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

What Should I Eat and Why? The Environmental, Genetic, and Behavioral Determinants of Food Choice: Summary from a Pennington Scientific Symposium

This review details the proceedings of a Pennington Biomedical scientific symposium titled, "What Should I Eat and Why? The Environmental, Genetic, and Behavioral Determinants of Food Choice." The symposium was designed to review the literature about energy homeostasis, particularly related to food choice and feeding behaviors, from psychology to physiology. This review discusses the intrinsic determinants of food choice, including biological mechanisms (genetics), peripheral and central signals, brain correlates, and the potential role of the microbiome. This review also address the extrinsic determinants (environment) of food choice within our physical and social environments. Finally, this review reports the current treatment practices for the clinical management of eating-induced overweight and obesity. An improved understanding of these determinants will inform best practices for the clinical treatment and prevention of obesity. Strategies paired with systemic shifts in our public health policies and changes in our "obesogenic" environment will be most effective at attenuating the obesity epidemic.

Metabolic surgery for the treatment of type 2 diabetes: A network meta-analysis of randomized controlled trials

AIM

To compare different types of metabolic surgery (MS) with medical therapy (MT) for the treatment of type 2 diabetes (T2D).

MATERIALS AND METHODS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different MS techniques versus MT in people with T2D, with a duration of ≥24 weeks. Primary endpoints were glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and diabetes remission. Indirect comparisons of different types of surgery were performed by NMA. Mean and 95% confidence intervals for continuous variables, and Mantel-Haenzel odds ratios for categorial variables, were calculated using random effect models. Types of MS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); and duodenojejunal bypass.

RESULTS

The 24 retrieved trials included 1351 patients (1014 with MS and 337 with MT). The mean baseline BMI was 36.8 kg/m² . MS was associated with significantly greater reductions in HbA1c and FPG and greater diabetes remission when compared to MT. In the NMA, a significant reduction in HbA1c was observed with OAGB and SG. All surgical procedures were associated with a significant increase in diabetes remission, except GCP and LAGB. All procedures were associated with a reduction of body mass index (BMI).

CONCLUSIONS

Metabolic surgery is an interesting option for the treatment of T2D, although further data are needed to demonstrate its long-term efficacy and safety. Present data are not sufficient to modify current recommendations, which consider MS a possible treatment for T2D in those with a BMI >35 kg/m² .

Exercise-Induced Increases in Insulin Sensitivity After Bariatric Surgery Are Mediated By Muscle Extracellular Matrix Remodeling

Exercise seems to enhance the beneficial effect of bariatric (Roux-en-Y gastric bypass [RYGB]) surgery on insulin resistance. We hypothesized that skeletal muscle extracellular matrix (ECM) remodeling may underlie these benefits. Women were randomized to either a combined aerobic and resistance exercise training program following RYGB (RYGB + ET) or standard of care (RYGB). Insulin sensitivity was assessed by oral glucose tolerance test. Muscle biopsy specimens were obtained at baseline and 3 and 9 months after surgery and subjected to comprehensive phenotyping, transcriptome profiling, molecular pathway identification, and validation in vitro. Exercise training improved insulin sensitivity beyond surgery alone (e.g., Matsuda index: RYGB 123% vs. RYGB + ET 325%; P ≤ 0.0001). ECM remodeling was reduced by surgery alone, with an additive benefit of surgery and exercise training (e.g., collagen I: RYGB -41% vs. RYGB + ET -76%; P ≤ 0.0001). Exercise and RYGB had an additive effect on enhancing insulin sensitivity, but surgery alone did not resolve insulin resistance and ECM remodeling. We identified candidates modulated by exercise training that may become therapeutic targets for treating insulin resistance, in particular, the transforming growth factor-β1/SMAD 2/3 pathway and its antagonist follistatin. Exercise-induced increases in insulin sensitivity after bariatric surgery are at least partially mediated by muscle ECM remodeling.

Diabetes Update 2020: das Wichtigste für die ärztliche Praxis

Bei der virtuellen Veranstaltung Diabetes Update 2020 wurden zahlreiche neue Erkenntnisse und Empfehlungen zu Diagnostik, Therapie und Management des Diabetes und benachbarter Themen vorgestellt, von denen die Bereiche Typ-2-Diabetes, Diabetes und Herz, Diabetes und Schwangerschaft sowie Impfungen im aktuellen Heft von Der Diabetologe in separaten Beiträgen ausführlich beschrieben werden. Im Folgenden sollen die aus Sicht des Autors wichtigsten und für die Praxis relevantesten Neuigkeiten aus den anderen referierten diabetesbezogenen Themengebieten in aller Kürze wiedergegeben werden.

Metabolic endoscopy: Today's science-tomorrow's treatment

Obesity, type 2 diabetes mellitus (T2DM) and nonalcoholic steatohepatitis are increasing pandemic metabolic disorders. Lifestyle intervention (LSI) is the cornerstone treatment for these but is successful as standard care alone in only a few patients, given the modest weight loss at mid and long term. Conversely, bariatric surgery is the only proven effective treatment for these metabolic disorders, albeit offered only in a small percentage of cases because of its invasiveness and cost. The so-called endoscopic bariatric and metabolic therapies (EBMTs) include new, less-invasive technologies such as intragastric balloons, aspiration therapy, endoscopic sleeve gastroplasty, diversion devices, and duodenal mucosal resurfacing, currently at various stages of development. EBMTs, as an add-on to LSI, might represent an effective treatment filling the gap between medical and surgical management, taking into account, however, that obesity and its associated comorbidities constitute a chronic disease that needs lifelong therapy. In this review we describe the current scientific evidence surrounding EBMTs as well as future opportunities for such treatments in managing obesity and metabolic disorders.

Insulin resistance in bariatric surgery

PURPOSE OF REVIEW

To give an updated review on the underlying mechanisms and clinical effects of improved glucose control after bariatric surgery.

RECENT FINDINGS

The basic principles of the mechanism for the metabolic effects of bariatric surgery can be categorized into calorie restriction, deviation of nutrients, and reduced amounts of adipose tissue. Recent findings suggest the importance of early changes following deviation of nutrients to more distal parts of the small bowel resulting in altered release of gastrointestinal hormones, altered gut microbiota, and weight-reduction. In the long-term, loss of adipose tissue results in reduced inflammation and improved insulin sensitivity. From a clinical perspective these changes are associated with remission of diabetes in patients with morbid obesity and type 2 diabetes, prevention of diabetes in patients with insulin resistance without overt type 2 diabetes and prevention of both microvascular and macrovascular complications for all patients with morbid obesity.

SUMMARY

At present, bariatric surgery remains the most effective treatment option to improve glucose control and long-term complications associated with hyperglycemia in patients with obesity.Although the mechanisms behind these metabolic effects remain only partially understood, further knowledge on these complex mechanisms may help identifying durable treatment options for morbid obesity and important metabolic comorbidities.

Safety and Efficacy of Bariatric Surgery in Inflammatory Bowel Disease Patients: a Systematic Review and Meta-analysis

BACKGROUND

The safety and efficacy of bariatric surgery in inflammatory bowel disease (IBD) patients is poorly understood. We conducted a systematic review and meta-analysis studying safety and efficacy of bariatric surgery in IBD patients as well as the impact of bariatric surgery on IBD course.

METHODS

We conducted a comprehensive search of multiple databases (through September 2019) to identify studies that reported outcome of bariatric surgery in IBD patients. Outcomes assessed included the pooled rate of adverse events, change in medications after bariatric surgery, and 12-month excess weight loss (EWL) and body mass index (BMI) reduction after bariatric surgery.

RESULTS

A total of 10 studies were included in final analysis. The pooled rate of early and late adverse events was 15.9% (95% CI, 9.3-25.9) and 16.9% (95% CI, 12.1-23.1), respectively. The rate of adverse events in Roux-en-Y gastric bypass was 45.6% (95% CI, 21.9-71.4) compared with 21.6% (95% CI, 11.1-38) in sleeve gastrectomy (p = 0.11). The pooled rate of 12-month EWL and BMI reduction after surgery was 66.1% (95% CI, 59.8-72.3%) and 13.7 kg/m² (95% CI, 12.5-14.9), respectively. The pooled rate of decrease, increase, and no change of IBD medications were 45.6% (95% CI, 23.8-69.2), 11% (95% CI, 6.3-18.4), and 57.6% (95% CI, 39.2-74.1), respectively.

CONCLUSIONS

Bariatric surgery has acceptable safety and efficacy profile in IBD patients. Nearly half of patients had decrease in their IBD medications after bariatric surgery, and only 10% experienced therapeutic escalation following bariatric surgery. Sleeve gastrectomy may be the preferred procedure in this population.

The Association Between Adverse Childhood Experiences (ACEs) and Postoperative Bariatric Surgery Weight Loss Outcomes

PURPOSE

Previous research demonstrates that exposure to adverse childhood experiences (ACEs) is associated with development of obesity. The same mechanisms mediating this relationship could theoretically affect attempts to lose weight in adulthood. However, it is unclear whether or not exposure to ACEs impacts the effectiveness of bariatric surgery. The present study aimed to examine the association of exposure to ACEs to postoperative weight loss outcomes.

MATERIALS AND METHODS

One hundred ninety-eight patients undergoing bariatric surgery were evaluated for their exposure to ACEs, determined by a presurgical questionnaire and recorded as an ACEs score. Percent total weight loss (%TWL) was calculated to evaluate postoperative weight loss at 1-, 3-, and 6-month intervals postoperatively. One hundred forty-two participants were available for follow-up at the 6-month postoperative interval.

RESULTS

The sample consisted of 167 women and 31 men with a mean age of 47.7. Twenty-five percent of participants experienced high exposure to ACEs, defined as experiencing ≥ 4 ACEs. The average %TWL at 6 months was 16.52%. Multilevel modeling found no significant relationship between ACEs score and %TWL at any of the postoperative time intervals, both before and after adjusting for age, sex, and race.

CONCLUSION

High exposure to ACEs was not associated with poorer weight loss outcomes, and participants with a large number of ACEs generally lost the anticipated amount of weight.

Pre-operative Obesity-Associated Hyperandrogenemia in Women and Hypogonadism in Men Have No Impact on Weight Loss Following Bariatric Surgery

Background

In severe obesity, hypogonadism in men and androgen excess in women are frequently observed. Sex hormones play an important role in body composition and glucose and lipid metabolism. However, whether pre-operative gonadal dysfunction impacts weight loss after bariatric surgery is not fully known.

Methods

A total of 49 men and 104 women were included in a retrospective analysis. Anthropometric characteristics, glucose and lipid metabolism, and androgen concentrations were assessed pre-operatively and 17.9 ± 11 or 19.3 ± 12 months post-operatively in men and women. Men with (HYPO_male) and without (controls: CON_male) pre-operative hypogonadism, as well as women with (HYPER_female) and without (controls: CON_female) pre-operative hyperandrogenemia, were compared.

Results

In men, pre-operative hypogonadism was present in 55% and linked to a higher body mass index (BMI): HYPO_male 50 ± 6 kg/m² vs. CON_male 44 ± 5 kg/m², p = 0.001. Bariatric surgery results in comparable changes in BMI in HYPO_male and CON_male − 16 ± 6 kg/m² vs. − 14 ± 5 kg/m², p = 0.30. Weight loss reversed hypogonadism in 93%. In women, androgen excess was present in 22%, independent of pre-operative BMI: CON_female 44 ± 7 kg/m² vs. HYPER_female 45 ± 7 kg/m², p = 0.57. Changes in BMI were comparable in HYPER_female and CON_female after bariatric surgery − 15 ± 6 kg/m² vs. − 15 ± 5 kg/m², p = 0.88. Hyperandrogenemia was reversed in 61%.

Conclusions

Besides being frequently observed, hypogonadism in men and androgen excess in women have no impact on post-surgical improvements in body weight and glucose and lipid metabolism. Weight loss resulted in reversal of hypogonadism in almost all men and of hyperandrogenemia in the majority of women.

Advances in Clinical Cardiology 2019: A Summary of Key Clinical Trials

INTRODUCTION

A large number of important clinical trials in cardiology were published or presented at major international conferences during 2019. This paper aims to offer a concise overview of these significant advances and to put them into clinical context.

METHODS

Trials presented at the major international cardiology meetings during 2019 were reviewed including The American College of Cardiology (ACC), Euro PCR, The European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), and the American Heart Association (AHA). In addition to this a literature search identified several other publications eligible for inclusion based on their relevance to clinical cardiology, their potential impact on clinical practice and on future guidelines.

RESULTS

A total of 70 trials met the inclusion criteria. New interventional and structural data include trials examining use of drug-coated balloons in patients with acute myocardial infarction (MI), interventions following shockable cardiac arrest, mechanical circulatory support in cardiogenic shock complicating MI, intervention in stable coronary artery disease, surgical or percutaneous revascularisation strategies in left main coronary artery disease, revascularisation strategy in ST elevation MI, transcatheter aortic valve replacement in low-risk patients, and percutaneous mitral or tricuspid valve interventions. Preventative cardiology data included the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors (dapagliflozin), proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (evolocumab), bempedoic acid, and novel approaches to the management of hypertension. Antiplatelet data included trials evaluating both the optimal length of course and combination of antiplatelet agents and regimes including combination antithrombotic therapies for patients with atrial fibrillation. Heart failure data included trials of sacubitril-valsartan in heart failure with preserved ejection fraction and the use of SGLT2 inhibitors in patients with heart failure but without diabetes. Electrophysiology data included trials examining alcohol in atrial fibrillation and the use of wearable fitness devices for identifying atrial fibrillation.

CONCLUSION

This article presents key clinical trials completed during 2019 and should be valuable to clinicians and researchers working in cardiology.

Safety and Efficacy of Bariatric and Metabolic Surgery

PURPOSE OF REVIEW

Bariatric surgery is the most effective and durable method for treating obesity. This review highlights the results and safety of bariatric surgery.

RECENT FINDINGS

The global prevalence of obesity and its related comorbidities including cancer are on the rise. Bariatric surgery has demonstrated more robust and durable weight loss than current medical treatment. Bariatric surgery also reduces significantly the risk of complications associated with obesity comorbidities, such as diabetes and cardiovascular disease, and the risk of mortality in comparison with medical management. Due to accreditation efforts, the safety profile of bariatric surgery is equivalent or superior to many common operations. Obesity is associated with increased all cause morbidity and mortality. The current bariatric procedures produce significant and durable weight loss and reduce the morbidity and mortality associated with obesity-related diseases substantially. The risk/benefit ratio for bariatric surgery is decidedly in favor for the benefit for bariatric surgery.

Obesity and cardiovascular disease in women

As the prevalence of obesity continues to grow worldwide, the health and financial burden of obesity-related comorbidities grows too. Cardiovascular disease (CVD) is clearly associated with increased adiposity. Importantly, women are at higher risk of CVD when obese and insulin resistant, in particular at higher risk of developing heart failure with preserved ejection fraction and ischemic heart disease. Increased aldosterone and mineralocorticoid receptor activation, aberrant estrogenic signaling and elevated levels of androgens are among some of the proposed mechanisms explaining the heightened CVD risk. In addition to traditional cardiovascular risk factors, understanding nontraditional risk factors specific to women, like excess weight gain during pregnancy, preeclampsia, gestational diabetes, and menopause are central to designing personalized interventions aimed to curb the epidemic of CVD. In the present review, we examine the available evidence supporting a differential cardiovascular impact of increased adiposity in women compared with men and the proposed pathophysiological mechanisms behind these differences. We also discuss women-specific cardiovascular risk factors associated with obesity and insulin resistance.

Treatment of Obesity in Mitigating Metabolic Risk

Through diverse mechanisms, obesity contributes to worsened cardiometabolic health and increases rates of cardiovascular events. Effective treatment of obesity is necessary to reduce the associated burdens of diabetes mellitus, cardiovascular disease, and death. Despite increasing cardiovascular outcome data on obesity interventions, only a small fraction of the population with obesity are optimally treated. This is a primary impetus for this article in which we describe the typical weight loss, as well as the associated impact on both traditional and novel cardiovascular disease risk factors, provided by the 4 primary modalities for obtaining weight loss in obesity-dietary modification, increasing physical activity, pharmacotherapy, and surgery. We also attempt to highlight instances where changes in metabolic risk are relatively specific to particular interventions and appear at least somewhat independent of weight loss. Finally, we suggest important areas for further research to reduce and prevent adverse cardiovascular consequences due to obesity.

Bariatric surgery to aLleviate OCcurrence of Atrial Fibrillation Hospitalization-BLOC-AF

Background

Obesity is associated with a higher incidence of atrial fibrillation (AF). Weight reduction improves outcomes in patients known to have AF.

Objective

The purpose of this study was to compare the incidence of heart failure (HF) or first-time AF hospitalization in obese patients undergoing bariatric surgery (BAS) vs other abdominal surgeries.

Methods

A retrospective cohort study was conducted using linked hospital discharge records from 1994–2014. Obese patients without known AF or atrial flutter (AFL) who had undergone abdominal hernia or laparoscopic cholecystectomy surgery were identified for each case that underwent BAS (2:1). Clinical outcomes were HF, first-time hospitalization for AF, AFL, gastrointestinal bleeding (GIB), and ischemic or hemorrhagic stroke. Outcomes were analyzed using conditional proportional hazard modeling accounting for the competing risk of death, adjusting for demographics and comorbidities.

Results

There were 1581 BAS cases and 3162 controls (48% age <50 years; 60% white; 79% female; mean CHA₂DS₂VASc score 1.6 ± 1.2) with follow-up of 66 months. Compared to controls, BAS cases had a significantly lower risk of new-onset AF (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.54–0.93) or HF (HR 0.74; 95% CI 0.60–0.91) but a higher risk of GIB (HR 2.1; 95% CI 1.5–3.0), with no differences in AFL, ischemic stroke, or hemorrhagic stroke. Reduction in AF improved as follow-up increased beyond 60 months.

Conclusion

In patients undergoing BAS, the risk of either HF or AF was reduced by ∼29% but with greater risk of GIB. The findings support the hypothesis that weight loss reduces the long-term risk of HF or incident AF hospitalization.

Long-term outcomes of bariatric surgery in patients with diabetes

Introduction: Initially seen as a weight-loss operation, bariatric surgery is now recognized as a metabolic procedure with a critical role in the management of type 2 diabetes mellitus (T2DM). Early improvement in glucose metabolism is a remarkable effect of surgery; however, what deserves equal thought are implications for long-term diabetes control and relapse. Evidence suggests the metabolic effects of surgery fatigue and a proportion of patients will experience relapse of T2DM, with or without weight regain. Herein, we discuss the evidence examining the durability of these effects and approaches to improve long-term control.Areas covered: PubMed, Embase, CENTRAL, and Medline were searched for trials looking at outcomes for patients with obesity and T2DM undergoing bariatric surgery between January 2000 andDecember 2019. Additional studies were found by searching publications from related journals and references.Export opinion: Bariatric surgery is a safe and effective treatment for T2DM and obesity however the response to surgery, like any other treatment is variable. Some patients will experience a relapse of diabetes in the long term. Recent developments in pharmacotherapy present an opportunity to augment or sustain what can be achieved with surgery. Combinational treatment may dramatically change the way both diseases are managed.

Association of Intensive Lifestyle Intervention, Fitness, and Body Mass Index With Risk of Heart Failure in Overweight or Obese Adults With Type 2 Diabetes Mellitus: An Analysis From the Look AHEAD Trial

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with a higher risk for heart failure (HF). The impact of a lifestyle intervention and changes in cardiorespiratory fitness (CRF) and body mass index on risk for HF is not well established.

METHODS

Participants from the Look AHEAD trial (Action for Health in Diabetes) without prevalent HF were included. Time-to-event analyses were used to compare the risk of incident HF between the intensive lifestyle intervention and diabetes support and education groups. The associations of baseline measures of CRF estimated from a maximal treadmill test, body mass index, and longitudinal changes in these parameters with risk of HF were evaluated with multivariable adjusted Cox models.

RESULTS

Among the 5109 trial participants, there was no significant difference in the risk of incident HF (n=257) between the intensive lifestyle intervention and the diabetes support and education groups (hazard ratio, 0.96 [95% CI, 0.75-1.23]) over a median follow-up of 12.4 years. In the most adjusted Cox models, the risk of HF was 39% and 62% lower among moderate fit (tertile 2: hazard ratio, 0.61 [95% CI, 0.44-0.83]) and high fit (tertile 3: hazard ratio, 0.38 [95% CI, 0.24-0.59]) groups, respectively (referent group: low fit, tertile 1). Among HF subtypes, after adjustment for traditional cardiovascular risk factors and interval incidence of myocardial infarction, baseline CRF was not significantly associated with risk of incident HF with reduced ejection fraction. In contrast, the risk of incident HF with preserved ejection fraction was 40% lower in the moderate fit group and 77% lower in the high fit group. Baseline body mass index also was not associated with risk of incident HF, HF with preserved ejection fraction, or HF with reduced ejection fraction after adjustment for CRF and traditional cardiovascular risk factors. Among participants with repeat CRF assessments (n=3902), improvements in CRF and weight loss over a 4-year follow-up were significantly associated with lower risk of HF (hazard ratio per 10% increase in CRF, 0.90 [95% CI, 0.82-0.99]; per 10% decrease in body mass index, 0.80 [95% CI, 0.69-0.94]).

CONCLUSIONS

Among participants with type 2 diabetes mellitus in the Look AHEAD trial, the intensive lifestyle intervention did not appear to modify the risk of HF. Higher baseline CRF and sustained improvements in CRF and weight loss were associated with lower risk of HF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00017953.

Bariatric Surgery Improves HDL Function Examined by ApoA1 Exchange Rate and Cholesterol Efflux Capacity in Patients with Obesity and Type 2 Diabetes

Bariatric surgery improves glycemic control better than medical therapy; however, the effect of bariatric surgery on HDL function is not well characterized. Serum samples were available at baseline, 1-, and 5-years post procedures, for 90 patients with obesity and type 2 diabetes who were randomized to intensive medical therapy (n = 20), Roux-en-Y gastric bypass (RYGB, n = 37), or sleeve gastrectomy (SG, n = 33) as part of the STAMPEDE clinical trial. We examined serum HDL function by two independent assays, apolipoprotein A-1 exchange rate (AER) and cholesterol efflux capacity (CEC). Compared with baseline, AER was significantly higher at 5 years for participants in all treatment groups, but only increased significantly at 1 year in the RYGB and SG groups. CEC was divided into ABCA1-dependent and independent fractions, and the later was correlated with AER. ABCA1-independent CEC increased significantly only at 5 years in both surgical groups, but did not significantly change in the medical therapy group. There was no significant change in ABCA1-dependent CEC in any group. The increase in AER, but not ABCA1-independent CEC, was correlated with the reduction in body mass index and glycated hemoglobin levels among all subjects at 5 years, indicating that AER as a measure of HDL function would be a better reflection of therapy versus CEC.

Predicting 10-Year Risk of End-Organ Complications of Type 2 Diabetes With and Without Metabolic Surgery: A Machine Learning Approach

OBJECTIVE

To construct and internally validate prediction models to estimate the risk of long-term end-organ complications and mortality in patients with type 2 diabetes and obesity that can be used to inform treatment decisions for patients and practitioners who are considering metabolic surgery.

RESEARCH DESIGN AND METHODS

A total of 2,287 patients with type 2 diabetes who underwent metabolic surgery between 1998 and 2017 in the Cleveland Clinic Health System were propensity-matched 1:5 to 11,435 nonsurgical patients with BMI ≥30 kg/m2 and type 2 diabetes who received usual care with follow-up through December 2018. Multivariable time-to-event regression and random forest machine learning models were built and internally validated using fivefold cross-validation to predict the 10-year risk for four outcomes of interest. The prediction models were programmed to construct user-friendly web-based and smartphone applications of Individualized Diabetes Complications (IDC) Risk Scores for clinical use.

RESULTS

The prediction tools demonstrated the following discrimination ability based on the area under the receiver operating characteristic curve (1 = perfect discrimination and 0.5 = chance) at 10 years in the surgical and nonsurgical groups, respectively: all-cause mortality (0.79 and 0.81), coronary artery events (0.66 and 0.67), heart failure (0.73 and 0.75), and nephropathy (0.73 and 0.76). When a patient's data are entered into the IDC application, it estimates the individualized 10-year morbidity and mortality risks with and without undergoing metabolic surgery.

CONCLUSIONS

The IDC Risk Scores can provide personalized evidence-based risk information for patients with type 2 diabetes and obesity about future cardiovascular outcomes and mortality with and without metabolic surgery based on their current status of obesity, diabetes, and related cardiometabolic conditions.

High Density Lipoproteins: Metabolism, Function, and Therapeutic Potential

High Density Lipoproteins (HDLs) have long been considered as “good cholesterol,” beneficial to the whole body and, in particular, to cardio-vascular health. However, HDLs are complex particles that undergoes dynamic remodeling through interactions with various enzymes and tissues throughout their life cycle, making the complete understanding of its functions and roles more complicated than initially expected. In this review, we explore the novel understanding of HDLs' behavior in health and disease as a multifaceted class of lipoprotein, with different size subclasses, molecular composition, receptor interactions, and functionality. Further, we report on emergent HDL-based therapeutics tested in small and larger scale clinical trials and their mixed successes.

Nonalcoholic Steatohepatitis: A Review

IMPORTANCE

Nonalcoholic steatohepatitis (NASH) is the inflammatory subtype of nonalcoholic fatty liver disease (NAFLD) and is associated with disease progression, development of cirrhosis, and need for liver transplant. Despite its importance, NASH is underrecognized in clinical practice.

OBSERVATIONS

NASH affects an estimated 3% to 6% of the US population and the prevalence is increasing. NASH is strongly associated with obesity, dyslipidemia, type 2 diabetes, and metabolic syndrome. Although a number of noninvasive tests and scoring systems exist to characterize NAFLD and NASH, liver biopsy is the only accepted method for diagnosis of NASH. Currently, no NASH-specific therapies are approved by the US Food and Drug Administration. Lifestyle modification is the mainstay of treatment, including dietary changes and exercise, with the primary goal being weight loss. Substantial improvement in histologic outcomes, including fibrosis, is directly correlated with increasing weight loss. In some cases, bariatric surgery may be indicated to achieve and maintain the necessary degree of weight loss required for therapeutic effect. An estimated 20% of patients with NASH will develop cirrhosis, and NASH is predicted to become the leading indication for liver transplants in the US. The mortality rate among patients with NASH is substantially higher than the general population or patients without this inflammatory subtype of NAFLD, with annual all-cause mortality rate of 25.56 per 1000 person-years and a liver-specific mortality rate of 11.77 per 1000 person-years.

CONCLUSIONS AND RELEVANCE

Nonalcoholic steatohepatitis affects 3% to 6% of the US population, is more prevalent in patients with metabolic disease and obesity, progresses to cirrhosis in approximately 20% of cases, and is associated with increased rates of liver-specific and overall mortality. Early identification and targeted treatment of patients with nonalcoholic steatohepatitis are needed to improve patient outcomes, including directing patients toward intensive lifestyle modification to promote weight loss and referral for bariatric surgery as indicated for management of obesity and metabolic disease.

Effect of Bariatric Surgery on Serum Enzyme Status in Obese Patients

BACKGROUND

Scarce data exists about serum enzyme in bariatric patients. We attempted to evaluate serum enzyme status in patients receiving Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) and to identify related predictors.

METHODS

We retrospectively reviewed the patients receiving RYGB and SG in our center from January 2013 to January 2018. Anthropometric data and serum enzyme data were collected preoperatively and 6 and 12 months postoperatively.

RESULTS

Five hundred patients (201 RYGB, 299 SG) were included. Serum enzyme abnormalities were common preoperatively, with 50.8% for elevated alanine aminotransferase (ALT), 33.0% for elevated aspartate aminotransferase (AST), 36.6% for elevated γ-glutamyltranspeptidase (γ-GT), 17.6% for elevated creatine kinase (CK), 15.2% for elevated lactic dehydrogenase (LDH), 9.0% for elevated adenosine deaminase (ADA), 6.2% for elevated hydroxybutyrate dehydrogenase (HBDH), and 8.4% for decreased superoxide dismutase (SOD). After RYGB and SG, the prevalence of serum ALT, AST, γ-GT, LDH, and HBDH abnormalities reduced. The levels of ALT, AST, γ-GT, ADA, cholinesterase (CHE), LDH, CK, and HBDH reduced significantly, while amylase and SOD levels increased. Age and preoperative γ-GT level were independent predictors of ALT, AST, γ-GT, and LDH change 1 year postoperatively. Preoperative ALT, AST, ALP, LDH, and HBDH levels could predict postoperative change, respectively. Gender and surgical procedure could predict postoperative ALP change.

CONCLUSION

Serum enzyme abnormalities are common in bariatric surgery candidates, with reduced prevalence of abnormalities postoperatively. RYGB and SG are related with reduced ALT, AST, γ-GT, ADA, CHE, LDH, CK, and HBDH levels, as well as increased amylase and SOD levels.

Late Relapse of Diabetes After Bariatric Surgery: Not Rare, but Not a Failure

OBJECTIVE

To characterize the status of cardiometabolic risk factors after late relapse of type 2 diabetes mellitus (T2DM) and to identify factors predicting relapse after initial diabetes remission following bariatric surgery to construct prediction models for clinical practice.

RESEARCH DESIGN AND METHODS

Outcomes of 736 patients with T2DM who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at an academic center (2004-2012) and had ≥5 years' glycemic follow-up were assessed. Of 736 patients, 425 (58%) experienced diabetes remission (HbA_1c <6.5% [48 mmol/mol] with patients off medications) in the 1st year after surgery. These 425 patients were followed for a median of 8 years (range 5-14) to characterize late relapse of diabetes.

RESULTS

In 136 (32%) patients who experienced late relapse, a statistically significant improvement in glycemic control, number of diabetes medications including insulin use, blood pressure, and lipid profile was still observed at long-term. Independent baseline predictors of late relapse were preoperative number of diabetes medications, duration of T2DM before surgery, and SG versus RYGB. Furthermore, patients who relapsed lost less weight during the 1st year after surgery and regained more weight afterward. Prediction models were constructed and externally validated.

CONCLUSIONS

While late relapse of T2DM is a real phenomenon (one-third of our cohort), it should not be considered a failure, as the trajectory of the disease and its related cardiometabolic risk factors is changed favorably after bariatric surgery. Earlier surgical intervention, RYGB (compared with SG) and more weight loss (less late weight regain) are associated with less diabetes relapse in the long-term.

Cardiovascular risk reduction following metabolic and bariatric surgery

Cardiovascular disease (CVD) is the world’s leading cause of mortality and obesity is a well-recognized risk factor of CVD. Early detection and management of CVD is critical to reduce CVD risk. Especially in patients suffering from obesity with obesity-related CVD risk factors such as hypertension (HTN), dyslipidemia, and diabetes mellitus (DM). A substantial and sustained decrease in body weight after metabolic and bariatric surgery is associated with a significant reduction of cardiovascular risk factors. This article reviews CVD risk models, mechanisms of CVD risk associated with obesity, and overall CVD risk reduction between different metabolic and bariatric procedures.

Medical and surgical management of obesity and diabetes: what's new?

We conducted a narrative review of the medical and surgical management of people with obesity and diabetes. Results of this review showed that a 5-10% loss in body weight can be achieved with a change in lifestyle, diet and behaviour and with approved pharmacological therapies in people with obesity and diabetes. New targeted therapies are now available for patients with previously untreatable genetic causes of obesity. Compared to medical treatment, metabolic and bariatric surgery is associated with significantly higher rates of remission from type 2 diabetes and lower rates of incident macrovascular and microvascular complications and mortality. The National Institute for Health and Care Excellence and the American Diabetes Association endorse metabolic and bariatric surgery in obese adults with type 2 diabetes and there may also be a role for this in obese individuals with type 1 diabetes. The paediatric committee of the American Society for Metabolic and Bariatric Surgery have recommended metabolic and bariatric surgery in obese adolescents with type 2 diabetes. Earlier and more aggressive treatment with metabolic and bariatric surgery in obese or overweight people with diabetes can improve morbidity and mortality.

Bariatric Surgery as a Long-Term Treatment for Type 2 Diabetes/Metabolic Syndrome

Metabolic surgery is increasingly becoming recognized as a more effective treatment for patients with type 2 diabetes (T2D) and obesity as compared to lifestyle modification and medical management alone. Both observational studies and clinical trials have shown metabolic surgery to result in sustained weight loss (20–30%), T2D remission rates ranging from 23% to 60%, and improvement in cardiovascular risk factors such as hypertension and dyslipidemia. Metabolic surgery is cost-effective and relatively safe, with perioperative risks and mortality comparable to low-risk procedures such as cholecystectomy, hysterectomy, and appendectomy. International diabetes and medical organizations have endorsed metabolic surgery as a standard treatment for T2D with obesity.

Does Colectomy Improve Type 2 Diabetes?

Gastrectomy and gastric bypass improve type 2 diabetes (T2DM), potentially through alterations in intestinal hormones and the microbiome. The aim of this study was to analyze whether colorectal resections result in improvement of T2DM. A total of 171 patients with T2DM who underwent colectomy for benign diseases were studied with a median postoperative follow-up of 3 years (interquartile range [IQR] 1-5). The median BMI and glycated hemoglobin (HbA_1c) at baseline and post-colectomy were 30.3 kg/m² (IQR 26.6-34.6) versus 30.4 kg/m² (IQR 26.2-35) (p = 0.1), and 6.7% (IQR 6.2-7.5) versus 6.5% (IQR 6.5-7.1) (p = 0.5), respectively. The proportion of patients taking diabetes medications at baseline versus post-colectomy did not differ significantly. Changes in BMI, HbA_1c, and status of diabetes medications were not statistically different between the subtypes of colorectal resection. Our experience suggests that colectomy for benign colorectal diseases is not associated with long-term changes in body weight or glycemic control.

Impact of therapeutic lifestyle changes in resistant hypertension

Hypertensive individuals are at an increased risk of developing heart disease and stroke. Adopting healthy lifestyles, such as being active on ≥4 days per week, weight-loss in the presence of obesity, consuming a diet rich in fruits and vegetables, and sodium below the recommended threshold, avoiding high alcohol consumption and refraining from smoking have been effective lifestyle therapies to prevent or control stage 1 hypertension (HTN). Among the 1 in 3 Americans who have HTN (systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 80 mmHg), 16% are diagnosed with resistant HTN (RHT). Although there are comparatively fewer studies examining the blood pressure lowering effects of therapeutic lifestyle interventions in patients with resistant HTN, the available literature appears promising. This paper reviews key studies that quantify the blood pressure lowering effects of certain therapeutic lifestyles in patients with RHT and highlights areas needing more attention.

Highlights from Selected Cardiovascular Disease Prevention Studies Presented at the 2019 European Society of Cardiology Congress

PURPOSE OF REVIEW

This review intends to highlight selected cardiovascular disease (CVD) prevention studies presented at the 2019 European Society of Cardiology (ESC) Congress.

RECENT FINDINGS

Results from the Inclisiran for Subjects with ASCVD or ASCVD-risk Equivalent and Elevated Low-density Lipoprotein Cholesterol (ORION-11) trial validate inclisiran's ability to significantly lower low-density lipoprotein cholesterol (LDL-C) levels in at-risk individuals on a background of maximally tolerated statin therapy. The EVOlocumab for Early Reduction of LDL-cholesterol Levels in Patients With Acute Coronary Syndromes (EVOPACS) trial provide additional support that a PCSK9 inhibitor can be initiated safely and effectively early after an acute coronary syndrome. A sub-study of the Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) trial provides further support for stratification of secondary prevention patients to help define the magnitude of risk reduction associated with PCSK9 inhibitor therapy. A post hoc analysis from the Aspirin in Reducing Events in the Elderly (ASPREE) trial suggest that any benefits associated with aspirin utilizing a risk-based approach are overwhelmed by increased bleeding risk. In a large retrospective cohort study of patients with diabetes mellitus and obesity, the addition of metabolic (weight loss) surgery to standard care led to greater improvement in CVD outcomes, weight loss, and glycemic control. Results from the Prospective Urban Rural Epidemiology (PURE) study demonstrate that while hypertension and dyslipidemia exert additive lifelong effects on CVD risk, other less established risk factors such as low education, household pollution, and poor diet also have a strong impact on CVD outcomes, especially in middle- and low-income countries. Finally, in the Heart Outcomes Prevention and Evaluation (HOPE) 4 trial, a comprehensive model of care adapted to address multiple barriers of specific communities led to substantial improved blood pressure (BP) control, medication use, and adherence. A number of studies presented at the 2019 ESC Congress reinforced the value of preventative interventions in CVD risk reduction.

Management of Diabetes in Patients Undergoing Bariatric Surgery

PURPOSE OF REVIEW

The number of bariatric surgeries for patients with type 1 or type 2 diabetes continues to grow. Clinicians are challenged to choose therapies that reach glycemic targets without inducing adverse effects in post-bariatric patients without published guidelines. This review evaluates data supporting the best strategies for diabetes management in patients undergoing bariatric surgery.

RECENT FINDINGS

Though few clinical trials have evaluated the safety and effectiveness of different glucose-lowering therapies following bariatric surgery, remission of diabetes or reduced medications is an established benefit of bariatric surgery. Adverse events including diabetic ketoacidosis in post-bariatric patients on sodium-glucose co-transporter 2 (SGLT2) inhibitors or inadequate insulin have been reported in patient's with both type 1 and type 2 diabetes. Metformin, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, SGLT2 inhibitors, insulin, and sulfonylureas have been used successfully in the perioperative period for other surgeries and guidelines recommend adjusting the doses of these medications especially in the perioperative period. Clinicians should favor weight-neutral or weight-loss promoting therapies in post-bariatric surgery patients such as medical nutrition therapy, metformin, GLP-1 agonists, SGLT2 inhibitors, and DPP-4 inhibitors.

Costs Associated With Modifiable Risk Factors in Ventral and Incisional Hernia Repair

IMPORTANCE

Ventral and incisional hernia repair (VIHR) is an extremely common operation, after which complications are also fairly common. A number of preoperative risk factors are known to contribute to increased complications after surgical repair; however, the individual relative association of these risk factors with adverse outcomes and increased spending is unclear. Quantifying the association of individual risk factors may help surgeons implement targeted surgical optimization, improve outcomes, and reduce spending.

OBJECTIVE

To identify the attributable association of modifiable risk factors for adverse outcomes after VIHR on outcomes and episode-of-care payments.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was performed using a population-based sample of adult patients and episode spending data from January 1, 2012, to December 31, 2018, from a statewide multipayer registry. A multilevel mixed-effects logistic regression model was used to examine the contribution of patient-specific risk factors to adverse outcomes. Attributable risk and population attributable risk fraction were calculated to estimate the additional spending attributable to individual risk factors. Data were analyzed from April 2018 to September 2018.

MAIN OUTCOMES AND MEASURES

Any complications, serious complication, discharge not to home, 30-day emergency department utilization, and 30-day readmission. Episode-of-care spending was calculated for these outcomes.

RESULTS

This study included 22 664 patients (median [interquartile range] age, 55 [44-64] years; 10 496 [46.3%] women) undergoing VIHR with identified significant preoperative risk factors. Fourth-quartile body mass index (BMI), calculated as weight in kilograms divided by height in meters squared and defined as a mean (SD) BMI of 43 (6), was associated with increased risk of any complication (odds ratio [OR], 1.64; 95% CI, 1.30-2.06; P < .001) and serious complication (OR, 1.67; 95% CI, 1.22-2.31; P = .002). Insulin-dependent diabetes was associated with increased risk of any complication (OR, 1.34; 95% CI, 1.03-1.73; P = .03), serious complication (OR, 1.51; 95% CI, 1.08-2.12; P = .02), discharge not to home (OR, 1.49; 95% CI, 1.12-1.98; P = .005), and 30-day readmission (OR, 1.68; 95% CI, 1.32-2.14; P < .001). Median (interquartile range) additional episode spending for any complication was $9934 ($9224-$11 851), of which $1304 ($1208-$1552) was attributable to fourth-quartile BMI. Median (interquartile range) additional episode spending for a serious complication was $26 648 ($20 632-$33 166), of which $3638 ($2827-$4544) was attributable to fourth-quartile BMI, $650 ($495-$796) was attributable to insulin-dependent diabetes, and $567 ($433-$696) was attributable to unhealthy alcohol use.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, modifiable risk factors, such as obesity, insulin-dependent diabetes, and unhealthy alcohol use, were associated with adverse outcomes after VIHR. These factors were significantly associated with increased health care spending; therefore, preoperative optimization may improve outcomes and decrease episode-of-care costs.