscopic intervention, with a potential benefit in high BMI patients. Revisional surgery is most commonly performed for weight regain and/or inadequate weight loss following an index procedure, or reflux, and generally characterized by higher postoperative complication rates and longer inpatient lengths of stay (LOS). Surgical intervention in adolescent populations has similar weight loss and postoperative complication profiles to those seen in adult populations, with improved outcomes related to T2DM. Bariatric and metabolic surgery continues to evolve as a treatment for obesity and obesity-related comorbidities. While effective for weight loss and remission of obesity-related disease, SG is associated with high rates of postoperative GERD.

Association between metabolic surgery and cardiovascular outcome in patients with hypertension: A nationwide matched cohort study

BACKGROUND

Hypertension, together with obesity, is a leading cause of mortality and disability. Whilst metabolic surgery offers remission of several metabolic comorbidities, the effect for patients with hypertension remains controversial. The objective of the present study was to evaluate the effect of metabolic surgery on cardiovascular events and mortality on patients with morbid obesity (body mass index [BMI] ≥ 35 kg/m2) and hypertension.

METHODS AND FINDINGS

We conducted a matched cohort study of 11,863 patients with morbid obesity and pharmacologically treated hypertension operated on with metabolic surgery and a matched non-operated-on control group of 26,199 subjects with hypertension (matched by age, sex, and area of residence) of varied matching ratios from 1:1 to 1:9, using data from the Scandinavian Obesity Surgery Register (SOReg), the Swedish National Patient Registers (NPR) for in-hospital and outpatient care, the Swedish Prescribed Drug Register, and Statistics Sweden. The main outcome was major adverse cardiovascular event (MACE), defined as first occurrence of acute coronary syndrome (ACS) event, cerebrovascular event, fatal cardiovascular event, or unattended sudden cardiac death. The mean age in the study group was 52.1 ± 7.46 years, with 65.8% being women (n = 7,810), and mean BMI was 41.9 ± 5.43 kg/m2. MACEs occurred in 379 operated-on patients (3.2%) and 1,125 subjects in the control group (4.5%). After adjustment for duration of hypertension, comorbidities, and education, a reduction in risk was seen in the metabolic surgery group (adjusted hazard ratio [HR] 0.73, 95% confidence intervals [CIs] 0.64-0.84, P < 0.001). The surgery group had lower risk for ACS events (adjusted HR 0.52, 95% CI 0.41-0.66, P < 0.001) and a tendency towards lower risk for cerebrovascular events (adjusted HR 0.81, 95% CI 0.63-1.01, P = 0.060) compared with controls. The main limitations with the study were the lack of information on BMI and history of smoking in the control group and the nonrandomised study design.

CONCLUSION

Metabolic surgery on patients with morbid obesity and pharmacologically treated hypertension was associated with lower risk for MACEs and all-cause mortality compared with age- and sex-matched controls with hypertension from the general population.

Benefits and Risks of Bariatric Surgery in Adults: A Review

Importance

Severe obesity and its related diseases, such as type 2 diabetes, hypertension, dyslipidemia, and sleep apnea, are very common in the United States, but currently very few patients with these conditions choose to undergo bariatric surgery. Summaries of the expanding evidence for both the benefits and risks of bariatric surgery are needed to better guide shared decision-making conversations.

Observations

There are approximately 252 000 bariatric procedures (per 2018 numbers) performed each year in the US, of which an estimated 15% are revisions. The 1991 National Institutes of Health guidelines recommended consideration of bariatric surgery in patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 40 or higher or 35 or higher with serious obesity-related comorbidities. These guidelines are still widely used; however, there is increasing evidence that bariatric procedures should also be considered for patients with type 2 diabetes and a body mass index of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment for type 2 diabetes. Substantial evidence indicates that surgery results in greater improvements in weight loss and type 2 diabetes outcomes, compared with nonsurgical interventions, regardless of the type of procedures used. The 2 most common procedures used currently, the sleeve gastrectomy and gastric bypass, have similar effects on weight loss and diabetes outcomes and similar safety through at least 5-year follow-up. However, emerging evidence suggests that the sleeve procedure is associated with fewer reoperations, and the bypass procedure may lead to more durable weight loss and glycemic control. Although safety is a concern, current data indicate that the perioperative mortality rates range from 0.03% to 0.2%, which has substantially improved since early 2000s. More long-term randomized studies are needed to assess the effect of bariatric procedures on cardiovascular disease, cancer, and other health outcomes and to evaluate emerging newer procedures.

Conclusions and Relevance

Modern bariatric procedures have strong evidence of efficacy and safety. All patients with severe obesity-and especially those with type 2 diabetes-should be engaged in a shared decision-making conversation about the risks and benefits of surgery compared with continuing usual medical and lifestyle treatment, and the decision about surgery should be driven primarily by informed patient preferences.

Impact of Metabolic Surgery on Type 2 Diabetes Mellitus, Cardiovascular Risk Factors, and Mortality: A Review

BACKGROUND

The association between obesity and a reduction in life expectancy is well established, and cardiovascular disease is a leading cause of mortality. Bariatric surgery has long been established as the most effective and durable intervention for obesity, and is the only intervention for obesity that consistently improves multiple comorbidities, reduces cardiovascular disease and long-term mortality. The purpose of this review is to describe the impact of metabolic/bariatric surgery on type 2 diabetes mellitus and cardiometabolic parameters, including cardiovascular mortality.

METHODS

A systematic literature search of Pubmed, MEDLINE, and Cochrane Central Register was performed. We included randomized controlled trials, meta-analysis, case-control trials, and cohort studies that contain data on reductions in cardiovascular risk factors and cardiovascular mortality in subjects who underwent metabolic/bariatric surgery from January 1, 2005 to June 1, 2020.

CONCLUSION

There is sufficient evidence from randomized controlled trials that metabolic/bariatric surgery is associated with a significant improvement of all cardiovascular risk factors. Although studies are showing a reduction of macrovascular events and cardiovascular mortality, these findings come from observational studies and should be confirmed in randomized clinical trials.

Bariatric Surgery: Remission of Inflammation, Cardiometabolic Benefits, and Common Adverse Effects

Obesity is associated with increased mortality as a result of several comorbidities which occur in tandem with the obese state. Chronic inflammation is well documented in obesity, and evidence from numerous studies support the notion that the increased inflammation in individuals with obesity accentuates the comorbidities seen in this condition. The remission of comorbidities such as metabolic, cardiovascular, and neurological complications occurs following bariatric procedures. Bariatric surgery significantly reduces mortality and results in remarkable weight loss and reversal in several obesity-related comorbidities. There is indisputable evidence that the resolution of inflammation that occurs after bariatric surgery mitigates some of these comorbidities. With the increasing use of bariatric surgery for the treatment of severe obesity, it is pivotal to elucidate the underlying mechanisms responsible for the notable improvements seen after the procedure. This review summarizes underlying mechanisms responsible for the remission of obesity-related abnormalities and discusses the common adverse effects of bariatric surgery. Well-stratified, large-scale studies are still needed for a proper evaluation of these underlying mechanisms.