Current and cutting-edge interventions for the treatment of obese patients

Periodontitis in obese adults with and without metabolic syndrome: a cross-sectional study

BACKGROUND

Epidemiological studies support an association between obesity, metabolic syndrome (MetS), and periodontitis. Still, understanding of the effects of low-grade inflammation in obese subjects on periodontitis and influence of MetS remains incomplete. The aims of this cross-sectional study were to explore the association between obesity related variables and periodontitis, and assess if MetS is a risk indicator for periodontitis in a sample of obese adults.

METHODS

The study sample comprised 52 adults with a body mass index (BMI) of ≥ 30 kg/m2 referred for obesity therapy at the Obesity Centre at Haukeland University Hospital (HUH), Bergen, Norway. The subjects had prior to enrolment completed a 5-month lifestyle intervention course as part of a 2-year managing program. According to the revised National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) classification of MetS, 38 subjects were recruited to the MetS group and 14 subjects to the non-MetS group. Medical data including peripheral blood samples were obtained from records at HUH at the time of enrolment. Probing depth, clinical attachment level, tooth mobility, furcation involvement, bleeding on probing (BoP) were recorded and intraoral bitewings evaluated at a full-mouth periodontal examination. Associations between risk variables for obesity/MetS and periodontitis were explored using linear and logistic regression models.

RESULTS

In the present sample 79% of the subjects were diagnosed with periodontitis. The prevalence of stage III/IV periodontitis was 42.9% in the non-MetS group vs. 36.8% in the MetS group (p = 0.200). In the non-MetS group 29.8% of the sites displayed BoP vs. 23.5% in the MetS group (p = 0.048). For stage III/IV periodontitis, the effect of age appeared to be significant for obesity related variables and MetS (p = 0.006, p = 0.002, respectively). None of the other analyses showed significant association with the outcome variables.

CONCLUSION

In the present sample of obese subjects, periodontitis occurred independently of MetS. Reaching a certain BMI level, suggested association between MetS and periodontitis might be non-significant due to the dominating impact of obesity related variables undermining the effect of other systemic factors.

TRIAL REGISTRATION

The principal clinical trial, entitled "Obesity and Oral Diseases", was prospectively registered in ClinicalTrials.gov with registration NCT04602572 (20.10.2020).

Combined liver transplantation and sleeve gastrectomy: Report of a brief-interval staged approach

Pretransplantation bariatric surgery in patients with high Model for End-Stage Liver Disease (MELD) score is fraught with risks. Bariatric surgery after liver transplantation (LT) may be complicated by surgical adhesions but could have advantages if performed at the time of transplantation. We investigated a method of brief-interval staging combining LT and sleeve gastrectomy (SG). LT recipients with a body mass index (BMI) > 40 kg/m 2 received an SG during the same hospitalization as the LT (LT/SG), at the same time as a planned brief-interval return to the operating room for biliary anastomosis. Differences in intraoperative attributes of the LT (Stage 1) versus SG (Stage 2) procedures were analyzed using Wilcoxon signed-rank test with significance p  < 0.05 and compared with patients with obesity having a two-stage LT without SG. A total of 14 cases {median MELD score 33 (interquartile range [IQR], 18-40)} were compared with 28 controls; 60% were critically ill prior to surgery with mechanical ventilation, vasopressors, or continuous renal replacement therapy. Median interval between procedures was 16.1 (IQR, 12.5-22.7) hours for cases and 12.2 (IQR, 11.1-16.6) hours for controls, p  = 0.27. Median BMI at LT/SG was 47.0 (IQR, 41.7-51.3) kg/m 2 versus 38.1 (IQR, 35.7-39.8) kg/m 2 for controls, p  < 0.001. At 1 year, median excess body weight loss was 74.0% (IQR, 46.2%-78.7%) in cases and 15.8% (IQR, -5.4% to 62.6%) in controls, p  = 0.13; total weight loss was 38.1% (IQR, 23.9-42.9) in cases versus 7.7% (IQR, -2.4% to 27.6%) for controls, p  = 0.03. Graft survival at 1 year was 92.9% for cases and 89.3% for controls with similar early postoperative outcomes. This proof-of-concept study revealed that a brief-interval SG during LT is feasible in patients with high MELD and resulted in sustained weight loss at 1 year with similar graft survival. Further studies are needed to determine an optimal strategy.

Identifying the Predictors of Short Term Weight Loss Failure after Roux-En-Y Gastric Bypass

INTRODUCTION

Gastric bypass surgery is a gold standard therapy for severe obesity. This study aimed to evaluate anthropometric predictors for short-term excess weight loss (EWL) after Roux-en-Y gastric bypass surgery (RYGB) in a sample of severely obese patients.

MATERIALS AND METHODS

This cohort study was conducted on severely obese candidates for RYGB bariatric surgery in Mashhad, Iran. Indirect calorimetry, anthropometric measurements, and body composition data were collected before, one, and six months after RYGB.

RESULTS

Fifty-four participants (43, 79.6% women and 11, 20.4% men) with a mean age of 39.63 ± 9.66 years participated in this study. The mean total weight and BMI loss within six months were 32.89 ± 20.22 kg and 12.37 ± 7.34 kg/m², respectively. The mean reduction in adipose tissue and fat-free mass was 24.49 kg and 7.46 kg, respectively. The mean resting metabolism rate (RMR) reduction at one and six months after RYGB was 260.49 kcal and 396.07 kcal, respectively. There was a significant difference in mean RMR between the baseline and one and six months after RYGB (p < 0.001). There was no significant gender difference in mean weight and BMI loss percentage at six months post-RYGB (p > 0.05). Baseline skeletal muscle mass (SMM), excess BMI loss (EBMIL) at first month after surgery, and baseline neck circumference (NC) could predict EWL six months after surgery.

CONCLUSION

Reduced RMR shortly after RYGB may be due to FFM reduction. Some anthropometric and their acute changes after RYGB may predict the short-term EWL in RYGB patients.

Left gastric artery embolization for obesity treatment: a systematic review and meta-analysis of human and animal studies

PURPOSE

The main purpose of this systematic review was to reflect on recent literature on bariatric LGA embolization for obesity treatment and to compare this new procedure in human and animal studies.

METHODS

A systematic search of Scopus, MEDLINE, Web of Science, Embase, and Google Scholar was performed to identify human and animal studies employing bariatric LGA embolization to treat obesity. As well, Cochrane's Q test and the I² statistic were utilized to determine heterogeneity.

RESULTS

Nine human and four animal studies recruiting a total of 118 cases (n = 78 patients and n = 40 animals) were included in analysis. All assessments on body mass index (BMI), weight, and ghrelin levels had been fulfilled based on before-after (human studies) and intervention-control designs (animal studies) using bariatric LGA embolization. The findings suggested that bariatric LGA embolization had significantly decreased BMI (mean difference (MD): - 2.66, 95% confidence interval [CI] - 3.74, - 1.58, P < 0.001) and weight (MD: - 8.69, 95% CI - 10.48, - 6.89, P < 0.001) in humans. Although overall pooled estimate showed no significant changes in ghrelin levels following this procedure (Hedges' g statistic: - 0.91, 95% CI - 1.83, 0.01, P = 0.05) in humans, a significant reduction was observed in animal studies (MD: - 756.56, 95% CI - 1098.79, - 414.33, P < 0.001) along with a significant drop in weight (MD: - 7.64, 95% CI - 13.73, - 1.54, P < 0.001).

CONCLUSION

The present study concluded that ghrelin levels in humans had not been affected, although bariatric LGA embolization might significantly improve BMI and weight.

The regulation of gastric ghrelin secretion

Ghrelin is a gastric hormone with multiple physiological functions, including the stimulation of food intake and adiposity. It is well established that circulating ghrelin levels are closely associated with feeding patterns, rising strongly before a meal and lowering upon food intake. However, the mechanisms underlying the modulation of ghrelin secretion are not fully understood. The purpose of this review is to discuss current knowledge on the circadian oscillation of circulating ghrelin levels, the neural mechanisms stimulating fasting ghrelin levels and peripheral mechanisms modulating postprandial ghrelin levels. Furthermore, the therapeutic potential of targeting the ghrelin pathway is discussed in the context of the treatment of various metabolic disorders, including obesity, type 2 diabetes, diabetic gastroparesis and Prader-Willi syndrome. Moreover, eating disorders including anorexia nervosa, bulimia nervosa and binge-eating disorder are also discussed.

New technologies and advances in weight loss therapy

Bariatric surgery is the most effective treatment for obesity and its comorbidities but there are barriers that prevent its general acceptance. The growing obesity epidemic has resulted in the need for the creation of new, less invasive treatments, with a wide margin of safety and effectiveness for conditioning weight loss, at least greater than that resulting from treatment based on diet and exercise. Emerging therapies include devices that are endoscopically placed and removed, classified as: space-occupying devices, restrictive or anatomic-remodeling procedures, endoluminal bypass, and duodenal mucosal resurfacing. Percutaneous techniques and less invasive surgeries are also included. In general, results have shown improvement in glucose metabolism in diabetic patients. With respect to weight loss, results do not surpass those of bariatric surgery, but are better than results with conservative treatment (diet and exercise) and have a low rate of adverse events. Clinical use of a new technique should be carried out within a multidisciplinary management program that includes nutritional, psychologic, physical activity, and medical support. It must be understood that novel therapies are not being created to substitute bariatric surgery, but rather to increase treatment options in the general population, with greater reach and impact. The aim of the present study was to provide an up-to-date literature review on emerging technologies for the treatment of obesity.

Teenagers with obesity: Long-term results of laparoscopic adjustable gastric banding

BACKGROUND

Obesity is a rapidly spreading chronic disease worldwide. Long-term results are critical to assess the effectiveness of a bariatric procedure, particularly in young patients who have long life expectancy.

METHODS

A retrospective study on adolescents with morbid obesity who underwent Laparoscopic Adjustable Gastric Banding (LAGB) at our institute from 1995 to 2018 was made. Primary endpoints were efficacy, in term of weight loss and comorbidity resolution, occurrence of complications and reoperations.

RESULTS

Fifty-nine patients underwent LAGB between 1995 and 2018. Intra- and post-operative mortality was absent. The patients' presence at follow-up at 5, 10 and 15 years was 38/50 (76%), 18/25 (72%) and 5/8 (63%), respectively. At those times the mean excess weight loss percentage was 61.7 ± 29.4, 48.1 ± 50.4 and 55.8 ± 51.2, respectively. Comorbidity resolution rates were 100% for patients with diabetes, 78% for patients with hypertension, 75% for joint pain suffers, 69% for patients with sleep apnea and 57% for patients with anxiety and depression. Total reoperation rate was 30.5%. The band was removed in 8 patients: 3 due to erosions, 3 by patients' choice and 2 conversions to other bariatric procedures.

CONCLUSION

LAGB, in combination with the patients' close follow-up performed by an interdisciplinary team, can be an effective long-term surgical treatment for teenagers with morbid obesity.

LEVEL OF EVIDENCE

Level IV.

Bariatric Embolization: A Narrative Review of Clinical Data From Human Trials

Bariatric arterial embolization (BAE) is a novel technique that is investigated as an alternative, often supplementary, method for weight management. BAE reduces blood perfusion to the gastric fundus, and thus, reduces the production of appetite-inducing hormones. No randomized controlled trial has evaluated the efficacy of BAE to date. Available evidence from published studies include retrospective evaluations of patients undergoing left gastric artery embolization for gastrointestinal bleeding, and early prospective, single-arm clinical trials. Review of clinical data from human trials suggest an average weight loss of about 8-9 kg (ranging 7.6-22.0 kg), corresponding to 8-9% (ranging 4.8-17.2%) of the patients' baseline weight. Common complications include superficial gastric ulcers. Though uncommon, gastric perforation and splenic infarct are important major complication that may arise after left gastric artery embolization. Overall, BAE is an effective, relatively safe procedure that may be associated with clinically significant weight loss in patients with obesity.

Laparoscopic adjustable gastric banding on 3566 patients up to 20-year follow-up: Long-term results of a standardized technique

BACKGROUND

As obesity is a chronic disease, any bariatric procedure should be validated by long-term results.

OBJECTIVE

To present our long-term results after laparoscopic adjustable gastric banding over a period of >20 years and to investigate the outcomes in terms of efficacy, complications, and reoperations.

SETTING

Private practice, Italy.

METHODS

From October 1995 to February 2018, 3566 laparoscopic adjustable gastric banding were performed by a single surgeon. Data were retrieved from a prospectively collected computer database and retrospectively analyzed. Furthermore, patients were stratified according to body mass index and age and results are evaluated for each subgroup.

RESULTS

All the operations were performed laparoscopically without any mortality and/or major specific complications. Nine hundred twenty-six patients (71.6%) completed at least 10-years follow-up and 180 (58.4%) reached 15-years follow-up. There was a mean of 49%, 52.6%, and 59.2% of excess weight loss at 10, 15, and 20 years, respectively. Major late complications were pouch herniation-dilation (5.8%) and erosion (2.5%), both solved by a replicable, less invasive operation. Total reoperation rate was 24.1%.

CONCLUSION

Our experience suggested that the combination of a standardized surgical technique and close patient follow-up, performed in collaboration with an interdisciplinary team, may make the laparoscopic adjustable gastric banding system a powerful long-term surgical tool in the treatment of morbid obesity. The best results were obtained in young patients with high body mass index but results were also satisfactory in elderly patients and in those with low body mass index.

Perceived oral health in patients after bariatric surgery using oral health-related quality of life measures

Obesity is an increasing problem of the 21st century. A frequent intervention is bariatric surgery. The impact of bariatric surgery on oral health is largely unknown. The aim of the present case-control study was to survey the perceived oral health amongst individuals that had undergone bariatric surgery and compare the measures with two cohorts consisting of healthy individuals with respectively at or below versus above a body mass index score of 30. Study volunteers were recruited from interest group on the Internet. The study participants completed online a validated oral health-related quality of life scale, that is, OHIP-S. The three cohorts consisted of individuals that had undergone bariatric surgery (OS, n = 77) and the healthy obese (ONS, n = 45) and nonobese individuals (HNS, n = 71). Nonparametric Kruskal-Wallis rank sum tests were used to estimate likelihood of nondifference amongst the three cohorts. Individuals that had undergone bariatric surgery reported significant more oral health problems than the study participants in with the two other cohorts. Their perception of oral health-related quality of life was higher or similar to the obese study participants and lower than for nonobese study participants. Perceived oral health problems appear to be more frequent amongst individuals that have undergone bariatric surgery in comparison with healthy obese and nonobese individuals. Bariatric surgery may be consider a risk marker for impaired oral health.

Hibiscus and lemon verbena polyphenols modulate appetite-related biomarkers in overweight subjects: a randomized controlled trial

TRIAL DESIGN

Plant-derived polyphenols have shown potential to alleviate obesity-related pathologies by a multi-targeted mechanism in animal models and human intervention studies. A dietary supplement based on a combination of Lippia citriodora (LC) and Hibiscus sabdariffa (HS) polyphenolic extracts was assayed in a double blind and placebo-controlled intervention study with 54 overweight subjects.

METHODS

Blood pressure, body weight, height, triceps, biceps and abdominal skinfold thickness, and arm and abdominal circumferences were taken at the baseline, 30 and 60 days of the intervention period. The validated Visual Analogue Scale used to record hunger and satiety-related sensations was passed at the beginning and at 15, 30, 45 and 60 days of the intervention. Subjective health status was assessed through the validated SF-36 questionnaire at the beginning and end of the study. Finally, plasma from fasting blood samples was obtained at the beginning, 30 and 60 days of the study.

RESULTS

The results showed an improvement of anthropometric measurements, decreased blood pressure and heart rate and a more positive perception in the overall health status. We also observed that plant polyphenols increased anorexigenic hormones (glucagon-like peptide-1) and decreased orexigenic hormones (ghrelin).

CONCLUSIONS

Based on previous evidence we postulate that AMP-activated protein kinase may have a role in such effects through its capability to modulate energy homeostasis, total daily energy expenditure and lipid management. Although further research may be required, we propose that this polyphenolic combination may be used for weight management by increasing long-term weight loss maintenance through the modulation of appetite biomarkers. This may help to avoid the undesired weight regain typical of calorie restriction diets.

Timing of eating in adults across the weight spectrum: Metabolic factors and potential circadian mechanisms

Timing of eating is recognized as a significant contributor to body weight regulation. Disruption of sleep-wake cycles from a predominantly diurnal (daytime) to a delayed (evening) lifestyle leads to altered circadian rhythms and metabolic dysfunction. This article reviews current evidence for timed and delayed eating in individuals of normal weight and those with overweight or obesity: although some findings indicate a benefit of eating earlier in the daytime on weight and/or metabolic outcomes, results have not been uniformly consistent, and more rigorous and longer-duration studies are needed. We also review potential circadian mechanisms underlying the metabolic- and weight-related changes resulting from timed and delayed eating. Further identification of such mechanisms using deep phenotyping is required to determine targets for medical interventions for obesity and for prevention of metabolic syndrome and diabetes, and to inform clinical guidelines regarding eating schedules for management of weight and metabolic disease.

Enhancing enterocyte fatty acid oxidation in mice affects glycemic control depending on dietary fat

Studies indicate that modulating enterocyte metabolism might affect whole body glucose homeostasis and the development of diet-induced obesity (DIO). We tested whether enhancing enterocyte fatty acid oxidation (FAO) could protect mice from DIO and impaired glycemic control. To this end, we used mice expressing a mutant form of carnitine palmitoyltransferase-1a (CPT1mt), insensitive to inhibition by malonyl-CoA, in their enterocytes (iCPT1mt) and fed them low-fat control diet (CD) or high-fat diet (HFD) chronically. CPT1mt expression led to an upregulation of FAO in the enterocytes. On CD, iCPT1mt mice had impaired glycemic control and showed concomitant activation of lipogenesis, glycolysis and gluconeogenesis in their enterocytes. On HFD, both iCPT1mt and control mice developed DIO, but iCPT1mt mice showed improved glycemic control and reduced visceral fat mass. Together these data indicate that modulating enterocyte metabolism in iCPT1mt mice affects glycemic control in a body weight-independent, but dietary fat-dependent manner.

Additive Effects of Intermittent Hypobaric Hypoxia and Endurance Training on Bodyweight, Food Intake, and Oxygen Consumption in Rats

Cabrera-Aguilera, Ignacio, David Rizo-Roca, Elisa A. Marques, Garoa Santocildes, Teresa Pagès, Gines Viscor, António A. Ascensão, José Magalhães, and Joan Ramon Torrella. Additive effects of intermittent hypobaric hypoxia and endurance training on bodyweight, food intake, and oxygen consumption in rats. High Alt Med Biol. 19:278-285, 2018.-We used an animal model to elucidate the effects of an intermittent hypobaric hypoxia (IHH) and endurance exercise training (EET) protocol on bodyweight (BW), food and water intake, and oxygen consumption. Twenty-eight young adult male rats were divided into four groups: normoxic sedentary (NS), normoxic exercised (NE), hypoxic sedentary (HS), and hypoxic exercised (HE). Normoxic groups were maintained at an atmospheric pressure equivalent to sea level, whereas the IHH protocol consisted of 5 hours per day for 33 days at a simulated altitude of 6000 m. Exercised groups ran in normobaric conditions on a treadmill for 1 hour/day for 5 weeks at a speed of 25 m/min. At the end of the protocol, both hypoxic groups showed significant decreases in BW from the ninth day of exposure, reaching final 10% (HS) to 14.5% (HE) differences when compared with NS. NE rats also showed a significant weight reduction after the 19th day, with a decrease of 7.4%. The BW of hypoxic animals was related to significant hypophagia elicited by IHH exposure (from 8% to 12%). In contrast, EET had no effect on food ingestion. Total water intake was not affected by hypoxia but was significantly increased by exercise. An analysis of oxygen consumption at rest (mL O₂/[kg·min]) revealed two findings: a significant decrease in both hypoxic groups after the protocol (HS, 21.7 ± 0.70 vs. 19.1 ± 0.78 and HE, 22.8 ± 0.80 vs. 17.1 ± 0.90) and a significant difference at the end of the protocol between NE (21.3 ± 0.77) and HE (17.1 ± 0.90). These results demonstrate that IHH and EET had an additive effect on BW loss, providing evidence that rats underwent a metabolic adaptation through a reduction in oxygen consumption measured under normoxic conditions. These data suggest that the combination of IHH and EET could serve as an alternative treatment for the management of overweight and obesity.

Gut as an emerging organ for the treatment of diabetes: focus on mechanism of action of bariatric and endoscopic interventions

Increasing worldwide prevalence of type 2 diabetes mellitus and its accompanying pathologies such as obesity, arterial hypertension and dyslipidemia represents one of the most important challenges of current medicine. Despite intensive efforts, high percentage of patients with type 2 diabetes does not achieve treatment goals and struggle with increasing body weight and poor glucose control. While novel classes of antidiabetic medications such as incretin-based therapies and gliflozins have some favorable characteristics compared to older antidiabetics, the only therapeutic option shown to substantially modify the progression of diabetes or to achieve its remission is bariatric surgery. Its efficacy in the treatment of diabetes is well established, but the exact underlying modes of action are still only partially described. They include restriction of food amount, enhanced passage of chymus into distal part of small intestine with subsequent modification of gastrointestinal hormones and bile acids secretion, neural mechanisms, changes in gut microbiota and many other possible mechanisms underscoring the importance of the gut in the regulation of glucose metabolism. In addition to bariatric surgery, less-invasive endoscopic methods based on the principles of bariatric surgery were introduced and showed promising results. This review highlights the role of the intestine in the regulation of glucose homeostasis focusing on the mechanisms of action of bariatric and especially endoscopic methods of the treatment of diabetes. A better understanding of these mechanisms may lead to less invasive endoscopic treatments of diabetes and obesity that may complement and widen current therapeutic options.

Alteration of serum immunoglobins, C-reactive protein, vitamin D, and electrolyte by atenolol and amlodipine in stress-induced hypertensive rats

The present study is designed for the assessment of various pathological changes like immunoglobins, C-reactive protein, vitamin D, sodium, potassium, calcium in stress-induced hypertensive rats. Albino Wistar rats of sex male were grouped into six. Each group consists of six animals. Groups were Group I (normal control), Group II (disease control), Group III (amlodipine control), Group IV (atenolol control), Group V (amlodipine treatment), and Group VI (atenolol treatment). Group II, V, and VI animals exposed to regular stress by placing them in cages individually and giving foot electric shocks (1 mA, 50 ms duration with 0.5-1 min of intervals regulated randomly by a computer) along with forced swimming (30 min) in order to induce hypertension in rats. This stress was given two times daily (morning and evening) for regular 15 days. Induction of hypertension was confirmed by measuring the tail arterial pressure of blood and angiotensin II. For next 1 month, Group III and V animals are treated with amlodipine with 1 mg/kg, s.c. dose while Group IV and VI animals were given 10 mg/kg, s.c. the dose of atenolol once daily. At the end of the experimental work, blood collected, rats sacrificed, and serum separated. Serum sodium, potassium, immunoglobins, C-reactive protein, vitamin D, and calcium were measured by semi-auto-analyzer. Stress-induced hypertension in rats produced altered serum sodium, potassium, immunoglobins, C-reactive protein, vitamin D, and calcium level which is restored by atenolol. Administration of amlodipine in animals without hypertension shows alteration in the level of immunoglobins, calcium, vitamin D, and electrolytes.

Peptide-Based Regulation of Metabolism as Related to Obesity

Currently there are few, if any, approved and effective medicines for the attenuation of obesity, diabetes, and insulin resistance. This commentary addresses a communication describing the effect on glucose dynamics and obesity of a peptide monoclonal antibody for fibroblast growth factor (FGF) receptor 1c isoform (FGFR1c). The general lack of suitable, effective drugs is discussed, as is the treatment potential of FGF family receptors. The FGFR1c monoclonal antibody developed by the authors lowers body weight gain, blood glucose, and adipose tissue weight. It also enhances glucose uptake by fat cells [white adipose tissue (WAT) and 3T3-L1]. The robust weight loss, fat loss, and lower blood glucose were attributed to an observed potential futile cycle of continuous lipogenesis and lipolysis and adenosine triphosphate use in WAT.