Bariatric Surgery versus Intensive Medical Therapy for Diabetes - 5-Year Outcomes

Factors Associated with Statin Discontinuation Following Metabolic and Bariatric Surgery: A Retrospective Analysis of 2012-2021 Electronic Medical Records Network Data

BACKGROUND

Bariatric surgery has been shown to improve hyperlipidemia, decreasing the need for statin medications. Although maintaining statin therapy post-surgery for those with a history of atherosclerotic cardiovascular disease (ASCVD) is advised, it is uncertain if discontinuation risks differ between those with and without ASCVD history.

AIM

The study aims to analyze the rate and reasons for statin cessation post-bariatric surgery in the US using real-world data.

METHODS

Using the TriNetX electronic medical records network from 2012 to 2021, the study involved patients aged 18 or older on statins at the time of bariatric surgery. They were categorized into primary and secondary prevention groups based on prior ASCVD. Statin discontinuation was defined as a 90-day gap post the last statin dosage. The Cox model assessed factors influencing statin cessation.

RESULTS

Seven hundred and thirty-three statin users undergoing bariatric surgery were identified, with 564 (77%) in primary prevention. Six months post-surgery, 48% of primary prevention patients and 34.5% of secondary ones stopped statins. Primary prevention patients had a 30% higher likelihood of cessation compared to secondary prevention (hazard ratio, 1.30; 95% CI, 1.06-1.60) as shown by multivariable analysis.

CONCLUSIONS

Post-bariatric surgery, primary prevention patients are more likely to discontinue statins than secondary prevention patients.

Comparison of health care costs following sleeve gastrectomy versus Roux-en-Y gastric bypass among patients with type 2 diabetes

OBJECTIVE

The objective of this study was to compare the impact of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on overall and diabetes-specific health care costs among patients with type 2 diabetes.

METHODS

This retrospective cohort study examined patients with type 2 diabetes after SG and RYGB using data from Optum's deidentified Clinformatics® Data Mart database. The matched study group included 9608 patients who underwent SG or RYGB and were enrolled between 2007 and 2019. The primary outcomes assessed were overall and diabetes-specific health care costs.

RESULTS

Health care costs associated with type 2 diabetes declined substantially in the first few years following both SG and RYGB. RYGB was associated with a larger decrease in pharmacy costs, as well as type 2 diabetes-specific office and laboratory costs. SG was associated with lower total health care costs in the first three follow-up periods and lower acute care costs in the first 2 years after surgery.

CONCLUSIONS

In this nationwide study, patients with type 2 diabetes at baseline undergoing RYGB appear to experience a reduced need for ambulatory type 2 diabetes monitoring and reduced requirements for antidiabetes medication but, despite this, did not experience an overall medical cost-benefit in the first few years after RYGB versus SG.

Prognostic factors in resolution of nonalcoholic fatty liver disease post bariatric surgery in adolescents

BACKGROUND

The long-term effect of bariatric surgery on adolescent non-alcoholic fatty liver disease is not clear.

OBJECTIVES

To evaluate longitudinal change in serum alanine aminotransferase (ALT) levels and to determine the factors independently associated with this change over 2 years after bariatric surgery in adolescents with severe obesity.

SETTING

An observational prospective cohort from the Teen-LABS Consortium.

METHODS

We examined the relationship of longitudinal change in serum ALT (% change and normalization) to change in body mass index (BMI), homeostasis model assessment of insulin resistance (HOMA-IR), triglycerides (TG), high- (HDL) and low-density lipoprotein cholesterol, A1C and fasting glucose, accounting for age, sex, race-ethnicity, blood pressure, and baseline BMI in 219 adolescents during the first 2 years post-surgery.

RESULTS

Mean BMI declined from a baseline of 52.6 to 37.2 kg/m2 at 2 years (P < .01). Alanine aminotransferase decreased significantly from baseline (36.5 [95% CI: 31.4, 41.7]) to 6 months (30.5 [95% CI: 25.4, 35.6]), and remained stable at 12 and 24 months, all P < .01 versus baseline. After adjustment, improvement in BMI, fasting glucose, HOMA-IR, triglycerides, TG/HDL ratio, and HDL were independently associated with reduced ALT at 6 months. These remained significantly associated with a decline in ALT after adjusting for BMI change. The %participants with elevated ALT decreased from 71% at baseline to 42% and 36% at 1 and 2 years post-surgery.

CONCLUSIONS

Bariatric surgery resulted in significant and sustained improvement in ALT levels over 2 years. Although associated with weight loss, this decline was also associated with improved metabolic indices, independent of weight loss.

Early prediction of the impact of public health policies on obesity and lifetime risk of type 2 diabetes: A modelling approach

OBJECTIVE

Help public health decision-making requires a better understanding of the dynamics of obesity and type 2 diabetes and an assessement of different strategies to decrease their burdens.

METHODS

Based on 97,848 individual data, collected in the French Health, Health Care and Insurance Survey over 1998-2014, a Markov model was developed to describe the progression of being overweight to obesity, and the onset of type 2 diabetes. This model traces and predicts 2022-2027 burdens of obesity and type 2 diabetes, and lifetime risk of diabetes, according to different scenarios aiming at minimum to stabilize obesity at 5 years.

RESULTS

Estimated risks of type 2 diabetes increase from 0.09% (normal weight) to 1.56% (obesity II-III). Compared to the before 1995 period, progression risks are estimated to have nearly doubled for obesity and tripled for type 2 diabetes. Consequently, over 2022-2027, the prevalence of obesity and type 2 diabetes will continue to increase from 17.3% to 18.2% and from 7.3% to 8.1%, respectively. Scenarios statibilizing obesity would require a 22%-decrease in the probability of move up (scenario 1) or a 33%-increase in the probability of move down (scenario 2) one BMI class. However, this stabilization will not affect the increase of diabetes prevalence whereas lifetime risk of diabetes would decrease (30.9% to 27.0%). Combining both scenarios would decrease obesity by 9.9%. Only the prevalence of obesity III shows early change able to predict the outcome of a strategy: for example, 6.7%-decrease at one year, 13.3%-decrease at two years with scenario 1 stabilizing obesity at 5 years.

CONCLUSIONS

Prevalences of obesity and type 2 diabetes will still increase over the next 5 years. Stabilizing obesity may decrease lifetime risks of type 2 diabetes without affecting its short-term prevalence. Our study highlights that, to early assess the effectiveness of their program, public health policy makers should rely on the change in prevalence of obesity III.

Obesity: current state of the problem, multidisciplinary approach. (based on the consensus of the World Gastroenterological Organization “Obesity 2023” and the European guideline on obesity care in patients with gastrointestinal and liver diseases, 2022)

Obesity is the largest pandemic in the world, and its prevalence continues to increase. The purpose of the presented publication is to raise awareness of doctors about modern methods of diagnosing obesity and approaches to therapy, using an interdisciplinary team approach similar to that used in other chronic diseases, such as diabetes, heart disease and cancer. The article presents data from the World Gastroenterological Organization (2023) and the European Guidelines for the Treatment of Obesity in patients with diseases of the gastrointestinal tract and liver (2022). According to modern approaches, obesity should be considered as a chronic recurrent progressive disease, the treatment of which requires a comprehensive interdisciplinary approach involving psychologists and psychiatrists, nutritionists/nutritionists, therapists, endoscopists and surgeons, including lifestyle changes, a well-defined diet and exercise regimen, drug therapy, endoscopic or surgical methods of treatment. Conclusions. In order to stop the growing wave of obesity and its many complications and costs, doctors, insurance companies and health authorities should make systematic efforts to raise public awareness of both the adverse health risks associated with obesity and the potential reduction of risks through a comprehensive approach to therapy.

Is Sigstad's score really capable of detecting post-surgical late dumping syndrome?

BACKGROUND

This clinical trial explores the Sigstad score for late dumping syndrome in postoperative patients who have undergone sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB). The aims of this study are to investigate the correlations with late dumping syndrome, to evaluate the reliability and validity of the Sigstad score and to discuss a modified scoring system.

METHODS

The study was conducted at the Obesity Center of the Westküstenklinikum Heide and included 271 patients. Data collection involved conducting interviews, diet diaries and measuring blood glucose levels. Non-parametric tests, logistic regression and McDonald's Omega were the selected statistical approaches.

RESULTS

Body Mass Index (BMI) decreased over time (-9.67 kg/m2 at 4 months, -15.58 kg/m2 at 12 months). Preoperatively, the Sigstad score exhibited the highest value, and no occurrences of late dumping syndrome were observed. No significant differences were found in BMI concerning late dumping syndrome or Sigstad score among postoperative patients. Postoperative patients experienced an increase in gastrointestinal symptoms. The reliability test showed a McDonald's omega value of 0.509. The analysis conducted through binary logistic regression indicated dizziness as a significant predictor of late dumping syndrome; however, this finding did not hold up after performing Bonferroni correction.

CONCLUSION

The Sigstad score is not a reliable or valid method for detecting late dumping syndrome after surgery for obesity and metabolic disorders. It is necessary to have alternatives that use objective measures and assess the quality of life, and that these alternatives be validated in large patient cohorts.

GLP-1 and PYY for the treatment of obesity: a pilot study on the use of agonists and antagonists in diet-induced rats

Objective

Combination therapies with gut hormone analogs represent promising treatment strategies for obesity. This pilot study investigates the therapeutic potential of modulators of the glucagon-like peptide 1 (GLP-1) and neuropeptide Y (NPY) system using GLP-1 receptor agonists (semaglutide) and antagonists (exendin 9-39), as well as non-selective and NPY-Y2-receptor selective peptide tyrosine tyrosine (PYY) analogs (PYY3-36/NNC0165-0020 and NNC0165-1273) and an NPY-Y2 receptor antagonist (JNJ31020028).

Methods

High-fat diet (HFD)-induced obese rats were randomized into following treatment groups: group 1, nonselective PYY analog + semaglutide (n = 4); group 2, non-selective and NPY-Y2 receptor selective PYY analog + semaglutide (n = 2); group 3, GLP-1 receptor antagonist + NPY-Y2 receptor antagonist (n = 3); group 4, semaglutide (n = 5); and group 5, control (n = 5). Animals had free access to HFD and low-fat diet. Food intake, HFD preference and body weight were measured daily.

Results

A combinatory treatment with a non-selective PYY analog and semaglutide led to a maximum body weight loss of 14.0 ± 4.9% vs 9.9 ± 1.5% with semaglutide alone. Group 2 showed a maximum weight loss of 20.5 ± 2.4%. While HFD preference was decreased in group 2, a strong increase in HFD preference was detected in group 3.

Conclusions

PYY analogs (especially NPY-Y2 selective receptor agonists) could represent a promising therapeutic approach for obesity in combination with GLP-1 receptor agonists. Additionally, combined GLP-1 and PYY3-36 receptor agonists might have beneficial effects on food preference.

Do patients with obesity undergoing bariatric surgery modify their objectively measured physical activity? A systematic review and meta-analysis

BACKGROUND

Obesity is a chronic disease associated with adverse outcomes and its prevalence is increasing, which makes it a concern. One of the obesity treatment options is bariatric surgery, which effectively reduces calorie absorption and total body mass, but its effects on physical activity (PA) levels need to be clarified, considering the protective effect of the PA against cardiovascular disease, independently of the weight loss alone.

OBJECTIVES

To carry out a systematic review and meta-analysis of observational studies that evaluated PA in pre- and post-bariatric surgery periods through objective evaluation.

METHODS

A systematic search was carried out following the PRISMA criteria of studies with adult individuals who underwent bariatric surgery and were objectively evaluated for PA pre- and post-surgery. Studies with interventions were excluded.

RESULTS

A total of 419 records were found, and after excluding duplicates and applying the eligibility criteria, 10 studies remained. This meta-analysis found a significant increase in the steps by day (MD = 1340; 95% CI = 933.90; 1745.35, p < 0.001) and the light physical activity level (MD = 16.8 min/day; 95% CI = 2.60; 30.98, p = 0.02), but not in moderate to vigorous physical activity (MD = 0.24; 95% CI = -0.08; 1.57, p = 0.92).

CONCLUSIONS

Patients undergoing bariatric surgery increased their steps by day and light physical activity but did not increase moderate to vigorous physical activity.

Tipping the scale in abdominal wall reconstruction: An analysis of short- and long-term outcomes by body mass index

BACKGROUND

Morbid obesity, with a body mass index 35 kg/m2, is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short-term wound morbidity, its effect on long-term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long-term outcomes.

METHODS

Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90-day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, inflammatory bowel disease, mesh weight, and mesh-to-hernia size ratio.

RESULTS

A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14-1.77; P < .01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13-1.74; P < .01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P < .01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P = .01). Hernia recurrence rate at 1 year was lower for the body mass index ≥35 kg/m2 group (7% vs 12%; P = .02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02-1.74; P = .04) was associated with recurrence; body mass index was not (P = .11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year.

CONCLUSION

Morbid obesity is associated with 90-day wound morbidity; however, short-term complications did not translate to higher reoperation or long-term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m2 should not be used to deny symptomatic patients abdominal wall reconstruction.

Standardized Assessment of Metabolic Bariatric Surgery Outcomes: Secondary Analysis of 2 Randomized Clinical Trials

Importance

A standardized definition and reporting of metabolic bariatric surgery (MBS) outcomes is not available for actual clinical practice and science.

Objective

To assess the feasibility of using a clinically relevant and feasible MBS outcome score (Swiss-Finnish Bariatric Metabolic Outcome Score [SF-BARI Score]).

Design, Setting, and Participants

This assessment of a bariatric surgery outcome score is based on the secondary analysis of merged 5-year individual patient data (N = 457) of 2 large randomized clinical trials (Swiss SM-BOSS [Swiss Multicenter Bypass or Sleeve Study], conducted from January 2007 to November 2011, and Finnish SLEEVEPASS [Laparoscopic Gastric Bypass Vs Sleeve Gastrectomy to Treat Morbid Obesity], conducted from March 2008 until June 2010) that compared laparoscopic sleeve gastrectomy with laparoscopic Roux-en-Y gastric bypass in the treatment of severe obesity. This secondary analysis was performed from January 2022 to January 2023.

Main Outcomes and Measures

The main outcome was the feasibility of the SF-BARI Score and the SF-BARI Score QOL (quality of life) as tools to assess MBS outcomes. The score includes percentage of total weight loss (%TWL), 4 obesity-related comorbidities (type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea), complications, and QOL, if available.

Results

Among the 457 included patients, 323 (70.7%) were female and 134 (29.3%) were male, and the mean (SD) age was 45.6 (10.7) years. Outcomes for the SF-BARI Score were available for 435 patients (95.2%) at 1 year and 398 patients (87.1%) at 5 years and for SF-BARI Score QOL in 289 (63.2%) patients at 1 year and 318 patients (69.6%) at 5 years. The SF-BARI Score was correlated with both the SF-BARI Score QOL (r = 0.96; 95% CI, 0.95-0.96; P < .001) and %TWL (r = 0.86; 95% CI, 0.84-0.89; P < .001) and with the Bariatric Analysis and Reporting Outcome System (r = 0.59; 95% CI, 0.51-0.65; P < .001). Score outcomes were categorized as excellent, very good, good, fair, and suboptimal response. There was a statistically significant difference in scores at 1 vs 5 years (4.0; 95% CI, 1.4-6.6; P = .003), and the gastric bypass group had a higher score compared with the sleeve gastrectomy group (7.4; 95% CI, 3.4-11.5; P < .001).

Conclusions and Relevance

These findings indicate that this metabolic bariatric surgery outcome score is a simple, relevant, and feasible composite tool to define and measure MBS outcomes, enabling standardized reporting.

Trial Registration

ClinicalTrials.gov Identifiers: NCT00356213 (SM-BOSS) and NCT00793143 (SLEEVEPASS).

Systematic Review and Meta-analysis of the Effects of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy on Dyslipidemia

The aim of this meta-analysis was to compare the effects of LRYGB and LSG on dyslipidemia. Studies comparing the effects of LRYGB and LSG on dyslipidemia with follow-up of 12 months or more were included. Twenty-four studies comprising seven RCTs and 17 comparative observational studies were included. Meta-analysis of RCTs (n=487) showed that improvement/resolution of dyslipidemia was better after LRYGB (68.5%, n=161/235) compared to LSG (48.4%, n=122/252). Patients undergoing LRYGB were more than twice as likely to experience improvement/resolution in dyslipidemia compared to those undergoing LSG (OR 2.28, 95% CI 1.21-4.29, p=0.010). Both LRGYB and LSG appears effective in improving dyslipidemia at >12 months after surgery; however, this improvement is more than twice higher after LRYGB compared to LSG.

Management of Patients With Kidney Disease Undergoing Bariatric Surgery: A Multidisciplinary Approach

Bariatric surgery is increasingly recognized as a safe and effective treatment for obesity in patients with chronic kidney disease (CKD), including stages 4, 5, and 5D (on dialysis). Among the available surgical methods, sleeve gastrectomy (SG) is the most commonly performed weight loss procedure and is mainly done to facilitate kidney transplantation (KT). However, many KT candidates treated with SG remain on the transplant waiting list for months to years, with some never receiving a transplant. Therefore, appropriate candidates for SG must be selected, and post-SG management should address the unique needs of this population, with a focus on sustaining the metabolic benefits of surgery while minimizing potential side effects related to rapid weight loss which may inadvertently lead to muscle and bone catabolism. Multidisciplinary post-SG care in this population may lead to overall better health on the transplant waiting list, resulting in a higher percentage of post-SG patients ultimately receiving KT. To tailor the effective treatment for these patients, clinicians should acknowledge that patients with CKD stage 4-5D have different nutritional needs and are metabolically and psychosocially distinct from the general bariatric surgery population. Sarcopenia is highly prevalent and may be exacerbated by muscle catabolism following SG if not adequately addressed. Blood pressure, glucose, and bone metabolism are all affected by the CKD stage 4-5D, and therefore require distinct diagnostic and management approaches. Long-standing chronic disease, associated comorbidities, and low adherence to medical therapies require ongoing comprehensive psychosocial assessment and support. This paper aims to review and consolidate the existing literature concerning the intersection of CKD stage 4-5D and the consequences of SG. We also suggest future clinical outcome studies examining novel treatment approaches for this medically complex population.

Improvement of Triglyceride-Glucose Index Following Bariatric Surgery: a Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery is an effective intervention for the management of severe obesity and its associated comorbidities, including metabolic abnormalities. This meta-analysis aimed to evaluate the impact of bariatric surgery on the triglyceride-glucose (TyG) index, a novel marker of insulin resistance and metabolic syndrome.

METHODS

A systematic search was conducted in Embase, PubMed, Web of Science, and Scopus. The meta-analysis was performed using Comprehensive Meta-Analysis (CMA) V4 software. The overall effect size was determined by a random-effects meta-analysis and the leave-one-out approach.

RESULTS

A total of 9 trials including 1620 individuals confirmed a significant reduction in TyG following bariatric surgery (weighted mean difference (WMD) - 0.770, 95% CI - 1.006, - 0.534, p < 0.001). In a sub-analysis according to the type of bariatric surgery there was a significant reduction in TyG index for Roux-en-Y gastric bypass (WMD - 0.775, 95% CI - 1.000, - 0.550, p < 0.001), and sleeve gastrectomy (WMD - 0.920, 95% CI - 1.368, - 0.473, p < 0.001). In a sub-analysis according to the follow-up duration there was similarly a significant reduction in TyG index for both < 12 months (WMD - 1.645, 95% CI - 2.123, - 1.167, p < 0.001), and ≥ 12 months follow-up (WMD - 0.954, 95% CI - 1.606, - 0.303, p < 0.001).

CONCLUSION

The results of this meta-analysis demonstrated a significant reduction in the TyG index following bariatric surgery, indicating improved insulin sensitivity and metabolic health. These findings highlight the potential of bariatric surgery as a valuable therapeutic option for individuals with obesity and its metabolic consequences.

Bariatric Surgery and Longitudinal Cancer Risk: A Review

Importance

Cancer is one of the leading causes of death in the United States, with the obesity epidemic contributing to its steady increase every year. Recent cohort studies find an association between bariatric surgery and reduced longitudinal cancer risk, but with heterogeneous findings.

Observations

This review summarizes how obesity leads to an increased risk of developing cancer and synthesizes current evidence behind the potential for bariatric surgery to reduce longitudinal cancer risk. Overall, bariatric surgery appears to have the strongest and most consistent association with decreased incidence of developing breast, ovarian, and endometrial cancers. The association of bariatric surgery and the development of esophageal, gastric, liver, and pancreas cancer is heterogenous with studies showing either no association or decreased longitudinal incidences. Conversely, there have been preclinical and cohort studies implying an increased risk of developing colon and rectal cancer after bariatric surgery. A review and synthesis of the existing literature reveals epidemiologic shortcomings of cohort studies that potentially explain incongruencies observed between studies.

Conclusions and Relevance

Studies examining the association of bariatric surgery and longitudinal cancer risk remain heterogeneous and could be explained by certain epidemiologic considerations. This review provides a framework to better define subgroups of patients at higher risk of developing cancer who would potentially benefit more from bariatric surgery, as well as subgroups where more caution should be exercised.

Association of bariatric surgery with indicated and unintended outcomes: An umbrella review and meta-analysis for risk-benefit assessment

Bariatric surgery can cause numerous functional changes to recipients, some of which are unintended. However, a systematic evaluation of wide-angled health benefits and risks following bariatric surgery has not been conducted. We systematically evaluated published systematic reviews of randomized controlled trials and observational studies reporting the association between bariatric surgery and health outcomes. We performed subgroup analyses by surgery type and sensitivity analysis, excluding gastric band. Thirty systematic reviews and 82 meta-analyzed health outcomes were included in this review. A total of 66 (80%) health outcomes were significantly associated with bariatric surgery, of which 10 were adverse outcomes, including suicide, fracture, gastroesophageal reflux after sleeve gastrectomy, and neonatal morbidities. The other 56 outcomes were health benefits including new-onset diabetes mellitus (DM) (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.19-0.79), hypertension (OR = 0.36; 95% CI = 0.33-0.40), dyslipidemia (OR = 0.33; 95% CI = 0.14-0.81), cancers (OR = 0.65; 95% CI = 0.53-0.80), cardiovascular diseases (CVDs), and women's health. Surgery is associated with reductions in all-cause mortality and death due to cancer, DM, and CVD. Bariatric surgery has both beneficial and harmful effects on a broader than expected array of patients' health outcomes. An expansion of the indication for bariatric surgery could be discussed to include a broader population with metabolic vulnerabilities.

Evaluation of Healthcare Utilisation and Expenditures in Persons with Type 2 Diabetes Undergoing Bariatric-Metabolic Surgery

PURPOSE

Changes in healthcare utilisation and expenditures after bariatric-metabolic surgery (BMS) for people with type 2 diabetes mellitus (T2DM) are unclear. We used the Dutch national all-payer claims database (APCD) to evaluate utilisation and expenditures in people with T2DM who underwent BMS.

METHODS

In this cohort study, patients with T2DM who had BMS in 2016 were identified in the APCD. This group was matched 1:2 to a control group with T2DM who did not undergo BMS based on age, gender and healthcare expenditures. Data on healthcare expenditures and utilisation were collected for 2013-2019.

RESULTS

In total, 1751 patients were included in the surgery group and 3502 in the control group. After BMS, total median expenditures in the surgery group stabilised (€ 3156 to € 3120) and increased in the control group (€ 3174 to € 3434). Total pharmaceutical expenditures decreased 28% in the surgery group (€957 to €494) and increased 55% in the control group (€605 to €936). In the surgery group, 67.1% did not use medication for T2DM in 2019 compared to 13.3% in the control group. Healthcare use for microvascular complications increased in the control group, but not in the surgery group.

CONCLUSION

BMS in people with T2DM stabilises healthcare expenditures and decreases medication use and care use for microvascular complications. In contrast, healthcare use and expenditures in T2DM patients who do not undergo surgery gradually increase over time. Due to the progressive nature of T2DM, it is expected that these differences will become larger in the long-term.

Barriers to metabolic surgery and how to address them

After bariatric surgery, patients with obesity achieve sustainable weight loss, gain in mobility, quality of life and life expectancy. Bariatric surgery can lead to remission of type 2 diabetes or to long term glycaemic control for patients with type 2 diabetes, while medical treatment has a preventive efficacy on micro and macrovascular complications. This has led to the concept of metabolic surgery to treat type 2 diabetes. Despite the benefits, only a small proportion of eligible patients undergo bariatric/metabolic surgery. Powerful antidiabetic medications, self-estimated lack of knowledge by medical professionals and fear of surgical complications are some of the arguments to prefer medical treatment of type 2 diabetes obesity versus metabolic surgery. We have reviewed in this paper the barriers which explain the low referral rate to metabolic surgery. With the point of view of the diabetologist, the general practitioner and the patient, we have addressed them to help clinicians and patients model an evidenced-based patient-oriented medical plan.

Gastroesophageal reflux disease following laparoscopic vertical sleeve gastrectomy and laparoscopic roux-en-Y gastric bypass: meta-analysis and systematic review of 5-year data

To compare 5-year gastroesophageal reflux outcomes following Laparoscopic Vertical Sleeve Gastrectomy (LVSG) and Laparoscopic Roux-en-Y gastric bypass (LRYGB) based on high quality randomized controlled trials (RCTs). We conducted a sub-analysis of our systematic review and meta-analysis of RCTs of primary LVSG and LRYGB procedures in adults for 5-year post-operative complications (PROSPERO CRD42018112054). Electronic databases were searched from January 2015 to July 2021 for publications meeting inclusion criteria. The Hartung-Knapp-Sidik-Jonkman random effects model was utilized to estimate weighted mean differences where meta-analysis was possible. Bias and certainty of evidence was assessed using the Cochrane Risk of Bias Tool 2 and GRADE. Four RCTs were included (LVSG n = 266, LRYGB n = 259). An increase in adverse GERD outcomes were observed at 5 years postoperatively in LVSG compared to LRYGB in all outcomes considered: Overall worsened GERD, including the development de novo GERD, occurred more commonly following LVSG compared to LRYGB (OR 5.34, 95% CI 1.67 to 17.05; p = 0.02; I2 = 0%; (Moderate level of certainty); Reoperations to treat severe GERD (OR 7.22, 95% CI 0.82 to 63.63; p = 0.06; I2 = 0%; High level of certainty) and non-surgical management for worsened GERD (OR 3.42, 95% CI 1.16 to 10.05; p = 0.04; I2 = 0%; Low level of certainty) was more common in LVSG patients. LVSG is associated with the development and worsening of GERD symptoms compared to LRYGB at 5 years postoperatively leading to either introduction/increased pharmacological requirement or further surgical treatment. Appropriate patient/surgical selection is critical to minimize these postoperative risks.

Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes

Importance

Randomized clinical trials of bariatric surgery have been limited in size, type of surgical procedure, and follow-up duration.

Objective

To determine long-term glycemic control and safety of bariatric surgery compared with medical/lifestyle management of type 2 diabetes.

Design, Setting, and Participants

ARMMS-T2D (Alliance of Randomized Trials of Medicine vs Metabolic Surgery in Type 2 Diabetes) is a pooled analysis from 4 US single-center randomized trials conducted between May 2007 and August 2013, with observational follow-up through July 2022.

Intervention

Participants were originally randomized to undergo either medical/lifestyle management or 1 of the following 3 bariatric surgical procedures: Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding.

Main Outcome and Measures

The primary outcome was change in hemoglobin A1c (HbA1c) from baseline to 7 years for all participants. Data are reported for up to 12 years.

Results

A total of 262 of 305 eligible participants (86%) enrolled in long-term follow-up for this pooled analysis. The mean (SD) age of participants was 49.9 (8.3) years, mean (SD) body mass index was 36.4 (3.5), 68.3% were women, 31% were Black, and 67.2% were White. During follow-up, 25% of participants randomized to undergo medical/lifestyle management underwent bariatric surgery. The median follow-up was 11 years. At 7 years, HbA1c decreased by 0.2% (95% CI, -0.5% to 0.2%), from a baseline of 8.2%, in the medical/lifestyle group and by 1.6% (95% CI, -1.8% to -1.3%), from a baseline of 8.7%, in the bariatric surgery group. The between-group difference was -1.4% (95% CI, -1.8% to -1.0%; P < .001) at 7 years and -1.1% (95% CI, -1.7% to -0.5%; P = .002) at 12 years. Fewer antidiabetes medications were used in the bariatric surgery group. Diabetes remission was greater after bariatric surgery (6.2% in the medical/lifestyle group vs 18.2% in the bariatric surgery group; P = .02) at 7 years and at 12 years (0.0% in the medical/lifestyle group vs 12.7% in the bariatric surgery group; P < .001). There were 4 deaths (2.2%), 2 in each group, and no differences in major cardiovascular adverse events. Anemia, fractures, and gastrointestinal adverse events were more common after bariatric surgery.

Conclusion and Relevance

After 7 to 12 years of follow-up, individuals originally randomized to undergo bariatric surgery compared with medical/lifestyle intervention had superior glycemic control with less diabetes medication use and higher rates of diabetes remission.

Trial Registration

ClinicalTrials.gov Identifier: NCT02328599.

Beneficial effects of simultaneously targeting calorie intake and calorie efficiency in diet-induced obese mice

Semaglutide is an anti-diabetes and weight loss drug that decreases food intake, slows gastric emptying, and increases insulin secretion. Patients begin treatment with low-dose semaglutide and increase dosage over time as efficacy plateaus. With increasing dosage, there is also greater incidence of gastrointestinal side effects. One reason for the plateau in semaglutide efficacy despite continued low food intake is due to compensatory actions whereby the body becomes more metabolically efficient to defend against further weight loss. Mitochondrial uncoupler drugs decrease metabolic efficiency, therefore we sought to investigate the combination therapy of semaglutide with the mitochondrial uncoupler BAM15 in diet-induced obese mice. Mice were fed high-fat western diet (WD) and stratified into six treatment groups including WD control, BAM15, low-dose semaglutide without or with BAM15, and high-dose semaglutide without or with BAM15. Combining BAM15 with either semaglutide dose decreased body fat and liver triglycerides, which was not achieved by any monotherapy, while high-dose semaglutide with BAM15 had the greatest effect on glucose homeostasis. This study demonstrates a novel approach to improve weight loss without loss of lean mass and improve glucose control by simultaneously targeting energy intake and energy efficiency. Such a combination may decrease the need for semaglutide dose escalation and hence minimize potential gastrointestinal side effects.

Restoration of blood vessel regeneration in the era of combination SGLT2i and GLP-1RA therapy for diabetes and obesity

Ischaemic cardiovascular diseases, including peripheral and coronary artery disease, myocardial infarction, and stroke, remain major comorbidities for individuals with type 2 diabetes (T2D) and obesity. During cardiometabolic chronic disease (CMCD), hyperglycaemia and excess adiposity elevate oxidative stress and promote endothelial damage, alongside an imbalance in circulating pro-vascular progenitor cells that mediate vascular repair. Individuals with CMCD demonstrate pro-vascular 'regenerative cell exhaustion' (RCE) characterized by excess pro-inflammatory granulocyte precursor mobilization into the circulation, monocyte polarization towards pro-inflammatory vs. anti-inflammatory phenotype, and decreased pro-vascular progenitor cell content, impairing the capacity for vessel repair. Remarkably, targeted treatment with the sodium-glucose cotransporter-2 inhibitor (SGLT2i) empagliflozin in subjects with T2D and coronary artery disease, and gastric bypass surgery in subjects with severe obesity, has been shown to partially reverse these RCE phenotypes. SGLT2is and glucagon-like peptide-1 receptor agonists (GLP-1RAs) have reshaped the management of individuals with T2D and comorbid obesity. In addition to glucose-lowering action, both drug classes have been shown to induce weight loss and reduce mortality and adverse cardiovascular outcomes in landmark clinical trials. Furthermore, both drug families also act to reduce systemic oxidative stress through altered activity of overlapping oxidase and antioxidant pathways, providing a putative mechanism to augment circulating pro-vascular progenitor cell content. As SGLT2i and GLP-1RA combination therapies are emerging as a novel therapeutic opportunity for individuals with poorly controlled hyperglycaemia, potential additive effects in the reduction of oxidative stress may also enhance vascular repair and further reduce the ischaemic cardiovascular comorbidities associated with T2D and obesity.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Reduction of prevalence of patients meeting the criteria for metabolic syndrome with tirzepatide: a post hoc analysis from the SURPASS Clinical Trial Program

BACKGROUND

Metabolic syndrome is characterized as the co-occurrence of interrelated cardiovascular risk factors, including insulin resistance, hyperinsulinemia, abdominal obesity, dyslipidemia and hypertension. Once weekly tirzepatide is approved in the US and EU for the treatment of type 2 diabetes (T2D) and obesity. In the SURPASS clinical trial program for T2D, tirzepatide demonstrated greater improvements in glycemic control, body weight reduction and other cardiometabolic risk factors versus placebo, subcutaneous semaglutide 1 mg, insulin degludec, and insulin glargine. This post hoc analysis assessed the effect of tirzepatide use on the prevalence of patients meeting the criteria for metabolic syndrome across SURPASS 1-5.

METHODS

Metabolic syndrome was defined as having ≥ 3 of 5 criteria according to the US National Cholesterol Education Program: Adult Treatment Panel III. Analyses were based on on-treatment data at the primary endpoint from patients adherent to treatment (taking ≥ 75% study drug). A logistic regression model with metabolic syndrome status as the response variable, metabolic syndrome status at the baseline visit as an adjustment, and randomized treatment as fixed explanatory effect was used. The effect of tirzepatide use on the prevalence of patients meeting the criteria for metabolic syndrome by categorical weight loss, background medication and gender were assessed.

RESULTS

In SURPASS, the prevalence of patients meeting the criteria for metabolic syndrome at baseline was 67-88% across treatment groups with reductions at the primary endpoint to 38-64% with tirzepatide versus 64-82% with comparators. Reductions in the prevalence of patients meeting the criteria for metabolic syndrome was significantly greater with all tirzepatide doses versus placebo, semaglutide 1 mg, insulin glargine, and insulin degludec (p < 0.001). Individual components of metabolic syndrome were also reduced to a greater extent with tirzepatide vs comparators. Greater reductions in body weight were associated with greater reductions in the prevalence of patients meeting the criteria for metabolic syndrome and its individual components. Background SGLT2i or sulfonylurea use or gender did not impact the change in prevalence of patients meeting the criteria for metabolic syndrome.

CONCLUSIONS

In this post hoc analysis, tirzepatide at all doses studied was associated with a greater reduction in the prevalence of patients meeting the criteria for metabolic syndrome compared to placebo, semaglutide 1 mg, insulin degludec, and insulin glargine. Although more evidence is needed, these data would support greater potential improvement in cardiovascular risk factor profile with tirzepatide treatment in people across the continuum of T2D.

Prevention of cardiorenal complications in people with type 2 diabetes and obesity

Traditional approaches to prevention of the complications of type 2 diabetes (T2D) and obesity have focused on reduction of blood glucose and body weight. The development of new classes of medications, together with evidence from dietary weight loss and bariatric surgery trials, provides new options for prevention of heart failure, chronic kidney disease, myocardial infarction, stroke, metabolic liver disease, cancer, T2D, and neurodegenerative disorders. Here I review evidence for use of lifestyle modification, SGLT-2 inhibitors, GLP-1 receptor agonists, selective mineralocorticoid receptor antagonists, and bariatric surgery, for prevention of cardiorenal and metabolic complications in people with T2D or obesity, highlighting the contributions of weight loss, as well as weight loss-independent mechanisms of action. Collectively, the evidence supports a tailored approach to selection of therapeutic interventions for T2D and obesity based on the likelihood of developing specific complications, rather than a stepwise approach focused exclusively on glycemic or weight control.

Can Nonalcoholic Steatohepatitis Be Surgically Cured?: Liver Histologic Comparison After Metabolic Surgery Versus Usual Care

OBJECTIVE

To compare histologic outcomes in patients with fibrotic nonalcoholic steatohepatitis (NASH) and obesity after metabolic surgery versus nonsurgical care.

BACKGROUND

There are no published data comparing the effects of metabolic surgery versus nonsurgical care on histologic progression of NASH.

METHODS

Repeat liver biopsies were performed in patients with body mass index >30 kg/m 2 at a US health system whose baseline liver biopsy between 2004 and 2016 confirmed a histologic diagnosis of NASH including the presence of liver fibrosis, but without cirrhosis. Baseline characteristics of liver histology for patients who underwent simultaneous liver biopsy at the time of metabolic surgery were balanced with a nonsurgical control group using overlap weighting methods. The primary composite endpoint required both resolution of NASH and improvement of at least 1 fibrosis stage in the repeat liver biopsy.

RESULTS

A total of 133 patients (42 metabolic surgery and 91 nonsurgical controls) had a repeat liver biopsy with a median interval of 2 years. Overlap weighting provided balance for baseline histologic disease activity, fibrosis stage, and time interval between liver biopsies. In overlap-weighted patients, 50.1% in the surgical and 12.1% in the nonsurgical group met the primary endpoint (odds ratio=7.3; 95% CI, 2.8-19.2, P <0.001). NASH resolution and fibrosis improvement occurred in 68.5% and 64.1% of surgical patients, respectively. Surgical and nonsurgical patients who met the primary endpoint lost more weight than their counterparts who did not meet the primary endpoint [mean weight loss difference in the surgical group: 12.2% (95% CI, 7.3%-17.2%) and in the nonsurgical group: 11.6% (95% CI, 6.2%-16.9%)].

CONCLUSIONS

Among patients with fibrotic noncirrhotic NASH, metabolic surgery resulted in simultaneous NASH resolution and fibrosis improvement in half of patients.

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy generates sustained improvement of glycemic control compared with sleeve gastrectomy in the diet-induced obese rat model

Bariatric surgery has become a recognized and effective procedure for treating obesity and type 2 diabetes (T2D). Our objective was to directly compare the caloric intake-independent effects of sleeve gastrectomy (SG) and single anastomosis duodenoileal bypass with SG (SADI-S) on glucose tolerance in rats with diet-induced obesity (DIO) and to elucidate the differences between bariatric surgery and caloric restriction.A total of 120 adult male Wistar rats with DIO and insulin resistance were randomly assigned to surgical (sham operation, SG, and SADI-S) and dietary (pair-feeding the amount of food eaten by animals undergoing the SG or SADI-S surgeries) interventions. Body weight and food intake were weekly monitored, and 6 weeks after interventions, fasting plasma glucose, oral glucose and insulin tolerance tests, plasma insulin, adiponectin, GIP, GLP-1, and ghrelin levels were determined.The body weight of SADI-S rats was significantly (p < 0.001) lower as compared to the sham-operated, SG, and pair-fed groups. Furthermore, SADI-S rats exhibited decreased whole body fat mass (p < 0.001), lower food efficiency rates (p < 0.001), and increased insulin sensitivity, as well as improved glucose and lipid metabolism compared to that of the SG and pair-fed rats.SADI-S was more effective than SG, or caloric restriction, in improving glycemic control and metabolic profile, with a higher remission of insulin resistance as well as long-term weight loss.

Advances in obesity pharmacotherapy; learning from metabolic surgery and beyond

Currently, metabolic surgery (MS) constitutes the most effective means for durable weight loss of clinically meaningful magnitude, type 2 diabetes remission and resolution of non-alcoholic steatohepatitis, as well as other obesity-related comorbidities. Accumulating evidence on the mechanisms through which MS exerts its actions has highlighted the altered secretion of hormonally active peptides of intestinal origin with biological actions crucial to energy metabolism as key drivers of MS clinical effects. The initial success of glucagon-like peptide-1 (GLP-1) receptor agonists regarding weight loss and metabolic amelioration have been followed by the development of unimolecular dual and triple polyagonists, additionally exploiting the effects of glucagon and/or glucose-dependent insulinotropic polypeptide (GIP) which achieves a magnitude of weight loss approximating that of common MS operations. Through the implementation of such therapies, the feasibility of a "medical bypass", namely the replication of the clinical effects of MS through non-surgical interventions may be foreseeable in the near future. Apart from weight loss, this approach ought to be put to the test also regarding other clinical outcomes, such as liver steatosis and steatohepatitis, cardiovascular disease, and overall prognosis, on which MS has a robustly demonstrated impact. Besides, a medical bypass as an alternative, salvage, or combination strategy to MS may promote precision medicine in obesity therapeutics.

Bariatric Surgery in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine condition in premenopausal women and is a common cause of anovulatory subfertility. Although obesity does not form part of the diagnostic criteria, it affects a significant proportion of women with PCOS and is strongly implicated in the pathophysiology of the disease. Both PCOS and obesity are known to impact fertility in women; obesity also reduces the success of assisted reproductive technology (ART). With or without pharmacotherapy, lifestyle intervention remains the first-line treatment in women with PCOS and obesity. Bariatric surgery is still an experimental treatment in women with PCOS and subfertility. This review will present an overview of the pathophysiology of PCOS and obesity and the role of bariatric surgery. Although data are sparse regarding the impact of bariatric surgery on subfertility in women with PCOS and obesity, existing studies point to a beneficial role in treating metabolic and reproductive dysfunction.

Evaluation of a Magnetic Compression Anastomosis for Jejunoileal Partial Diversion in Rhesus Macaques

PURPOSE

Metabolic surgery remains underutilized for treating type 2 diabetes, as less invasive alternative interventions with improved risk profiles are needed. We conducted a pilot study to evaluate the feasibility of a novel magnetic compression device to create a patent limited caliber side-to-side jejunoileal partial diversion in a nonhuman primate model.

MATERIALS AND METHODS

Using an established nonhuman primate model of diet-induced insulin resistance, a magnetic compression device was used to create a side-to-side jejunoileal anastomosis. Primary outcomes evaluated feasibility (e.g., device mating and anastomosis patency) and safety (e.g., device-related complications). Secondary outcomes evaluated the device's ability to produce metabolic changes associated with jejunoileal partial diversion (e.g., homeostatic model assessment of insulin resistance [HOMA-IR] and body weight).

RESULTS

Device mating, spontaneous detachment, and excretion occurred in all animals (n = 5). There were no device-related adverse events. Upon completion of the study, ex vivo anastomoses were widely patent with healthy mucosa and no evidence of stricture. At 6 weeks post-device placement, HOMA-IR improved to below baseline values (p < 0.05). Total weight also decreased in a linear fashion (R2 = 0.97) with total weight loss at 6 weeks post-device placement of 14.4% (p < 0.05).

CONCLUSION

The use of this novel magnetic compression device to create a limited caliber side-to-side jejunoileal anastomosis is safe and likely feasible in a nonhuman primate model. The observed glucoregulatory and metabolic effects of a partial jejunoileal bypass with this device warrant further investigation to validate the long-term glucometabolic impact of this approach.

Can Weight of The Resected Stomach Predict Weight Loss Results After Laparoscopic Sleeve Gastrectomy?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Many factors have been investigated in the literature to predict weight loss outcomes after LSG. However, insufficient data regarding the resected stomach weight (RGW) exists. This retrospective study aimed to investigate the association between RGW and weight loss outcomes 1 year after LSG.

MATERIALS AND METHODS

Fifty-four patients who underwent LSG in a tertiary care center were evaluated retrospectively. The statistical analyses were performed to investigate the correlation between preoperative demographics, RGW, and the excess weight loss percentage (%EWL) and percent total weight loss (%TWL).

RESULTS

The mean RGW was 169.7±40.1, ranging from 101 to 295 grams. The RGW was significantly correlated with preoperative weight (r=0.486; P<0.001), body mass index (r=0.420; P=0.002), and age (r=0.327; P=0.01). However, RGW did not predict postoperative weight loss, as measured by percent total weight loss (%TWL) and percent excess weight loss (%EWL), respectively (r=0.044; P=0.75 and r=-0.216; P=0.11). Multiple linear regression analysis identified age as a negative predictor for both %TWL (β=-0.351, P=0.005) and %EWL (β=-0.265, P=0.03), while preoperative body mass index was a negative predictor for %EWL (β=-0.469, P<0.001).

CONCLUSION

The RGW, although correlated with patient characteristics, does not serve as a reliable predictor of postoperative weight loss in the first year after LSG. Further research is needed to improve predictive models and patient care in bariatric surgery.

Addressing uncertainty about the role of structured lifestyle modification for metabolic surgery patients

There is good evidence that structured lifestyle modification programmes improve health in patients with metabolic and cardiovascular disorders, but there is no specific evidence that they improve outcomes in patients undergoing metabolic or obesity surgery. Despite expert consensus guidelines stating this fact, some healthcare systems still compel patients to participate in a structured lifestyle modification programme prior to metabolic or obesity surgery. There is a well-established need for individualised multidisciplinary dietetic and physical activity care for metabolic and obesity surgery patients, and the benefits of intentional weight loss prior to surgery are well proven, but these are distinct from potentially harmful requirements for patients to undertake compulsory structured lifestyle programmes of fixed duration, frequency and intensity, which may delay surgery and reinforce obesity stigma. A critical step in rejuvenating metabolic surgery is to reframe patient participation in structured lifestyle modification programmes as an opportunity for education and empowerment, not as an indicator of motivation or suitability for metabolic surgery. Large, well-designed and adequately powered clinical trials are needed to address uncertainties in the evidence base for these programmes. Given genuine equipoise, they will need to determine whether "surgery plus lifestyle" is superior to "surgery plus placebo". Moreover, they will need to determine the cost-effectiveness of these programmes and identify some of the factors giving rise to the substantial heterogeneity in responses to structured lifestyle modification.

Evaluation of prescription medication changes following sleeve gastrectomy surgery

Objective

The increasing global prevalence of obesity, coupled with its association with chronic health conditions and rising healthcare costs, highlights the need for effective interventions; however, despite the availability of treatment options, the ongoing success of primary interventions in maintaining long-term weight loss remains limited. This study examined the prescription medication dispensing changes following sleeve gastrectomy in Australians aged 45 years and over.

Methods

In a retrospective analysis of 847 bariatric surgery patients from the New South Wales 45 and Up Study, the assessment of medication patterns categorizing into three groups: gastrointestinal, metabolic, cardiorespiratory, musculoskeletal, and nervous systems was conducted. Each drug class was analyzed, focusing on patients with dispensing records within the 12 months before surgery. This study employed interrupted time-series analysis to compare pre- and post-surgery medication usage.

Results

With a predominantly female population (76.9%) and an average age of 57.2 (standard deviation 5.71), there were statistically significant reductions in both unique medications (12.5% decrease, p = 0.004) and total medications dispensed (15.9% decrease, p = 0.003) from 12 months before surgery to 13-24 months after bariatric surgery. All medication categories, except opioids, showed reductions. Notably, the most significant reductions were observed in diabetes (38.6%), agents acting on the renin-angiotensin system (40.4%), lipid modifying agents (26.5%), anti-inflammatory products (46.3%), and obstructive airway diseases (53.3%) medications during this time frame.

Conclusion

These findings suggest that sleeve gastrectomy provides an effective therapeutic intervention for patients with comorbidities requiring multiple medications, especially for obesity-related diseases such as diabetes, cardiovascular, respiratory and musculoskeletal disorders.

Increased glycemic variability in pregnant women with Roux-en-Y gastric bypass compared with sleeve gastrectomy

INTRODUCTION

Bariatric surgery is associated with adverse pregnancy outcomes such as reduced birth weight and premature birth. One possible mechanism for this is increased glycemic variability (GV) which occurs after bariatric surgery. The objective of this study was to compare the effect of Roux-en-Y gastric bypass (RYGB) versus vertical sleeve gastrectomy (SG) on GV during pregnancy and to investigate the relationships of GV, type of bariatric surgery and maternal and neonatal outcomes.

RESEARCH DESIGN AND METHODS

Fourteen pregnant women after RYGB and 14 after SG were investigated with continuous glucose monitoring in their second or third trimester in this observational study carried out as part of routine clinical care.

RESULTS

Pregnant women with RYGB had similar mean interstitial glucose values but significantly increased indices of GV and a lower %time in range 3.9-7.8 mmol/L (70-140 mg/dL), compared with SG.

CONCLUSIONS

Pregnant women who have undergone RYGB have greater GV during pregnancy compared with those who have undergone SG. Further research is needed to establish the relationship between GV and pregnancy outcomes to determine the preferred bariatric operation in women of reproductive age, and whether interventions to reduce GV might improve outcomes.

Metabolic and bariatric surgery in patients with class I obesity; a two-year follow-up

BACKGROUND

Patients with class I obesity may need metabolic and bariatric surgery (MBS) in the presence of obesity-associated medical problems, but MBS in this class of obesity is under debate. This study aimed to investigate the efficacy and safety of MBS in patients with class I obesity.

METHODS AND MATERIALS

This study was a historical cohort carried out on 112 patients with class I obesity with body mass index (BMI) of 30-35 kg/m2 with a 24-month follow-up underwent MBS at Rasoul-e-Akram Hospital. The required data were extracted through the Iran National Obesity Surgery Database. The data required for the study consisted of demographic information such as age, gender, and obesity-associated medical problems like type-2 diabetes mellitus (T2DM), hypertension, obstructive sleep apnea, and dyslipidemia before surgery, 6, 12, and 24 months after surgery.

RESULTS

Mean age of the patients was 38.10 ± 10.04 years; mean BMI was 32.96 ± 1.35 kg/m2 and 83.9% (n = 94) of patients were female. Out of 18 patients with T2DM, 11 patients (61.11%) had complete remission and seven patients (38.88%) had partial remission. Obstructive sleep apnea, hypertension, dyslipidemia, and gastroesophageal reflux disease were observed in 18 (16.07%), 23 (20.53%), 43 (38.39%), and 13 patients (11.60%) before surgery and resolved at 24-month follow-up. Post-operative complications during the 24-month follow-up were checked to assess safety and there were no De novo gastroesophageal reflux disease, intolerance, leakage, pulmonary thromboembolism, deep vein thrombosis, incisional hernia, hypoalbuminemia (Albumin < 3.5 g/dl), excessive weight loss (BMI < 18.5 kg/m2) at any time during 24-months follow-ups and mortality. Early complications occurred as splenic injury in one case (0.89%), wound infection in one patient (0.89%), and extra-luminal bleeding in 10 (8.92%) after surgery, without any mortality.

CONCLUSION

MBS is safe and effective in class I obesity and can be considered in selected patients with obesity-associated medical problems.

Metabolic surgery in patients with diabesity: A review of the historical backgrounds and scoring systems

Diabesity is a modern term that describes the coexistence of adverse health effects of diabetes mellitus and obesity and indicates a causal pathophysiological relationship between the two phenomena. The progression of diabesity leads to a deterioration of multiple organs and systems. Effective intervention for patients with diabesity must include optimal obesity therapy to prevent secondary complications. Metabolic surgery is the most effective and sustainable therapy for severe obesity and the elimination or prevention of many associated diseases, including type 2 diabetes mellitus, hypertension, sleep apnea, heart disease, and certain cancers. This review provides an up-to-date overview of surgical interventions for obesity, particularly the development of metabolic surgery. It evaluates different scoring systems for evidence-based selection of metabolic surgery based on disease severity. We reviewed different predictive scoring systems for better evidence-based selection of the best metabolic surgery for patients with diabesity. We found that medication type, fasting insulin level, and C-peptide influence the outcomes of different types of metabolic surgery and heterogeneous remission rates. There are different predictive scoring systems for evidence-based selection of the best metabolic surgery, either sleeve or mini-bypass, that will ensure the highest chance of diabetes remission. Using the metabolic score calculator is a useful tool to help medical specialists determine the optimal treatment strategy for a particular patient. More research is needed before we can agree on the ideal bariatric procedure that offers the highest chance of remission with the lowest incidence of hypoglycemia.

Comparison of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass: A Randomized Clinical Trial

Importance

Laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) are widely used bariatric procedures for which comparative efficacy and safety remain unclear.

Objective

To compare perioperative outcomes in SG and RYGB.

Design, Setting, and Participants

In this registry-based, multicenter randomized clinical trial (Bypass Equipoise Sleeve Trial), baseline and perioperative data for patients undergoing bariatric surgery from October 6, 2015, to March 31, 2022, were analyzed. Patients were from university, regional, county, and private hospitals in Sweden (n = 20) and Norway (n = 3). Adults (aged ≥18 years) eligible for bariatric surgery with body mass indexes (BMIs; calculated as weight in kilograms divided by height in meters squared) of 35 to 50 were studied.

Interventions

Laparoscopic SG or RYGB.

Main Outcomes and Measures

Perioperative complications were analyzed as all adverse events and serious adverse events (Clavien-Dindo grade >IIIb). Ninety-day mortality was also assessed.

Results

A total of 1735 of 14 182 eligible patients (12%; 1282 [73.9%] female; mean (SD) age, 42.9 [11.1] years; mean [SD] BMI, 40.8 [3.7]) were included in the study. Patients were randomized and underwent SG (n = 878) or RYGB (n = 857). The mean (SD) operating time was shorter in those undergoing SG vs RYGB (47 [18] vs 68 [25] minutes; P < .001). The median (IQR) postoperative hospital stay was 1 (1-1) day in both groups. The 30-day readmission rate was 3.1% after SG and 4.0% after RYGB (P = .33). There was no 90-day mortality. The 30-day incidence of any adverse event was 40 (4.6%) and 54 (6.3%) in the SG and RYGB groups, respectively (odds ratio, 0.71; 95% CI, 0.47-1.08; P = .11). Corresponding figures for serious adverse events were 15 (1.7%) for the SG group and 23 (2.7%) for the RYGB group (odds ratio, 0.63; 95% CI, 0.33-1.22; P = .19).

Conclusions and Relevance

This randomized clinical trial of 1735 patients undergoing primary bariatric surgery found that both SG and RYGB were performed with a low perioperative risk without clinically significant differences between groups.

Trial Registration

ClinicalTrials.gov Identifier: NCT02767505.

Sleeve gastrectomy and one-year outcomes: Impact on cardiovascular, renal and metabolic parameters

Background

Cardiovascular and renal diseases represent a major determinant for the morbidity and mortality associated with obesity and type 2 diabetes mellitus (T2DM). Bariatric surgery is considered one of the few treatments with the potential to reverse cardiovascular, renal and metabolic disease.

Methods

Prospective study of patients undergoing sleeve gastrectomy collecting pre- and post-surgery creatinine, eGFR, glucose, insulin, total, LDL/HDL cholesterol, triglycerides, parathyroid hormone, vitamin D3, C- Reactive Protein (CRP), blood count, weight, body mass index (BMI), bilateral carotid intima media thickness (IMT), flow-mediated dilation (FMD) and epicardial adipose tissue (EAT). Measurements were compared at 1 year follow up.

Results

24 patients were included in the study. Cardiovascular parameters, as HDL-cholesterol (p = 0.002), IMT (p = 0.003), EAT (p < 0.001) and FMD (p = 0.001) showed significant improvement after surgery. Secondary renal outcomes including Vitamin D3 (p < 0.0001), Calcium (p = 0.006), RBCs (p = 0.007), HCO3- (p = 0.05) also ameliorated as well as BMI (p < 0.001).

Conclusions

Sleeve gastrectomy has a positive impact on cardiovascular, renal, and metabolic parameters in patients with morbid obesity, suggesting it may halt the progression of these diseases even in the preclinical stage. Further research is needed to explore the long-term effects underlying these improvements.

Comparing Safety and Efficacy Outcomes of Gastric Bypass and Sleeve Gastrectomy in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Sleeve Gastrectomy (SG) could be done by the removal of a big portion of the stomach, leading to reduced amounts of food taken as a result of the smaller stomach size. In contrast, Roux-en-Y Gastric Bypass (RYGB) can be done by creating a small stomach pouch and rerouting a part of the small intestine, employing combined mechanisms of restriction and malabsorption to limit food intake and modify nutrient absorption. Our aim is to identify the most effective and safest surgical intervention for individuals with both Type 2 Diabetes Mellitus (T2DM) and obesity, considering both short and long-term outcomes. We will assess participants undergoing either SG or RYGB to determine the optimal surgical approach. We made a thorough search of PubMed, Cochrane Library, Scopus, and Web of Science databases up to November 2023. Our focus was on randomized controlled trials (RCTs) comparing the safety and efficacy of RYGB and SG in T2DM regarding any extractable data. We excluded studies of other designs, such as cohorts, case reports, case series, reviews, in vitro studies, postmortem analyses, and conference abstracts. Utilizing Review Manager 5.4, we performed a meta-analysis, combining risk ratios (RR) with a 95% confidence interval (CI) conducted for binary outcomes, while mean with SD and 95% CI are pooled for the continuous ones. The total number of participants in our study is 4,148 patients. Our analysis indicates superior outcomes in the group undergoing RYGB surgery compared to the SG group (RR = 0.76, 95% (CI) (0.66 to 0.88), P = 0.0002). The pooled data exhibited homogeneity (P = 0.51, I2 = 0%) after employing the leave-one-out method. For the 1-3 year period, six studies involving 332 patients with T2DM yielded non-significant results (RR = 0.83, 95% CI (0.66 to 1.06), P = 0.14) with homogeneity (P = 0.24, I2 = 28%). Conversely, the 5-10 year period, with six studies comprising 728 DM patients, demonstrated significant results (RR = 0.69, 95% CI (0.56 to 0.85), P = 0.14) and homogeneity (P = 0.84, I2 = 0%). In terms of total body weight loss, our findings indicate significantly higher weight loss with RYGB (mean difference (MD) = -6.13, 95% CI (-8.65 to -3.6), P > 0.00001). However, pooled data exhibited considerable heterogeneity (P > 0.00001, I2 = 93%). Subgroup analyses for the 1-3 year period (five studies, 364 DM patients) and 5-10 year period (six studies, 985 DM patients) also revealed significant differences favoring RYGB, with heterogeneity observed in both periods (1-3 years: P > 0.00001, I2 = 95%; 5-10 years: P = 0.001, I2 = 75%). RYGB demonstrated significant long-term improvement in diabetes remission and superior total body weight loss compared to SG. While no notable differences were observed in other efficacy outcomes, safety parameters require further investigation. no significant distinctions were found in any of the safety outcomes: hypertension (HTN), high-density lipoprotein (HDL), hyperlipidemia, fasting blood glucose, vomiting, low-density lipoprotein (LDL), and total cholesterol. Further research is essential to comprehensively assess safety outcomes for both surgical approaches.

Clinical Perspectives, Eligibility, and Success Criteria for Bariatric/Metabolic Surgery

Obesity is a worldwide chronic, complex, and progressive disease that poses a challenge for physicians to pursue optimal therapeutic decision making. This chapter focuses on the definition of obesity, based on excessive fat accumulation, and thus underscores the importance of body composition, and the clinical tools used to diagnose it in the context of excess weight, metabolic alteration, and obesity-associated comorbidity development. Additionally, it addresses the indications for surgery that are currently applicable and the description of the different types of patients who could benefit the most from the surgical management of excessive body fat and its associated metabolic derangements and quality of life improvement. Furthermore, it also highlights plausible underlying mechanisms of action for the beneficial effects following bariatric/metabolic surgery.

Meta-analysis of the Impact of Bariatric Surgery on Circulating TMAO Levels as a Predictor of Cardiovascular Disease Risk

INTRODUCTION

Trimethylamine N-oxide (TMAO) is a metabolite of the gut microbiota that is considered a cardiovascular risk factor. Because bariatric surgery (BS) produces changes in the composition of the gut microbiota, the production of TMAO can be compromised. Thus, the purpose of this meta-analysis was to determine the effect of BS on circulating TMAO levels.

METHODS

A systematic search was carried on in Embase, PubMed, Web of Science, and Scopus databases. The meta-analysis was conducted using Comprehensive Meta-Analysis (CMA) V2 software. The overall effect size was determined by a random-effects metaanalysis and the leave-one-out approach.

RESULTS

Random-effects meta-analysis of 5 studies consisting of 142 subjects demonstrated a significant increase in circulating TMAO levels after BS (SMD: 1.190, 95% CI: 0.521, 1.858, p<0.001; I2:89.30%).

CONCLUSION

Considering that levels of TMAO are affected after BS due to gut microbial metabolism alteration, there has been a significant elevation in TMAO concentrations observed to occur after BS in obese subjects.

Safety and Efficacy of 12-Month Intra-gastric Balloon-Series of over 1100 Patients

BACKGROUND

Intra-gastric balloons (IGB) are a mainstay of endoscopic treatment of overweight and obesity. In recent years, an IGB which can remain in situ for 12 months has been developed. The current study aimed to analyse the safety and efficacy of this 12-month IGB.

METHODS

Consecutive patients receiving the Orbera 365TM IGB (Apollo Endosurgery, TX, USA) between September 2017 and August 2021 were included in a prospective database. Patients received regular follow-up consultations followed by endoscopic removal at 12 months. Demographic data along with weight loss data were collected. All adverse events were recorded.

RESULTS

In total, 1149 patients were included in the study. A majority of the patients were female (87.13%). Median body mass index (BMI) prior to insertion was 36.30 kg/m2 (IQR 32.60-40.00 kg/m2). Median absolute weight loss for all patients was 11.36 kg (IQR 6.70-16.82 kg). There was ongoing sustained weight loss until device removal at week 52. For patients with a weight recording at point of IGB removal, median weight loss was greater (15.88 kg, IQR 10.43-21.72) with percentage total body weight loss of 15.38% (IQR 10.99-21.77) and excess weight loss of 53.99% (IQR 32.44-76.30). Increased patient engagement with post-procedural follow-up was associated with increased weight loss (p<0.001). There were 60 total complications (5.22%). Fifty patients required balloon removal due to intolerance. There were eight cases of balloon rupture. There were only two severe complications (0.17%).

CONCLUSION

The current study has confirmed safety of this IGB at 12 months with adverse events comparable to published literature. Weight loss increased up until the point of removal at 12 months.

French National Authority for Health assessment of metabolic surgery for type 2 diabetes remission-A meta-analysis in patients with class I to III obesity

OBJECTIVE

Randomized controlled trials (RCTs) have demonstrated the superiority of metabolic surgery (MS) over medical therapy (MT) in patients with obesity and type 2 diabetes, leading, to a joint statement in 2016 proposing MS to patients with class I obesity and uncontrolled glycemia. Yet, these RCTs included few patients with class I obesity (body mass index 30-35 kg/m2) and even fewer patients with overweight. Our aim was to provide an updated systematic review (SR) with meta-analysis (MA) of RCTs reporting diabetes remission (DR) after MS in these patients.

RESEARCH DESIGN AND METHODS

We included in the SR with MA only RCTs with at least 24-month follow-up found in Medline, Cochrane Library, Embase, and LiSSA between January 2008 and September 2022 comparing DR post-MT versus post-MS. We calculated relative risk (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel random-effects approach to examine differences in DR between patients allocated to MS versus MT.

RESULTS

DR was significantly higher in MS versus MT after 36 months' follow-up in patients with obesity (RR = 6.65 [95 %CI 2.24;19.79]; I² = 27 %; 5 trials, 404 patients), but also specifically in patients with class I obesity (RR = 5.27 [1.31;21.23]; I² = 0 %; 4 trials, 80 patients). Furthermore, and in line with previous results, all additional MAs performed in patients with obesity in this work favor MS (specifically Roux-en-Y gastric bypass) over MT at 24, 36 (only) and 60 months of follow-up.

CONCLUSIONS

Although the data available in patients with class I obesity and type 2 diabetes remains limited, MA shows higher rates of DR after MS compared with MT after 36 months' follow-up in these patients. Consequently, the French National Authority for Health French (HAS) recommends MS for these patients.

Clinical outcomes and adverse events of bariatric surgery in adults with severe obesity in Scotland: the SCOTS observational cohort study

Background

Bariatric surgery is a common procedure worldwide for the treatment of severe obesity and associated comorbid conditions but there is a lack of evidence as to medium-term safety and effectiveness outcomes in a United Kingdom setting.

Objective

To establish the clinical outcomes and adverse events of different bariatric surgical procedures, their impact on quality of life and the effect on comorbidities.

Design

Prospective observational cohort study.

Setting

National Health Service secondary care and private practice in Scotland, United Kingdom.

Participants

Adults (age >16 years) undergoing their first bariatric surgery procedure.

Main outcome measures

Change in weight, hospital length of stay, readmission and reoperation rate, mortality, diabetes outcomes (HbA1c, medications), quality of life, anxiety, depression.

Data sources

Patient-reported outcome measures, hospital records, national electronic health records (Scottish Morbidity Record 01, Scottish Care Information Diabetes, National Records Scotland, Prescription Information System).

Results

Between December 2013 and February 2017, 548 eligible patients were approached and 445 participants were enrolled in the study. Of those, 335 had bariatric surgery and 1 withdrew from the study. Mean age was 46.0 (9.2) years, 74.7% were female and the median body mass index was 46.4 (42.4; 52.0) kg/m2. Weight was available for 128 participants at 3 years: mean change was -19.0% (±14.1) from the operation and -24.2% (±12.8) from the start of the preoperative weight-management programme. One hundred and thirty-nine (41.4%) participants were readmitted to hospital in the same or subsequent 35 months post surgery, 18 (5.4% of the operated cohort) had a reoperation or procedure considered to be related to bariatric surgery gastrointestinal complications or revisions. Fewer than five participants (<2%) died during follow-up. HbA1c was available for 93/182 and diabetes medications for 139/182 participants who had type 2 diabetes prior to surgery; HbA1c mean change was -5.72 (±16.71) (p = 0.001) mmol/mol and 65.5% required no diabetes medications (p < 0.001) at 3 years post surgery. Physical quality of life, available for 101/335 participants, improved in the 3 years post surgery, mean change in Rand 12-item Short Form Survey physical component score 8.32 (±8.95) (p < 0.001); however, there was no change in the prevalence of anxiety or depression.

Limitations

Due to low numbers of bariatric surgery procedures in Scotland, recruitment was stopped before achieving the intended 2000 participants and follow-up was reduced from 10 years to 3 years.

Conclusions

Bariatric surgery is a safe and effective treatment for obesity. Patients in Scotland, UK, appear to be older and have higher body mass than international comparators, which may be due to the small number of procedures performed.

Future work

Intervention studies are required to identify the optimal pre- and post surgery pathway to maximise safety and cost-effectiveness.

Study registration

This study is registered as ISRCTN47072588.

Funding details

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 10/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 7. See the NIHR Funding and Awards website for further award information.

American Diabetes Association Professional Practice Committee, ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Kushner RF, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2024

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

IFSO Consensus on Definitions and Clinical Practice Guidelines for Obesity Management-an International Delphi Study

INTRODUCTION

This survey of international experts in obesity management was conducted to achieve consensus on standardized definitions and to identify areas of consensus and non-consensus in metabolic bariatric surgery (MBS) to assist in an algorithm of clinical practice guidelines for the management of obesity.

METHODS

A three-round Delphi survey with 136 statements was conducted by 43 experts in obesity management comprising 26 bariatric surgeons, 4 endoscopists, 8 endocrinologists, 2 nutritionists, 2 counsellors, an internist, and a pediatrician spanning six continents over a 2-day meeting in Hamburg, Germany. To reduce bias, voting was unanimous, and the statements were neither favorable nor unfavorable to the issue voted or evenly balanced between favorable and unfavorable. Consensus was defined as ≥ 70% inter-voter agreement.

RESULTS

Consensus was reached on all 15 essential definitional and reporting statements, including initial suboptimal clinical response, baseline weight, recurrent weight gain, conversion, and revision surgery. Consensus was reached on 95/121 statements on the type of surgical procedures favoring Roux-en-Y gastric bypass, sleeve gastrectomy, and endoscopic sleeve gastroplasty. Moderate consensus was reached for sleeve gastrectomy single-anastomosis duodenoileostomy and none on the role of intra-gastric balloons. Consensus was reached for MBS in patients > 65 and < 18 years old, with a BMI > 50 kg/m2, and with various obesity-related complications such as type 2 diabetes, liver, and kidney disease.

CONCLUSIONS

In this survey of 43 multi-disciplinary experts, consensus was reached on standardized definitions and reporting standards applicable to the whole medical community. An algorithm for treating patients with obesity was explored utilizing a thoughtful multimodal approach.

Risk Stratification and Treatment of Obesity for Primary and Secondary Prevention of Cardiovascular Disease

PURPOSE OF REVIEW

In this review, we discuss contemporary and emerging approaches for risk stratification and management of excess adiposity for the primary and secondary prevention of cardiovascular disease.

RECENT FINDINGS

Obesity is simultaneously a pandemic-scale disease and major risk factor for the incidence and progression of a wide range of cardiometabolic conditions, but risk stratification and treatment remain clinically challenging. However, sex-, race-, and ethnicity-sensitive anthropometric measures, body composition-focused imaging, and health burden-centric staging systems have emerged as important facilitators of holistic risk prediction. Further, expanding therapeutic approaches, including comprehensive lifestyle programs, anti-obesity pharmacotherapies, device/endoscopy-based interventions, metabolic surgery, and novel healthcare delivery resources offer new empowerment for cardiovascular risk reduction in individuals with obesity. Personalized risk stratification and weight management are central to reducing the lifetime prevalence and impact of cardiovascular disease. Further evidence informing long-term safety, efficacy, and cost-effectiveness of novel approaches targeting obesity are critically needed.

[Results of the first All-Russian consensus conference on bariatric surgery]

Until now, there has not been organized consensus for standardization in bariatric surgery In Russia. We present the results of the first Bariatric Surgery Consensus Conference conducted in Barnaul (March, 2023). A list of questions was proposed within 6 blocks: 1) general issues of bariatric surgery, 2) sleeve gastrectomy, 3) one-anastomosis gastric bypass («mini-gastric bypass»), 4) Roux-en-Y Gastric Bypass, 5) Single Anastomosis Duodenal Switch and other options for biliopancreatic bypass, 6) rare procedures. Consensus (>70% agreement) was reached for 51 out of 96 statements. Stratification by the level of expertise was carried out, and responses of the expert group were compared with responses of all participants.

The oral disposition index calculated from a meal tolerance test is a crucial indicator for evaluating differential normalization of postprandial glucose and triglyceride excursions in morbidly obese patients after laparoscopic sleeve gastrectomy

To determine the normalization of postprandial blood glucose (PG) and triglyceride (TG) excursions in 30 morbidly obese patients with or without diabetes mellitus (DM) 1-year after they underwent a laparoscopic sleeve gastrectomy (LSG) vs. their pre-surgery data, we administered the 75-g oral glucose tolerance test (OGTT) and a meal tolerance test (MTT) using a 75-g glucose-equivalent carbohydrate- and fat-containing meal. The results were as follows; (i) Postoperative body-weight reduction was associated with DM remission and reduced multiple cardiometabolic risks. (ii) OGTT data showing postprandial hyper-insulinemic hypoglycemia in many post-surgery patients were associated with overdiagnosis of improved glucose tolerance. However, postoperative MTT data without hypoglycemia showed no improvement in the glucose tolerance vs. pre-surgery data. (iii) The disposition index (DI) i.e., [Matsuda index] × (Glucose-induced insulin secretion) was progressively worsened from normal glucose tolerance to DM patients after LSG. These post-surgery DI values measured by the MTT were correlated with 2h-plasma glucose levels and were not normalized in DM patients. (iv) The baseline, 2h-TG, and an increase in 2h-TG values above baseline were correlated with the insulin resistance index, DI, or HbA1c; These TG values were normalized post-LSG. In conclusion, the glucose tolerance curve measured by the MTT was not normalized in T2DM patients, which was associated with impaired normalization of the DI values in those patients 1-year after the LSG. However, the baseline TG and a fat-induced 2h-TG values were normalized postoperatively. The MTT can be used to assess normalization in postprandial glucose and TG excursions after LSG.