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Guimarães M, Pereira SS, Monteiro MP. From Entero-Endocrine Cell Biology to Surgical Interventional Therapies for Type 2 Diabetes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1307:273-297. [PMID: 32016913 DOI: 10.1007/5584_2020_480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The physiological roles of the enteroendocrine system in relation to energy and glucose homeostasis regulation have been extensively studied in the past few decades. Considerable advances were made that enabled to disclose the potential use of gastro-intestinal (GI) hormones to target obesity and type 2 diabetes (T2D). The recognition of the clinical relevance of these discoveries has led the pharmaceutical industry to design several hormone analogues to either to mitigate physiological defects or target pharmacologically T2D.Amongst several advances, a major breakthrough in the field was the unexpected observation that enteroendocrine system modulation to T2D target could be achieved by surgically induced anatomical rearrangement of the GI tract. These findings resulted from the widespread use of bariatric surgery procedures for obesity treatment, which despite initially devised to induce weight loss by limiting the systemic availably of nutrients, are now well recognized to influence GI hormone dynamics in a manner that is highly dependent on the type of anatomical rearrangement produced.This chapter will focus on enteroendocrine system related mechanisms leading to improved glycemic control in T2D after bariatric surgery interventions.
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Affiliation(s)
- Marta Guimarães
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Porto, Portugal.,Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal.,Department of General Surgery, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Sofia S Pereira
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Porto, Portugal.,Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal.,Instituto de Investigação e Inovação em Saúde (I3S), Universidade do Porto, Porto, Portugal.,Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
| | - Mariana P Monteiro
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Porto, Portugal. .,Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal.
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Hofmann B, Hjelmesæth J, Søvik TT. Moral challenges with surgical treatment of type 2 diabetes. J Diabetes Complications 2013; 27:597-603. [PMID: 24028746 DOI: 10.1016/j.jdiacomp.2013.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 12/27/2022]
Abstract
AIM To review the most important moral challenges following from the widespread use of bariatric surgery for type 2 diabetes for patients with BMI <35kg/m(2), although high quality evidence for its short and long term effectiveness and safety is limited. METHODS Extensive literature search to identify and analyze morally relevant issues. A question based method in ethics was applied to facilitate assessment and decision making. RESULTS Several important moral issues were identified: assessing and informing about safety, patient outcomes, and stakeholder interests; acquiring valid informed consent; defining and selecting outcome measures; stigmatization and discrimination of the patient group, as well as providing just distribution of health care. The main sources of these challenges are lack of high quality evidence, disagreement on clinical indications and endpoints, and the disciplining of human behavior by surgical interventions. CONCLUSION A lack of high quality evidence on the effect of bariatric surgery for the treatment of T2DM in patients with BMI<35/kg/m(2) poses a wide variety of moral challenges, which are important for decisions on the individual patient level, on the management level, and on the health policy making level. Strong preferences among surgeons and patients may hamper high quality research.
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Affiliation(s)
- Bjørn Hofmann
- Department of Health, Technology and Society, University College of Gjøvik, Norway; Center for Medical Ethics, University of Oslo, Norway.
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Zhang H, Wu C, Chen Q, Chen X, Xu Z, Wu J, Cai D. Treatment of obesity and diabetes using oxytocin or analogs in patients and mouse models. PLoS One 2013; 8:e61477. [PMID: 23700406 PMCID: PMC3658979 DOI: 10.1371/journal.pone.0061477] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 03/09/2013] [Indexed: 01/06/2023] Open
Abstract
Obesity is important for the development of type-2 diabetes as a result of obesity-induced insulin resistance accompanied by impaired compensation of insulin secretion from pancreatic beta cells. Here, based on a randomized pilot clinical trial, we report that intranasal oxytocin administration over an 8-week period led to effective reduction of obesity and reversal of related prediabetic changes in patients. Using mouse models, we further systematically evaluated whether oxytocin and its analogs yield therapeutic effects against prediabetic or diabetic disorders regardless of obesity. Our results showed that oxytocin and two analogs including [Ser4, Ile8]-oxytocin or [Asu1,6]-oxytocin worked in mice to reverse insulin resistance and glucose intolerance prior to reduction of obesity. In parallel, using streptozotocin-induced diabetic mouse model, we found that treatment with oxytocin or its analogs reduced the magnitude of glucose intolerance through improving insulin secretion. The anti-diabetic effects of oxytocin and its analogs in these animal models can be produced similarly whether central or peripheral administration was used. In conclusion, oxytocin and its analogs have multi-level effects in improving weight control, insulin sensitivity and insulin secretion, and bear potentials for being developed as therapeutic peptides for obesity and diabetes.
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Affiliation(s)
- Hai Zhang
- Department of Molecular Pharmacology, Diabetes Research Center, Institute of Aging, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Chenguang Wu
- Department of Medicine, Endocrine Division, the Affiliated People’s Hospital of Jiangsu University, Jiangsu Province, Zhenjiang, P. R. China
| | - Qiaofen Chen
- Department of Medicine, Endocrine Division, the Affiliated People’s Hospital of Jiangsu University, Jiangsu Province, Zhenjiang, P. R. China
| | - Xiaoluo Chen
- Department of Medicine, Endocrine Division, the Affiliated People’s Hospital of Jiangsu University, Jiangsu Province, Zhenjiang, P. R. China
| | - Zhigang Xu
- Department of Medicine, Endocrine Division, the Affiliated People’s Hospital of Jiangsu University, Jiangsu Province, Zhenjiang, P. R. China
| | - Jing Wu
- Department of Medicine, Endocrine Division, the Affiliated People’s Hospital of Jiangsu University, Jiangsu Province, Zhenjiang, P. R. China
| | - Dongsheng Cai
- Department of Molecular Pharmacology, Diabetes Research Center, Institute of Aging, Albert Einstein College of Medicine, Bronx, New York, United States of America
- * E-mail:
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Ide P, Fitzgerald-O'Shea C, Lautz DB. Implementing a Bariatric Surgery Program. AORN J 2013; 97:195-206; quiz 207-9. [DOI: 10.1016/j.aorn.2012.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Accepted: 11/21/2012] [Indexed: 02/05/2023]
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O'Rourke RW. Inflammation, obesity, and the promise of immunotherapy for metabolic disease. Surg Obes Relat Dis 2012; 9:609-16. [PMID: 22959472 DOI: 10.1016/j.soard.2012.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Robert W O'Rourke
- Department of Surgery, Oregon Health and Science University, Portland, Oregon.
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Arterburn DE, Westbrook EO, Bogart TA, Sepucha KR, Bock SN, Weppner WG. Randomized trial of a video-based patient decision aid for bariatric surgery. Obesity (Silver Spring) 2011; 19:1669-75. [PMID: 21475138 DOI: 10.1038/oby.2011.65] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The decision to have bariatric surgery should be based on accurate information on possible risks and benefits of all treatment options. The goal of this study was to determine whether a video-based bariatric decision aid intervention results in superior decision quality compared to an educational booklet. We conducted a prospective, randomized controlled trial among adult patients in a single health plan who met standard criteria for bariatric surgery. Patients were randomly assigned to review either a video-based decision aid (intervention) or an educational booklet on bariatric surgery (control). Changes in patient decision quality were assessed using bariatric-specific measures of knowledge, values, and treatment preference after 3 months. Of 152 eligible participants, 75 were randomly assigned to the intervention and 77 to the control. The 3-month follow-up rate was 95%. Among all participants, significant improvements were observed in knowledge (P < 0.001), values concordance (P = 0.009), decisional conflict (P < 0.001), decisional self-efficacy (P < 0.001), and in the proportion who were "unsure" of their treatment choice (P < 0.001). The intervention group had larger improvements in knowledge (P = 0.03), decisional conflict (P = 0.03), and outcome expectancies (P = 0.001). The proportion of participants choosing bariatric surgery did not differ significantly between groups, although there was a trend toward decreased surgical choice in the intervention group (59% booklet vs. 42% video at 3 months; P = 0.16). The use of bariatric surgery decision aids was followed by improved decision quality and reduced uncertainty about treatment at 3 months. The video-based decision aid appeared to have a greater impact than the educational booklet on patient knowledge, decisional conflict, and outcome expectancies.
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Affiliation(s)
- Andrei Keidar
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Nyenwe EA, Jerkins TW, Umpierrez GE, Kitabchi AE. Management of type 2 diabetes: evolving strategies for the treatment of patients with type 2 diabetes. Metabolism 2011; 60:1-23. [PMID: 21134520 PMCID: PMC3746516 DOI: 10.1016/j.metabol.2010.09.010] [Citation(s) in RCA: 208] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 09/18/2010] [Indexed: 01/08/2023]
Abstract
The prevalence of type 2 diabetes continues to increase at an alarming rate around the world, with even more people being affected by prediabetes. Although the pathogenesis and long-term complications of type 2 diabetes are fairly well known, its treatment has remained challenging, with only half of the patients achieving the recommended hemoglobin A(1c) target. This narrative review explores the pathogenetic rationale for the treatment of type 2 diabetes, with the view of fostering better understanding of the evolving treatment modalities. The diagnostic criteria including the role of hemoglobin A(1c) in the diagnosis of diabetes are discussed. Due attention is given to the different therapeutic maneuvers and their utility in the management of the diabetic patient. The evidence supporting the role of exercise, medical nutrition therapy, glucose monitoring, and antiobesity measures including pharmacotherapy and bariatric surgery is discussed. The controversial subject of optimum glycemic control in hospitalized and ambulatory patients is discussed in detail. An update of the available pharmacologic options for the management of type 2 diabetes is provided with particular emphasis on newer and emerging modalities. Special attention has been given to the initiation of insulin therapy in patients with type 2 diabetes, with explanation of the pathophysiologic basis for insulin therapy in the ambulatory diabetic patient. A review of the evidence supporting the efficacy of the different preventive measures is also provided.
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Affiliation(s)
- Ebenezer A. Nyenwe
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | | | | | - Abbas E. Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Hofmann B. Stuck in the middle: the many moral challenges with bariatric surgery. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:3-11. [PMID: 21161829 DOI: 10.1080/15265161.2010.528509] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Bariatric surgery is effective on short- and medium-term weight loss, reduction of comorbidities, and overall mortality. A large and increasing portion of the population is eligible for bariatric surgery, which increases instant health care costs. A review of the literature identifies a series of ethical challenges: unjust distribution of bariatric surgery, autonomy and informed consent, classification of obesity and selecting assessment endpoints, prejudice among health professionals, intervention in people's life-world, and medicalization of appearance. Bariatric surgery is particularly interesting because it uses surgical methods to modify healthy organs, is not curative, but offers symptoms relief for a condition that it is considered to result from lack of self-control and is subject to significant prejudice. Taking the reviewed ethical issues into account is important when meeting persons eligible for bariatric surgery, as well as in the assessment of and decision making on surgery for obesity.
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Affiliation(s)
- Bjørn Hofmann
- University College of Gjøvik, University of Oslo, Oslo, Norway.
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Metabolic or bariatric surgery? Long-term effects of malabsorptive vs restrictive bariatric techniques on body composition and cardiometabolic risk factors. Int J Obes (Lond) 2010; 34:1404-14. [PMID: 20404828 DOI: 10.1038/ijo.2010.54] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Obesity is an increasing health problem and surgery seems to be the only treatment effective in achieving weight loss without relapse. Among bariatric techniques, many differences exist in terms of weight loss and resolution of comorbidities. Up to now, there are no prospective studies comparing long-term effects of malabsorptive vs restrictive techniques. OBJECTIVE In this study, cardiometabolic risk factors and body composition changes after malabsorptive biliointestinal bypass (BIBP) and restrictive laparoscopic adjustable gastric banding (LAGB) were compared during a 4-year follow-up. DESIGN Prospective, case-control and cohort study. PATIENTS In all, 80 obese subjects, matched for weight and age. Altogether, 40 patients underwent BIBP and 40 underwent LAGB. MEASUREMENTS Weight, body composition, fasting and post-loading plasma glucose and insulin, homeostatic model assessment index (HOMA-I), lipid profile, blood pressure (BP), erythrocyte sedimentation rate and fibrinogen were monitored at baseline, 12 and 48 months. RESULTS At 12 months after surgery, a significant reduction in body mass index, total fat mass (FM), trunk FM (trFM), trFM/legs FM (lFM) ratio (trFM/lFM), triglycerides, BP and inflammation markers was observed in both groups. BIBP patients showed a significant reduction in total cholesterol (Tot-C), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), whereas the LAGB group showed a significant increase of HDL-C. A further improvement of all the parameters evaluated was seen in the BIBP group at 48 months after surgery. CONCLUSIONS Both bariatric procedures exerted positive effects on cardiometabolic risk factors and on weight loss in the population studied, but on the long-term period, HOMA-I, Tot-C/HDL-C ratio and body composition improvements were more evident after BIBP. We conclude that malabsorptive BIBP seems to be more effective than LAGB in treating visceral obesity and its metabolic complications.
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Scheen AJ, De Flines J, De Roover A, Paquot N. Bariatric surgery in patients with type 2 diabetes: benefits, risks, indications and perspectives. DIABETES & METABOLISM 2010; 35:537-43. [PMID: 20152741 DOI: 10.1016/s1262-3636(09)73463-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Obesity plays a key role in the pathophysiology of type 2 diabetes (T2DM), and weight loss is a major objective, although difficult to achieve with medical treatments. Bariatric surgery has proven its efficacy in obtaining marked and sustained weight loss, and is also associated with a significant improvement in glucose control and even diabetes remission. Roux-en-Y gastric bypass appears to be more effective in diabetic patients than the restrictive gastroplasty procedure. This may be explained not only by greater weight reduction, but also by specific hormonal changes. Indeed, increased levels of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) may lead to improved beta-cell function and insulin secretion as well as reduced insulin resistance associated with weight loss. The presence of T2DM in obese individuals is a further argument to propose bariatric surgery, and even more so when diabetes is difficult to manage by medical means and other weight-related complications may occur. Bariatric surgery is associated with a better cardiovascular prognosis and reduced mortality, even though acute and long-term complications are present. The observation that surgical rerouting of nutrients triggers changes in the release of incretin hormones that, in turn, ameliorate the diabetic state in the absence of weight loss has led to the recent development of innovative surgical procedures. Thus, bariatric surgery may be said to be progressing towards so-called 'metabolic surgery', which merits further evaluation in patients with T2DM within a multidisciplinary approach that involves both surgeons and endocrinologists.
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Affiliation(s)
- A-J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Sart Tilman, University of Liège, Liège, Belgium.
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Abstract
Lifestyle modifications and pharmacologic therapy have been the mainstays of treatment for patients with type 2 diabetes mellitus. Bariatric surgery, originally designed as a weight loss treatment, has been proven to ameliorate and even cure diabetes. The significant improvement in glycemic control found after bariatric surgery in patients with diabetes often precedes major weight loss. Therefore, a weight-independent mechanism has been thought to initiate this amelioration in glucose control. Reviews of the recent literature question the goal of bariatric surgery, not only to treat obesity through restriction and malabsorption, but also as a possible treatment for diabetes regardless of the degree of obesity. Procedures such as Roux-en-Y gastric bypass, adjustable gastric banding, and biliopancreatic diversion have proven to be extremely effective in controlling diabetes mellitus. Mechanisms explaining the effectiveness of weight reduction surgery include effects on incretins, ghrelin secretion, and insulin sensitivity. Some centers have been performing gastric bypass surgeries on patients with a lower body mass index than that recommended by current NIH guidelines. New considerations for recommending bypass surgery are warranted as the indications for antiobesity surgeries grow to encompass both the treatment and cure of diabetes.
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Jakobsen GS, Hofsø D, Røislien J, Sandbu R, Hjelmesaeth J. Morbidly obese patients--who undergoes bariatric surgery? Obes Surg 2010; 20:1142-8. [PMID: 20049653 PMCID: PMC2910888 DOI: 10.1007/s11695-009-0053-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 12/01/2009] [Indexed: 12/31/2022]
Abstract
Background Bariatric surgery particularly benefits patients with obesity-related comorbidities such as type 2 diabetes and obstructive sleep apnea. We aimed to examine whether the variables that influence treatment choice differ between morbidly obese patients undergoing bariatric surgery and those opting for conservative treatments. Methods A total of 505 consecutive morbidly obese patients (72% women; mean (SD) age 42 (12) years) who attended our tertiary care center between December 2005 and February 2007 were examined by a multidisciplinary team and offered surgical or conservative treatment. The chi-square test, independent samples t test, and multiple logistic regression were used in the statistical analyses. Results A total of 249 (49%) patients underwent bariatric surgery. When compared to the conservative group of patients, the surgery group was characterized by a significantly higher mean (SD) BMI (46.5(6.2) vs. 43.2(5.5) kg/m2, p < 0.001), earlier onset of obesity (40% vs. 26% before 12 years of age, p < 0.001), and lower age (41(11) vs. 44(13) years, p = 0.002). In contrast, the groups did not differ significantly with respect to gender or obesity-related comorbidities. After adjustments for gender, age, onset of obesity, and the number of comorbidities, multiple regression revealed that patients with BMI 40–50 or >50 kg/m2 had between 3 (OR = 3.0; 95% CI 1.9–4.9, p < 0.001) and 6 (OR = 5.7; 95% CI 3.0–11.0, p < 0.001) times the chance of undergoing bariatric surgery when compared to patients with a BMI <40 kg/m2 (reference). Conclusion Our data indicates that increasing BMI rather than obesity-related comorbidities, predicted treatment choice in morbidly obese patients.
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Affiliation(s)
- Gunn Signe Jakobsen
- Morbid Obesity Centre, Vestfold Hospital Trust, Box 2168, 3103, Tønsberg, Norway.
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