Weight Loss and the Prevention and Treatment of Type 2 Diabetes Using Lifestyle Therapy, Pharmacotherapy, and Bariatric Surgery: Mechanisms of Action

Novel perspectives of testosterone therapy in men with functional hypogonadism: traversing the gaps of knowledge

INTRODUCTION

In the past decade, there has been a significant augmentation in the corpus of evidence pertaining to functional hypogonadism. Despite this, prevailing clinical guidelines continue to advise against the universal screening for hypogonadism in middle-aged and elderly males.

FINDINGS

Numerous randomized controlled trials have scrutinized the effects of testosterone therapy in males afflicted with type 2 diabetes and/or obesity. However, these guidelines uniformly assert that lifestyle modifications and weight reduction should be the primary intervention strategies in overweight and obese males, relegating testosterone therapy to a secondary, selective option. It is extensively documented that testosterone therapy can yield substantial improvements in various metabolic parameters as well as ameliorate symptoms of erectile dysfunction. Moreover, recent studies have demonstrated the potential of testosterone therapy in reversing type 2 diabetes in males with low-normal testosterone levels who are at elevated risk for this condition, in comparison to the outcomes achievable through lifestyle modifications alone.

CONCLUSION

This focused review article aims to present a comprehensive update on the latest data concerning the innovative aspects of testosterone therapy in males with functional hypogonadism, particularly in the context of type 2 diabetes and/or obesity. Additionally, it will delve into the cardiovascular safety of such interventions within this high-risk demographic, with a special emphasis on insights gleaned from the TRAVERSE trial.

Bariatric surgery modulates plasma levels of antibodies against angiotensin II type 1 and endothelin 1 type A receptor in severe obesity

PURPOSE

The contribution of endothelial-targeted autoantibodies against the angiotensin II type 1 receptor (anti-AT1R) and the anti-endothelin 1 type A receptor (anti-ETAR1) has been proposed in the development of cardiovascular diseases. However, no data have been reported yet in obesity. In this observational study we evaluated the relationship between anthropometric and metabolic parameters and anti-AT1R and anti-ETAR1 concentrations in a cohort of patients with severe obesity and associated comorbidities undergoing bariatric surgery.

METHODS

Clinical evaluation and metabolic assessment were performed in 36 subjects referring to our Center for the Study and Integrated Treatment of Obesity at the University Hospital of Padova. Circulating inflammatory adipocytokines and the endothelial dysfunction marker asymmetric dimethylarginine (ADMA) were evaluated; plasma levels of anti-AT1R and anti-ETAR1 were also determined. 10 normal-weight subjects were considered as a control group. 29 patients out of 36 were re-evaluated after surgery.

RESULTS

With respect to normal-weight controls patients showed significantly higher plasma levels of anti-AT1R (28 ± 20.4 vs 13.5 ± 2.8 U/mL, p < 0.005) and ADMA (0.8 ± 0.1 vs 0.54 ± 0.08 uM/L, p < 0.0001) but not anti-ETAR1 (14.2 ± 1.3 vs 13.3 ± 2 U/mL, p = 0.1). Anti-AT1R concentration showed an increasing trend with the worsening of glycemic status, while the presence of arterial hypertension among the patients did not affect autoantibodies levels. One year after surgery, a significant improvement in body weight and metabolic and inflammatory parameters was observed, along with a significant reduction of anti-AT1R (28.1 ± 20.4 U/mL vs 22.6 ± 16 U/mL, p < 0.05) and anti-ETAR1 (14.2 ± 1.3 U/L vs 13 ± 1.6 U/L, p < 0.01).

CONCLUSIONS

Subjects with obesity present higher plasma levels of anti-AT1R which are more related to glycemic profile than blood pressure levels, and are reduced by bariatric surgery. Considering the detrimental effects of these autoantibodies on vascular health, they should be assessed as potential biomarkers in obesity and metabolic diseases.

Characterisation of cotadutide's dual GLP-1/glucagon receptor agonistic effects on glycaemic control using an in vivo human glucose regulation quantitative systems pharmacology model

BACKGROUND AND PURPOSE

Cotadutide is a dual GLP-1 and glucagon receptor agonist with balanced agonistic activity at each receptor designed to harness the advantages on promoting liver health, weight loss and glycaemic control. We characterised the effects of cotadutide on glucose, insulin, GLP-1, GIP, and glucagon over time in a quantitative manner using our glucose dynamics systems model (4GI systems model), in combination with clinical data from a multiple ascending dose/Phase 2a (MAD/Ph2a) study in overweight and obese subjects with a history of Type 2 diabetes mellitus (NCT02548585).

EXPERIMENTAL APPROACH

The cotadutide PK-4GI systems model was calibrated to clinical data by re-estimating only food related parameters. In vivo cotadutide efficacy was scaled based on in vitro potency. The model was used to explore the effect of weight loss on insulin sensitivity and predict the relative contribution of the GLP-1 and glucagon receptor agonistic effects on glucose.

KEY RESULTS

Cotadutide MAD/Ph2a clinical endpoints were successfully predicted. The 4GI model captured a positive effect of weight loss on insulin sensitivity and showed that the stimulating effect of glucagon on glucose production counteracts the GLP-1 receptor-mediated decrease in glucose, resulting in a plateau for glucose decrease around a 200-μg cotadutide dose.

CONCLUSION AND IMPLICATIONS

The 4GI quantitative systems pharmacology model was able to predict the clinical effects of cotadutide on glucose, insulin, GLP-1, glucagon and GIP given known in vitro potency. The analyses demonstrated that the quantitative systems pharmacology model, and its successive refinements, will be a valuable tool to support the clinical development of cotadutide and related compounds.

Comparative impact of Roux-en-Y gastric bypass, sleeve gastrectomy or diet alone on beta-cell function in insulin-treated type 2 diabetes patients

Although bariatric surgery is an effective treatment for type 2 diabetes by inducing weight loss and augmenting gut hormone secretion, the immediate effect on beta-cell function itself remains to be elucidated in type 2 diabetes. Therefore, a prospective, randomized trial was performed in 30 patients with insulin-treated type 2 diabetes and a body mass index ≥ 35 kg/m2. Patients were randomly assigned (1:1:1) to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in combination with protein-sparing modified fast (PSMF), or to PSMF alone. Eu- and hyperglycemic clamps were performed before and 3 weeks after surgery and/or PSMF initiation. The primary outcome was the evolution of insulin sensitivity and beta-cell function after surgery, calculated using the composite measures of glucose disposal rate, insulin secretion rate, and disposition index (DI). Results revealed that markers of insulin sensitivity increased similarly in all arms (p = 0.43). A higher marker for maximal beta-cell function was observed when comparing SG to PSMF (p = 0.007). The DI showed a clear positive evolution after RYGB and SG, but not after PSMF alone. Altogether, these findings indicate that bariatric surgery results in an immediate beta-cell function recovery in insulin-treated type 2 diabetes.

The impact of weight loss on renal function in individuals with obesity and type 2 diabetes: a comprehensive review

Obesity and Type 2 Diabetes (T2D) are two highly prevalent diseases that exhibit a complex interplay between them. Obesity serves as a primary risk factor for the development of T2D, and conversely, individuals with T2D often exhibit comorbid obesity. Renal dysfunction emerges as a critical consequence of the convergence of obesity and Type 2 Diabetes, contributing significantly to the overall burden of complications associated with these conditions. Recognizing the profound implications of renal dysfunction in individuals contending with both obesity and Type 2 Diabetes, interventions targeting weight loss have gained prominence as potential therapeutic avenues. Weight loss not only addresses the primary risk factor of obesity but also holds the promise of mitigating the progression of Type 2 Diabetes and its associated renal complications. This comprehensive review aims to explore the impact of weight loss on renal function in individuals contending with the convergence of obesity and T2D.

Effects of intermittent fasting on the histology and mRNA expression of major drug-metabolizing cyp450s in the liver of diabetic mice

Introduction:There is a variation in drug response among patients who practice intermittent fasting. Alteration in the expression of drug-metabolizing enzymes (DMEs) can affect the pharmacokinetics and drug response.Aims: This research aimed to determine the effect of intermittent fasting on the mRNA expression of major drug-metabolizing cyp450s in the liver of diabetic mice.Methods: Thirty-two male Balb/c mice were divided into four groups; control, nonfasting diabetic, non-diabetic fasting, and diabetic fasting mice. Insulin-dependent diabetes was induced in mice by a single high-dose (250 mg/kg) streptozocin. Mice of non-diabetic and diabetic fasting groups were subjected to 10-day intermittent fasting for 17 hours daily. Then, the mRNA expression of mouse phase I DMEs cyp1a1, cyp2c29, cyp2d9, and cyp3a11 was analyzed using real-time polymerase chain reaction. In addition, the liver of mice in all groups was examined for pathohistological alterations.Results: Diabetes downregulated the mRNA expression of hepatic drug-metabolizing cyp450s in diabetic mice, while intermittent fasting significantly (P < 0.05) increased it. Also, cyp2d9 and cyp3a11 were upregulated in the liver of diabetic fasting mice. These alterations in the gene expression were correlated with the pathohistological alterations, where livers of diabetic mice showed dilatation in the blood sinusoids and inflammatory cells leukocyte infiltrations. Whereas livers of diabetic fasting mice showed almost comparable histological findings to control mice.Conclusions: Intermittent fasting can protect the liver against diabetes-induced hepatotoxicity and the down-regulation of DME genes in the diabetic liver. These results can explain, at least partly, the inter-individual variation in the drug response during practicing fasting.

Prevalence and associated factors of overweight and obesity among persons with type 2 diabetes in Africa: a systematic review and meta-analysis

BACKGROUND

Type 2 diabetes and obesity are serious public health concerns globally and a growing burden in Africa. Both conditions have serious repercussions on health when they co-occur, yet the extent of their co-occurrence in Africa remains unknown. Therefore, this review aimed to identify the prevalence and associated factors of overweight and obesity among persons with type 2 diabetes in Africa.

METHOD

A systematic search was conducted on PubMed, MEDLINE, Embase, African Index Medicus (AIM), and African Journals Online (AJOL) for observational studies that reported the prevalence of overweight and/or obesity among type 2 diabetes patients in Africa. The prevalence data from individual studies were aggregated through a random-effects meta-analysis. The I² statistic was used to evaluate between-studies heterogeneity, while subgroup analysis and mixed-effects meta-regression were performed to identify sources of heterogeneity. We assessed publication bias using funnel plots and Egger's test. This review adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.

RESULTS

Of 1753 records retrieved, 80 articles were eligible for this review, with 74 cross-sectional studies included in the meta-analysis. The pooled prevalence of overweight and obesity was 35.6% and 25.6% respectively, while the overall prevalence of both overweight and obesity was 61.4%. Also, the pooled prevalence of both overweight and obesity across the five geographical areas in Africa ranged from 56.9% in East Africa to 88.5% in Southern Africa. Nineteen factors were significantly associated with overweight and obesity among patients with type 2 diabetes.

CONCLUSION

The high prevalence of overweight and obesity among patients with type 2 diabetes is a significant public health concern that transcends geographical boundaries within Africa. The findings from this review highlight the need for innovative weight management interventions that are tailored to the cultural context of the African setting.KEY MESSAGESThere was a high prevalence of overweight and obesity among the type 2 diabetes patients.Nineteen factors were identified to be significantly associated with overweight and obesity among type 2 diabetes patients.Only 12 out of the 80 included studies primarily focused on the prevalence of overweight and/or obesity which reflects a dearth of interest in this topic.

Comparing bariatric surgery and medical therapy for obese adolescents with type 2 diabetes

BACKGROUND

Mounting evidence in recent years has demonstrated that the number of obese adolescents has continued to rise. Obese adolescents are more likely to be diagnosed with type 2 diabetes, which causes additional harm. This study aimed to compare the clinical outcomes of bariatric surgery and medical treatment.

METHODS

We conducted a multicenter, nonrandomized, retrospective study on 202 obese adolescents with type 2 diabetes who received surgery or medical treatment in three hospitals from 2017 to 2019. We analyzed the effects of surgery and medical treatment in terms of weight loss, glycemic control and the remission of type 2 diabetes. Propensity score matching was conducted to balance the confounding factors.

RESULTS

Among the 202 adolescents, 109 adolescents underwent surgery, and the remaining 93 adolescents received nonsurgical treatment. Both in the entire cohort and in the propensity-score matching cohort, the mean body mass index (BMI) and total weight in the surgery group notably decreased. Similarly, the effect of surgery on glycemic control (with respect to HBG, HbA1c, HOMA-IR) was superior to that of medical treatment. In the surgery group, the remission rate of diabetes was 76.1% in the entire cohort and 80.5% in the matched group, which was significantly higher than that in the control group (6.5% and 5.7%, respectively). In addition, LRYGB had better effects on weight loss and glycemic control than LSG.

CONCLUSION

Bariatric surgery is more effective in the control of weight loss and type 2 diabetes than medical treatment. The effects between different types of bariatric surgeries remain to be further investigated, and longer follow-up times are needed.

Understanding Type 2 Diabetes Mellitus Risk Parameters through Intermittent Fasting: A Machine Learning Approach

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder characterized by elevated blood glucose levels. Despite the availability of pharmacological treatments, dietary plans, and exercise regimens, T2DM remains a significant global cause of mortality. As a result, there is an increasing interest in exploring lifestyle interventions, such as intermittent fasting (IF). This study aims to identify underlying patterns and principles for effectively improving T2DM risk parameters through IF. By analyzing data from multiple randomized clinical trials investigating various IF interventions in humans, a machine learning algorithm was employed to develop a personalized recommendation system. This system offers guidance tailored to pre-diabetic and diabetic individuals, suggesting the most suitable IF interventions to improve T2DM risk parameters. With a success rate of 95%, this recommendation system provides highly individualized advice, optimizing the benefits of IF for diverse population subgroups. The outcomes of this study lead us to conclude that weight is a crucial feature for females, while age plays a determining role for males in reducing glucose levels in blood. By revealing patterns in diabetes risk parameters among individuals, this study not only offers practical guidance but also sheds light on the underlying mechanisms of T2DM, contributing to a deeper understanding of this complex metabolic disorder.

Effect of almond consumption on insulin sensitivity and serum lipids among Asian Indian adults with overweight and obesity- A randomized controlled trial

Background

Asian Indians have an increased susceptibility to type 2 diabetes and premature coronary artery disease. Nuts, like almonds, are rich in unsaturated fat and micronutrients with known health benefits.

Objectives

This study aimed to assess the efficacy of almonds for reduction of insulin resistance and improving lipid profile in overweight Asian Indian adults.

Methods

This parallel-arm, randomized, controlled trial was conducted in Chennai, India on 400 participants aged 25-65 years with a body mass index ≥ 23 kg/m². The intervention group received 43 g of almonds/day for 12 weeks, while the control group was advised to consume a customary diet but to avoid nuts. Anthropometric, clinical, and dietary data were assessed at periodic intervals. Glucose tolerance, serum insulin, glycated hemoglobin, C-peptide and lipid profile were assessed at baseline and end of the study. Insulin resistance (homeostasis assessment model-HOMA IR) and oral insulin disposition index (DIo) were calculated.

Results

A total of 352 participants completed the study. Significant improvement was seen in DIo [mean (95% CI) = + 0.7 mmol/L (0.1, 1.3); p = 0.03], HOMA IR (-0.4 (-0.7, -0.04; p = 0.03) and total cholesterol (-5.4 mg/dl (-10.2, -0.6); p = 0.03) in the intervention group compared to the control group. Incremental area under the curve (IAUC) and mean amplitude of glycemic excursion (MAGE) assessed using continuous glucose monitoring systems were also significantly lower in the intervention group. Dietary 24-h recalls showed a higher significant reduction in carbohydrate and increase in mono unsaturated fatty acid (MUFA) and polyunsaturated fatty acids (PUFA) intake in the intervention group compared to the control group.

Conclusion

Daily consumption of almonds increased the intake of MUFA with decrease in carbohydrate calories and decreases insulin resistance, improves insulin sensitivity and lowers serum cholesterol in Asian Indians with overweight/obesity. These effects in the long run could aid in reducing the risk of diabetes and other cardiometabolic disease.

Diabetes Prevention and Measures to Ensuring a Healthy Lifestyle during COVID-19 Pandemic and after

The incidence of diabetes mellitus (DM) is increasing exponentially globally, with 90% of the confirmed cases being type 2 DM. The global incidence of DM is expected to increase by 48% during 2017-2045. The coronavirus disease 2019 (COVID-19) pandemic continues to have a massive impact on human health, causing sudden lifestyle changes through quarantine measures, such as lockdown, social distancing, various curfews, and isolation at home. This in turn might increase the risk of developing numerous chronic diseases, such as DM, obesity, and cardiovascular diseases, which increase the severity of COVID-19. To this end, we performed a comprehensive review to determine viable measures for the prevention of DM and its subsequent upsurge globally. Additionally, we have determined strategies that should be adopted globally to ensure a healthy lifestyle during the COVID-19 pandemic and later.

Bariatric Surgery: Targeting pancreatic β cells to treat type II diabetes

Pancreatic β-cell function impairment and insulin resistance are central to the development of obesity-related type 2 diabetes mellitus (T2DM). Bariatric surgery (BS) is a practical treatment approach to treat morbid obesity and achieve lasting T2DM remission. Traditionally, sustained postoperative glycemic control was considered a direct result of decreased nutrient intake and weight loss. However, mounting evidence in recent years implicated a weight-independent mechanism that involves pancreatic islet reconstruction and improved β-cell function. In this article, we summarize the role of β-cell in the pathogenesis of T2DM, review recent research progress focusing on the impact of Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) on pancreatic β-cell pathophysiology, and finally discuss therapeutics that have the potential to assist in the treatment effect of surgery and prevent T2D relapse.

Retinal Oxygen Metabolism in Patients With Type 2 Diabetes and Different Stages of Diabetic Retinopathy

The aim of this cross-sectional study was to assess retinal oxygen metabolism in patients with type 2 diabetes and different stages of nonproliferative diabetic retinopathy (DR) (n = 67) compared with healthy control subjects (n = 20). Thirty-four patients had no DR, 15 had mild DR, and 18 had moderate to severe DR. Retinal oxygen saturation in arteries and veins was measured using the oxygen module of a retinal vessel analyzer. Total retinal blood flow (TRBF) was measured using a custom-built Doppler optical coherence tomography system. Retinal oxygen extraction was calculated from retinal oxygen saturation and TRBF. Arteriovenous difference in oxygen saturation was highest in healthy subjects (34.9 ± 7.5%), followed by patients with no DR (32.5 ± 6.3%) and moderate to severe DR (30.3 ± 6.5%). The lowest values were found in patients with mild DR (27.3 ± 8.0%, P = 0.010 vs. healthy subjects). TRBF tended to be higher in patients with no DR (40.1 ± 9.2 μL/min) and mild DR (41.8 ± 15.0 μL/min) than in healthy subjects (37.2 ± 5.7 μL/min) and patients with moderate to severe DR (34.6 ± 10.4 μL/min). Retinal oxygen extraction was the highest in healthy subjects (2.24 ± 0.57 μL O2/min), followed by patients with no DR (2.14 ± 0.6 μL O2/min), mild DR (1.90 ± 0.77 μL O2/min), and moderate to severe DR (1.78 ± 0.57 μL O2/min, P = 0.040 vs. healthy subjects). These results indicate that retinal oxygen metabolism is altered in patients with type 2 diabetes. Furthermore, retinal oxygen extraction decreases with increasing severity of DR.

Assessment of Eating Disorders and Eating Behavior to Improve Treatment Outcomes in Women with Polycystic Ovary Syndrome

The essential role of the frequent coexistence of mental disorders and polycystic ovary syndrome (PCOS) is being increasingly recognized in the management of PCOS patients since it influences the success of weight loss interventions. Patients frequently experience disrupted eating behaviors, evidenced by the high prevalence of eating disorders in this population. Therefore, assessment and potential modification of eating disorders and eating-related behavior might be especially relevant to improve obesity treatment outcomes in this population, which remains the most efficient causal treatment in PCOS patients with high metabolic risk. Following a literature overview on common eating disorders and eating behaviors in PCOS, the aim of this review was to explore the prevalence and underlying mechanisms behind those occurrences. Understanding the clinical relevance of those associations and the addition of the assessments of eating disorders as well as eating phenotypes, eating chronotypes, and eating content as essential determinants of eating behavior could aid in the successful management of women with PCOS. In addition, the review also covers the potential of using eating disorders and eating behavior as a tool for the personalization of obesity treatment in PCOS.

Effects of Time-Restricted Feeding and Ramadan Fasting on Body Weight, Body Composition, Glucose Responses, and Insulin Resistance: A Systematic Review of Randomized Controlled Trials

Time-restricted feeding (TRF) and Ramadan fasting (RF) have been recently associated with several health outcomes. However, it is not yet clear if they are superior to existing treatments in terms of glucose metabolism, insulin action, and weight loss. This review aims to summarize the current data on the effects of these regimes on body weight, body composition, and glycemia. An electronic search was conducted in PUBMED and SCOPUS databases up to August 2022. Twenty-four records met the inclusion criteria and underwent a risk-of-bias assessment. The main outcomes were: (a) TRF may result in moderate weight loss in individuals with overweight/obesity; when TRF is combined with caloric restriction, weight loss is >5% of the initial body weight, (b) 14 h of fasting may be as effective as 16 h in terms of weight loss, and (c) TRF may lead to improved insulin sensitivity and glycemic responses/variability throughout the day in individuals with overweight/obesity. Concerning RF, only two studies were available and thus, conclusions were not drawn. TRF may be an effective nutritional approach for weight loss, and the amelioration of glycemic control and insulin sensitivity in individuals with overweight/obesity. However, more long-term, well-designed studies are needed.

Proteomics, dietary intake, and changes in cardiometabolic health within a behavioral weight-loss intervention: A pilot study

OBJECTIVE

Identifying associations among circulating proteins, dietary intakes, and clinically relevant indicators of cardiometabolic health during weight loss may elucidate biologically relevant pathways affected by diet, allowing for an incorporation of precision nutrition approaches when designing future interventions. This study hypothesized that plasma proteins would be associated with diet and cardiometabolic health indicators within a behavioral weight-loss intervention.

METHODS

This secondary data analysis included participants (n = 20, mean [SD], age: 40.1 [9.5] years, BMI: 34.2 [4.0] kg/m2 ) who completed a 1-year behavioral weight-loss intervention. Cardiovascular disease-related plasma proteins, diet, and cardiometabolic health indicators were evaluated at baseline and 3 months. Associations were determined via linear regression and integrated networks created using Visualization Of LineAr Regression Elements (VOLARE).

RESULTS

A total of 16 plasma proteins were associated with ≥1 diet or health indicator at baseline (p < 0.001); changes in 42 proteins were associated with changes in diet or health indicators from baseline to 3 months (p < 0.005). Baseline tumor necrosis factor receptor superfamily member 10C (TNFRSF10C) was associated with intakes of dark green vegetables (r = -0.712), and fatty acid-binding protein 4 (FABP4) was associated with intakes of unsweetened coffee (r = -0.689). Changes in refined-grain intakes were associated with changes in scavenger receptor cysteine-rich type 1 protein M130 (CD163; r = 0.725), interleukin-1 receptor type 1 (IL1R-T1; r = 0.624), insulin (r = 0.656), and triglycerides (r = 0.648).

CONCLUSIONS

Circulating cardiovascular disease-related proteins were associated with diet and cardiometabolic health indicators prior to and in response to weight loss.

The effect of a randomised controlled lifestyle intervention on weight loss and plasma proneurotensin

AIMS

Proneurotensin (Pro-NT) is a strong predictor of cardiometabolic disease including type 2 diabetes and obesity, however, the effect of lifestyle change on Pro-NT has not been investigated in this context. Middle Eastern (ME) immigrants represent the largest and fastest growing minority population in Europe and are a high-risk population for obesity and type 2 diabetes. In this randomised controlled lifestyle intervention (RCT) addressing ME immigrants to Sweden where weight-loss was previously studied as the main outcome, as a secondary analysis we aimed to study change in Pro-NT during follow-up and if baseline Pro-NT predicted weight loss.

METHODS

Immigrants from the Middle East at high risk for type 2 diabetes were invited to participate in this RCT adapted lifestyle intervention of four months' duration. The intervention group (N = 48) received a culturally adapted lifestyle intervention comprising seven group sessions and a cooking class addressing healthier diet and increased physical activity. The control group (N = 44) received treatment as usual with information to improve lifestyle habits on their own. Data assessed using mixed effects regression.

OUTCOMES

Primary outcome; change in Pro-NT. Secondary outcome; change in BMI in relation to baseline plasma concentration of Pro-NT.

RESULTS

During the four months follow up, weight was significantly reduced in the intervention (-2.5 kg) compared to the control group (0.8 kg) (β -0.12, 95% CI -0.24 to -0.01, P = 0.028). Pro-NT increased to a significantly greater extent in the intervention compared to the control group during follow up (28.2 vs. 3.5 pmol/L) (β 11.4; 4.8 to 18.02, P < 0.001). Change over time in BMI was associated with baseline Pro-NT (β 0.02; 0.01 to 0.04, P = 0.041).

CONCLUSION

In consistence with data from surgical weight loss, this RCT paradoxically shows increased levels of Pro-NT during a multifactorial lifestyle intervention resulting in weight loss. Long term studies of Pro-NT following weight loss are needed.

TRIAL REGISTRATION

This study is a secondary analysis of the RCT trial registered at www.

CLINICALTRIALS

gov .

REGISTRATION NUMBER

NCT01420198. Date of registration 19/08/2011. The performance and results of this trial conform to the CONSORT 2010 guidelines.

Use and Impact of Type 2 Diabetes Prevention Interventions

INTRODUCTION

RCTs have found that type 2 diabetes can be prevented among high-risk individuals by metformin medication and evidence-based lifestyle change programs. The purpose of this study is to estimate the use of interventions to prevent type 2 diabetes in real-world clinical practice settings and determine the impact on diabetes-related clinical outcomes.

METHODS

The analysis performed in 2020 used 2010‒2018 electronic health record data from 69,434 patients aged ≥18 years at high risk for type 2 diabetes in 2 health systems. The use and impact of prescribed metformin, lifestyle change program, bariatric surgery, and combinations of the 3 were examined. A subanalysis was performed to examine uptake and retention among patients referred to the National Diabetes Prevention Program.

RESULTS

Mean HbA1c values declined from before to after intervention for patients who were prescribed metformin (-0.067%; p<0.001) or had bariatric surgery (-0.318%; p<0.001). Among patients referred to the National Diabetes Prevention Program lifestyle change program, the type 2 diabetes postintervention incidence proportion was 14.0% for nonattendees, 12.8% for some attendance, and 7.5% for those who attended ≥4 sessions (p<0.001). Among referred patients to the National Diabetes Prevention Program lifestyle change program, uptake was low (13% for 1‒3 sessions, 15% for ≥4 sessions), especially among males and Hispanic patients.

CONCLUSIONS

Findings suggest that metformin and bariatric surgery may improve HbA1c levels and that participation in the National Diabetes Prevention Program may reduce type 2 diabetes incidence. Efforts to increase the use of these interventions may have positive impacts on diabetes-related health outcomes.

A qualitative study to examine meaningful change in physical function associated with weight-loss

PURPOSE

This study explored perceptions of meaningful weight-loss and the level of change on two patient-reported outcome (PRO) measures, the 36-item Short Form Health Survey® [SF-36v2®] and Impact of Weight on Quality of Life Lite-Clinical Trials^© [IWQOL-Lite-CT^©], that individuals living with overweight or obesity consider to be meaningful and indicative of treatment success.

METHODS

Thirty-three qualitative interviews were conducted in the US with adults living with overweight or obesity. Concept elicitation explored perceptions of minimally important/meaningful weight-loss using open-ended questions. Cognitive debriefing was used to understand thresholds for meaningful change on both measures.

RESULTS

Most participants (n = 23/33) expected a 5% total body weight-loss to yield some benefit in physical functioning, while all participants expected a 10% weight-loss to provide a meaningful and noticeable improvement in their physical functioning. Participants indicated that an item-level 1-point score change on each measure would represent a noticeable improvement in physical functioning and indicate treatment success.

CONCLUSIONS

Participants expected moderate weight-losses to be noticeable, with ≥ 10% weight-loss yielding the most consistent results. The findings suggested that both measures provide strong opportunity to demonstrate treatment benefit in relation to physical functioning as a small change on the response scale would represent a noticeable improvement in participants' daily lives.

MitoTEMPOL Inhibits ROS-Induced Retinal Vascularization Pattern by Modulating Autophagy and Apoptosis in Rat-Injected Streptozotocin Model

Diabetic retinopathy leads to retinal malfunction, blindness, and reduced quality of life in adult diabetes patients. The involvement of reactive oxygen species (ROS) regulation stimulated by high blood glucose levels opens the opportunity for ROS modulator agents such as MitoTEMPOL. This study aims to explore the effect of MitoTEMPOL on ROS balance that may be correlated with retinal vascularization pattern, autophagy, and apoptosis in a streptozotocin-induced rat model. Four groups of male Wistar rats (i.e., control, TEMPOL (100 mg/kg body weight [BW]), diabetic (streptozotocin, 50 mg/kg BW single dose), and diabetic + TEMPOL; n = 5 for each group) were used in the study. MitoTEMPOL was given for 5 weeks, followed by funduscopy, and gene and protein expression were explored from the rat’s retina. Streptozotocin injection decreased bodyweight and increased food and water intake, as well as fasting blood glucose. The results showed that MitoTEMPOL reduced retinal vascularization pattern and decreased superoxide dismutase gene expression and protein carbonyl, caspase 3, and caspase 9 protein levels. A modulation of autophagy in diabetes that was reversed in the diabetic + TEMPOL group was found. In conclusion, MitoTEMPOL modulation on autophagy and apoptosis contributes to its role as a potent antioxidant to prevent diabetic retinopathy by inhibiting ROS-induced retinal vascularization patterns.

Risk Factors for Dementia in Patients With Atrial Fibrillation

Although dementia and atrial fibrillation (AF) are common in older adults, risk factors for dementia have not been sufficiently characterized in patients with AF. We studied 621,773 patients with AF without dementia at the time of AF diagnosis who were enrolled in the MarketScan Commercial and Medicare Supplemental databases from 2007 to 2015. Dementia incidence and presence of predictors at the time of AF diagnosis (cardiometabolic conditions, mental and neurologic disorders, and other chronic conditions) were based on International Classification of Diseases, Ninth Revision, Clinical Modification codes in outpatient and inpatient claims, whereas medication usage was based on outpatient pharmacy claims. A frailty score was calculated using a previously established algorithm. The associations between the predictors of interest and dementia were assessed with multivariable Cox models. Patients had a mean age of 68 years (SD 14 years) and 41% were women. During a mean follow-up of 2.0 years, there were 16,073 cases of dementia. The strongest predictors of dementia were frailty (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.40 to 1.45, per 1-SD increase in the score), cognitive impairment (HR 1.50, 95% CI 1.36 to 1.65), mood disorders (HR 1.49, 95% CI 1.32 to 1.70), schizophrenia (HR 1.86, 95% CI 1.75 to 1.98), and substance abuse (HR 1.58, 95% CI 1.39 to 1.80). Among cardiometabolic conditions, only stroke (HR 1.17, 95% CI 1.13 to 1.22) and diabetes mellitus (HR 1.14, 95% CI 1.11 to 1.18) were associated with small increases in dementia risk after adjusting for demographics, frailty, co-morbidities, and medications. We have identified several risk factors for dementia in patients with AF.

Pharmacotherapy of obesity in complex diseases

More than 40% of adults in the United States suffer from obesity. Obesity is inextricably linked to many chronic illnesses like type-2 diabetes mellitus, hypertension, hyperlipidemia, heart disease, sleep apnea, stroke, and cancers. When used in combination with lifestyle modifications, pharmacotherapy has a vital role in treating obesity and improves short-term and long-term outcomes. A growing number of physicians are now interested in obesity medicine, and many of them are seeking guidance on how to treat complex patients with co-morbidities. This review provides a practical guide to the use of anti-obesity medications across various obesity-related comorbidities. It provides a general review of the currently approved anti-obesity medications and effective combinations. It discusses the highlights of the major trials and recent studies assessing the benefits of anti-obesity medications in comorbid conditions such as type-2 diabetes mellitus, psychiatric disorders, cardiovascular diseases, hypertension, renal diseases, and liver diseases. This review briefly examines the aspects of recognizing and addressing iatrogenic weight gain; discusses the precautions and prescribing considerations of anti-obesity medications, including side effects and possible dose adjustments in various comorbid conditions; and provides an expert opinion on an individualized choice of the best anti-obesity medication.

The activation of hypothalamic AMP-activated protein kinase by oxidative stress is related to hyperphagia in diabetic rats

OBJECTIVE

During diabetes, there are increased blood glucose levels and oxidative stress. The relationship between oxidative stress and the phosphorylation of AMP-activated protein kinase at the hypothalamic level has been little studied. The objective of this study was to analyze the relationship between oxidative stress and AMP-activated protein kinase activation in Wistar rats with hyperphagia and hyperglycemia.

METHODS

Rats at 7, 14, and 28 days with diabetes were used. Control rats were included. Food intake was calculated to determine hyperphagia. The hypothalamus was extracted to evaluate oxidative stress markers by spectrophotometry; phosphorylation of AMP-activated protein kinase, growth hormone receptor 1a, and neuropeptide Y expression were determined by Western blot.

RESULTS

There was a significant increase in the consumption of food in the experimental groups. The level of malondialdehyde decreased in the 7-day group (33%) and increased significantly in the 28-day group (90%), glutathione peroxidase activity increased in the 7-day group (70%) and decreased in the 28-day group (34%), and the phosphorylation of AMP-activated protein kinase increased significantly in the 28-day group (86%). Under ex-vivo conditions in animals with 28 days of hyperglycemia, glutathione peroxidase activity increased 195%, the malondialdehyde level decreased 87%, phosphorylation of AMP-activated protein kinase decreased 53%, and growth hormone receptor 1a expression decreased 66%, when treating hyperglycemic hypothalamic tissue with an antioxidant. NPY expression increased in hyperglycemia, and antioxidant treatment did not regulate its expression.

CONCLUSIONS

The activation of AMP-activated protein kinase is related with an increase in oxidative stress markers in hyperglycemic and hyperphagic rats.

Genetic risk score prediction of leg fat and insulin sensitivity differs by race/ethnicity in early pubertal children

BACKGROUND

In the United States, the underlying reasons for racial/ethnic disparities in type 2 diabetes risk remain unclear. However, differences in genetic risk for insulin resistance and peripheral adipose tissue distribution may be contributing factors.

OBJECTIVE

To investigate racial/ethnic differences in associations of genetic risk for insulin resistance with leg fat and insulin sensitivity in a cohort of American children.

METHODS

Participants were healthy European-American (n = 83), African-American (n = 79) and Hispanic-American (n = 74) children aged 7-12 years. Genetic risk scores were derived from published variants associated with insulin resistance phenotypes in European adults. Body composition was assessed using dual-energy X-ray absorptiometry. Insulin sensitivity was determined from the frequently sampled intravenous glucose tolerance test and minimal modelling. Statistical models were adjusted for age, sex, pubertal stage and body composition.

RESULTS

In the combined cohort, risk score was inversely associated with insulin sensitivity (p = 0.033) but not leg fat (p = 0.170). Within Hispanic Americans, risk score was inversely associated with insulin sensitivity (p = 0.027) and leg fat (p = 0.005), while associations were non-significant in European and African Americans (p > 0.200).

CONCLUSIONS

The higher type 2 diabetes risk observed among Hispanic Americans may have a genetic basis related to an inability to store lipid in peripheral adipose tissue.

Feeding frequency affects glucose and lipid metabolism through SIRT1/AMPK pathway in growing pigs with the same amount of daily feed

Eating patterns are associated with obesity and metabolic health. However, the regulating mechanism of different eating patterns on body metabolism are not fully cleare. In this study, a pig model was used to evaluate the effects of feeding frequency on glucose and lipid metabolism and reveal its regulating mechanism. Twenty-four growing barrows were randomly allocated to 1-meal (M1), 3-meal (M3), or 5-meal (M5) per day groups with the same amount of daily feed. GSEA was conducted on the liver to investigate the pathways of different feeding frequencies on the metabolism. The serum glucose, NEFA, VLDL-C levels were higher for M1 group than for M3 and M5 groups, however, the hepatic TRIG level was lower. Liver transcriptome showed that glycolysis/gluconeogenesis and fatty acid metabolism pathways were suppressed with the increase of feeding frequency. The increase of gluconeogenic substrates (glycerol and lactate) and enzymes (PEPCK1 and G6Pase) in liver indicated that hepatic gluconeogenesis was enhanced in the M1 group. AMPK/PPARα signaling associated genes were positively correlated with NEFA and β-HB levels in M1 group, which promoted fatty acid oxidation and ketogenesis in liver. Moreover, compared with M3 and M5 groups, the higher NAD⁺/NADH ratio in the liver of M1 group activated SIRT1, which stimulated the AMPK signaling associated pathways by up-regulating the LKB1 gene. These findings provide evidence for the regulating roles of feeding frequency on glucose and lipid metabolism through SIRT1/AMPK pathway, which greatly contributes to the regulation of energy metabolism through daily eating patterns in animals.

Is Obesity/Adiposity-Based Chronic Disease Curable: The Set Point Theory, the Environment, and Second Generation Medications

Adiposity-Based Chronic Disease (ABCD) is a chronic disease and requires life-long treatment and follow-up. Obesity protects obesity through altered regulation of caloric intake and set point mechanisms that maintains a high equilibrium body weight. Lifestyle interventions and obesity medications do not permanently alter the set point which often makes weight loss achieved by lifestyle short-lived and operates to drive weight regain once medications are discontinued. Bariatric surgery procedures can alter appetite and lower the "set point" for equilibrium body weight via unknown mechanisms. However, few patients attain ideal body weight following surgery, many regain weight, and all require long-term follow-up for the disease. The excess adiposity of ABCD gives rise to complications that impair health and confer morbidity and mortality; however, the genetic risks and potential interactions between genes and environment that give rise to complications also cannot be eliminated. The equilibrium body weight around which set point mechanisms operate can be modified by environment, which underscores the importance of a less obesogenic environment for prevention and treatment of ABCD on a population basis. If ABCD will eventually be curable, this will depend on a clear understanding of the molecular mechanisms that determine the set point regulation of body weight, and an ability to permanently modulate the set point to oscillate around and a lean body mass. The conceptualization of ABCD as a chronic disease, however, does present us with opportunities for primary, secondary, and tertiary prevention to avert disease progression. For tertiary care, the advent of new, more effective, second-generation obesity medications will allow clinicians to treat-to-target via active management of body weight into a target range that will ameliorate specific complications.

Targeting the insulin granule for modulation of insulin exocytosis

The pancreatic β-cells control insulin secretion in the body to regulate glucose homeostasis, and β-cell stress and dysfunction is characteristic of Type 2 Diabetes. Pharmacological targeting of the β-cell to increase insulin secretion is typically utilised, however, extended use of common drugs such as sulfonylureas are known to result in secondary failure. Moreover, there is evidence they may induce β-cell failure in the long term. Within β-cells, insulin secretory granules (ISG) serve as compartments to store, process and traffic insulin for exocytosis. There is now growing evidence that ISG exist in multiple populations, distinct in their protein composition, motility, age, and capacity for secretion. In this review, we discuss the implications of a heterogenous ISG population in β-cells and highlight the need for more understanding into how unique ISG populations may be targeted in anti-diabetic therapies.

The aetiology and molecular landscape of insulin resistance

Insulin resistance, defined as a defect in insulin-mediated control of glucose metabolism in tissues - prominently in muscle, fat and liver - is one of the earliest manifestations of a constellation of human diseases that includes type 2 diabetes and cardiovascular disease. These diseases are typically associated with intertwined metabolic abnormalities, including obesity, hyperinsulinaemia, hyperglycaemia and hyperlipidaemia. Insulin resistance is caused by a combination of genetic and environmental factors. Recent genetic and biochemical studies suggest a key role for adipose tissue in the development of insulin resistance, potentially by releasing lipids and other circulating factors that promote insulin resistance in other organs. These extracellular factors perturb the intracellular concentration of a range of intermediates, including ceramide and other lipids, leading to defects in responsiveness of cells to insulin. Such intermediates may cause insulin resistance by inhibiting one or more of the proximal components in the signalling cascade downstream of insulin (insulin receptor, insulin receptor substrate (IRS) proteins or AKT). However, there is now evidence to support the view that insulin resistance is a heterogeneous disorder that may variably arise in a range of metabolic tissues and that the mechanism for this effect likely involves a unified insulin resistance pathway that affects a distal step in the insulin action pathway that is more closely linked to the terminal biological response. Identifying these targets is of major importance, as it will reveal potential new targets for treatments of diseases associated with insulin resistance.

GRB10 rs1800504 Polymorphism Is Associated With the Risk of Coronary Heart Disease in Patients With Type 2 Diabetes Mellitus

Diabetic vascular complications are one of the main causes of death and disability. Previous studies have reported that genetic variation is associated with diabetic vascular complications. In this study, we aimed to investigate the association between GRB10 polymorphisms and susceptibility to type 2 diabetes mellitus (T2DM) vascular complications. Eight single nucleotide polymorphisms (SNPs) in the GRB10 gene were genotyped by MassARRAY system and 934 patients with type 2 diabetes mellitus (T2DM) were included for investigation. We found that GRB10 rs1800504 CC+CT genotypes were significantly associated with increased risk of coronary heart disease (CHD) compared with TT genotype (OR = 2.24; 95%CI: 1.36-3.70, p = 0.002). Consistently, levels of cholesterol (CHOL) (CC+CT vs. TT, 4.44 ± 1.25 vs. 4.10 ± 1.00 mmol/L; p = 0.009) and low density lipoprotein cholesterin (LDL-CH) (CC+CT vs. TT, 2.81 ± 1.07 vs. 2.53 ± 0.82 mmol/L; p = 0.01) in T2DM patients with TT genotype were significant lower than those of CC+CT genotypes. We further validated in MIHA cell that the total cholesterol (TC) level in GRB10-Mut was significantly reduced compared with GRB10-WT; p = 0.0005. Likewise, the reversed palmitic acid (PA) induced lipid droplet formation in GRB10-Mut was more effective than in GRB10-WT. These results suggest that rs1800504 of GRB10 variant may be associated with the blood lipids and then may also related to the risk of CHD in patients with T2DM.

Oral semaglutide improves postprandial glucose and lipid metabolism, and delays gastric emptying, in subjects with type 2 diabetes

AIM

To assess the effects of oral semaglutide on postprandial glucose and lipid metabolism, and gastric emptying, in subjects with type 2 diabetes (T2D).

MATERIALS AND METHODS

In this randomized, double-blind, single-centre, crossover trial, subjects with T2D received once-daily oral semaglutide (escalated to 14 mg) followed by placebo, or vice versa, over two consecutive 12-week periods. Glucose and lipid metabolism, and gastric emptying (paracetamol absorption) were assessed before and after two types of standardized meals (standard and/or fat-rich) at the end of each treatment period. The primary endpoint was area under the glucose 0-5-h curve (AUC_0-5h ) after the standard breakfast.

RESULTS

Fifteen subjects were enrolled (mean age 58.2 years, HbA1c 6.9%, body weight 93.9 kg, diabetes duration 3.1 years; 13 [86.7%] males). Fasting concentrations of glucose were significantly lower, and C-peptide significantly greater, with oral semaglutide versus placebo. Postprandial glucose (AUC_0-5h ) was significantly lower with oral semaglutide versus placebo (estimated treatment ratio, 0.71; 95% CI, 0.63, 0.81; p < .0001); glucose incremental AUC (iAUC_0-5h/5h ) and glucagon AUC_0-5h were also significantly reduced, with similar results after the fat-rich breakfast. Fasting concentrations of triglycerides, very low-density lipoprotein (VLDL) and apolipoprotein B48 (ApoB48) were significantly lower with oral semaglutide versus placebo. AUC_0-8h for triglycerides, VLDL and ApoB48, and triglycerides iAUC_0-8h/8h , were significantly reduced after oral semaglutide versus placebo. During the first postprandial hour, gastric emptying was delayed (a 31% decrease in paracetamol AUC_0-1h ) with oral semaglutide versus placebo. One serious adverse event (acute myocardial infarction) occurred during oral semaglutide treatment.

CONCLUSION

Oral semaglutide significantly improved fasting and postprandial glucose and lipid metabolism, and delayed gastric emptying.

Hepatic Function and Fibrosis Assessment Via 2D-Shear Wave Elastography and Related Biochemical Markers Pre- and Post-Gastric Bypass Surgery

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) exhibits a worldwide distribution and encompasses a wider range of hepatic abnormalities that can culminate in serious clinical outcomes. The growing incidence of NAFLD necessitates more efficient management strategies particularly in clinically severe obese patients. Weight reduction is the cornerstone of NAFLD treatment; therefore, bariatric surgery could be a therapeutic approach in selected obese patients afflicted with NAFLD and other cardiometabolic comorbidities.

OBJECTIVE

The present study focused on the potential role of bariatric surgery on hepatic function and NAFLD-related histopathological features measured through a noninvasive method.

METHOD

Ninety patients entered to this study and underwent initial preoperative assessments including demographic profile, anthropometric measurements, standard laboratory tests, and hepatic biopsy. Liver stiffness was also evaluated via two-dimensional shear wave elastography (2D-SWE). All assessments were repeated over the subsequent 6 months following surgery except for liver biopsy.

RESULTS

Postoperative hepatic elasticity was lessened after 6 months (p = 0/002).The levels of alanine aminotransferase, gamma-glutamyl transferase, total protein, lipid indices, glucose, and platelet count were also improved following surgery (p < 0/001). Further progression of fibrosis was observed in 25% of patients after surgery.

CONCLUSION

Bariatric surgery was associated with a favorable impact on anthropometric and hepatic elasticity indices as well as metabolic parameters. The ideal target population for bariatric surgery should be thoroughly addressed, and the underlying risk factors for fibrosis progression need to be controlled before surgery. However, expanded research designed as comprehensive randomized controlled trials are recommended to confirm these findings.

Different Curve Shapes of Fasting Glucose and Various Obesity-Related Indices by Diabetes and Sex

Fasting plasma glucose (FPG) and obesity-related indices are prognostic factors for adverse outcomes in both subjects with and without diabetes. A few studies have investigated sex differences in obesity indices related to the risk of diabetes, however no studies have compared the relationship between FPG and obesity-related indices by diabetes and sex. Therefore, in this study, we compared the curve shapes of FPG and various obesity-related indices by diabetes, and further explored sex differences in these associations. Data were derived from the Taiwan Biobank database, which included 5000 registered individuals. We used an adjusted generalized linear regression model and calculated the difference of least square means (Lsmean; standard error, SE) for males and females with and without diabetes. Associations between obesity-related indices and fasting glucose level by diabetes and sex groups were estimated, and the ORTHOREG procedure was used to construct B-splines. The post-fitting for linear models procedure was used to determine the range at which the trends separated significantly. The diabetes/sex/FPG interaction term was significant for all obesity-related indices, including body mass index, waist circumference, hip circumference, waist-to-hip ratio, waist-to-height ratio, lipid accumulation product, body roundness index, conicity index, body adiposity index and abdominal volume index. B-spline comparisons between males and females did not reach significance. However, FPG affected the trend towards obesity-related indices. As the fasting glucose level increased, the values of obesity-related indices varied more obviously in the participants without diabetes than in those with diabetes mellitus. The current study revealed that there was a different relationship between FPG and obesity-related indices by diabetes and sex. FPG affected the trend towards obesity-related indices more obviously in participants without diabetes than in those with diabetes. Further studies with a longitudinal design would provide a better understanding of the underlying mechanisms for the relationships.

Glycemic benefits with adherence to testosterone therapy in men with hypogonadism and type 2 diabetes mellitus

BACKGROUND

While previous studies have demonstrated testosterone's beneficial effects on glycemic control in men with hypogonadism and Type 2 Diabetes, the extent to which these improvements are observed based on the degree of treatment adherence has been unclear.

OBJECTIVES

To evaluate the effects of long-term testosterone therapy in A1C levels in men with Type 2 Diabetes Mellitus and hypogonadism, controlling for BMI, pre-treatment A1C, and age among different testosterone therapy adherence groups.

MATERIALS AND METHODS

We performed a retrospective analysis of 1737 men with diabetes and hypogonadism on testosterone therapy for 5 years of data from 2008-2018, isolating A1C, lipid panels, and BMI results for analysis. Subjects were categorized into adherence groups based on quartiles of the proportion of days covered (> 75% of days, 51-75% of days, 26-50% of days and 0-25% of days), with >75% of days covered considered adherent to therapy.

RESULTS

Pre-treatment median A1C was 6.8%. Post-treatment median A1C was 7.1%. The adherent group, >75%, was the only group notable for a decrease in A1C, with a median decrease of -0.2 (p = 0.0022). BMI improvement was associated with improved post-treatment A1C (p = 0.007). When controlling for BMI, age, and pre-treatment A1C, the >75% adherence group was associated with improved post-treatment A1C (p < 0.001).

DISCUSSION

When controlling for all studied variables, testosterone adherence was associated with improved post-treatment A1C. The higher the initial A1C at the initiation of therapy, the higher the potential for lowering the patient's A1C with >75% adherence. Further, all groups showed some reduction in BMI, which may indicate that testosterone therapy may affect A1C independent of weight loss.

CONCLUSION

Even when controlling for improved BMI, pre-treatment A1C, and age, testosterone positively impacted glycemic control in diabetes patients with hypogonadism, with the most benefit noted in those most adherent to therapy (>75%).

The Double Whammy of Obesity and Diabetes on Female Reproductive Health

The rising global prevalence of obesity and diabetes, especially in youth, confers substantial metabolic consequences and increased mortality in affected individuals. While obesity is strongly tied to the development of insulin resistance and type 2 diabetes, emerging evidence shows that obesity rates are also increasing exponentially in those with type 1 diabetes, contributing to insulin resistance and cardiometabolic sequelae. In addition, both obesity and diabetes can exert adverse effects on female reproductive health independently, with the presence of both conditions likely to exacerbate reproductive dysfunction in this cohort. If the current trends in obesity and diabetes incidence persist, it is likely that more women will be at risk of obesity- and diabetes-related reproductive disorders. This review aims to describe the epidemiology and mechanisms of obesity in women with diabetes, and summarize current literature regarding reproductive disorders in diabetes and weight management strategies in this cohort.

Cultivating Lifestyle Transformations in Obstructive Sleep Apnea

Today, our well-being and awareness have become markedly determined by our way of living through our everyday activities. Needless to say, daily practices specifically have a significant impact on the quality of sleep. Obstructive sleep apnea (OSA) is an exhausting sleep disorder regulating an individual's routine life. Although several therapeutic modalities are available for curing OSA, behavioral therapies are also utilized for a positive outcome. Besides, several studies are performed to prove the efficacy of lifestyle strategies to resolute OSA in adults. Reducing weight, quitting alcohol and smoking, eating a nutritional diet, and exercising are the modifications to benefit people. This review aims to expand our knowledge of the association between alterations to comportment and better treatment outcomes for sleep apnea.

Is Laparoscopic Roux-en-Y Gastric Bypass Still the Gold Standard Procedure for Indians? Mid- to Long-Term Outcomes from a Tertiary Care Center

PURPOSE

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the oldest and most widely performed bariatric surgery worldwide. There is, however, a scarcity of mid- to long-term data of RYGB, especially from the Indian subcontinent.

MATERIALS AND METHODS

The study was a single-center, retrospective analysis from patients who underwent RYGB between January 2009 and November 2014 from a tertiary care center in India. Percent of total weight loss (%TWL) was taken as the primary outcome of the study. Secondary outcomes included type 2 diabetes mellitus (T2DM) remission, comorbidity resolution, revisional surgeries, and complications related to RYGB at 1 year, at 3 years, and during the long term, following surgery. Postoperative visits took place at 1 and 3 years, while the long-term outcome was at median 8.3 years (range 5.4-11.2 years), with a follow-up of 92.4% (488/528), 80.5% (424/527) and 69.5% (363/522), respectively.

RESULTS

Out of 528 patients studied, 56% were females. The mean body mass index (BMI) was 40.6 ± 6.9 kg/m². The %TWL in the long-term follow-up was 21.8 ± 11.3%. T2DM remission rates at 1 year, at 3 years, and during the long term were 84.5%, 70.0%, and 60.0%, respectively. Preoperative HBA1c (p = 0.002) and insulin usage (p = 0.016) had a significant predictive effect on T2DM remission. Gastroesophageal reflux disease (GERD) improved significantly (p < 0.001). Early (< 30 days) and late (> 30 days) complications were observed in 2.3% and 4.3% of the patients, respectively.

CONCLUSION

Weight loss during mid to long-term follow-up was maintained in the majority of the patients after RYGB. However, a small proportion had significant weight regain in the long term. T2DM, GERD, and other comorbidities were well improved after RYGB.

Safflower Yellow and Its Main Component HSYA Alleviate Diet-Induced Obesity in Mice: Possible Involvement of the Increased Antioxidant Enzymes in Liver and Adipose Tissue

Purpose

Oxidative stress plays an important role in the pathogenesis of obesity and its associated disorders. Safflower yellow (SY) and hydroxysafflor yellow A (HSYA), the natural compounds isolated from Carthamus tinctorius L., has been found to possess antioxidative and anti-obesity properties. The purpose of the present study is to investigate whether SY and its main component HSYA alleviate obesity by the antioxidant effects.

Methods

Diet-induced obese (DIO) mice were treated with 200 mg/kg/d SY or HSYA for 10 weeks. Body weight, fat mass, serum biochemical parameters and superoxide dismutase (SOD) activities were measured. Glucose and insulin tolerance tests were performed. The expression of antioxidant enzymes in liver and adipose tissue were measured. In vitro, H₂O₂-induced oxidative stress HepG2 cells and 3T3-L1 adipocytes were treated with SY and HSYA to investigate the direct effects of SY and HSYA on the expression of antioxidant enzymes.

Results

SY and HSYA significantly decreased the body weight gain of DIO mice, and decreased fat mass to 57.8% and 61.6% of the control mice, respectively (P < 0.05). The parameters of glucose metabolism and liver function were improved after SY and HSYA treatment. The hepatic SOD activities and the mRNA levels of antioxidant enzymes in liver and adipose tissue of SY and HSYA treated mice were increased (P < 0.05). Meanwhile, the administration of SY and HSYA on the H₂O₂-induced oxidative stress HepG2 cells and adipocytes also increased the expression of the antioxidant factor and antioxidant enzymes to 1.2~3.3 folds of the control cells (P < 0.05).

Conclusion

SY and its main component HSYA could significantly decrease the fat mass, and improve glucose metabolism and liver function in diet-induced obese mice. The beneficial effects of SY and HSYA on obesity and metabolism may be associated with the increased expression of antioxidant enzymes in liver and adipose tissue.

Prevalence and determinants of type 2 diabetes among lean African migrants and non-migrants: the RODAM study

Background

Exposure to adverse conditions earlier in life-course can predispose to type 2 diabetes in adulthood, irrespective of body mass index (BMI). However, the burden of type 2 diabetes in lean Africans is not well understood despite higher exposure to adverse early life conditions. Mirroring ongoing epidemiological transition, we assessed the burden and determinants of type 2 diabetes in a homogenous group of lean Ghanaians residing in rural and urban Ghana, and as migrants in Europe.

Methods

Baseline data from 2179 RODAM study participants with BMI<25kg/m² (25-70 years) were analyzed. Prevalence and determinants of type 2 diabetes were estimated using logistic regression analysis. Adjustments were made for socio-demographic and lifestyle factors, use of anti-diabetic medication and optimal blood glucose control.

Results

Prevalence of type 2 diabetes in rural, urban and migrant lean participants were 3.5%, 8.9% and 7.5% respectively, representing 55.4%, 35.6%, 13.2% of all participants with type 2 diabetes. Compared with lean rural participants, the odds of type 2 diabetes were higher in lean urban participants (adjusted OR = 8.81, 95% CI = 6.56-11.06), followed by migrants (5.27, 95% CI = 3.51-6.91). Irrespective of site, determinants of type 2 diabetes in lean participants include; presence of hypertension, physical inactivity, hypercholesterolemia and age (>45 years).

Conclusions

Our study shows a high prevalence of type 2 diabetes among lean African populations in different geographical settings. Future studies are needed in-order to examine how contextual differences are related to the pathophysiology of type 2 diabetes in lean individuals.

Anti-hyperglycemic and ameliorative effect of concentrated hot water-infusion of Phragmanthera incana leaves on type 2 diabetes and indices of complications in diabetic rats

Objectives

This study investigated the anti-hyperglycemic effects of concentrated hot water infusion of Phragmanthra incana leaves as well as its ameliorative effect on indices related to diabetic complications in a type 2 diabetes model of rats.

Methods

Type 2 diabetes was induced by feeding 10% fructose solution ad libitum for two weeks followed by an intraperitoneal injection of streptozotocin (40 mg/kg body weight (b.w.)). Concentrated plant infusion was administered orally at a dose of 150 and 300 mg/kg b.w. to two type 2 diabetes rat groups. Diabetic rats without treatment served as a negative control while the group administered with metformin was served as a positive control. The intervention lasted for 4 weeks when a single oral dose was given daily for 5 days a week. Body weight and blood glucose were determined every week. An oral glucose tolerance test was performed in the last week of treatment. The rats were sacrificed after 4 weeks of intervention, and the blood and organs were harvested for further analysis.

Results

Both dosages of the plant infusion significantly improved body weight, pancreatic β-cell function (HOMA-β), insulin secretion and reduced blood glucose, insulin resistance (HOMA-IR) with concomitant reduction in the elevated level of serum α-amylase activity, fructosamine, uric acid, urea, and liver function enzymes. The liver glycogen content was significantly improved while the activity of liver glucose-6-phosphatase was significantly reduced.

Conclusion

The results demonstrate the anti-hyperglycemic ability of P. incana and its ability to delay the onset of diabetic complications which can be exploited for the anti-diabetic drug discovery.

Effects of probiotic, cinnamon, and synbiotic supplementation on glycemic control and antioxidant status in people with type 2 diabetes; a randomized, double-blind, placebo-controlled study

Purpose

The aim of this study was to investigate the effect of probiotic bacteria of Lactobacillus acidophilus, cinnamon powder and their combinations on the glycemic and antioxidant indices in patients with type 2 diabetes.

Methods

A total of 136 patients randomized with type 2 diabetes entered the study and were randomly divided into four groups who were matched for age and gender. Thereafter, alongside their routine pharmacotherapy, each group followed one of the following diets: Group A: Lactobacillus acidophilus 10⁸ cfu and 0.5 g of powdered cinnamon (synbiotic). Group B: Lactobacillus acidophilus (probiotic), Group C: powdered cinnamon. Group D: rice flour powder as placebo. At the beginning and end of the intervention, fasting blood sugar (FBS), HbA1c, advance glycation end products (AGE), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and antioxidant enzymes of superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (CAT) were measured.

Results

Following 3 months of treatment, the mean FBS level was decreased significantly in probiotic, cinnamon, and synbiotic supplementation groups compared with control (P < 0.01). FBS levels in probiotic, cinnamon, and synbiotic groups were significantly decreased compared with the control group (P = 0.001, P = 0.063 and P = 0.001, respectively). The mean HbA1C in probiotic, cinnamon, and synbiotic groups were also decreased (P = 0.001, P = 0.001 and P = 0.04, respectively). The mean AGE in synbiotic group was significantly decreased (P = 0.037). Probiotic, cinnamon and synbiotic all could improve antioxidant enzyme activity modestly. However, the most significant effect was seen in probiotic group.

Conclusions

According to the current results, the use of probiotic supplements (individually or in combination with cinnamon) leads to a reduction in blood glucose and an increase in antioxidant enzymes in people with type 2 diabetes.

The Role of Diet in Patients with Metabolic Syndrome

Metabolic syndrome is a frequent metabolic disorder characterized by obesity and insulin resistance seems to be the main pathophysiological alteration. The goal of treating metabolic syndrome is to reduce the risk of coronary heart disease and the development of type 2 diabetes. The lifestyle modification therapy combines specific recommendations on diet alone or combined with other strategies. In this review, we address the following topics: 1) the importance of the high prevalence of metabolic syndrome and obesity, and 2) the role of lifestyle modification focusing on dietary fat intake in the management of MS.

Gastric bypass versus sleeve gastrectomy in patients with type 2 diabetes (Oseberg): a single-centre, triple-blind, randomised controlled trial

BACKGROUND

For patients with obesity and type 2 diabetes, weight loss improves insulin sensitivity and β-cell function, and can induce remission of diabetes. The comparative efficacy of various bariatric procedures for the remission of type 2 diabetes has not been fully elucidated. We aimed to compare the effects of the two most common bariatric procedures, gastric bypass and sleeve gastrectomy, on remission of diabetes and β-cell function.

METHODS

We conducted a single-centre, triple-blind, randomised trial at Vestfold Hospital Trust (Tønsberg, Norway), in which patients (aged ≥18 years) with type 2 diabetes and obesity were randomly assigned (1:1) to receive gastric bypass or sleeve gastrectomy (the Oseberg study). Randomisation was performed with a computerised random number generator and a block size of 10. Treatment allocation was masked from participants, study personnel, and outcome assessors and was concealed with sealed opaque envelopes. Surgeons used identical skin incisions during both surgeries and were not involved in patient follow-up. The primary clinical outcome was the proportion of participants with complete remission of type 2 diabetes (HbA_1c of ≤6·0% [42 mmol/mol] without the use of glucose-lowering medication) at 1 year after surgery. The primary physiological outcome was disposition index (a measure of β-cell function) at 1 year after surgery, as assessed by an intravenous glucose tolerance test. Primary outcomes were analysed in the intention-to-treat and per-protocol populations. This trial is ongoing and closed to recruitment, and is registered with ClinicalTrials.gov, NCT01778738.

FINDINGS

Between Oct 15, 2012, and Sept 1, 2017, 1305 patients who were preparing for bariatric surgery were screened, of whom 319 consecutive patients with type 2 diabetes were assessed for eligibility. 109 patients were enrolled and randomly assigned to gastric bypass (n=54) or sleeve gastrectomy (n=55). 107 (98%) of 109 patients completed 1-year follow-up, with one patient in each group withdrawing after surgery (per-protocol population). In the intention-to-treat population, diabetes remission rates were higher in the gastric bypass group than in the sleeve gastrectomy group (risk difference 27% [95% CI 10 to 44]; relative risk [RR] 1·57 [1·14 to 2·16], p=0·0054); results were similar in the per-protocol population (risk difference 27% [95% CI 10 to 45]; RR 1·57 [1·14 to 2·15], p=0·0036). In the intention-to-treat population, disposition index increased in both groups (between-group difference 55 [-111 to 220], p=0·52); results were similar in the per-protocol population (between-group difference 21 [-214 to 256], p=0.86). In the gastric bypass group, ten of 54 participants had early complications and 17 of 53 had late side-effects. In the sleeve gastrectomy group, eight of 55 participants had early complications and 22 of 54 had late side-effects. No deaths occurred in either group.

INTERPRETATION

Gastric bypass was found to be superior to sleeve gastrectomy for remission of type 2 diabetes at 1 year after surgery, and the two procedures had a similar beneficial effect on β-cell function. The use of gastric bypass as the preferred bariatric procedure for patients with obesity and type 2 diabetes could improve diabetes care and reduce related societal costs.

FUNDING

Morbid Obesity Centre, Vestfold Hospital Trust.

Association Between Late Bedtime and Diabetes Mellitus: A Large Community-Based Study

STUDY OBJECTIVES

The aim of this study was to investigate the association of bedtime with the prevalence of diabetes mellitus (DM) based on a large community-based population.

METHODS

In total, 5,420 participants (2,574 males and 2,846 females; aged 63.5 ± 11.0 years) from the Sleep Heart Health Study database were selected in this study. Sleep habit was recorded based on a questionnaire administered to patients upon recruitment. Bedtime was categorized as 11:00 pm and before, 11:00 pm to 12:00 am, and 12:00 am and later in the current study. Multivariate logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) to determine the relationship between bedtime and the prevalence of DM.

RESULTS

The distribution of weekday bedtime at 11:00 pm and before, 11:00 pm to 12:00 am, 12:00 am and later was observed in 3,316 participants (61.2%), 991 participants (18.3%), and 1,113 participants (20.5%), respectively. Meanwhile, individuals with weekday bedtime of 12:00 am and later had a higher prevalence of DM than those with bedtime at 11:00 pm to 12:00 am, and 11:00 pm and before (10.6% versus 5.7% versus 6.6%, respectively; P < .001). In the adjusted multivariate logistic regression model, bedtime at 12:00 am and later on a weekday was significantly associated DM prevalence (OR 1.446, 95% CI 1.107-1.888, P = .007). No significant association was found between weekend bedtime and DM.

CONCLUSION

Late bedtime at 12:00 am and later on a weekday may be a risk factor for the prevalence of DM. Stable sleep timing leads to lower risk of DM deserves future exploration.

Effects of Consuming Almonds on Insulin Sensitivity and Other Cardiometabolic Health Markers in Adults With Prediabetes

Objective: This study was designed to assess the effects of replacing high-carbohydrate (CHO) foods with raw almonds on insulin sensitivity and cardiometabolic health markers in overweight or obese adults with prediabetes.Method: This randomized crossover study consisted of two 6-week dietary intervention periods, separated by a ≥ 4-week washout. Subjects incorporated 1.5 oz of raw almonds twice daily or isocaloric CHO-based foods into their diets, with instructions to maintain body weight. Dietary intakes as well as insulin sensitivity, CHO metabolism indices, lipoprotein lipids and particles, and inflammatory markers were assessed.Results: Thirty-three subjects (17 male, 16 female), mean age 48.3 ± 2.2 years and body mass index 30.5 ± 0.7 kg/m², provided evaluable data. Compared to CHO, almonds resulted in significantly (p < 0.01) higher intakes of protein, fat (unsaturated fatty acids), fiber, and magnesium and significantly (p < 0.001) lower intakes of CHO and sugars. No differences were observed between diet conditions for changes from baseline in the insulin sensitivity index from a short intravenous glucose tolerance test or other indices of glucose homeostasis. No significant differences were observed in biomarkers of cardiovascular risk except that the CHO intervention led to a shift toward a higher concentration of cholesterol in small, dense low-density lipoprotein subfraction 3+4 (LDL3 + 4) particles (p = 0.024 vs almonds).Conclusions: Intake of 3.0 oz/d raw almonds, vs energy-matched CHO foods, improved the dietary nutrient profile, but did not significantly affect insulin sensitivity and most markers of cardiometabolic health in overweight and obese men and women with prediabetes.

Safety, tolerability and efficacy of a novel self-use biodegradable device for management of obesity

OBJECTIVE

Obesity is a major public health issue with significant impact on quality of life, morbidity and mortality rates. It is estimated that if the current trends continue, 18% of men and 21% of women worldwide will be obese by 2025. All the current therapies are not optimal due to limited efficacy or safety; thus, there is a need for additional devices for the treatment of obesity. This study aimed to examine the safety, tolerability, and efficacy of a biodegradable encapsulated Epitomee device for weight loss. The technology is based on absorbent pharmaceuticals polymers and bonding materials that self-expand in the stomach to create a pH-sensitive super absorbent gel structure for weight loss.

METHODS

A prospective, 12-week twice daily use of the encapsulated device in patients with body mass index of 27-40 kg m-2. Efficacy endpoints were the percent total body weight loss (%TBWL), proportion of participants with 5% TBWL and changes in cardio-metabolic markers. Safety analysis included evaluation of adverse events, laboratory and endoscopic findings.

RESULTS

Overall, 52 patients completed the study. TBWL per intension-to-treat analysis was 3.68 ± 3.07% (3.23 ± 2.69 kg) and 4.52 ± 2.97% (3.95 ± 2.57 kg) per protocol. No device serious adverse effects reported. The most common adverse events were headache (18.1%), viral infection (11.5%), abdominal discomfort (10.1%), bloating (7.9%), nausea and constipation (5% each) and flatulence (4.3%). Endoscopy in 26 patients revealed mild, asymptomatic gastric/duodenal erythema without erosions in five patients.

CONCLUSIONS

Twelve weeks of Epitomee capsules treatment combined with lifestyle counselling resulted in 3.68-4.52% of TBWL. With continued research, the Epitomee capsules have considerable potential to become a non-invasive, safe and effective treatment option for weight loss.

The Effect of Bariatric Surgery Prior to Lower-Extremity Total Joint Arthroplasty: A Systematic Review

BACKGROUND

Obesity is an independent risk factor for osteoarthritis and has been associated with increased rate of complications following lower-extremity total joint arthroplasty (TJA). Bariatric surgery (BS) is a surgical option for weight loss and for reducing obesity-related comorbidities in morbidly obese patients.

PURPOSE/QUESTIONS

The goal of this systematic review was to answer the following questions: (1) Does BS prior to TJA correlate with lower post-operative complication rates in morbidly obese patients undergoing TJA? (2) Does BS have an impact on revision rates following TJA?

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist, a systematic review of medical databases (PubMed/ MEDLINE, Cochrane Library, Web of Science, and Clinicaltrials.gov) was undertaken for articles published in English from January 1990 to September 2018. Inclusion criteria were studies that included at least ten patients who underwent BS prior to TJA, collected data on complications or other outcomes, and followed patients for at least 90 days after TJA. A descriptive and critical analysis of the results was performed.

RESULTS

From 799 studies, 13 met inclusion criteria. A total of 11,770 patients who had undergone bariatric surgery prior to TJA were analyzed. The quality of the evidence ranged between moderate and high. There was no consensus on the effect of previous BS on early- to short-term outcomes reported after TJA.

CONCLUSION

The literature remains conflicted on the impact of BS prior to TJA on early, short-term, and long-term complications after TJA. Additional well-matched, observational studies may further our understanding of the impact of BS prior to TJA on outcomes. In particular the effect of various types of BS prior to TJA on outcomes has yet to be elucidated. Ideally, prospective studies with higher level of evidence will be more definitive on the effects of BS prior to TJA.Prospero Registration Number: CRD42016043025.

Design, synthesis and biological activity evaluation of a new class of 2,4-thiazolidinedione compounds as insulin enhancers

Diabetes mellitus (DM) is a global disease with a high incidence of type 2 diabetes. Current studies have shown that insulin enhancers play an important role in the treatment of type 2 diabetes and have great importance in the improvement of type 2 diabetes. In this research, Rosiglitazone was taken as the lead compound, and the structure was modified by using the bioisostere principle, and a new class of 2,4-thiazolanedione compound was designed and synthesised. The novel series of compounds were studied for their biological activities in vitro and in vivo. In vitro tests, the biological activities showed that the target compounds have good selective activation of peroxisome-proliferator-activated receptor γ (PPARγ), such as the compounds 6a, 6e, 6f, 6g and 6i, especially the compound 6e to PPARγ was EC₅₀ = 0.03 ± 0.01 μmol/L in vitro. Then, in vivo biological activities’ test results showed that the tendency of increasing in blood sugar had an obvious inhibiting effect, and had a significant insulin hypoglycaemic effect of enhancing and extending the exogenous. In addition, the results of cytotoxicity tests and acute toxicity tests (LD₅₀) showed that these compounds belong to the low toxicity compounds.