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Gillani SMR, Raghavan R, Singh BM. A 5-year assessment of the epidemiology and natural history of possible diabetes in remission. Prim Care Diabetes 2021; 15:688-692. [PMID: 33967016 DOI: 10.1016/j.pcd.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Type 2 diabetes is considered a chronic and progressive disease. The term diabetes in remission has no consensus definition and the question whether diabetes "remission" or "cure" can achieve any long-term benefits in people with type 2 diabetes remains unclear. The aim of our study was a review of our district wide diabetes population to determine the epidemiology and clinical characteristics of those who had a diagnosis of diabetes but did not meet the diagnostic criteria for diabetes at the point of assessment in 2014 and then to review their diabetes outcomes over a 5-year time frame. METHODS In a whole population based non-interventional epidemiological study amongst 17,308 people with diabetes, we identified 991 with diet treated type 2 diabetes who met the baseline criteria for diabetes in remission (HbA1c < 48 mmol/mol (6.5%)). Over the next 5 years, 385 (39%) people had a cumulative HbA1c attainment of <48 mmol/mol (6.5%) and remained free of diabetes medication. RESULTS In this erstwhile remission group only 130 (13%) were free of any vasculopathy, whilst 255 (26%) had some form of micro or macrovascular disease, of which 64 people had been without micro or macrovascular vascular complications at baseline. Only 20 people had a HbA1c consistently ≤37 mmol/mol (5.7%) who were free of diabetes vascular complications and of diabetes medication. CONCLUSIONS The definition of 'diabetes in remission' remains unclear most especially regarding the inclusion of baseline prevalent or incident macro or microvascular disease, the durability of potential remission is poor, and the likelihood of cure is remote.
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Affiliation(s)
- Syed M R Gillani
- Wolverhampton Diabetes Centre, New Cross Hospital, Wolverhampton WV10 0QP, UK.
| | - Rajeev Raghavan
- Wolverhampton Diabetes Centre, New Cross Hospital, Wolverhampton WV10 0QP, UK
| | - Baldev M Singh
- Wolverhampton Diabetes Centre, New Cross Hospital, Wolverhampton WV10 0QP, UK; Academic Institute of Medicine, School of Medicine and Clinical Practice, University of Wolverhampton, WV1 1 LY, UK
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Ali M, Khan SA, Mushtaq M, Haider SA. Comparison of Laparoscopic Sleeve Gastrectomy (LSG) with Laparoscopic Gastric Bypass (LRYGB) in Bariatric Surgery. Cureus 2021; 13:e14022. [PMID: 33889462 PMCID: PMC8057121 DOI: 10.7759/cureus.14022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Introduction The objective of our study was to compare the 30-day post-operative outcomes of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Materials and Methods This randomized controlled study contained patients who underwent bariatric surgery from June 13, 2018 to October 12, 2019. A total of 116 patients having body mass index (BMI) > 35 kg/m2 (morbidly obese), age 18 to 65 years and with failure of conservative treatment were included. Group I patients underwent bariatric surgery using LRYGB technique while group II patients underwent bariatric surgery using the LSG technique. All patients were followed 30 days after surgery to determine early post-operative outcomes. Results The demographic profile, such as age and BMI, was similar between the groups. The mean operating time was 72 ±12 minutes in the LSG group and 156 ± 18 min in the LRYGB group (p-value 0.0001). Major complications were seen in five (8.62%) patients in LSG patients and in four (6.89%) patients in LRYGB group (p-value 0.12). Minor complications were seen in 21 (36.2%) patients in LSG group and in 19 (32.75%) patients in LRYGB group (p-value 0.15). The length of stay in the hospital in LSG group was 6.2±4.2 versus 9.4± 4.6 (p-value 0.0002). Conclusion Both LRYGB and LSG are effective and safe bariatric procedures with a similar incidence of major complications. However, LSG is associated with shorter operative time and hospital stay. Long-term follow-up studies are required to compare the effectiveness of these procedures.
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Affiliation(s)
- Manzar Ali
- General and Colorectal Surgery, Ibn-e-Siena Hospital and Research Institute, Multan, PAK
| | - Safdar Ali Khan
- General Surgery, Ibn-e-Siena Hospital and Research Institute, Multan, PAK
| | - Muhammad Mushtaq
- General Surgery, Ibn-e-Siena Hospital and Research Institute, Multan, PAK
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Comparative Effectiveness of Roux-en Y Gastric Bypass Versus Vertical Sleeve Gastrectomy for Sustained Remission of Type 2 Diabetes Mellitus. J Surg Res 2021; 261:407-416. [PMID: 33515868 DOI: 10.1016/j.jss.2020.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/20/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bariatric surgery results in rapid weight loss and resolution of comorbidities such as type 2 diabetes mellitus (T2DM). We aimed to determine whether the type of surgical procedure-vertical sleeve gastrectomy (VSG) versus Roux-en-Y gastric bypass (RYGB)-was associated with sustained remission from T2DM, and to identify other independent predictors of sustained remission. METHODS Using the IBM MarketScan database of privately insured patients in the United States, we performed a retrospective cohort study on individuals aged 18-65 y with T2DM on hypoglycemic medication, who underwent either VSG or RYGB from 2010 to 2016. Remission was defined as no refill of antidiabetic medication 180 d after a patient's medication was expected to run out and recurrence as medication refill after at least 180 d of remission. RESULTS Of 5119 patients in our cohort, 4127 (81%) experienced remission of T2DM, and 816 (19.8%) of the 4127 patients experienced recurrence. Patients who underwent RYGB had a 24% (HR = 1.24, 95% CI: 1.16, 1.32) increased probability of achieving remission compared with VSG. RYGB had a 36% (HR = 0.64, 95% CI: 0.55, 0.74) decreased risk of recurrence compared with VSG. A higher number of diabetic medications at the time of surgery and a higher Charlson index score were associated with decreased probability of remission and an increased risk of recurrence of T2DM. CONCLUSIONS While both procedures are initially effective, RYGB may be better than VSG at providing lasting remission of T2DM.
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Ciudin A, Simó-Servat A, Palmas F, Barahona MJ. Obesidad sarcopénica: un nuevo reto en la clínica práctica. ENDOCRINOL DIAB NUTR 2020; 67:672-681. [DOI: 10.1016/j.endinu.2020.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/04/2020] [Accepted: 03/18/2020] [Indexed: 12/17/2022]
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Ciudin A, Fidilio E, Ortiz A, Pich S, Salas E, Mesa J, Hernández C, Simó-Servat O, Lecube A, Simó R. Genetic Testing to Predict Weight Loss and Diabetes Remission and Long-Term Sustainability after Bariatric Surgery: A Pilot Study. J Clin Med 2019; 8:jcm8070964. [PMID: 31277226 PMCID: PMC6679039 DOI: 10.3390/jcm8070964] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction: The aim of this pilot study was to assess genetic predisposition risk scores (GPS) in type 2 diabetic and non-diabetic patients in order to predict the better response to bariatric surgery (BS) in terms of either weight loss or diabetes remission. Research Design and Methods: A case-control study in which 96 females (47 with type 2 diabetes) underwent Roux-en-Y gastric by-pass were included. The DNA was extracted from saliva samples and SNPs were examined and grouped into 3 GPS. ROC curves were used to calculate sensitivity and specificity. Results: A highly sensitive and specific predictive model of response to BS was obtained by combining the GPS in non-diabetic subjects. This combination was different in diabetic subjects and highly predictive of diabetes remission. Additionally, the model was able to predict the weight regain and type 2 diabetes relapse after 5 years’ follow-up. Conclusions: Genetic testing is a simple, reliable and useful tool for implementing personalized medicine in type 2 diabetic patients requiring BS.
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Affiliation(s)
- Andreea Ciudin
- Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona (VHIR-UAB), 08035 Barcelona, Spain.
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 08950 Barcelona, Spain.
| | - Enzamaria Fidilio
- Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona (VHIR-UAB), 08035 Barcelona, Spain
| | - Angel Ortiz
- Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona (VHIR-UAB), 08035 Barcelona, Spain
| | - Sara Pich
- Scientific Department, Gendiag.exe, Joan XXIII, 10, Esplugues de LLobregat, 08950 Barcelona, Spain
| | - Eduardo Salas
- Scientific Department, Gendiag.exe, Joan XXIII, 10, Esplugues de LLobregat, 08950 Barcelona, Spain
| | - Jordi Mesa
- Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona (VHIR-UAB), 08035 Barcelona, Spain
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 08950 Barcelona, Spain
| | - Cristina Hernández
- Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona (VHIR-UAB), 08035 Barcelona, Spain
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 08950 Barcelona, Spain
| | - Olga Simó-Servat
- Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona (VHIR-UAB), 08035 Barcelona, Spain
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 08950 Barcelona, Spain
| | - Albert Lecube
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 08950 Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Universitari Arnau de Vilanova, IRBLleida, Universitat de Lleida, 25198 Lleida, Spain
| | - Rafael Simó
- Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona (VHIR-UAB), 08035 Barcelona, Spain.
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 08950 Barcelona, Spain.
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Howard HA. Settler Colonial Biogovernance and the Logic of a Surgical Cure for Diabetes. AMERICAN ANTHROPOLOGIST 2018. [DOI: 10.1111/aman.13140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Shouhed D, Steggerda J, Burch M, Noureddin M. The role of bariatric surgery in nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Expert Rev Gastroenterol Hepatol 2017; 11:797-811. [PMID: 28712339 DOI: 10.1080/17474124.2017.1355731] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) affects between 25% and 33% of the population, is more common in obese individuals, and is the most common cause of chronic liver disease in the United States. However, despite rising prevalence, effective treatments remain limited. Areas covered: We performed a literature search across multiple databases (Pubmed, Medline, etc.) to identify significant original research and review articles to provide an up-to-date and concise overview of disease pathogenesis and diagnostic evaluation and to expand on available treatment options with a specific focus on the potential role of bariatric surgery. Here we provide the most comprehensive review of bariatric surgery for the management of NAFLD, noting benefits from different procedures and multiple reports showing improvements in steatosis, inflammation and fibrosis over the duration of follow-up. Expert commentary: The morbidity of NAFLD is significant as it may become the most common indication for liver transplantation within the next 5 years. In addition to known benefits of weight loss and diabetes resolution, bariatric surgery has the potential to halt and reverse disease progression and future controlled trials should be performed to further define its benefit in the treatment of NAFLD in morbidly obese patients.
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Affiliation(s)
- Daniel Shouhed
- a Department of Surgery , Cedars-Sinai Medical Center , Los Angeles , CA , USA.,b Division of Bariatric Surgery , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Justin Steggerda
- a Department of Surgery , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Miguel Burch
- a Department of Surgery , Cedars-Sinai Medical Center , Los Angeles , CA , USA.,b Division of Bariatric Surgery , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Mazen Noureddin
- c Fatty Liver Disease Program, Division of Digestive and Liver Diseases, Department of Medicine , Comprehensive Transplant Center, Cedars-Sinai Medical Center , Los Angeles , CA , USA
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Trastulli S, Desiderio J, Grandone I, Fontana L, Paolini L, Altomare M, D'Angelo P, Palazzi M, Cirocchi R, Leotta S, Fatati G, Parisi A. Rationale and design of the Early Sleeve gastrectomy In New Onset Diabetic Obese Patients (ESINODOP) trial. Endocrine 2017; 55:748-753. [PMID: 27259508 DOI: 10.1007/s12020-016-0996-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/19/2016] [Indexed: 01/06/2023]
Abstract
No randomized clinical trials (RCTs) have yet evaluated the bariatric surgery's efficacy and safety in patients newly diagnosed with type 2 diabetes mellitus (T2DM). The aim of this multicenter RCT is to compare bariatric surgery, particularly laparoscopic sleeve gastrectomy (LSG), with conventional medical therapy (CMT) in obese patients (body mass index between 30 and 42 kg/m2) newly diagnosed with T2DM and without any diabetes-related complications at any stage. A total of 100 eligible patients will be randomized at a 1:1 ratio to undergo one of the two planned treatments and will be followed for at least 6 years after randomization. The main objective of the ESINODOP trial is to investigate the efficacy of LSG compared with CMT alone in inducing and maintaining a remission of T2DM (defined as HbA1c levels ≤6.0 %, without active pharmacologic therapy after 1 year). The remission of T2DM will also be evaluated with the criteria provided by the American Diabetes Association (ADA), and the additional parameters such as adverse event rates, micro- and macrovascular complications, weight loss, gastrointestinal hormones, and quality of life will be compared. The study started on September 2015 and the planned recruitment period is 3 years. Patient recruitment and follow-up take place in the two diabetology and nutrition centers participating in the study, which are performed on a national basis. The ESINODOP trial is designed with the intent of comparing the efficacy of CMT alone to that of CMT in conjunction with LSG performed at the time of diabetes diagnosis in mildly obese diabetic patients. Currently, patients with these characteristics are not eligible for bariatric/metabolic surgery.
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Affiliation(s)
- Stefano Trastulli
- Department of Digestive Surgery and Liver Unit, Santa Maria Hospital, Via Tristano di Joannuccio 1, 05100, Terni, Italy.
- Department of Chemistry, Biology and Biotechnology, University of Perugia, Perugia, Italy.
| | - Jacopo Desiderio
- Department of Digestive Surgery and Liver Unit, Santa Maria Hospital, Via Tristano di Joannuccio 1, 05100, Terni, Italy
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Ilenia Grandone
- Department of Diabetology, Dietology and Clinical Nutrition, S. Maria Hospital, Terni, Italy
| | - Lucia Fontana
- Department of Diabetology and Clinical Nutrition, Sandro Pertini Hospital, Rome, Italy
| | - Luisa Paolini
- Department of Diabetology, Dietology and Clinical Nutrition, S. Maria Hospital, Terni, Italy
| | - Maria Altomare
- Department of Diabetology and Clinical Nutrition, Sandro Pertini Hospital, Rome, Italy
| | - Paola D'Angelo
- Department of Diabetology and Clinical Nutrition, Sandro Pertini Hospital, Rome, Italy
| | - Mariangela Palazzi
- Department of Diabetology, Dietology and Clinical Nutrition, S. Maria Hospital, Terni, Italy
| | - Roberto Cirocchi
- Department of Digestive Surgery and Liver Unit, Santa Maria Hospital, Via Tristano di Joannuccio 1, 05100, Terni, Italy
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Sergio Leotta
- Department of Diabetology and Clinical Nutrition, Sandro Pertini Hospital, Rome, Italy
| | - Giuseppe Fatati
- Department of Diabetology, Dietology and Clinical Nutrition, S. Maria Hospital, Terni, Italy
| | - Amilcare Parisi
- Department of Digestive Surgery and Liver Unit, Santa Maria Hospital, Via Tristano di Joannuccio 1, 05100, Terni, Italy
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Sedjo RL, Flatt SW, Byers T, Colditz GA, Demark-Wahnefried W, Ganz PA, Wolin KY, Elias A, Krontiras H, Liu J, Naughton M, Pakiz B, Parker BA, Wyatt H, Rock CL. Impact of a behavioral weight loss intervention on comorbidities in overweight and obese breast cancer survivors. Support Care Cancer 2016; 24:3285-93. [PMID: 26945570 PMCID: PMC5323258 DOI: 10.1007/s00520-016-3141-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/22/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Comorbid medical conditions are common among breast cancer survivors, contribute to poorer long-term survival and increased overall mortality, and may be ameliorated by weight loss. This secondary analysis evaluated the impact of a weight loss intervention on comorbid medical conditions immediately following an intervention (12 months) and 1-year postintervention (24 months) using data from the Exercise and Nutrition to Enhance Recovery and Good health for You (ENERGY) trial-a phase III trial which was aimed at and successfully promoted weight loss. METHODS ENERGY randomized 692 overweight/obese women who had completed treatment for early stage breast cancer to either a 1-year group-based behavioral intervention designed to achieve and maintain weight loss or to a less intensive control intervention. Minimal support was provided postintervention. New medical conditions, medical conditions in which non-cancer medications were prescribed, hospitalizations, and emergency room visits, were compared at baseline, year 1, and year 2. Changes over time were analyzed using chi-squared tests, Kaplan-Meier, and logistic regression analyses. RESULTS At 12 months, women randomized to the intervention had fewer new medical conditions compared to the control group (19.6 vs. 32.2 %, p < 0.001); however, by 24 months, there was no longer a significant difference. No difference was observed in each of the four conditions for which non-cancer medications were prescribed, hospital visits, or emergency visits at either 12 or 24 months. CONCLUSIONS These results support a short-term benefit of modest weight loss on the likelihood of comorbid conditions; however, recidivism and weight regain likely explain no benefit at 1-year postintervention follow-up.
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Affiliation(s)
- Rebecca L Sedjo
- University of Colorado Anschutz Medical Campus, 13001 East 17th Place, MS F519, Aurora, CO, 80045, USA.
| | - Shirley W Flatt
- University of California, San Diego, 3855 Health Sciences Drive, La Jolla, CA, 92093, USA
| | - Tim Byers
- University of Colorado Anschutz Medical Campus, 13001 East 17th Place, MS F519, Aurora, CO, 80045, USA
| | - Graham A Colditz
- Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8100, Saint Louis, MO, 63110, USA
| | - Wendy Demark-Wahnefried
- University of Alabama at Birmingham, 1824 6th Avenue, Wallace Tumor Institute, Rm. 310D, Birmingham, AL, 35294, USA
| | - Patricia A Ganz
- Jonsson Comprehensive Cancer Center, and the UCLA Fielding School of Public Health, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, 90095, CA, USA
| | - Kathleen Y Wolin
- Coeus Health LLC, 222 Merchandise Mart Pl, Suite 1230, Chicago, IL, 60654, USA
| | - Anthony Elias
- University of Colorado Anschutz Medical Campus, 13001 East 17th Place, MS F519, Aurora, CO, 80045, USA
| | - Helen Krontiras
- University of Alabama at Birmingham, 1824 6th Avenue, Wallace Tumor Institute, Rm. 310D, Birmingham, AL, 35294, USA
| | - Jingxia Liu
- Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8100, Saint Louis, MO, 63110, USA
| | - Michael Naughton
- Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8100, Saint Louis, MO, 63110, USA
| | - Bilgé Pakiz
- University of California, San Diego, 3855 Health Sciences Drive, La Jolla, CA, 92093, USA
| | - Barbara A Parker
- University of California, San Diego, 3855 Health Sciences Drive, La Jolla, CA, 92093, USA
| | - Holly Wyatt
- University of Colorado Anschutz Medical Campus, 13001 East 17th Place, MS F519, Aurora, CO, 80045, USA
| | - Cheryl L Rock
- University of California, San Diego, 3855 Health Sciences Drive, La Jolla, CA, 92093, USA
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Abstract
Levels of obesity have reached epidemic proportions on a global scale, which has led to considerable increases in health problems and increased risk of several diseases, including cardiovascular and pulmonary diseases, cancer and diabetes mellitus. People with obesity consume more food than is needed to maintain an ideal body weight, despite the discrimination that accompanies being overweight and the wealth of available information that overconsumption is detrimental to health. The relationship between energy expenditure and energy intake throughout an individual's lifetime is far more complicated than previously thought. An improved comprehension of the relationships between taste, palatability, taste receptors and hedonic responses to food might lead to increased understanding of the biological underpinnings of energy acquisition, as well as why humans sometimes eat more than is needed and more than we know is healthy. This Review discusses the role of taste receptors in the tongue, gut, pancreas and brain and their hormonal involvement in taste perception, as well as the relationship between taste perception, overeating and the development of obesity.
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Affiliation(s)
- Sara Santa-Cruz Calvo
- Laboratory of Clinical Investigation, National Institute on Aging, NIH, Biomedical Research Center, Room 09B133, 251 Bayview Boulevard, Suite 100, Baltimore, MD 21224-6825, USA
| | - Josephine M Egan
- Laboratory of Clinical Investigation, National Institute on Aging, NIH, Biomedical Research Center, Room 09B133, 251 Bayview Boulevard, Suite 100, Baltimore, MD 21224-6825, USA
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