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

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Preoperative predictors of early relapse/no-remission of type-2 diabetes after metabolic surgery in Chinese patients

Remission of type 2 diabetes mellitus (T2DM) after metabolic surgery in some patients is not sustained. There is limited data regarding the preoperative factors predicting early relapse of T2DM in Chinese patients. The objective of this study is to look for preoperative predictors of early T2DM relapse/no remission in patients with obesity and diabetes who underwent Roux-en-Y gastric bypass (RYGB) or loop duodeno-jejunal bypass with sleeve gastrectomy (LDJB-SG). This is a retrospective study of 113 patients who underwent RYGB or LDJB-SG for T2DM. All T2DM patients with BMI 27.5 to 37.5 kg/m² , having uncontrolled diabetes and T2DM patients with BMI > 37.5 were included in the study. A multivariate analysis with a logistic regression model was used for analysed factors. Nineteen patients (16.8%) had early relapse and 12 (10.6%) did not have remission. Mean age of patients was significantly more who relapsed/no-remission (44.9 vs 40.3 years). On univariate analysis, base line weight (86 vs 96.7 kg) was significantly lower in patients who relapsed/no-remission. Patients with sustained remission had statistically significant low glycosylated haemoglobin (P < .030), plasma glucose (120 minutes) (P < .002) on OGTT, area under curve glucose (P < .011) values and more C-peptide (P < .006) on univariate analysis. Only duration of diabetes (OR 2.78, 95% CI 1.56-4.97, P < .001) was found to be independent preoperative factor associated with early relapse/no-remission. Two years of diabetes duration was the cut-off point to predict relapse/no-remission (sensitivity 78.9, specificity 63.4, receiver operating characteristic curve 0.71). Duration of diabetes is the most probable, independent preoperative predictor of early T2DM relapse/no-remission in patient with obesity and diabetes undergoing metabolic surgery.

Demographic and Clinical Factors Associated with Development of Type 2 Diabetes: A Review of the Literature

Diabetes mellitus is a complex and chronic condition that requires lifelong management and interaction with a healthcare system. Failure to control risk factors through preventive care may lead to a host of diabetes-related complications. Underperforming healthcare systems and poor awareness among the general population/healthcare professionals has been suggested as reasons why so many patients remain undiagnosed. Due to the asymptomatic nature of early and even intermediate diabetes mellitus, several years may pass without any diagnosis before complications begin to manifest. Other factors include age, gender, ethnicity, education, marital and unemployment status which may also increase the risk of developing morbidity and mortality associated with diabetes mellitus. This review summarizes the current demographic risk factors and clinical characteristics associated with diabetes mellitus. A literature search was conducted using PubMed, MEDLINE, and Sabinet by using the following search terms: diabetes mellitus, risk factors, characteristics and complications.

Bariatric Surgery vs Lifestyle Intervention for Diabetes Treatment: 5-Year Outcomes From a Randomized Trial

CONTEXT

Questions remain about bariatric surgery for type 2 diabetes mellitus (T2DM) treatment.

OBJECTIVE

Compare the remission of T2DM following surgical or nonsurgical treatments.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial at the University of Pittsburgh, in the United States. Five-year follow-up from February 2015 until June 2016.

INTERVENTIONS

61 participants with obesity and T2DM who were initially randomized to either bariatric surgical treatments (Roux-en-Y gastric bypass [RYGB] or laparoscopic adjustable gastric banding [LAGB]) or an intensive lifestyle weight loss intervention (LWLI) program for 1 year. Lower level lifestyle weight loss interventions (LLLIs) were then delivered for 4 years.

MAIN OUTCOMES AND MEASURES

Diabetes remission assessed at 5 years.

RESULTS

The mean age of the patients was 47 ± 6.6 years, 82% were women, and 21% African American. Mean hemoglobin A1c level 7.8% ± 1.9%, body mass index (BMI) 35.7 ± 3.1 kg/m2, and 26 participants (43%) had BMI < 35 kg/m2. Partial or complete T2DM remission was achieved by 30% (n = 6) of RYGB, 19% (n = 4) of LAGB, and no LWLI participants (P = .0208). At 5 years those in the RYGB group had the largest percentage of individuals (56%) not requiring any medications for T2DM compared with those in the LAGB (45%) and LWLI (0%) groups (P = .0065). Mean reductions in percent body weight at 5 years was the greatest after RYGB 25.2% ± 2.1%, followed by LAGB 12.7% ± 2.0% and lifestyle treatment 5.1% ± 2.5% (all pairwise P < .01).

CONCLUSIONS

Surgical treatments are more effective than lifestyle intervention alone for T2DM treatment.

Five-year effectiveness of bariatric surgery on disease remission, weight loss, and changes of metabolic parameters in obese patients with type 2 diabetes: A population-based propensity score-matched cohort study

AIMS

To compare disease remission rates, weight loss, and changes of metabolic parameters of patients after bariatric surgery with nonsurgical patients.

METHODS

Based on the 2006-2017 Hospital Authority database, a population-based retrospective cohort of obese type 2 diabetes mellitus (T2DM) patients with and without bariatric surgery were identified. Surgical patients were matched with nonsurgical patients on 1-to-5 propensity score. Remission rates of diabetes, hypertension, and dyslipidaemia were reported annually up to 60 months. Changes in weight loss measurements (Body Mass Index [BMI], percentage of total weight loss [%TWL], percentage of excess weight loss [%EWL], and percentage of rebound in excess weight loss [%REWL]) and metabolic parameters (haemoglobin A_1c [HbA_1c ], systolic blood pressure [SBP], diastolic blood pressure [DBP], and low-density lipoprotein cholesterol [LDL-C]) were measured for both groups.

RESULTS

Four hundred one surgical patients (310 restrictive surgeries; 91 bypass surgeries) and 1894 nonsurgical patients were included. Surgical patients had higher remission rates in diabetes and dyslipidaemia and better glycaemic control at 12 to 60 months (all Ps < .01). SBP and DBP were significantly lower for surgical group up to 12 months and similar between two groups after 12 months. Surgical patients had significantly lower BMI during follow-up period. %TWL and %EWL were higher in the surgery group (15.7% vs 3.7%; 48.8% vs 12.0%) at 60 months (P < .001); differences in %REWL between two groups were insignificant. The effectiveness of restrictive and bypass surgeries was similar at 60 months, although restrictive surgeries were slightly more effective in T2DM remission.

CONCLUSIONS

Bariatric surgery was effective in weight loss, remission of diabetes, and dyslipidaemia in 5-year post-surgery.

Diagnostic strategies and clinical management of lipodystrophy

Introduction: Lipodystrophy is a heterogeneous group of rare diseases characterized by various degrees of fat loss which leads to serious morbidity due to metabolic abnormalities associated with insulin resistance and subtype-specific clinical features associated with underlying molecular etiology.Areas covered: This article aims to help physicians address challenges in diagnosing and managing lipodystrophy. We systematically reviewed the literature on PubMed and Google Scholar databases to summarize the current knowledge in lipodystrophy management.Expert opinion: Adipose tissue is a highly active endocrine organ that regulates metabolic homeostasis in the human body through a comprehensive communication network with other organ systems such as the central nervous system, liver, digestive system, and the immune system. The adipose tissue is capable of producing and secreting numerous factors with important endocrine functions such as leptin that regulates energy homeostasis. Recent developments in the field have helped to solve some of the mysteries behind lipodystrophy that allowed us to get a better understanding of adipocyte function and differentiation. From a clinical standpoint, physicians who suspect lipodystrophy should distinguish the disease from several others that may present with similar clinical features. It is also important for physicians to carefully interpret clinical features, laboratory, and imaging results before moving to more sophisticated tests and making decisions about therapy.

Continuous Glucose Monitoring in Bariatric Patients Undergoing Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-En-Y Gastric Bypass

BACKGROUND

Few investigations have been conducted that compared blood glucose in patients with diabetes mellitus (DM2) and morbid obesity who had undergone laparoscopic sleeve gastrectomy (LSG) or gastric bypass (LRYGB). We aimed to compare the effects of these procedures using continuous glucose monitoring (CGM).

METHODS

We prospectively studied patients that had qualified for LSG or LRYGB. The inclusion criteria were DM2 of ≤ 5 years, for which patients were taking oral anti-diabetic drugs, or no glucose metabolism disorder; and morbid obesity. CGM was performed between admission and the 10th postoperative day.

RESULTS

We studied 16 patients with DM2 and 16 without. Eighteen patients underwent LSG and 14 underwent LRYGB. The median hemoglobin A1c was 5.5% (5.4-5.9%) in DM2 patients, which did not differ from control (p = 0.460). Preoperative mean daily glucose concentration was similar between DM2 and control patients (p = 0.622). For patients with DM2, LRYGB was associated with more frequent low glucose status, and these episodes lasted longer than in DM2 patients that underwent LSG (p = 0.035 and 0.049, respectively). DM2 patients that underwent LRYGB demonstrated lower glucose concentrations from third postoperative day than those that underwent LSG. Patients without DM2 did not demonstrate differences in daily mean glucose concentrations, or in incidence nor duration of hypoglycemia throughout the observation period.

CONCLUSION

A significantly larger reduction in interstitial glucose concentration is present from third day in patients with DM2 who undergo LRYGB vs. LSG, accompanied by a lower incidence and shorter duration of low glucose episodes.

The metabolic benefits of different bariatric operations: what procedure to choose?

Bariatric surgery is established as a highly effective treatment for obesity and related metabolic complications. Although once seen as a last resort for patients with obesity, given the data demonstrating the profound weight loss, improvement in comorbidity and safety, perceptions have since shifted. There is evidence from 12 RCTs demonstrating its safety and efficacy in terms of weight loss which is sustained in the long term with a resultant improvement in co-morbidity. Clinicians are increasingly recognising the importance of timely intervention to maximise the effects of bariatric surgery, particularly in light of the low likelihood of being able to adequately manage patients with medication or lifestyle interventions alone. The inclusion of bariatric surgery in the standard treatment algorithm has been a step forward in the approach to treating patients with obesity. What remains challenging for clinicians is knowing which procedure is most beneficial to patients. There is no level one data demonstrating the superiority of one procedure over another. Head to head RCTs are ongoing which may shed light on this question; however, it is likely that there is no single procedure that will be demonstrated to be the gold standard. Herein we review the most commonly performed procedures along with the evidence available to support their effects with regards to weight loss and metabolic changes along with their limitations and recognised risks. The aim is to provide a general framework to allow clinicians to take advantage of the variety of operative approaches to tailor their treatment strategy to the individual patient.

Obesity-related hypertension: a review of pathophysiology, management, and the role of metabolic surgery

Obesity is a significant public health challenge worldwide and is inextricably linked to adverse cardiovascular outcomes. The relationship between excess adiposity and increased blood pressure is well established, and it is estimated that obesity accounts for 65-78% of cases of primary hypertension. The mechanisms through which obesity causes hypertension are complex and include sympathetic nervous system overactivation, stimulation of the renin-angiotensin-aldosterone system, alterations in adipose-derived cytokines, insulin resistance, and structural and functional renal changes. Weight loss is the primary goal of treatment for obesity-related hypertension, although few individuals achieve success with nonpharmacological management alone. Specific considerations apply when selecting the most appropriate pharmacological therapy for obese hypertensive patients. Metabolic surgery has proved to be the most effective means of ensuring substantial and sustained weight loss and has also been shown to confer beneficial effects in type 2 diabetes mellitus. Increasing evidence suggests that metabolic surgery may also be an effective treatment for obesity-related hypertension, although prospective data on long-term blood pressure outcomes are awaited. This review will discuss the pathophysiological mechanisms that link obesity with hypertension and will provide an overview of treatment strategies, with a focus on metabolic surgery.

Efficacy of metformin in preventing progression to diabetes in a Chinese population with impaired glucose regulation: Protocol for a multicentre, open-label, randomized controlled clinical study

AIM

To investigate the effectiveness of metformin in delaying or preventing progression to diabetes in a Chinese population with impaired glucose regulation (IGR).

MATERIALS AND METHODS

This multicentre, randomized, open-label, controlled study (NCT03441750) will assess the efficacy of metformin in preventing diabetes over ≥2 years. Eligible participants will be randomly assigned (1:1) to lifestyle intervention (LSI) or metformin plus LSI, with stratification based on blood pressure, anti-hypertensive medication use and isolated/non-isolated impaired fasting glucose. All participants will receive LSI advice. Participants in the metformin plus LSI group will receive metformin 850 mg once daily for the first 2 weeks, and twice daily thereafter, according to tolerability.

RESULTS

The primary objective is to compare rates of newly diagnosed diabetes in the two intervention groups. Changes in glycaemia, blood pressure, body weight, insulin resistance, and safety outcomes will also be evaluated.

CONCLUSIONS

This large clinical trial in a Chinese population with IGR aims to provide critical information to guide clinical decision-making in order to alleviate the current diabetes epidemic.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

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

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

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

"Dysfunctions" induced by Roux-en-Y gastric bypass surgery are concomitant with metabolic improvement independent of weight loss

Metabolic surgery has been increasingly recommended for obese diabetic patients, but questions remain as to its molecular mechanism that leads to improved metabolic parameters independently of weight loss from a network viewpoint. We evaluated the role of the Roux limb (RL) in Roux-en-Y gastric bypass (RYGB) surgery in nonobese diabetic rat models. Improvements in metabolic parameters were greater in the long-RL RYGB group. Transcriptome profiles reveal that amelioration of diabetes state following RYGB differs remarkably from both normal and diabetic states. According to functional analysis, RYGB surgery significantly affected a major gene group, i.e., the newly changed group, which represented diabetes-irrelevant genes abnormally expressed after RYGB. We hypothesize that novel "dysfunctions" carried by this newly changed gene group induced by RYGB rebalance diabetic states and contribute to amelioration of metabolic parameters. An unusual increase in cholesterol (CHOL) biosynthesis in RL enriched by the newly changed group was concomitant with ameliorated metabolic parameters, as demonstrated by measurements of physiological parameters and biodistribution analysis using [14C]-labeled glucose. Our findings demonstrate RYGB-induced "dysfunctions" in the newly changed group as a compensatory role contributes to amelioration of diabetes. Rather than attempting to normalize "abnormal" molecules, we suggest a new disease treatment strategy of turning "normal" molecules "abnormal" in order to achieve a new "normal" physiological balance. It further implies a novel strategy for drug discovery, i.e. targeting also on "normal" molecules, which are traditionally ignored in pharmaceutical development.

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.

Laparoscopic Sleeve Gastrectomy-Induced Decreases in FT3 and TSH are Related to Fasting C-Peptide in Euthyroid Patients with Obesity

OBJECTIVE

Laparoscopic sleeve gastrectomy (LSG) is one of the most effective therapies to treat obesity. However, whether LSG affects thyroid function remains elusive. Due to a lack of longitudinal research, we explored changes in thyroid function in euthyroid patients with obesity before and after LSG.

METHODS

In total, 109 participants (59 obese patients, 30 normal controls and 20 overweight subjects) were recruited from the Second Xiangya Hospital of Central South University (CSU). All patients underwent LSG, and metabolic indicators and free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH) were evaluated at baseline, 6 and 12 months postoperatively.

RESULTS

Compared to the normal control group, the concentrations of FT4 were decreased and TSH were increased in the obese group at baseline. Thyroid hormone levels in all participants were within the normal range during the 12 months after LSG. The concentrations of FT3 (4.83 ± 0.06 vs 5.03 ± 0.08, P = 0.023) and TSH (1.67 ± 0.11 vs 2.25 ± 0.18, P = 0.000) significantly decreased from baseline to 12 months postoperatively, while the concentrations of FT4 significantly increased (17.40 ± 0.52 vs 15.80 ± 0.32, P = 0.004). The decrease in fasting C-peptide (FCP) was related to the decline in FT3 and TSH during 12 months after LSG.

CONCLUSION

Obesity is closely related to thyroid function. LSG promoted a significant decrease in FT3 and TSH and a significant increase in FT4 in euthyroid patients with obesity after LSG. The decline in FCP may be involved in the decrease in FT3 and TSH after LSG.

NAFLD as a continuum: from obesity to metabolic syndrome and diabetes

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) has been increasing rapidly. It is nowadays recognized as the most frequent liver disease, affecting a quarter of global population and regularly coexisting with metabolic disorders such as type 2 diabetes, hypertension, obesity, and cardiovascular disease. In a more simplistic view, NAFLD could be defined as an increase in liver fat content, in the absence of secondary cause of steatosis. In fact, the clinical onset of the disease is a much more complex process, closely related to insulin resistance, limited expandability and dysfunctionality of adipose tissue. A fatty liver is a main driver for a new recognized liver-pancreatic α-cell axis and increased glucagon, contributing to diabetes pathophysiology.

MAIN TEXT

This review will focus on the clinical and pathophysiological connections between NAFLD, insulin resistance and type 2 diabetes. We reviewed non-invasive methods and several scoring systems for estimative of steatosis and fibrosis, proposing a multistep process for NAFLD evaluation. We will also discuss treatment options with a more comprehensive view, focusing on the current available therapies for obesity and/or type 2 diabetes that impact each stage of NAFLD.

CONCLUSION

The proper understanding of NAFLD spectrum-as a continuum from obesity to metabolic syndrome and diabetes-may contribute to the early identification and for establishment of targeted treatment.

The Effect of Metabolic Surgery on the Complications of Diabetes: What Are the Unanswered Questions?

It is now established that metabolic surgery (also known as bariatric surgery or obesity surgery) is an effective treatment for type 2 diabetes. Data from several randomized controlled trials have shown that surgery, when used as an adjunct to best medical therapy, is superior to medical therapy alone in achieving glycaemic and metabolic treatment targets in diabetes care. This has resulting in metabolic surgery being recommended as a treatment option for obesity-associated type 2 diabetes in national and international diabetes care guidelines. While the superior glycaemic effect of surgery is clear, the effect of surgery on the complications of diabetes is not fully understood. There are observational and epidemiological data that indicate a preventative effect in cohorts who do not have complications at baseline, as well as a positive effect on those with established diabetic kidney disease. However, there is a dearth of randomized controlled studies that specifically examine the effect of surgery on the complications of diabetes. Therefore, we should remain cautious in some cases, especially in those with retinopathy or neuropathy, as there is potential for deterioration of disease post-operatively. Further study is needed on this important topic. A lot is known, but there remain several unanswered questions. This article summarizes what we know about the effect of metabolic surgery on the complications of diabetes, poses some unanswered questions, and suggests how we could answer them.

Effects of Laparoscopic Sleeve Gastrectomy on Bone Mineral Density and Bone Metabolism in Chinese Patients with Obesity

OBJECTIVE

Laparoscopic sleeve gastrectomy (LSG) is one of the most effective therapies to treat obesity. Due to a lack of longitudinal research, we explored the changes in BMD and bone metabolism in Chinese patients with obesity before and after LSG.

MATERIALS AND METHODS

A total of 49 obese Chinese patients with obesity were recruited from the Second Xiangya Hospital of Central South University. All patients underwent LSG, and the metabolic indicators were evaluated, including the serum osteocalcin (OC), total-terminal propeptide of type I procollagen (TPINP) and carboxy terminal telopeptide of collagen type I (CTX) levels at baseline and 2, 6 and 12 months postoperatively. Dual energy X-ray absorptiometry (DEXA) was used to measure body composition and BMD before and 12 months after LSG.

RESULTS

The body mass index (BMI) significantly decreased at 12 months postoperatively, and no patients developed osteoporosis. The BMD of femoral neck and total hip significantly decreased from the baseline to 12 months postoperatively, while the BMD of lumbar spine did not change significantly. The OC, TPINP and CTX levels significantly increased at 12 months postoperatively. The excess BMI loss (EBMIL) was positively related while the reduction in visceral adipose tissue (VAT) mass was negatively related to the decreases in BMD of the femoral neck and total hip at 12 months postoperatively. The increase in OC was negatively correlated with the decrease in BMD of the femoral neck, while the increase in TPINP was positively correlated with the decrease in BMD of total hip.

CONCLUSION

Based on the 12-month follow-up results, the BMD of the femoral neck and total hip was decreased in Chinese patients with obesity after LSG, while bone remodelling was active. This finding suggested that weight loss, a decrease in the VAT mass and an increase in bone remodelling may be correlated with a reduction in BMD.

Eligibility and Awareness Regarding Metabolic Surgery in Patients With Type 2 Diabetes Mellitus in the Real-World Clinical Setting; Estimate of Possible Diabetes Remission

Despite high-quality evidence highlighting metabolic surgery as an effective treatment option for type 2 diabetes mellitus (T2DM), the number of patients receiving bariatric surgery (BS) remains low. Since the introduction of the Diabetes Surgery Summit II (DSS-II) eligibility criteria, data on eligibility rates for BS in T2DM cohorts remain scarce. The aims of the present study were to examine in a real-world clinical setting: (i) what is the percentage of T2DM patients visiting diabetes outpatient clinics who meet the DSS-II eligibility criteria, (ii) how many of these have been informed about the option of BS, and (iii) what are the characteristics associated with eligibility and awareness of BS. Demographic, anthropometric, clinical and socioeconomic data were obtained for all patients with T2DM who were consecutively examined in the outpatient clinics of three large-volume university hospitals (n = 1167). A medical registry form was completed to screen for BS eligibility. Patients were considered eligible if the recommendation by DSS-II criteria was either to "consider" or "recommend" BS. Eligible patients were further inquired whether they had ever been informed about the option of BS by their physicians. The advanced DiaRem score (ADRS) was applied to eligible patients to assess their probability of achieving postoperative T2DM remission. A significant percentage of T2DM patients who are routinely assessed in outpatient clinics meet the DSS-II eligibility criteria (15.3%). Eligible patients are younger and more obese, have a shorter T2DM duration, worse glycaemic control and better renal function, compared to non-eligible ones. Among eligible patients, only 39.3% have been medically informed about the option of BS. Informed patients are younger and more severely obese than non-informed ones. A significant percentage of non-informed patients (35%) have an ADRS ≤10, indicating a considerable probability for T2DM remission after BS, and are thus deprived of this opportunity due to lack of appropriate medical counseling. Screening and awareness of BS remain an unmet need in current T2DM management. Future research should focus on intensifying screening for BS eligibility at every medical visit and promoting evidence-based clinical recommendations for patients expected to benefit the most.

Bariatric surgery for Prader-Willi syndrome was ineffective in producing sustainable weight loss: Long term results for up to 10 years

BACKGROUND

Obesity control in Prader-Willi syndrome (PWS) is notoriously difficult. The role of bariatric surgery in PWS remains controversial as long-term data are lacking.

OBJECTIVES

To evaluate the 10-year outcomes of bariatric surgery in PWS.

METHODS

This was a prospective observational study on PWS patients who received bariatric surgery and multidisciplinary follow-up programmes for obesity control. Outcomes on weight reduction and comorbidity resolution were evaluated.

RESULTS

Between 2008 and 2013, five PWS patients (two males, mean age 19.2 ± 3.0 years) with body mass index of 47.3 ± 6.9 kg m^-2 received sleeve gastrectomy (n = 2), one anastomosis gastric bypass (n = 2), and Roux-en-Y gastric bypass (n = 1) after failing all non-operative weight loss programmes. The median follow-up was 8.4 ± 2.2 years. The best mean percentage of total weight loss (%TWL) was achieved at 2 years (24.7%). %TWL dropped to 23.3% at 3 years, 11.9% at 5 years, 4.1% at 8 years, and 0% at 10 years. Each patient had at least three comorbidities preoperatively, but none of them had resolution of any one of the comorbidities at the last follow-up.

CONCLUSIONS

Bariatric surgery could not produce sustainable long-term weight loss or comorbidity resolution in PWS. This study suggests that bariatric surgery cannot be recommended to PWS patients as a standard treatment.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The Effects of Bariatric Surgery on Type 2 Diabetes in Asian Populations: a Meta-analysis of Randomized Controlled Trials

BACKGROUND

To evaluate the effects of bariatric surgery on patients with type 2 diabetes through comparing Asian and non-Asian populations according to follow-up time.

METHODS

In this meta-analysis of randomized controlled trials (RCTs), we searched PubMed databases for relevant articles. A meta-analysis was undertaken of 37 eligible RCTs.

RESULTS

Diabetes remission rates among Asian populations were similar to those of non-Asian populations at 1 year (95% confidence interval (CI) 0.519 [0.417, 0.619] vs 0.571 [0.316, 0.794], respectively) but were found to be higher in Asian populations at 2 years compared to non-Asian populations (95% CI 0.672 [0.469, 0.826] vs 0.563 [0.220, 0.855], respectively). Asian populations showed greater reductions in HbA1c (- 3.512 [- 2.726, - 4.299], - 3.001 [- 1.433, - 4.569], and - 3.345 [- 2.267, - 4.423]) than non-Asian populations (- 2.129 [- 1.821, - 2.438], - 2.301 [- 1.881, - 2.722], and - 2.107 [- 1.941, - 2.273]) at 1, 2, and 5 years, respectively. Asian populations also showed greater reductions of fasting plasma glucose than non-Asian populations, and these effects were prominent at 3- and 5-year follow-up (Asian populations, - 83.297 [- 73.264, - 93.331]; non-Asian populations, - 54.288 [- 37.409, - 71.166] at 3 years; Asian populations, - 99.014 [- 82.239, - 115.788]; non-Asian populations, - 45.756 [- 21.892, - 69.621] at 5 years).

CONCLUSIONS

Bariatric surgery is more successful in diabetes remission and glucose outcome improvement in Asian populations with type 2 diabetes than in non-Asian populations, even over long-term follow-up periods. Bariatric surgery can be considered an effective treatment option and may present an appropriate opportunity to improve the prognosis for Asian patients with type 2 diabetes.

Bariatric Surgery in the Treatment of Type 2 Diabetes

PURPOSE OF REVIEW

We seek to characterize the impact of bariatric surgery on diabetes mellitus by recalling its history, examining the clinical data, exploring the putative mechanisms of action, and anticipating its future.

RECENT FINDINGS

Results of clinical trials reveal that bariatric surgery induces remission of diabetes in 33-90% of individuals at 1-year post-treatment versus 0-39% of medically managed. Remission rates decrease over time but remain higher in surgically treated individuals. Investigations have revealed numerous actions of surgery including effects on intestinal physiology, neuronal signaling, incretin hormone secretion, bile acid metabolism, and microbiome changes. Bariatric surgery improves control of diabetes through both weight-dependent and weight-independent actions. These various mechanisms help explain the difference between individuals treated surgically vs. medically. They also explain differing effects of various bariatric surgery procedure types. Understanding how surgery affects diabetes will help optimize utilization of the therapy for both disease prevention and treatment.

Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V., Mayorov A.Yu. 9th edition

Dear Colleagues! We are glad to present the 9th Edition (revised) of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2018, 2019), American Association of Clinical Endocrinologists (AACE, 2019), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014, 2018) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EXAMINE, ELIXA, SUSTAIN, DEVOTE, EMPA-REG OUTCOME, CANVAS, DECLARE, CARMELINA, REWIND, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 463 million patients by the end of 2019. According to the current estimation by the International Diabetes Federation, 578 million patients will be suffering from diabetes mellitus by by 2030 and 700 million by 2045. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4 584 575 patients with DM in this country by the end of 2018 (3,1% of population) with 92% (4 238 503) Type 2 DM, 6% (256 202) Type 1 DM and 2% (89 870) other types of DM, including 8 006 women with gestational DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) con- firmed that only 54% of Type 2 DM are diagnosed. So real number of patients with DM in Russia is 9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications. Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. In сurrent edition of the Standards: New goals of glycemic control for the elderly, based on the presence of functional dependence, as well as for pregnant women, children and adolescents, are given. Added a snippet that describes the continuous glucose monitoring. Only low-density lipoprotein cholesterol level is used as a target for lipid metabolism. Proposes more stringent target levels of blood pressure. It also features updated guidelines on stratification of treatment in newly diagnosed Type 2 diabetes: the excess of the initial level of HbA1c over the target level was used as a criterion. In the recommendations for the personalization of the choice of antidiabetic agents, it is taken into account that in certain clinical situations (the presence of atherosclerotic cardiovascular diseases and their risk factors, chronic heart failure, chronic kidney disease, obesity, the risk of hypoglycemia) certain classes of hypoglycemic agents (or individual drugs) have proven advantages. Recommendations for psychosocial support are added. The position of metabolic surgery as a method of treatment of DM with morbid obesity is updated. Recommendations for diagnostic and treatment of hypogonadism syndrome in men with DM are added. For the first time, evidence levels of confidence and credibility levels of recommendations for diagnostic, therapeutic, rehabilitative and preventive interventions based on a systematic review of the literature are given in accordance with the recommendations of the Center for Healthcare Quality Assessment and Control of the Ministry of Health of the Russian Federation. This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discus- sions held at national meetings and forums. These guidelines are intended for endocrinologists, primary care physicians and other medical professionals involved in the treatment of DM. On behalf of the Working Group

Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V., Mayorov A.Yu. 9th edition

Dear Colleagues! We are glad to present the 9th Edition (revised) of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2018, 2019), American Association of Clinical Endocrinologists (AACE, 2019), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014, 2018) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EXAMINE, ELIXA, SUSTAIN, DEVOTE, EMPA-REG OUTCOME, CANVAS, DECLARE, CARMELINA, REWIND, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 463 million patients by the end of 2019. According to the current estimation by the International Diabetes Federation, 578 million patients will be suffering from diabetes mellitus by by 2030 and 700 million by 2045. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4 584 575 patients with DM in this country by the end of 2018 (3,1% of population) with 92% (4 238 503) Type 2 DM, 6% (256 202) Type 1 DM and 2% (89 870) other types of DM, including 8 006 women with gestational DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) con- firmed that only 54% of Type 2 DM are diagnosed. So real number of patients with DM in Russia is 9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications. Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. In сurrent edition of the Standards: New goals of glycemic control for the elderly, based on the presence of functional dependence, as well as for pregnant women, children and adolescents, are given. Added a snippet that describes the continuous glucose monitoring. Only low-density lipoprotein cholesterol level is used as a target for lipid metabolism. Proposes more stringent target levels of blood pressure. It also features updated guidelines on stratification of treatment in newly diagnosed Type 2 diabetes: the excess of the initial level of HbA1c over the target level was used as a criterion. In the recommendations for the personalization of the choice of antidiabetic agents, it is taken into account that in certain clinical situations (the presence of atherosclerotic cardiovascular diseases and their risk factors, chronic heart failure, chronic kidney disease, obesity, the risk of hypoglycemia) certain classes of hypoglycemic agents (or individual drugs) have proven advantages. Recommendations for psychosocial support are added. The position of metabolic surgery as a method of treatment of DM with morbid obesity is updated. Recommendations for diagnostic and treatment of hypogonadism syndrome in men with DM are added. For the first time, evidence levels of confidence and credibility levels of recommendations for diagnostic, therapeutic, rehabilitative and preventive interventions based on a systematic review of the literature are given in accordance with the recommendations of the Center for Healthcare Quality Assessment and Control of the Ministry of Health of the Russian Federation. This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discus- sions held at national meetings and forums. These guidelines are intended for endocrinologists, primary care physicians and other medical professionals involved in the treatment of DM. On behalf of the Working Group

Does Metabolic Surgery Lead to Diabetes Remission in Patients with BMI < 30 kg/m2?: a Meta-analysis

BACKGROUND

Bariatric surgery has demonstrated to be effective in remission of type 2 diabetes in obese patients, but it is unclear in non-obese patients. The aim of this study is to investigate if metabolic surgery is effective in diabetes resolution in patients with BMI < 30 kg/m².

MATERIALS AND METHODS

A systematic review was performed and the content of the PubMed, Ovid, and the Cochrane Library databases covering the period January 2008 to April 2018 was searched. Studies with metabolic surgery performed in patients with type 2 diabetes, BMI < 30 kg/m² and a follow-up ≥ 6 months were included. Type 2 diabetes remission rate and metabolic parameters changes were measured. A meta-analysis was conducted with the selected studies.

RESULTS

Twenty-six studies were included in the meta-analysis (1105 patients). The mixed-effects meta-analysis model for overall diabetes remission rate produced an estimate of 43% (95% IC 34-53%, p < 0.001). Moderator effects of the variables race, preoperative HbA1c, BMI, months of follow-up, duration of diabetes, and age on diabetes remission were also assessed, with no significant effects being found in any of them. A reduction in BMI (- 3.57 kg/m²), fasting blood glucose (- 55.93 mg/dL) and HbA1c (- 2.08%) was observed after surgery.

CONCLUSIONS

Metabolic surgery could be effective in remission of type 2 diabetes in BMI < 30 kg/m² patients but randomized and long-term studies are necessary. The scientific community should agree in a single definition of type 2 diabetes remission, in order to know the real effect of metabolic surgery in this group of patients.

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.

Duration of type 2 diabetes and remission rates after bariatric surgery in Sweden 2007-2015: A registry-based cohort study

BACKGROUND

Although bariatric surgery is an effective treatment for type 2 diabetes (T2D) in patients with morbid obesity, further studies are needed to evaluate factors influencing the chance of achieving diabetes remission. The objective of the present study was to investigate the association between T2D duration and the chance of achieving remission of T2D after bariatric surgery.

METHODS AND FINDINGS

We conducted a nationwide register-based cohort study including all adult patients with T2D and BMI ≥ 35 kg/m2 who received primary bariatric surgery in Sweden between 2007 and 2015 identified through the Scandinavian Obesity Surgery Registry. The main outcome was remission of T2D, defined as being free from diabetes medication or as complete remission (HbA1c < 42 mmol/mol without medication). In all, 8,546 patients with T2D were included. Mean age was 47.8 ± 10.1 years, mean BMI was 42.2 ± 5.8 kg/m2, 5,277 (61.7%) were women, and mean HbA1c was 58.9 ± 17.4 mmol/mol. The proportion of patients free from diabetes medication 2 years after surgery was 76.6% (n = 6,499), and 69.9% at 5 years (n = 3,765). The chance of being free from T2D medication was less in patients with longer preoperative duration of diabetes both at 2 years (odds ratio [OR] 0.80/year, 95% CI 0.79-0.81, p < 0.001) and 5 years after surgery (OR 0.76/year, 95% CI 0.75-0.78, p < 0.001). Complete remission of T2D was achieved in 58.2% (n = 2,090) at 2 years, and 46.6% at 5 years (n = 681). The chance of achieving complete remission correlated negatively with the duration of diabetes (adjusted OR 0.87/year, 95% CI 0.85-0.89, p < 0.001), insulin treatment (adjusted OR 0.25, 95% CI 0.20-0.31, p < 0.001), age (adjusted OR 0.94/year, 95% CI 0.93-0.95, p < 0.001), and HbA1c at baseline (adjusted OR 0.98/mmol/mol, 95% CI 0.97-0.98, p < 0.001), but was greater among males (adjusted OR 1.57, 95% CI 1.29-1.90, p < 0.001) and patients with higher BMI at baseline (adjusted OR 1.07/kg/m2, 95% CI 1.05-1.09, p < 0.001). The main limitations of the study lie in its retrospective nature and the low availability of HbA1c values at long-term follow-up.

CONCLUSIONS

In this study, we found that remission of T2D after bariatric surgery was inversely associated with duration of diabetes and was highest among patients with recent onset and those without insulin treatment.

Will medications that mimic gut hormones or target their receptors eventually replace bariatric surgery?

Bariatric surgery is currently the most effective therapeutic modality through which sustained beneficial effects on weight loss and metabolic improvement are achieved. During recent years, indications for bariatric surgery have been expanded to include cases of poorly controlled type 2 (T2DM) diabetes mellitus in lesser extremes of body weight. A spectrum of the beneficial effects of surgery is attributed to robust changes of postprandial gut peptide responses that are observed post operatively. Consolidated knowledge regarding gut peptide physiology as well as emerging new evidence shedding light on the mode of action of previously overlooked gut hormones provide appealing potential obesity and T2DM therapeutic perspectives. The accumulation of evidence from the effect of exogenous administration of native gut peptides alone or in combinations to humans as well as the development of mimetic agents exerting agonistic effects on combinations of gut hormone receptors pave the way for future integrated gut peptide-based treatments, which may mimic the effects of bariatric surgery.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

The Impact of Preoperative BMI (Obesity Class I, II, and III) on the 12-Month Evolution of Patients Undergoing Laparoscopic Gastric Bypass

BACKGROUND

Whether or not the initial body mass index (BMI) influences weight loss and comorbidities improvement after bariatric surgery continues to be a matter of debate. The main reason for this is a lack of studies including obesity class I.

METHODS

Retrospective study with patients submitted to gastric bypass at a single institution. They were classified based on initial BMI (obesity class I, II, and III), and a comparative analysis of their metabolic profile (glucose, HbA1c%, C-peptide, insulin and diabetes medication), lipid profile (triglycerides, total cholesterol, HDL, LDL), and clinical data (systolic/diastolic blood pressure and cardiovascular risk) was performed at 0 and 12 months. Diabetes remission and weight loss were also analyzed.

RESULTS

Two-hundred and twenty patients were included (23 in group 1, 113 in group 2, and 84 in group 3). Initial weight, BMI, and number of patients with T2DM were statistically different in group 1; other parameters were homogenous. At 12 months, every group had similar improvement of the metabolic profile, excepting serum insulin. Diabetes remission was 57.9, 61.1, and 60% for group 1, 2, and 3. For weight loss, there were differences between groups when using BMI and percentage of excess weight loss, but not with percentage of total weight loss. The non-metabolic and clinical data improved without differences, except for total cholesterol and LDL.

CONCLUSIONS

The metabolic, lipid, and clinical profiles associated with obesity present similar improvement 1 year after laparoscopic gastric bypass, despite different baseline BMI. Diabetes remission and percentage of total weight loss were also similar.

Selection of Bypass vs Sleeve for the Management of Type-2 Diabetes in Severely Obese: Could Ethnicity Play a Role?

PURPOSE

Prospective data was evaluated to see whether bariatric procedure type made any difference to diabetes remission.

METHODS

One hundred eighty-six consecutive patients of Indian ethnicity (M:F 89:97) with type 2 diabetes mellitus (T2DM) and HbA1c > 6.5 were assessed before and at 1 year following surgery. Age, BMI, C-peptide and duration of diabetes (ABCD - described by WJ Lee), insulin use, baseline HbA1c, and % weight loss were tested as modifiers. We present remission rates (HbA1c ≤ 6.0%) and between group remission odds ratio (OR) and adjusted OR after controlling for key modifiers.

RESULTS

Patients selecting RYGB (n = 113) vs SG (n = 73) were older (50.7 vs 44.2 years), had a lower BMI (44.1 vs 46.7), lower C-peptide (3.5 vs 4.7 ng/ml), greater duration of diabetes (8 vs 3 years), and higher HbA1c (8.90 and 7.9%) respectively p < 0.05 for all (combined R² = 0.38). Weight loss at 1 year was 27 and 30% for RYGB and SG respectively (p = 0.01). Remission at 1 year was achieved by 37% of patient selecting RYGB and 74% for the SG (OR = 0.21, 95% CI 0.11-0.41, p < 0.001). After adjusting for ABCD, the adjusted OR (AOR) still favored the SG (AOR = 0.32, 0.14-0.74, p = 0.01), and adjustment for HbA1c and weight loss (AOR 0.4, 0.17-0.95, p = 0.038) attenuated the effect.

CONCLUSION

The analysis suggests SG may be superior to RYGB in this Indian population. Ethnicity may play a role in predicting the response to bariatric surgery and hence the choice of procedure. A randomized controlled trial is needed to clarify the relative benefit.

Long-limb Roux-en-Y Reconstruction after Subtotal Gastrectomy to Treat Severe Diabetic Gastroparesis

The role of surgical intervention in patients with diabetic gastroparesis is unclear. We report a case of a 37-year-old man with a history of recurrent episodes of vomiting and long-standing type 2 diabetes mellitus. Esophagogastroduodenoscopy did not reveal any findings of reflux esophagitis or obstructive lesions. A gastric emptying time scan showed prolonged gastric emptying half-time (344 minutes) indicating delayed gastric emptying. Laboratory tests revealed elevated fasting serum glucose and glycosylated hemoglobin (HbA1c, 12.9%) and normal fasting C-peptide and insulin levels. We performed Roux-en-Y reconstruction after subtotal gastrectomy to treat gastroparesis and improve glycemic control, and the patient showed complete resolution of gastrointestinal symptoms postoperatively. Barium swallow test and gastric emptying time scan performed at follow-up revealed regular progression of barium and normal gastric emptying. Three months postoperatively, his fasting serum glucose level was within normal limits without the administration of insulin or oral antidiabetic drugs with a reduced HbA1c level (6.9%). Long-limb Roux-en-Y reconstruction after subtotal gastrectomy may be useful to treat severe diabetic gastroparesis by improving gastric emptying and glycemic control.

Barriers to accessing weight-loss interventions for patients with class II or III obesity in primary care: a qualitative study

BACKGROUND

Over 1 million Canadians have class II or III obesity; however, access to weight-loss interventions for these patients remains limited. The purpose of our study was to identify the barriers to accessing medical and surgical weight-loss interventions from the perspectives of 3 groups: family physicians, patients who were referred for weight-loss intervention and patients who were not referred for weight-loss intervention.

METHODS

Between November 2017 and May 2018, we conducted a qualitative exploratory research study using focus groups with family physicians and interviews with patients with class II or III obesity from 1 region in southern Ontario. We conducted a thematic analysis to identify emergent themes and used the barriers to change theory to classify the similarities and differences between the perspectives of family physicians, referred patients and nonreferred patients in first- and second-order barriers.

RESULTS

Seventeen family physicians participated in 7 focus groups (1-4 participants/group), and we interviewed 8 referred patients and 7 nonreferred patients. We identified lack of resource supports, logistics and lack of knowledge about weight-loss interventions as first-order barriers to change, and lack of knowledge about root causes of obesity, lack of patient readiness for change and family physicians' perceptions about surgical weight loss as second-order barriers to change. Family physicians and patients had similar perceptions regarding lack of resource supports in the community, logistical issues, family physicians' lack of knowledge regarding weight-loss interventions, patients' lack of motivation and family physicians' perceptions of bariatric surgery as being high risk. They differed regarding the root cause of obesity, with family physicians attributing obesity to multiple extrinsic and intrinsic causes, whereas patients believed obesity was largely due to intrinsic causes alone.

INTERPRETATION

It is important to address first- and second-order barriers to accessing weight-loss interventions through continuing professional development activities for family physicians to help ensure effective and timely treatment for patients with class II or III obesity and related comorbidities.

Endoscopic sleeve gastroplasty: a modified technique with greater curvature compression sutures

Background  Endoscopic sleeve gastroplasty (ESG) is rapidly becoming established as a safe and effective means of achieving substantial weight loss via the transoral route. New ESG suture patterns are emerging. Our aim was to investigate whether superior weight loss outcomes can be achieved by using a unique combination of longitudinal compression sutures and "U"-shaped sutures. Methods  This is a retrospective review of prospectively collected data of all patients undergoing ESG by a single operator in a single UK center. Results  Between January 2016 and December 2017, 32 patients (23 female) underwent ESG; n = 9 cases were completed utilizing a commonly used triangular suture pattern ("no longitudinal compression") and n = 23 cases were completed using our unique "longitudinal compression" suture pattern. In the no compression and compression groups, the mean ages were 45 ± 12 years and 43 ± 10 years, the median baseline weights were 113.6 kg (range 82.0 - 156.4) and 107 kg (range 74.0 - 136.0), and the median baseline body mass indexes (BMIs) were 35.9 kg/m ² (range 30.9 - 43.8) and 36.5 kg/m ² (range 29.8 - 42.9), respectively. After 6 months, body weight had decreased by 21.1 kg (range, 12.2 - 34.0) in the compression group (n = 7) versus 10.8 kg (range, 7.0 - 25.8) in the no compression group (n = 5) ( P  = 0.042). Correspondingly, BMI decreased by 7.8 kg/m ² (range, 4.9 - 11.2) and 4.1 kg/m ² (range, 2.6 - 7.2) in each group, respectively ( P  = 0.019). Total body weight loss (%TBWL) was greater in the compression group at 19.5 % (range, 12.9 - 30.4 %) compared to 13.2 % (range, 6.2 - 17.1 %) in the non-compression group ( P  = 0.042). No significant adverse events were reported in this series. Conclusion  The technique of ESG is evolving and outcomes from endoscopic bariatric therapies continue to improve. We provide preliminary evidence of superior weight loss achieved through a modified gastroplasty suture pattern.

Glycemic Control after Sleeve Gastrectomy and Roux-En-Y Gastric Bypass in Obese Subjects with Type 2 Diabetes Mellitus

Background

Roux-en-Y gastric bypass (LRYGB) has weight-independent effects on glycemia in obese type 2 diabetic patients, whereas sleeve gastrectomy (LSG) is less well characterized. This study aims to compare early weight-independent and later weight-dependent glycemic effects of LRYGB and LSG.

Methods

Eighteen LRYGB and 15 LSG patients were included in the study. Glucose, insulin, GLP-1, and GIP levels were monitored during a modified 30 g oral glucose tolerance test before surgery and 2 days, 3 weeks, and 12 months after surgery. Patients self-monitored glucose levels 2 weeks before and after surgery.

Results

Postoperative fasting blood glucose decreased similarly in both groups (LRYGB vs. SG; baseline—8.1 ± 0.6 vs. 8.2 ± 0.4 mmol/l, 2 days—7.8 ± 0.5 vs. 7.4 ± 0.3 mmol/l, 3 weeks—6.6 ± 0.4 vs. 6.6 ± 0.3 mmol/l, respectively, P < 0.01 vs. baseline for both groups; 12 months—6.6 ± 0.4 vs. 5.9 ± 0.4, respectively, P < 0.05 for LRYGB and P < 0.001 for LSG vs. baseline, P = ns between the groups at all times). LSG, but not LRYGB, showed increased peak insulin levels 2 days postoperatively (mean ± SEM; LSG + 58 ± 14%, P < 0.01; LRYGB − 8 ± 17%, P = ns). GLP-1 levels increased similarly at 2 days, but were higher in LRYGB at 3 weeks (AUC; 7525 ± 1258 vs. 4779 ± 712 pmol × min, respectively, P < 0.05). GIP levels did not differ. Body mass index (BMI) decreased more after LRYGB than LSG (− 10.1 ± 0.9 vs. − 7.9 ± 0.5 kg/m², respectively, P < 0.05).

Conclusion

LRYGB and LSG show very similar effects on glycemic control, despite lower GLP-1 levels and inferior BMI decrease after LSG.

Electronic supplementary material

The online version of this article (10.1007/s11695-017-3061-3) contains supplementary material, which is available to authorized users.

Increased Bile Acid Signals After Duodenal-Jejunal Bypass Improve Non-alcoholic Steatohepatitis (NASH) in a Rodent Model of Diet-Induced NASH

BACKGROUND

The increasing incidence of non-alcoholic steatohepatitis (NASH) has resulted in it becoming a common cause of liver-related mortality; however, no efficient treatment has been established. It has been reported that bariatric surgery improves metabolic comorbidities, such as diabetes mellitus and NASH. Although the mechanism is unclear, it is thought that the changes in bile acid (BA) signaling via its nuclear receptor, farnesoid X receptor (FXR), produce various metabolic effects. We sought to investigate the effects and mechanisms of bariatric surgery on NASH improvement.

METHODS

Male Sprague-Dawley rats were fed by a high-fat and high-fructose diet, which results in obesity, insulin resistance, and NASH. Rats underwent duodenal-jejunal bypass (DJB), which is a main component of bariatric procedures. The liver pathological findings and the expression level of mRNA of FXR were investigated. The plasma BA level was measured in peripheral and portal vein blood.

RESULTS

DJB suppressed weight gain, improved insulin resistance, and ameliorated NASH mainly in a point of inflammation. The plasma BA level along with the expression of FXR and its target transcriptional factor, small heterodimer partner (SHP), in the liver were elevated.

CONCLUSIONS

DJB has a direct effect on NASH improvement, and there is a possibility that an anti-inflammatory effect is functioning as a part of the mechanism. The increase of plasma bile acid level followed by the stimulation of FXR signaling may contribute to this phenomenon.

Obesity in the Workplace: Impact, Outcomes, and Recommendations

OBJECTIVE

To conduct a comprehensive literature review to develop recommendations for managing obesity among workers to improve health outcomes and to explore the impact of obesity on health costs to determine whether a case can be made for surgical interventions and insurance coverage.

METHODS

We searched PubMed from 2011 to 2016, and CINAHL, Scopus, and Cochrane Registry of Clinical Trials for interventions addressing obesity in the workplace.

RESULTS

A total of 1419 articles were screened, resulting in 275 articles being included. Several areas were identified that require more research and investigation.

CONCLUSIONS

Our findings support the use of both lifestyle modification and bariatric surgery to assist appropriate patients in losing weight.

Discovery of Orexant and Anorexant Agents with Indazole Scaffold Endowed with Peripheral Antiedema Activity

The endocannabinoid system represents an integrated neuronal network involved in the control of several organisms' functions, such as feeding behavior. A series of hybrids of 5-(4-chlorophenyl)-1-(2,4-dichloro-phenyl)-4-methyl-N-(piperidin-1-yl)-1H-pyrazole-3-carboxamide (mimonabant), a well-known inverse agonist of the type-1 cannabinoid receptor (CB1), once used as an antiobesity drug, and the N-(2S)-substitutes of 1-[(4-fluorophenyl)methyl]indazole-3-carboxamide with 1-amino-3-methyl-1-oxobutane (AB-Fubinaca), 1-amino-3,3-dimethyl-1-oxobutane (ADB-Fubinaca), and 3-methylbutanoate (AMB-Fubinaca), endowed with potent agonistic activity towards cannabinoid receptors CB1 and CB2 were in solution as C-terminal amides, acids, methyl esters and N-methyl amides. These compounds have been studied by binding assays to cannabinoid receptors and by functional receptor assays, using rat brain membranes in vitro. The most active among them as an agonist, (S)-1-(2,4-dichlorobenzyl)-N-(3,3-dimethyl-1-(methylamino)-1-oxobutan-2-yl)-1H-indazole-3-carboxamide (LONI11), and an antagonist, (S)-2-(1-(2,4-dichlorobenzyl)-1H-indazole-3-carboxamido)-3-methylbutanoic acid (LONI4), were tested in vivo in mic, to evaluate their ability to stimulate or suppress feeding behavior after intraperitoneal (i.p.) administration. For a LONI11 formalin test and a tail flick test after an administration by the subcutaneous (s.c.) and intracerebroventricular (i.c.v.) routes, respectively, were also carried out in vivo in mice to investigate the antinociceptive property at the central and peripheral levesl. We observed a significant orexant effect for LONI11 and an intense anorexant effect for (S)-methyl 2-(1-(2,4-dichlorobenzyl)-1H-indazole-3-carboxamido)-3,3-dimethylbutanoate (LONI2) and LONI4. In zymosan-induced edema and hyperalgesia, LONI11 reduced the percent of paw volume increase and paw latency after s.c. administration, also suggesting a possible peripheral anti-inflammatory activity.

["Diabesity"-Obesity and type 2 diabetes (Update 2019)]

For several years obesity and type 2 diabetes have been increasingly summarized under the name "diabesity". This is due to the fact that in most cases obesity precedes diabetes and is the most important risk factor for the worldwide increase of type 2 diabetes. The body mass index (BMI) is a very crude measure of body fatness in individuals. Even normal weight persons can have too much body fat in cases of a lack of muscle mass (sarcopenia), which is why additional measurements of waist circumference and body fatness, e. g. bioimpedance analysis (BIA), are recommended. Lifestyle management including nutrition modification and increase in physical activity are important measures for the prevention and treatment of diabetes. Regarding the treatment of type 2 diabetes, body weight is increasingly used as a secondary target parameter. The choice of anti-diabetic treatment and also concomitant treatment is increasingly influenced by body weight. The significance of anti-obesity medications in the treatment of type 2 diabetes will have to be clarified by future studies with body weight as the primary endpoint. Bariatric surgery is at present indicated with a BMI >35 kg/m² with concomitant risk factors, such as diabetes and can lead at least to partial diabetes remission but has to be incorporated into an appropriate lifelong care concept.