Effects of gastric bypass on type 2 diabetes in patients with BMI 30 to 35

The effect of laparoscopic sleeve gastrectomy on type 2 diabetes remission outcomes in patients with body mass index higher than 25 kg/m2 but lower than 32.5 kg/m2

BACKGROUND

The effect of laparoscopic sleeve gastrectomy (LSG) in the treatment of type 2 diabetes (T2D) patients with body mass index (BMI is calculated by dividing weight in kilograms by height in meters squared) higher than 25 kg/m² but lower than 32.5 kg/m², especially in East Asian population characterized by abdominal obesity, are still unclear. This study aims to explore the effect of LSG in T2D patients with BMI higher than 25 kg/m² but lower than 32.5 kg/m².

METHODS

A total of 49 T2D patients with BMI(25-32.5 kg/m²) treated successfully with LSG were included in our study. The effect of LSG on T2D remission outcomes at 12 and 24 months after operation was analyzed.

RESULTS

All patients were treated successfully with LSG without conversion. The mean preoperative body weight,BMI, fasting plasma glucose, glycosylated hemoglobin (A1c) and fasting C-peptide were 81.7 ± 10.0 kg, 29.1 ± 2.4 kg/m², 10.4 ± 3.9 mmol/L,8.2 ± 1.5%, and 2.3 ± 1.1 nmol/L,respectively.The age, duration of diabetes and ABCD score were 48.6 ± 9.6 years,6.6 ± 5.1 years, and 2.9 ± 1.5. The mean fasting plasma glucose,A1c, and C-peptide levels were significantly decreased at 12 and 24 months after operation. At postoperative 24 months, 18 out of 49 patients (36.7%) reached diabetes complete remission (A1c levels≤6.0%).14 out of 49 patients (28.6%) reached partial remission (6.0% < A1c levels<6.5%). 8 out of 49 patients (16.3%) reached notable improvement (6.5% < A1c levels<7%). At 24 months after LSG, the complete remission rate of T2D patients with a BMI of 25-27.5 kg/m² was 35.3%, the complete remission rate of patients with a BMI of 27.5-30 kg/m² was 11.1%, and the complete remission rate of patients with a BMI of 30-32.5 kg/m² was 47.8%.At postoperative 24 months, the complete remission rate of T2D patients with ABCD score≤2 was 5.0%, the complete remission rate of patients with ABCD score 3 to 4 was 52.4%, and the complete remission rate of patients with ABCD score≥5 was 75.0%.

CONCLUSION

Our study demonstrates that LSG could result in a significant effect on T2D in patients with BMI 30-32.5 kg/m². In addition, our study indicates that higher ABCD score can predict a better diabetes remission outcome in diabetes patients with BMI ≤32.5 kg/m².

Effect of Roux-en-Y Gastric Bypass for Patients with Type 2 Diabetes Mellitus and a BMI < 32.5 kg/m2: a 6-Year Study in Chinese Patients

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbidly obese patients to improve type 2 diabetes mellitus (T2DM). Recently, T2DM patients with a lower body mass index (BMI) have been receiving more attention, and these patients could benefit from RYGB.

METHODS

Fifty-two patients with T2DM underwent RYGB between October 2008 and December 2012 in our hospital. Weight, BMI, oral glucose tolerance test (OGTT), insulin release test (IRT), C-peptide release test (CRT), glycosylated hemoglobin (HbA1c), and lipid metabolic parameters were measured at baseline and at 3 and 6 months and 1, 2, 3, 4, 5, and 6 years after surgery.

RESULTS

The mean age of the 52 patients was 46.8 ± 9.5 years, and 57.7% were male. The mean duration of T2DM was 6.5 ± 4.6 years. Compared with the baseline values, weight and BMI were significantly decreased at several time points after surgery. HbA1c decreased from 8.2 ± 1.7% at baseline to 6.5 ± 1.4% at 3 months, 6.5 ± 1.4% at 6 months, 7.2 ± 1.3% at 4 years, and 7.5 ± 1.2% at 6 years. OGTT, OGTT-IRT, and OGTT-CRT improved after surgery. There was a decrease in triglycerides (TGs), total cholesterol (TC), and low-density lipoprotein (LDL) and an increase in high-density lipoprotein (HDL). At 6 years after surgery, 16.7% of patients achieved complete remission of T2DM, and 66.7% achieved improvement in T2DM.

CONCLUSION

RYGB may be a safe and effective treatment for T2DM patients with a BMI < 32.5 kg/m² in China. However, a long-term study without loss to follow-up is necessary for better evaluation.

Evaluating the safety of bariatric surgery for weight loss in class I obesity: A propensity-matched analysis of North American data

BACKGROUND

Bariatric surgery is an effective treatment for severe obesity. However, there has been an evolving role for bariatric surgery as a primary treatment in the management of class I obesity.

OBJECTIVES

We aimed to assess the safety of surgery by directly comparing surgical outcomes of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in class I obesity (body mass index [BMI] 30-35 kg/m²) with those with class II obesity (BMI 35-40 kg/m²) and higher (BMI >40 kg/m²) using an analysis of a large-scale matched-patient cohort analysis.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, United States and Canada.

METHODS

We performed a retrospective analysis using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, which collects patient information from >790 bariatric surgery centers in North America. Patients included in our analysis underwent surgery in the years 2015 and 2016 and had either LRYGB or LSG for weight loss.

RESULTS

Initial analysis included 274,091 patients. Propensity-matching resulted in 9104 patients for analysis in each of the class I and class II and higher groups. The overall major complication rate between the 2 matched groups was 3.9% for class I and 3.5% for class II and higher (P = .11). We did not find that class I obesity was associated with an increased risk of 30-day complication or death.

CONCLUSIONS

In our analysis of propensity-matched patients undergoing LSG and LRYGB for weight loss, class I obesity did not have statistically higher risk of postoperative complication rates compared with class II and higher.

A Prospective Single-Arm Trial of Modified Long Biliopancreatic and Short Alimentary Limbs Roux-En-Y Gastric Bypass in Type 2 Diabetes Patients with Mild Obesity

BACKGROUND

Type-2 diabetes (T2D) patients with body mass index (BMI) below 35 kg/m² carry lower remission rates than severely obese T2D individuals submitted to "standard limb lengths" Roux-en-Y gastric bypass (RYGB). Mild-obese patients appear to have more severe forms of T2D, where the mechanisms of glycemic control after a standard-RYGB may be insufficient. The elongation of the biliopancreatic limb may lead to greater stimulation of the distal intestine, alterations in bile acids and intestinal microbiota, among other mechanisms, leading to better metabolic outcomes. The aim of this study is to evaluate the safety and efficacy of the RYGB with a biliopancreatic limb of 200 cm in the control of T2D in patients with BMI 30-35 kg/m².

METHODS

From January 2011 to May 2015, 102 T2D patients with BMI from 30 to 34.9 kg/m² underwent laparoscopic RYGB with the biliopancreatic-limb of 200 cm and the alimentary-limb of 50 cm.

RESULTS

There were no deaths or reoperations. The mean follow-up was 28.1 months. The mean BMI dropped from 32.5 to 25.1 kg/m², while the mean fasting glucose decreased from 182.9 to 89.8 mg/dl and the mean glycated hemoglobin (HbA1c) went from 8.7 to 5.2%. During follow-up, 92.2% had their T2D under complete control (HbA1c < 6%, no anti-diabetic medications), while 7.8% were under partial control. Control of hypertension and dyslipidemia were 89.4 and 85.5%, respectively. No patient developed hypoalbuminemia, and there were mild micronutrient deficiencies.

CONCLUSIONS

RYGB with long-biliopancreatic and short-alimentary limbs is safe and seems effective in achieving complete control of T2D in patients with BMIs between 30 and 35 kg/m².

Peptide-based multi-agonists: a new paradigm in metabolic pharmacology

Obesity and its comorbidities, such as type 2 diabetes, are pressing worldwide health concerns. Available anti-obesity treatments include weight loss pharmacotherapies and bariatric surgery. Whilst surgical interventions typically result in significant and sustained weight loss, available pharmacotherapies are far less effective, typically decreasing body weight by no more than 5-10%. An emerging class of multi-agonist drugs may eventually bridge this gap. This new class of specially tailored drugs hybridizes the amino acid sequences of key metabolic hormones into one single entity with enhanced potency and sustained action. Successful examples of this strategy include multi-agonist drugs targeting the receptors for glucagon-like peptide-1 (GLP-1), glucagon and the glucose-dependent insulinotropic polypeptide (GIP). Due to the simultaneous activity at several metabolically relevant receptors, these multi-agonists offer improved body weight loss and glucose tolerance relative to their constituent monotherapies. Further advancing this concept, chimeras were generated that covalently link nuclear acting hormones such as oestrogen, thyroid hormone (T₃ ) or dexamethasone to peptide hormones such as GLP-1 or glucagon. The benefit of this strategy is to restrict the nuclear hormone action exclusively to cells expressing the peptide hormone receptor, thereby maximizing combinatorial metabolic efficacy of both drug constituents in the target cells whilst preventing the nuclear hormone cargo from entering and acting on cells devoid of the peptide hormone receptor, in which the nuclear hormone might have unwanted effects. Many of these multi-agonists are in preclinical and clinical development and may represent new and effective tools in the fight against obesity and its comorbidities.

Serum levels of osteopontin predict diabetes remission after bariatric surgery

AIM

Bariatric surgery has been shown to effectively improve glycaemic control in morbidly obese subjects. However, the molecular bases of this association are still elusive and may act independently of weight loss. Here, our retrospective study has investigated the inflammatory molecule osteopontin (OPN) as a potential predictor of type 2 diabetes mellitus (T2DM) remission.

METHODS

Baseline serum levels of OPN were analyzed in 41 T2DM patients who underwent bariatric surgery. Anthropometric measures and biochemical variables, including insulin sensitivity indices (HOMA2), were assessed at baseline and at 1 and 3 years after surgery.

RESULTS

At baseline, patients who experienced T2DM remission had increased waist circumference, body weight and BMI, and higher serum OPN, compared with non-remitters. Patients with and without T2DM remission improved their lipid and glucose profiles, although insulin resistance indices were only improved in the T2DM remission group. In the overall cohort of both T2DM remission and non-remission patients, baseline circulating levels of OPN significantly correlated with reductions of body weight and BMI over time, and insulin sensitivity improved as well. However, only the HOMA2-%S remained independently associated with serum OPN on multivariate linear regression analysis (B: 0.227, 95% CI: 0.067-0.387, β = 0.831; P = 0.010). Baseline values of OPN predicted 3-year T2DM remission independently of body weight loss, lower BMI and duration of diabetes (OR: 1.046, 95% CI: 1.004-1.090; P = 0.033).

CONCLUSION

Although larger studies are still needed to confirm our preliminary results, pre-operative OPN serum levels might be useful for predicting 3-year T2DM remission independently of weight loss in patients undergoing bariatric surgery.

Improved glycemic control with proximal intestinal bypass and weight loss following gastrectomy in non-obese diabetic gastric cancer patients

PURPOSE

The aim of this study was to assess whether gastrectomy influences glycemic control in non-obese diabetic gastric cancer patients and to identify factors related to glucose metabolism after gastrectomy.

MATERIALS AND METHODS

We retrospectively analyzed changes in glucose metabolism in 238 non-obese (body mass index < 30 kg/m2) patients with type II diabetes who underwent distal gastrectomy with either gastroduodenostomy (n = 91) or gastrojejunostomy (n = 147) for stage I gastric cancer. We collected demographics, diabetes-related features, surgery-related features, and changes in glucose metabolism during follow-up. The effect of surgery on the course of diabetes was evaluated at different time points according to fasting blood glucose levels and use of diabetes-related medication.

RESULTS

Preoperatively, the mean body mass index was 24.3 ± 2.3. Weight, body mass index and fasting blood glucose of all patients were significantly lower compared to preoperative levels at all time points. Weight loss after 6 months and the percentage of patients whose weight loss ratio was higher than 10% after one year were greater in the gastrojejunostomy group than the gastroduodenostomy group. Overall, 88 (37%) patients showed improvement in their diabetes course at one month after surgery; 152 (64%) showed improvement after 2 years. Duration of diabetes, weight loss, and reconstruction type were associated with improvement in diabetes at different time points. At 6 months and thereafter, the percentage of patients with an improved diabetes course was highest in the gastrojejunostomy plus higher than 10% weight loss group.

CONCLUSIONS

Although weight loss may be associated with adverse effects of gastrectomy, postoperative weight loss in an acceptable range is a useful measure of the better glycemic control for the group of diabetic patients. Selecting gastrojejunostomy during gastrectomy and inducing acceptable weight loss after gastrectomy could be beneficial to the non-obese diabetic gastric cancer patients for improved glycemic control.

Body Mass Index and Glycaemic Control in Patients with Diabetes Mellitus: A Case-Control Study

Background and Aims: Recent studies have brought evidence on the connection between excess weight and suboptimal glycemic control for Diabetes Mellitus (DM) patients. The aim of this study was to evaluate the association between increased Body Mass Index (BMI) and the likelihood of having suboptimal glycemic control in patients with Type 1 and Type 2 Diabetes Mellitus. Materials and Methods: A case-control study was conducted on 662 patients suffering from Diabetes Mellitus and statistical analysis was performed in order obtain evidence associating BMI and poor glycaemic control. We defined as increased BMI, values >25 kg/m2 and a hemoglobin A1c (HbA1c) value >7% reflected suboptimal glycemic control. Results: 559 (84%) patients had HbA1c >7%. 550 (83 %) patients had a BMI >25 kg/m2. In case of HbA1c >7%, a BMI >25 kg/m2 was found in a number of 457 patients (82 %), whereas a normal BMI was present in 102 (18%) patients. For the HbA1c<7% cases, the number of patients associating BMI >25 kg/m2 was 93 (90%) and a normal BMI was present in 10 (10%) patients. BMI >25 kg/m2 was not associated with a higher probability of having above-target HbA1c values compared to patients with target HbA1c (OR 0.48, 95% CI: 0.24 to 0.95), with a statistically significant p <0.05. Conclusions: The findings revealed that although in case of suboptimal glycemic control, the number of patients who had a BMI >25 kg/m2 was significantly higher than the number of patients with a BMI < 25 kg/m2, a BMI above target was not associated with greater odds of having HbA1c higher than the standard 7% level, compared to individuals with normal HbA1c levels. The results emphasize that a multitude of factors are involved in the process of achieving a targeted glycemic control and a stepped-care approach should be considered for optimum management of Diabetes Mellitus.

High baseline C-reactive protein levels predict partial type 2 diabetes mellitus remission after biliopancreatic diversion

BACKGROUND AND AIMS

Several studies demonstrated that surgery can improve inflammation parameters, such as C-reactive protein (CRP). Few biomarkers have been investigated to potentially predict type 2 diabetes mellitus (T2DM) remission. We aimed at determining whether pre-surgery serum CRP levels could predict T2DM remission after 3 years in patients undergoing bariatric surgery, especially biliopancreatic diversion (BPD).

METHODS AND RESULTS

This study was conducted from 2007 to 2009 at the Surgical Department of the University of Genoa, Italy. Forty-four patients with T2DM undergoing BPD (n = 38) or Roux-en-Y gastric bypass (n = 6) were enrolled. The primary endpoint was to evaluate whether pre-surgery CRP levels could predict T2DM partial remission at 3-year follow-up. Secondary endpoints were to assess whether glycaemic, lipid, and inflammatory parameters modified during the follow-up. At baseline, patients with T2DM ranged from overweight to morbid obesity, had mild dyslipidaemia, and a low-grade inflammation. Bariatric surgery improved body weight, lipid and glycaemic profile both at 1- and 3-year follow-up. Pre-surgery CRP levels progressively decreased at 1- and 3-year follow-up. Among inflammatory pre-surgery parameters, only high CRP levels were shown to predict T2DM partial remission after 3 years. Multivariate analysis confirmed the predictive value of pre-surgery CRP levels independently of age, gender, type of surgery, and body mass index.

CONCLUSION

Bariatric surgery, in particular BPD, improved both metabolic and inflammatory biomarkers at 1- and 3-year follow-up. Pre-surgery high CRP levels predicted 3-year T2DM partial remission, indicating a promising target population to be especially treated with BPD.

What is the role of bariatric surgery in the management of obesity?

Diet, exercise, cognitive behavioral therapy and pharmacotherapy are some of the means of assisting patients to lose weight, with bariatric surgery being the most effective. Over the last two decades, the increased awareness of the systemic benefits of bariatric surgery, as well as the improved safety and the wider use of the laparoscopic approach, has made bariatric surgery flourish. In the United Kingdom, the adjustable gastric band (10%), vertical sleeve gastrectomy (37%) and Roux-en-Y gastric bypass (45%) are the three most common procedures. Obesity-associated mortality and co-morbidities such as type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, renal dysfunction and depression improve significantly with bariatric surgery. The mechanisms of weight loss extend beyond restriction and malabsorption and include changes in hunger and satiety, food preferences, and possibly energy expenditure. Despite its safety and efficacy, bariatric surgery is underutilized as less than 1% of adults with obesity receive it. In view of the evolution of obesity into a global threat, access to bariatric surgery should be increased, whilst developing safer and less invasive weight loss treatments.

A comparative study of the metabolic effects of LSG and LRYGB in Chinese diabetes patients with BMI<35 kg/m2

BACKGROUND

The metabolic effects of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in type 2 diabetes (T2D) patients who do not meet National Institutes of Health indications has not been well studied.

OBJECTIVES

To compare the effectiveness of LSG and LRYGB in Chinese T2D patients with body mass index (BMI)<35 kg/m².

SETTING

University hospital, China.

METHODS

A nonrandomized cohort of patients who underwent LRYGB (n = 64) and LSG (n = 19) were followed up for 3 years and the outcomes (weight loss and remission of diabetes and other metabolic parameters) were compared. Univariate and multivariate analyses were applied to find associated parameters of T2D remission.

RESULTS

In total, 5 patients (6%) were lost to follow-up. No significant differences in mean percentage of excess weight loss and BMI were observed between the 2 groups at 2 years. At 3-year follow-up, the LRYGB group had significantly higher percentage of excess weight loss and lower BMI. The total (complete and partial) remission rate achieved with both bariatric procedures was 75.9% at 1 year and 56.4% at 3 years. Surgical safety, diabetes remission, and remission of other obesity-related co-morbidities were comparable between the 2 groups. Patients who achieved complete or partial remission had lower fasting plasma glucose, lower plasma glucose at 2 hours, lower glycated hemoglobin, and higher fasting C peptide than the other patients at baseline. High recurrence rates of hypertension and hyperuricemia were observed at 3 years postoperation.

CONCLUSIONS

Both LSG and LRYGB are safe and effective bariatric procedures for T2D in this Chinese population with diabetes and BMI<35 kg/m².

Recent advances in metabolic and bariatric surgery

Obesity and its associated medical conditions continue to increase and add significant burden to patients, as well as health-care systems, worldwide. Bariatric surgery is the most effective treatment for severe obesity and its comorbidities, and resolution of diabetes is weight loss-independent in the case of some operations. Although these weight-independent effects are frequently described clinically, the mechanisms behind them are not well understood and remain an intense area of focus in the growing field of metabolic and bariatric surgery. Perceptions of the mechanisms responsible for the beneficial metabolic effects of metabolic/bariatric operations have shifted from being mostly restrictive and malabsorption over the last 10 to 15 years to being more neuro-hormonal in origin. In this review, we describe recent basic and clinical findings of the major clinical procedures (adjustable gastric banding, vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion) as well as other experimental procedures (ileal interposition and bile diversion) that recapitulate many of the metabolic effects of these complex operations in a simpler fashion. As the role of bile acids and the gut microbiome on metabolism is becoming increasingly well described, their potential roles in these improvements following metabolic surgery are becoming better appreciated. Bile acid and gut microbiome changes, in light of recent developments, are discussed in the context of these surgical procedures, as well as their implications for future study.

Roux-en-Y Gastric Bypass Versus Medical Treatment for Type 2 Diabetes Mellitus in Obese Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim of the study is to compare Roux-en-Y gastric bypass (RYGB) surgery versus medical treatment for type 2 diabetes mellitus (T2DM) in obese patients.Bariatric surgery can achieve remission of T2DM in obese patients. RYGB surgery has been performed as one of the most common surgical treatment options for obese patients with T2DM, but the efficacy of RYGB surgery comparing with medical treatment alone has not been conclusively determined.A systematic literature search identified randomized controlled trials (RCTs) evaluating RYGB surgery versus medical treatment for T2DM in obese patients was conducted in PubMed, Embase, Cochrane Database, and Cochrane Clinical Trials Registry. This systematic review and meta-analysis were performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The primary outcome was T2DM remission. Additional analyses comprised hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), body mass index (BMI), waist circumference, serum lipid level, blood pressure, medication use, and adverse events. Random-effects meta-analyses were calculated and presented as weighted odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI).Six RCTs concerning 410 total obese T2DM patients were included. Follow-up ranged from 12 to 60 months. RYGB surgery was associated with a higher T2DM remission rate (OR: 76.37, 95% CI: 20.70-281.73, P < 0.001) and serum level of high-density lipoprotein cholesterol (MD: 0.24 mmol/L, 95% CI 0.18-0.30 mmol/L, P < 0.001) than medical treatment alone. HbA1c (MD: -1.25%, 95% CI: -1.88% to -0.63%, P < 0.001), BMI (MD: -6.54 kg/m, 95% CI: -9.28 to -3.80 kg/m, P < 0.001), waist circumference (MD: -15.60 cm, 95% CI: -18.21 to -13.00 cm, P < 0.001), triglyceride (MD: -0.87 mmol/L, 95% CI: -1.17 to -0.57 mmol/L, P < 0.001), low-density lipoprotein cholesterol (MD: -0.32 mmol/L, 95% CI: -0.62 to -0.02 mmol/L, P = 0.04), systolic blood pressure (MD: -2.83 mm Hg, 95% CI: -4.88 to -0.78 mm Hg, P < 0.01) were lower after RYGB surgery. However, FPG (MD: -1.58 mmol/L, 95% CI: -3.58 to 0.41 mmol/L, P = 0.12), total cholesterol (MD: -0.40 mmol/L, 95% CI: -0.92 to 0.12 mmol/L, P = 0.13), and diastolic blood pressure (MD: 0.28 mm Hg, 95% CI: -1.89 to 2.45 mm Hg, P = 0.80) were not significantly different between the 2 treatment groups. The medicine use and quality of life were solely improved in the surgical group. Nutritional deficiencies and anemia were noted more frequently in the RYGB group.RYGB surgery is superior to medical treatment for short- to medium-term remission of T2DM, improvement of metabolic condition, and cardiovascular risk factors. Further RCTs should address the safety and long-term benefits of RYGB surgery on obese patients with T2DM.

Obesity and glycemic control in patients with diabetes mellitus: Analysis of physician electronic health records in the US from 2009-2011

AIMS

Examine the association between obesity and glycemic control among patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM).

METHODS

Data from US physician electronic health records (Humedica®) from 2009-2011 were utilized. Patients were defined as having above-target glycemic control if they had an HbA1c ≥7% at any time during the study period. Multinomial logistic regressions were conducted separately for T1DM and T2DM patients, and examined associations between BMI categories and probability of having above-target glycemic control (≥7% and <8%, ≥8% and <9%, or ≥9%) while controlling for patient demographics, general health, comorbid conditions, and antihyperglycemic medication use.

RESULTS

There were 14,028 T1DM and 248,567 T2DM patients; 47.8% of T1DM and 63.4% of T2DM were obese (BMI ≥30kg/m(2)). For T1DM, being overweight (BMI 25-<30), obese class I (30-<35), II (35-<40), or III (≥40) was associated with a significantly higher probability of having HbA1c≥8% and <9% or ≥9%, while being overweight was associated with a significantly higher probability of having HbA1c ≥7% and <8% compared to normal BMI (BMI≥18.5 and<25). For T2DM patients, being overweight, obese class I, II, or III was associated with a significantly higher probability of having HbA1c ≥7% and <8%, ≥8% and <9%, or ≥9%.

CONCLUSIONS

For both T1DM and T2DM patients, there were positive and statistically significant associations between being overweight or obese and having suboptimal glycemic control. These findings quantify the associations between obesity and glycemic control, and highlight the potential importance of individual characteristics on glycemic control.

From bariatric to metabolic surgery: Looking for a “disease modifier” surgery for type 2 diabetes

In this review the recent evolution of the comprehension of clinical and metabolic consequences of bariatric surgery is depicted. At the beginning bariatric surgery aim was a significant and durable weight loss. Later on, it became evident that bariatric surgery was associated with metabolic changes, activated by unknown pathways, partially or totally independent of weight loss. Paradigm of this “metabolic” surgery is its effects on type 2 diabetes mellitus (T2DM). In morbid obese subjects it was observed a dramatic metabolic response leading to decrease blood glucose, till diabetes remission, before the achievement of clinically significant weight loss, opening the avenue to search for putative anti-diabetic “intestinal” factors. Both proximal duodenal (still unknown) and distal (GLP1) signals have been suggested as hormonal effectors of surgery on blood glucose decrease. Despite these findings T2DM remission was never considered a primary indication for bariatric surgery but only a secondary one. Recently T2DM remission in obese subjects with body mass index (BMI) greater than 35 has become a primary aim for surgery. This change supports the idea that “metabolic surgery” definition could more appropriate than bariatric, allowing to explore the possibility that metabolic surgery could represent a “disease modifier” for T2DM. Therefore, several patients have undergone surgery with a primary aim of a definitive cure of T2DM and today this surgery can be proposed as an alternative therapy. How much surgery can be considered truly metabolic is still unknown. To be truly “metabolic” it should be demonstrated that surgery could cause T2DM remission not only in subjects with BMI > 35 but also with BMI < 35 or even < 30. Available evidence on this topic is discussed in this mini-review.

What is the impact of sleeve gastrectomy and gastric bypass on metabolic control of diabetes? A clinic-based cohort of Mediterranean diabetic patients

BACKGROUND

Effectiveness of sleeve gastrectomy and gastric bypass on glycemic, blood pressure, and lipids control in obese type 2 diabetic patients is poorly known.

OBJECTIVE

To assess the effectiveness of bariatric surgery on obese patients with type 2 diabetes.

SETTING

University hospital, Italy.

METHODS

Diabetes remission and metabolic changes over postoperative follow-up were assessed in 135 obese patients with type 2 diabetes who underwent bariatric surgery in 2007-2011 (gastric bypass, n = 100; sleeve gastrectomy, n = 35). Repeated-measures analysis of variance and logistic regression were used.

RESULTS

Diabetes remission was observed in 22% and 21.5% of the patients, respectively, 1 and 2 years after surgery. Compared with the remaining patients, patients in diabetes remission were significantly younger, had lower diabetes duration, hemoglobin A1c (HbA1c), fasting plasma glucose, and frequency of insulin treatment. Trends of HbA1c, body mass index (BMI), blood pressure, and plasma triglycerides revealed a significant decrease over time and the trend of HDL-cholesterol revealed a significant increase over time in both treatment groups (P<.001). Patients reaching target levels for at least 3 out of 5 indicators of intermediate outcomes of care (composite indicator of good diabetes control) were 25.5% at the baseline and 66.1% at final follow-up visit (P<.001). In logistic regression, age (OR = .89, 95% CI .84-.95), HbA1c (OR = .67, 95% CI .49-0.91) and diabetes duration (OR = .87, 95% CI .77-1.00) were independent predictors of diabetes remission.

CONCLUSIONS

Bariatric surgery is an effective approach to optimize glucose, lipids, and blood pressure control in obese type 2 diabetic patients. Bariatric surgery should be offered earlier over the natural course of diabetes to increase the likelihood of diabetes remission in obese patients.