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Li Z, Zheng L, Wang J, Wang L, Qi Y, Amin B, Zhu J, Zhang N. Dopamine in the regulation of glucose and lipid metabolism: a narrative review. Obesity (Silver Spring) 2024; 32:1632-1645. [PMID: 39081007 DOI: 10.1002/oby.24068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 08/29/2024]
Abstract
OBJECTIVE Owing to the global obesity epidemic, understanding the regulatory mechanisms of glucose and lipid metabolism has become increasingly important. The dopaminergic system, including dopamine, dopamine receptors, dopamine transporters, and other components, is involved in numerous physiological and pathological processes. However, the mechanism of action of the dopaminergic system in glucose and lipid metabolism is poorly understood. In this review, we examine the role of the dopaminergic system in glucose and lipid metabolism. RESULTS The dopaminergic system regulates glucose and lipid metabolism through several mechanisms. It regulates various activities at the central level, including appetite control and decision-making, which contribute to regulating body weight and energy metabolism. In the pituitary gland, dopamine inhibits prolactin production and promotes insulin secretion through dopamine receptor 2. Furthermore, it can influence various physiological components in the peripheral system, such as pancreatic β cells, glucagon-like peptide-1, adipocytes, hepatocytes, and muscle, by regulating insulin and glucagon secretion, glucose uptake and use, and fatty acid metabolism. CONCLUSIONS The role of dopamine in regulating glucose and lipid metabolism has significant implications for the physiology and pathogenesis of disease. The potential therapeutic value of dopamine lies in its effects on metabolic disorders.
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Affiliation(s)
- Zhehong Li
- Surgery Centre of Diabetes Mellitus, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lifei Zheng
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Jing Wang
- Surgery Centre of Diabetes Mellitus, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Liang Wang
- Surgery Centre of Diabetes Mellitus, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yao Qi
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Buhe Amin
- Surgery Centre of Diabetes Mellitus, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jinxia Zhu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Nengwei Zhang
- Surgery Centre of Diabetes Mellitus, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Holst JJ, Madsbad S, Bojsen-Møller KN, Dirksen C, Svane M. New Lessons from the gut: Studies of the role of gut peptides in weight loss and diabetes resolution after gastric bypass and sleeve gastrectomy. Peptides 2024; 176:171199. [PMID: 38552903 DOI: 10.1016/j.peptides.2024.171199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/05/2024]
Abstract
It has been known since 2005 that the secretion of several gut hormones changes radically after gastric bypass operations and, although more moderately, after sleeve gastrectomy but not after gastric banding. It has therefore been speculated that increased secretion of particularly GLP-1 and Peptide YY (PYY), which both inhibit appetite and food intake, may be involved in the weight loss effects of surgery and for improvements in glucose tolerance. Experiments involving inhibition of hormone secretion with somatostatin, blockade of their actions with antagonists, or blockade of hormone formation/activation support this notion. However, differences between results of bypass and sleeve operations indicate that distinct mechanisms may also be involved. Although the reductions in ghrelin secretion after sleeve gastrectomy would seem to provide an obvious explanation, experiments with restoration of ghrelin levels pointed towards effects on insulin secretion and glucose tolerance rather than on food intake. It seems clear that changes in GLP-1 secretion are important for insulin secretion after bypass and appear to be responsible for postbariatric hypoglycemia in glucose-tolerant individuals; however, with time the improvements in insulin sensitivity, which in turn are secondary to the weight loss, may be more important. Changes in bile acid metabolism do not seem to be of particular importance in humans.
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Affiliation(s)
- Jens Juul Holst
- The NovoNordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Denmark.
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Denmark
| | | | - Carsten Dirksen
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Maria Svane
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Denmark
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Wilmington R, Abuawwad M, Holt G, Anderson R, Aldafas R, Awad S, Idris I. The Effects of Preoperative Glycaemic Control (HbA1c) on Bariatric and Metabolic Surgery Outcomes: Data from a Tertiary-Referral Bariatric Centre in the UK. Obes Surg 2024; 34:850-854. [PMID: 38221566 PMCID: PMC10899277 DOI: 10.1007/s11695-023-06964-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Current recommendations advocate the achievement of an optimal glucose control (HbA1c < 69 mmol/mol) prior to elective surgery to reduce risks of peri- and post-operative complications, but the relevance for this glycaemic threshold prior to Bariatric Metabolic Surgery (BMS) following a specialist weight management programme remains unclear. METHODS We undertook a retrospective cohort study of patients with type 2 diabetes mellitus (T2DM) who underwent BMS over a 6-year period (2016-2022) at a regional tertiary referral following completion of a specialist multidisciplinary weight management. Post-operative outcomes of interest included 30-day mortality, readmission rates, need for Intensive Care Unit (ICU) care and hospital length of stay (LOS) and were assessed according to HbA1c cut-off values of < 69 (N = 202) and > 69 mmol/mol (N = 67) as well as a continuous variable. RESULTS A total of 269 patients with T2D were included in this study. Patients underwent primary Roux en-Y gastric bypass (RYGB, n = 136), Sleeve Gastrectomy (SG, n = 124), insertion of gastric band (n = 4) or one-anastomosis gastric bypass (OAGB, n = 4). No significant differences in the rates of complications were observed between the two groups of pre-operative HbA1c cut-off values. No HbA1c threshold was observed for glycaemic control that would affect the peri- and post-operative complications following BMS. CONCLUSIONS We observed no associations between pre-operative HbA1C values and the risk of peri- and post-operative complications. In the context of a specialist multidisciplinary weight management programme, optimising pre-operative HbA1C to a recommended target value prior to BMS may not translate into reduced risks of peri- and post-operative complications.
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Affiliation(s)
- Rebekah Wilmington
- Clinical, Metabolic and Molecular Physiology Research Group, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, DE22 3NE, UK.
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK.
- East Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK.
| | - Mahmoud Abuawwad
- East Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | - Guy Holt
- East Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | - Robyn Anderson
- East Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | - Rami Aldafas
- Clinical, Metabolic and Molecular Physiology Research Group, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, DE22 3NE, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Sherif Awad
- East Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | - Iskandar Idris
- Clinical, Metabolic and Molecular Physiology Research Group, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, DE22 3NE, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
- East Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
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4
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Fineman MS, Bryant CLN, Colbert K, Jozefiak TH, Petersen JS, Horowitz M, Vora J, Rayner CK, Wabnitz P, Nimgaonkar A. First-in-human study of a pharmacological duodenal exclusion therapy shows reduced postprandial glucose and insulin and increased bile acid and gut hormone concentrations. Diabetes Obes Metab 2023. [PMID: 37380614 DOI: 10.1111/dom.15066] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 06/30/2023]
Abstract
AIMS To address the need for noninvasive alternatives to metabolic surgery or duodenal exclusion devices for the management of type 2 diabetes (T2D) and obesity by developing an orally administered therapeutic polymer, GLY-200, designed to bind to and enhance the barrier function of mucus in the gastrointestinal tract to establish duodenal exclusion noninvasively. MATERIALS AND METHODS A Phase 1, randomized, double-blind, placebo-controlled, single- (SAD) and multiple-ascending-dose (MAD) healthy volunteer study was conducted. In the SAD arm, four cohorts received a single dose of 0.5 g up to 6.0 g GLY-200 or placebo, while in the MAD arm, four cohorts received 5 days of twice-daily or three-times-daily dosing (total daily dose 2.0 g up to 6.0 g GLY-200 or placebo). Assessments included safety and tolerability (primary) and exploratory pharmacodynamics, including serum glucose, insulin, bile acids and gut hormones. RESULTS No safety signals were observed; tolerability signals were limited to mild to moderate dose-dependent gastrointestinal events. In the MAD arm (Day 5), reductions in glucose and insulin and increases in bile acids, glucagon-like peptide-1, peptide YY and glicentin, were observed following a nonstandardized meal in subjects receiving twice-daily dosing of 2.0 g GLY-200 (N = 9) versus those receiving placebo (N = 8). CONCLUSIONS GLY-200 is safe and generally well tolerated at doses of ≤2.0 g twice daily. Pharmacodynamic results mimic the biomarker signature observed after Roux-en-Y gastric bypass and duodenal exclusion devices, indicating a pharmacological effect in the proximal small intestine. This study represents the first clinical demonstration that duodenal exclusion can be achieved with an oral drug and supports further development of GLY-200 for the treatment of obesity and/or T2D.
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Affiliation(s)
| | | | - Kevin Colbert
- Glyscend Therapeutics, Inc., Lowell, Massachusetts, USA
| | | | | | - Michael Horowitz
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jiten Vora
- Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Christopher K Rayner
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Paul Wabnitz
- CALHN Integrated Care, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Transform Clinical Pty Ltd, CO-HAB Tonsley, St Marys, South Australia, Australia
| | - Ashish Nimgaonkar
- Glyscend Therapeutics, Inc., Lowell, Massachusetts, USA
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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de Souza Vilela DL, da Silva A, Pinto SL, Bressan J. Relationship between dietary macronutrient composition with weight loss after bariatric surgery: A systematic review. Obes Rev 2023; 24:e13559. [PMID: 36890787 DOI: 10.1111/obr.13559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 11/15/2022] [Accepted: 02/04/2023] [Indexed: 03/10/2023]
Abstract
This systematic review evaluated the relationship between macronutrient intake and weight loss after bariatric surgery (BS). The MEDLINE/Pubmed, EMBASE, COCHRANE/CENTRAL, and SCOPUS databases were accessed in August 2021 to search for eligible articles: original publications with adults undergoing BS and indicating the relationship between macronutrients and weight loss. Titles that did not meet these criteria were excluded. The review was written according to the PRISMA guide, and the risk of bias was according to the Joanna Briggs manual. Data were extracted by one reviewer and checked by another. Eight articles with 2.378 subjects were included. The studies indicated a positive relationship between weight loss and protein intake after BS. Prioritization of protein followed by carbohydrates with a lower percentage of lipids favors weight loss and increases weight stability after BS. Among the results found, a 1% increase in protein intake raises the probability of obesity remission by 6%, and high-protein diet increase 50% weight loss success. Limitations are the methods of included studies and review process. It is concluded that high-protein intake >60 g a 90 g/day may favor weight loss and maintenance after BS, but it is relevant to balance the other macronutrients.
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Affiliation(s)
- Darlene Larissa de Souza Vilela
- Laboratory of Energy Metabolism and Body Composition (LAMECC). Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Brazil
| | - Alessandra da Silva
- Laboratory of Energy Metabolism and Body Composition (LAMECC). Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Brazil
| | - Sônia Lopes Pinto
- Laboratory of Energy Metabolism and Body Composition (LAMECC). Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Brazil.,Nutrition Course, Universidade Federal de Tocantins, Palmas, Tocantins, Brazil
| | - Josefina Bressan
- Laboratory of Energy Metabolism and Body Composition (LAMECC). Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Brazil
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Llewellyn DC, Logan Ellis H, Aylwin SJB, Oštarijaš E, Green S, Sheridan W, Chew NWS, le Roux CW, Miras AD, Patel AG, Vincent RP, Dimitriadis GK. The efficacy of GLP-1RAs for the management of postprandial hypoglycemia following bariatric surgery: a systematic review. Obesity (Silver Spring) 2023; 31:20-30. [PMID: 36502288 PMCID: PMC10107620 DOI: 10.1002/oby.23600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/06/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Postprandial hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass and gastric sleeve surgery that may detrimentally affect patient quality of life. One likely causal factor is glucagon-like peptide-1 (GLP-1), which has an exaggerated rise following ingestion of carbohydrates after bariatric surgery. This paper sought to assess the role of GLP-1 receptor agonists (GLP-1RAs) in managing postprandial hypoglycemia following bariatric surgery. METHODS MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Scopus were systematically and critically appraised for all peer-reviewed publications that suitably fulfilled the inclusion criteria established a priori. This systematic review was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P). It followed methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions and is registered with PROSPERO (International Prospective Register of Systematic Reviews; identifier CRD420212716429). RESULTS AND CONCLUSIONS Postprandial hyperinsulinemic hypoglycemia remains a notoriously difficult to manage metabolic complication of bariatric surgery. This first, to the authors' knowledge, systematic review presents evidence suggesting that use of GLP-1RAs does not lead to an increase of hypoglycemic episodes, and, although this approach may appear counterintuitive, the findings suggest that GLP-1RAs could reduce the number of postprandial hypoglycemic episodes and improve glycemic variability.
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Affiliation(s)
- David C. Llewellyn
- Department of EndocrinologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Hugh Logan Ellis
- Department of EndocrinologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Simon J. B. Aylwin
- Department of EndocrinologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Eduard Oštarijaš
- Institute for Translational MedicineUniversity of Pécs Medical School, University of PécsPécsHungary
| | - Shauna Green
- Department of Acute MedicineLewisham and Greenwich NHS Foundation Trust, Queen Elizabeth HospitalLondonUK
| | - William Sheridan
- Faculty of Life Sciences and MedicineSchool of Life Course Sciences, King's College LondonLondonUK
| | - Nicholas W. S. Chew
- Department of CardiologyNational University Heart Centre, National University HospitalSingaporeSingapore
| | - Carel W. le Roux
- Diabetes Complication Research Centre, School of Medicine and Medical ScienceUCD Conway Institute, University College DublinBelfieldIreland
| | - Alexander D. Miras
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
| | - Ameet G. Patel
- Department of Minimal Access SurgeryKing's College Hospital NHS Foundation TrustLondonUK
| | - Royce P. Vincent
- Faculty of Life Sciences and MedicineSchool of Life Course Sciences, King's College LondonLondonUK
- Department of Clinical BiochemistryKing's College Hospital NHS Foundation TrustLondonUK
| | - Georgios K. Dimitriadis
- Department of EndocrinologyKing's College Hospital NHS Foundation TrustLondonUK
- Faculty of Life Sciences and Medicine, School of Cardiovascular Medicine and Sciences, Obesity, Type 2 Diabetes and Immunometabolism Research GroupKing's College LondonLondonUK
- Division of Reproductive Health, Warwick Medical SchoolUniversity of WarwickCoventryUK
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Akalestou E, Lopez-Noriega L, Tough IR, Hu M, Leclerc I, Cox HM, Rutter GA. Vertical Sleeve Gastrectomy Lowers SGLT2/Slc5a2 Expression in the Mouse Kidney. Diabetes 2022; 71:1623-1635. [PMID: 35594379 DOI: 10.2337/db21-0768] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 05/02/2022] [Indexed: 11/13/2022]
Abstract
Bariatric surgery improves glucose homeostasis, but the underlying mechanisms are not fully elucidated. Here, we show that the expression of sodium-glucose cotransporter 2 (SGLT2/Slc5a2) is reduced in the kidney of lean and obese mice following vertical sleeve gastrectomy (VSG). Indicating an important contribution of altered cotransporter expression to the impact of surgery, inactivation of the SGLT2/Slc5a2 gene by clustered regularly interspaced short palindromic repeats (CRISPR)/Cas9 attenuated the effects of VSG, with glucose excursions following intraperitoneal injection lowered by ∼30% in wild-type mice but by ∼20% in SGLT2-null animals. The effects of the SGLT2 inhibitor dapaglifozin were similarly blunted by surgery. Unexpectedly, effects of dapaglifozin were still observed in SGLT2-null mice, consistent with the existence of metabolically beneficial off-target effects of SGLT2 inhibitors. Thus, we describe a new mechanism involved in mediating the glucose-lowering effects of bariatric surgery.
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Affiliation(s)
- Elina Akalestou
- Section of Cell Biology and Functional Genomics, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, U.K
| | - Livia Lopez-Noriega
- Section of Cell Biology and Functional Genomics, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, U.K
| | - Iain R Tough
- Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London, U.K
| | - Ming Hu
- Section of Cell Biology and Functional Genomics, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, U.K
| | - Isabelle Leclerc
- Section of Cell Biology and Functional Genomics, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, U.K
- Centre de Recherches du Centre hospitalier de l'Université de Montréal (CHUM), University of Montreal, Montreal, Quebec, Canada
| | - Helen M Cox
- Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London, U.K
| | - Guy A Rutter
- Section of Cell Biology and Functional Genomics, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, U.K
- Centre de Recherches du Centre hospitalier de l'Université de Montréal (CHUM), University of Montreal, Montreal, Quebec, Canada
- Lee Kong Chian Imperial Medical School, Nanyang Technological University, Singapore
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Shibib L, Al-Qaisi M, Ahmed A, Miras AD, Nott D, Pelling M, Greenwald SE, Guess N. Reversal and Remission of T2DM - An Update for Practitioners. Vasc Health Risk Manag 2022; 18:417-443. [PMID: 35726218 PMCID: PMC9206440 DOI: 10.2147/vhrm.s345810] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/10/2022] [Indexed: 01/04/2023] Open
Abstract
Over the past 50 years, many countries around the world have faced an unchecked pandemic of obesity and type 2 diabetes (T2DM). As best practice treatment of T2DM has done very little to check its growth, the pandemic of diabesity now threatens to make health-care systems economically more difficult for governments and individuals to manage within their budgets. The conventional view has been that T2DM is irreversible and progressive. However, in 2016, the World Health Organization (WHO) global report on diabetes added for the first time a section on diabetes reversal and acknowledged that it could be achieved through a number of therapeutic approaches. Many studies indicate that diabetes reversal, and possibly even long-term remission, is achievable, belying the conventional view. However, T2DM reversal is not yet a standardized area of practice and some questions remain about long-term outcomes. Diabetes reversal through diet is not articulated or discussed as a first-line target (or even goal) of treatment by any internationally recognized guidelines, which are mostly silent on the topic beyond encouraging lifestyle interventions in general. This review paper examines all the sustainable, practical, and scalable approaches to T2DM reversal, highlighting the evidence base, and serves as an interim update for practitioners looking to fill the practical knowledge gap on this topic in conventional diabetes guidelines.
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Affiliation(s)
- Lina Shibib
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mo Al-Qaisi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ahmed Ahmed
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alexander D Miras
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - David Nott
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Marc Pelling
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephen E Greenwald
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Nicola Guess
- School of Life Sciences, Westminster University, London, UK
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9
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Genetic reprogramming of remnant duodenum may contribute to type 2 diabetes improvement after Roux en-Y gastric bypass. Nutrition 2022; 99-100:111631. [DOI: 10.1016/j.nut.2022.111631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/31/2021] [Accepted: 02/07/2022] [Indexed: 11/22/2022]
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10
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Lo T, Lee Y, Tseng CY, Hu Y, Connelly MA, Mantzoros CS, Karp JM, Tavakkoli A. Daily transient coating of the intestine leads to weight loss and improved glucose tolerance. Metabolism 2022; 126:154917. [PMID: 34687727 PMCID: PMC8666968 DOI: 10.1016/j.metabol.2021.154917] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Roux-en-Y gastric bypass surgery (RYGB) has been shown to be the gold standard treatment for obesity associated type-2-diabetes (T2D), however many T2D patients do not qualify or are reluctant to proceed with surgery due to its potential risks and permanent changes to GI anatomy. We have previously described a novel oral formulation, LuCI, that provides a transient coating of the proximal bowel and mimics the effects of RYGB. Herein, we aim to investigate the outcome of chronic LuCI administration on weight and glucose homeostasis. METHODS Sprague-Dawley rats on a high fat diet achieving diet-induced obesity (DIO) received 5 weeks of daily LuCI or normal saline as control (n = 8/group). Daily weights and glucose tolerance were monitored throughout the experiment. At 5 weeks, systemic blood was sampled through a surgically placed jugular vein catheter, before and during an intestinal glucose bolus, to investigate changes in key hormones involved in glucose metabolism. To elucidate the effects of LuCI on nutrient absorption, fecal output and food intake were measured simultaneously with the analysis of homogenized stool samples performed using bomb calorimetry. RESULTS At 5 weeks, LuCI animals weighted 8.3% less and had lower fasting glucose levels than Controls (77.6 ± 3.8 mg/dl vs. 99.1 ± 2.7 mg/dl, P < 0.001). LuCI-treated animals had lower baseline insulin and HOMA-IR. Post-prandially, LuCI group had increased GLP-1 and GIP secretion following a glucose challenge. Serum lipid analysis revealed lowered LDL levels highlighting the potential to not only improve glucose control but also modify cardiovascular risk. We then investigated whether LuCI's effect on proximal bowel exclusion may play a role in energy balance. Bomb calorimetry analysis suggested that LuCI reduced calorie absorption with no difference in caloric consumption. CONCLUSION We demonstrated that LuCI recapitulates the physical and hormonal changes seen after RYGB and can ameliorate weight gain and improve insulin sensitivity in a DIO rat model. Since LuCI's effect is transient and without systemic absorption, LuCI has the potential to be a novel therapy for overweight or obese T2D patients.
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Affiliation(s)
- Tammy Lo
- Laboratory for Surgical and Metabolic Research, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Yuhan Lee
- Department of Anesthesiology, Perioperative, and Pain Medicine, Center for Nanomedicine, Center for Regenerative Therapeutics, Brigham and Women's Hospital, Harvard Medical School, Harvard Stem Cell Institute, Harvard-MIT, Division of Health Sciences and Technology, Boston, MA, USA
| | - Chung-Yi Tseng
- Department of Anesthesiology, Perioperative, and Pain Medicine, Center for Nanomedicine, Center for Regenerative Therapeutics, Brigham and Women's Hospital, Harvard Medical School, Harvard Stem Cell Institute, Harvard-MIT, Division of Health Sciences and Technology, Boston, MA, USA
| | - Yangshuo Hu
- Department of Anesthesiology, Perioperative, and Pain Medicine, Center for Nanomedicine, Center for Regenerative Therapeutics, Brigham and Women's Hospital, Harvard Medical School, Harvard Stem Cell Institute, Harvard-MIT, Division of Health Sciences and Technology, Boston, MA, USA
| | - Margery A Connelly
- Laboratory Corporation of America Holdings (Labcorp), Morrisville, NC, USA
| | - Christos S Mantzoros
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Section of Endocrinology, Boston VA Healthcare System, Harvard Medical School, Boston, MA, USA
| | - Jeffrey M Karp
- Department of Anesthesiology, Perioperative, and Pain Medicine, Center for Nanomedicine, Center for Regenerative Therapeutics, Brigham and Women's Hospital, Harvard Medical School, Harvard Stem Cell Institute, Harvard-MIT, Division of Health Sciences and Technology, Boston, MA, USA.
| | - Ali Tavakkoli
- Laboratory for Surgical and Metabolic Research, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of General and GI Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Epidemiology of type 2 diabetes remission in Scotland in 2019: A cross-sectional population-based study. PLoS Med 2021; 18:e1003828. [PMID: 34727107 PMCID: PMC8562803 DOI: 10.1371/journal.pmed.1003828] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/30/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Clinical pathways are changing to incorporate support and appropriate follow-up for people to achieve remission of type 2 diabetes, but there is limited understanding of the prevalence of remission in current practice or patient characteristics associated with remission. METHODS AND FINDINGS We carried out a cross-sectional study estimating the prevalence of remission of type 2 diabetes in all adults in Scotland aged ≥30 years diagnosed with type 2 diabetes and alive on December 31, 2019. Remission of type 2 diabetes was assessed between January 1, 2019 and December 31, 2019. We defined remission as all HbA1c values <48 mmol/mol in the absence of glucose-lowering therapy (GLT) for a continuous duration of ≥365 days before the date of the last recorded HbA1c in 2019. Multivariable logistic regression in complete and multiply imputed datasets was used to examine characteristics associated with remission. Our cohort consisted of 162,316 individuals, all of whom had at least 1 HbA1c ≥48 mmol/mol (6.5%) at or after diagnosis of diabetes and at least 1 HbA1c recorded in 2019 (78.5% of the eligible population). Over half (56%) of our cohort was aged 65 years or over in 2019, and 64% had had type 2 diabetes for at least 6 years. Our cohort was predominantly of white ethnicity (74%), and ethnicity data were missing for 19% of the cohort. Median body mass index (BMI) at diagnosis was 32.3 kg/m2. A total of 7,710 people (4.8% [95% confidence interval [CI] 4.7 to 4.9]) were in remission of type 2 diabetes. Factors associated with remission were older age (odds ratio [OR] 1.48 [95% CI 1.34 to 1.62] P < 0.001) for people aged ≥75 years compared to 45 to 54 year group), HbA1c <48 mmol/mol at diagnosis (OR 1.31 [95% CI 1.24 to 1.39] P < 0.001) compared to 48 to 52 mmol/mol), no previous history of GLT (OR 14.6 [95% CI 13.7 to 15.5] P < 0.001), weight loss from diagnosis to 2019 (OR 4.45 [95% CI 3.89 to 5.10] P < 0.001) for ≥15 kg of weight loss compared to 0 to 4.9 kg weight gain), and previous bariatric surgery (OR 11.9 [95% CI 9.41 to 15.1] P < 0.001). Limitations of the study include the use of a limited subset of possible definitions of remission of type 2 diabetes, missing data, and inability to identify self-funded bariatric surgery. CONCLUSIONS In this study, we found that 4.8% of people with type 2 diabetes who had at least 1 HbA1c ≥48 mmol/mol (6.5%) after diagnosis of diabetes and had at least 1 HbA1c recorded in 2019 had evidence of type 2 diabetes remission. Guidelines are required for management and follow-up of this group and may differ depending on whether weight loss and remission of diabetes were intentional or unintentional. Our findings can be used to evaluate the impact of future initiatives on the prevalence of type 2 diabetes remission.
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Brown A, McArdle P, Taplin J, Unwin D, Unwin J, Deakin T, Wheatley S, Murdoch C, Malhotra A, Mellor D. Dietary strategies for remission of type 2 diabetes: A narrative review. J Hum Nutr Diet 2021; 35:165-178. [PMID: 34323335 DOI: 10.1111/jhn.12938] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 11/28/2022]
Abstract
Type 2 diabetes (T2DM) is a growing health issue globally, which until recently has been considered to be one that is both chronic and progressive. Treatments, although having lifestyle and dietary change as core components, have been focused on optimising glycaemic control using pharmaceutical agents. With data from bariatric surgery and, more recently, total diet replacement (TDR) studies which have set out to achieve remission; remission of T2DM has emerged as treatment goal. A group of specialist dietitians, medical practitioners was convened, supported by the British Dietetic Association and Diabetes UK, to discuss dietary approaches to T2DM, and undertook a review of the available clinical trial and practice audit data regarding dietary approaches to remission of T2DM. Current available evidence suggests a range of dietary approaches, including low energy diets (mostly using TDR) and low carbohydrate diets, can be used to support the achievement of euglycaemia and potentially remission. The most significant predictor of remission is weight loss, and although euglycaemia may occur on a low carbohydrate diet without weight loss, which does not meet some definitions of remission, but may rather constitute a 'state of mitigation' of T2DM. This technical point may not be considered important for people living with T2DM, aside from that it may only last as long as the carbohydrate restriction is maintained. The possibility of actively treating T2DM along with the possibility of achieving remission should be discussed by healthcare professionals with people living with T2DM, along with a range of different dietary approaches which can help to achieve it. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Adrian Brown
- Centre for Obesity Research, University College London, London, UK.,National Institute of Health Research, UCLH Biomedical Research Centre, London, UK
| | - Paul McArdle
- Birmingham Community Healthcare NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | | | - Campbell Murdoch
- Private GP, Farmborough, Bath, UK.,Diabetes Digital Media, Coventry, UK
| | - Aseem Malhotra
- Visiting Professor of Evidence Based Medicine, Bahiana School of Medicine and Public Heath, Salvador, Brazil
| | - Duane Mellor
- Aston Medical School, Aston University, Birmingham, UK
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Mueller A, Palilla S, Carter J. Optimal Surgical Treatment for Type 2 Diabetes: Sleeve Gastrectomy or Gastric Bypass? Adv Surg 2021; 55:1-8. [PMID: 34389085 DOI: 10.1016/j.yasu.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Amanda Mueller
- Department of Surgery, University of California - San Francisco, 513 Parnassus Avenue, HSW1601, San Francisco, CA 94143, USA
| | - Sarah Palilla
- Department of Surgery, University of California - San Francisco, 513 Parnassus Avenue, HSW1601, San Francisco, CA 94143, USA
| | - Jonathan Carter
- Department of Surgery, University of California - San Francisco, 513 Parnassus Avenue, HSW1601, San Francisco, CA 94143, USA.
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14
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Hounkpatin H, Stuart B, Farmer A, Dambha‐Miller H. Association of type 2 diabetes remission and risk of cardiovascular disease in pre-defined subgroups. Endocrinol Diabetes Metab 2021; 4:e00280. [PMID: 34277996 PMCID: PMC8279611 DOI: 10.1002/edm2.280] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/26/2021] [Accepted: 04/30/2021] [Indexed: 01/08/2023] Open
Abstract
AIM To quantify the association between type 2 diabetes remission and 5-year incidence of cardiovascular disease outcomes, overall and in pre-defined subgroups. METHODS Retrospective cohort analysis of 60,287 adults with type 2 diabetes from the Care and Health Information Analytics (CHIA) database. Multivariable Cox models were used to assess the association between remission within the first two years of follow-up and incidence of cardiovascular disease (CVD) outcomes including events, microvascular and macrovascular complications at 7-year follow-up. Effect modification by age, sex, diabetes duration, pre-existing CVD, baseline body mass index (BMI) and HbA1c level was assessed. RESULTS 7489 (12.4%) people achieved remission during the first two years of follow-up. Overall, remission was associated with lower risk of CVD outcomes. Remission was associated with lower risk of microvascular complications for younger compared with older age groups (eg aHR: 0.59 (0.41-0.84) and aHR: 0.78 (0.67-0.92) for those aged <45 years and 75-84 years, respectively). Amongst those achieving remission, those with no or 1-2 comorbidities had lower risk of microvascular complications (aHR: 0.65 (0.56-0.75)) compared to those with more than three comorbidities (aHR: 0.83 (0.69-0.99), respectively). There were no significant interactions in the remaining subgroups or for models assessing CVD events or macrovascular complications. CONCLUSIONS Achieving remission of type 2 diabetes is associated with a lower risk of microvascular complications, particularly for younger groups and those with fewer comorbidities. Targeted interventions that focus on promoting remission in these groups may reduce the impact of microvascular complications and associated health costs.
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Affiliation(s)
- Hilda Hounkpatin
- School of Primary CarePopulation Sciences and Medical Education, University of SouthamptonSouthamptonUK
- Primary Care Research CentreUniversity of SouthamptonSouthamptonUK
| | - Beth Stuart
- Primary Care Research CentreUniversity of SouthamptonSouthamptonUK
| | - Andrew Farmer
- Nuffield Department of Primary CareUniversity of OxfordOxfordUK
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15
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Cornejo-Pareja I, Molina-Vega M, Gómez-Pérez AM, Damas-Fuentes M, Tinahones FJ. Factors Related to Weight Loss Maintenance in the Medium-Long Term after Bariatric Surgery: A Review. J Clin Med 2021; 10:jcm10081739. [PMID: 33923789 PMCID: PMC8073104 DOI: 10.3390/jcm10081739] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022] Open
Abstract
Despite bariatric surgery being the most effective treatment for obesity, some individuals do not respond adequately, especially in the long term. Identifying the predictors of correct weight maintenance in the medium (from 1 to 3 years after surgery) and long term (from 3 years and above) is of vital importance to reduce failure after bariatric surgery; therefore, we summarize the evidence about certain factors, among which we highlight surgical technique, psychological factors, physical activity, adherence to diet, gastrointestinal hormones or neurological factors related to appetite control. We conducted a search in PubMed focused on the last five years (2015–2021). Main findings are as follows: despite Roux-en-Y gastric bypass being more effective in the long term, sleeve gastrectomy shows a more beneficial effectiveness–complications balance; pre-surgical psychological and behavioral evaluation along with post-surgical treatment improve long-term surgical outcomes; physical activity programs after bariatric surgery, in addition to continuous and comprehensive care interventions regarding diet habits, improve weight loss maintenance, but it is necessary to improve adherence; the impact of bariatric surgery on the gut–brain axis seems to influence weight maintenance. In conclusion, although interesting findings exist, the evidence is contradictory in some places, and long-term clinical trials are necessary to draw more robust conclusions.
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Affiliation(s)
- Isabel Cornejo-Pareja
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, 29010 Málaga, Spain; (I.C.-P.); (M.D.-F.); (F.J.T.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), Virgen de la Victoria University Hospital, 29010 Málaga, Spain
- Centro de Investigación Biomédica en Red de la Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - María Molina-Vega
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, 29010 Málaga, Spain; (I.C.-P.); (M.D.-F.); (F.J.T.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), Virgen de la Victoria University Hospital, 29010 Málaga, Spain
- Correspondence: (M.M.-V.); (A.M.G.-P.); Tel.: +34-95-1034-044 (M.M.-V. & A.M.G.-P.)
| | - Ana María Gómez-Pérez
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, 29010 Málaga, Spain; (I.C.-P.); (M.D.-F.); (F.J.T.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), Virgen de la Victoria University Hospital, 29010 Málaga, Spain
- Correspondence: (M.M.-V.); (A.M.G.-P.); Tel.: +34-95-1034-044 (M.M.-V. & A.M.G.-P.)
| | - Miguel Damas-Fuentes
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, 29010 Málaga, Spain; (I.C.-P.); (M.D.-F.); (F.J.T.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), Virgen de la Victoria University Hospital, 29010 Málaga, Spain
| | - Francisco J. Tinahones
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, 29010 Málaga, Spain; (I.C.-P.); (M.D.-F.); (F.J.T.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), Virgen de la Victoria University Hospital, 29010 Málaga, Spain
- Centro de Investigación Biomédica en Red de la Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain
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Temporal Effects of Sleeve Gastrectomy on Glucose-Insulin Homeostasis and Incretin Hormone Response at 1 and 6 Months. Obes Surg 2021; 30:2243-2250. [PMID: 32067166 PMCID: PMC7475060 DOI: 10.1007/s11695-020-04457-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bariatric surgery is an effective treatment for morbid obesity and glycaemic dysfunction. OBJECTIVES The aim of the work was to examine both the static and dynamic changes of glucose-insulin homeostasis and incretin hormone response following sleeve gastrectomy (SG) in a sample of 55 participants preoperatively and 1 month and 6 months postoperatively. The focus was on a sample of patients with impaired glucose tolerance and type 2 diabetes (T2D). SETTING Morriston Hospital, UK. METHODS Prospective study comprising of 55 participants with impaired glucose homeostasis and T2D undergoing SG (mean body mass index [BMI] 50.4 kg/m2, mean glycated haemoglobin [A1C] 7.4%). Serial measurements of glucose, insulin, C-peptide, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic hormone (GIP) were performed during oral glucose tolerance testing preoperatively and 1 and 6 months postoperatively. Areas under the curve (AUC) were examined at 30, 60, and 120 min. RESULTS We observed significant improvements in measures of obesity, as well as static and dynamic measures of glucose, insulin, C-peptide and HOMA. Furthermore, significant increases in GLP-1 response as early as 6 months postoperatively were also seen. CONCLUSIONS To our knowledge, no study has examined the detailed dynamic changes in glucose and insulin homeostasis in this number of participants undergoing SG in relation to incretin hormones GIP and GLP-1. This current study supports the role of SG for the treatment of obesity-related glucose dysregulation.
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17
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Gastric Sensory and Motor Functions and Energy Intake in Health and Obesity-Therapeutic Implications. Nutrients 2021; 13:nu13041158. [PMID: 33915747 PMCID: PMC8065811 DOI: 10.3390/nu13041158] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/18/2021] [Accepted: 03/26/2021] [Indexed: 01/19/2023] Open
Abstract
Sensory and motor functions of the stomach, including gastric emptying and accommodation, have significant effects on energy consumption and appetite. Obesity is characterized by energy imbalance; altered gastric functions, such as rapid gastric emptying and large fasting gastric volume in obesity, may result in increased food intake prior to reaching usual fullness and increased appetite. Thus, many different interventions for obesity, including different diets, anti-obesity medications, bariatric endoscopy, and surgery, alter gastric functions and gastrointestinal motility. In this review, we focus on the role of the gastric and intestinal functions in food intake, pathophysiology of obesity, and obesity management.
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18
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Hu S, Tang H, Wang H, Dong Z, Jiang S, Wang C, Chen X, Yang W. Hyperinsulinemic Hypoglycemia after Bariatric Surgery. JOURNAL OF METABOLIC AND BARIATRIC SURGERY 2020; 9:1-6. [PMID: 36686896 PMCID: PMC9847643 DOI: 10.17476/jmbs.2020.9.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/08/2020] [Accepted: 05/19/2020] [Indexed: 06/13/2023]
Abstract
Postprandial hyperinsulinemic hypoglycemia (PHH) is one of the serious complications after bariatric surgery, it can lead life-threatening neuroglycopenic symptoms, such as seizures, disorientation, impairment of version and loss of consciousness without any premonitory. The presentation, prevalence, diagnosis, pathology and treatment are reviewed in this summary.
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Affiliation(s)
- Songhao Hu
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hanlin Tang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Huaxi Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhiyong Dong
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shuwen Jiang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaomei Chen
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
- State Key Laboratory of Pharmaceutical Biotechnology, LKS Faculty of Medicine, The University of Hong Kong, China
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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19
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Colás A, Varela M, Mraz M, Novak D, Cuesta-Frau D, Vigil L, Benes M, Pelikanova T, Haluzik M, Burda V, Vargas B. Influence of glucometric 'dynamical' variables on duodenal-jejunal bypass liner (DJBL) anthropometric and metabolic outcomes. Diabetes Metab Res Rev 2020; 36:e3287. [PMID: 31916665 DOI: 10.1002/dmrr.3287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 11/19/2019] [Accepted: 12/30/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The endoscopically implanted duodenal-jejunal bypass liner (DJBL) is an attractive alternative to bariatric surgery for obese diabetic patients. This article aims to study dynamical aspects of the glycaemic profile that may influence DJBL effects. METHODS Thirty patients underwent DJBL implantation and were followed for 10 months. Continuous glucose monitoring (CGM) was performed before implantation and at month 10. Dynamical variables from CGM were measured: coefficient of variation of glycaemia, mean amplitude of glycaemic excursions (MAGE), detrended fluctuation analysis (DFA), % of time with glycaemia under 6.1 mmol/L (TU6.1), area over 7.8 mmol/L (AO7.8) and time in range. We analysed the correlation between changes in both anthropometric (body mass index, BMI and waist circumference) and metabolic (fasting blood glucose, FBG and HbA1c) variables and dynamical CGM-derived metrics and searched for variables in the basal CGM that could predict successful outcomes. RESULTS There was a poor correlation between anthropometric and metabolic outcomes. There was a strong correlation between anthropometric changes and changes in glycaemic tonic control (∆BMI-∆TU6.1: rho = - 0.67, P < .01) and between metabolic outcomes and glycaemic phasic control (∆FBG-∆AO7.8: r = .60, P < .01). Basal AO7.8 was a powerful predictor of successful metabolic outcome (0.85 in patients with AO7.8 above the median vs 0.31 in patients with AO7.8 below the median: Chi-squared = 5.67, P = .02). CONCLUSIONS In our population, anthropometric outcomes of DJBL correlate with improvement in tonic control of glycaemia, while metabolic outcomes correlate preferentially with improvement in phasic control. Assessment of basal phasic control may help in candidate profiling for DJBL implantation.
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Affiliation(s)
- Ana Colás
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Varela
- Department of Internal Medicine, Hospital Universitario de Móstoles, Madrid, Spain
| | - Milos Mraz
- Department of Diabetes, Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Department of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Daniel Novak
- Department of Cybernetics, Czech Technical University in Prague, Prague, Czech Republic
| | - David Cuesta-Frau
- Technological Institute of Informatics, Universitat Politècnica de València, Alcoi, Spain
| | - Luis Vigil
- Department of Internal Medicine, Hospital Universitario de Móstoles, Madrid, Spain
| | - Marek Benes
- Hepatogastroenterology Department, Transplantation Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Terezie Pelikanova
- Department of Diabetes, Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martin Haluzik
- Department of Diabetes, Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Department of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
- Laboratory of Experimental Diabetology, Experimental Medicine Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Vaclav Burda
- Department of Cybernetics, Czech Technical University in Prague, Prague, Czech Republic
| | - Borja Vargas
- Department of Internal Medicine, Hospital Universitario de Móstoles, Madrid, Spain
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Nautiyal HK, Guan W, Lin S, Liang H. Preoperative predictors of early relapse/no-remission of type-2 diabetes after metabolic surgery in Chinese patients. Clin Obes 2020; 10:e12350. [PMID: 31909571 DOI: 10.1111/cob.12350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 10/20/2019] [Accepted: 10/27/2019] [Indexed: 12/11/2022]
Abstract
Remission of type 2 diabetes mellitus (T2DM) after metabolic surgery in some patients is not sustained. There is limited data regarding the preoperative factors predicting early relapse of T2DM in Chinese patients. The objective of this study is to look for preoperative predictors of early T2DM relapse/no remission in patients with obesity and diabetes who underwent Roux-en-Y gastric bypass (RYGB) or loop duodeno-jejunal bypass with sleeve gastrectomy (LDJB-SG). This is a retrospective study of 113 patients who underwent RYGB or LDJB-SG for T2DM. All T2DM patients with BMI 27.5 to 37.5 kg/m2 , having uncontrolled diabetes and T2DM patients with BMI > 37.5 were included in the study. A multivariate analysis with a logistic regression model was used for analysed factors. Nineteen patients (16.8%) had early relapse and 12 (10.6%) did not have remission. Mean age of patients was significantly more who relapsed/no-remission (44.9 vs 40.3 years). On univariate analysis, base line weight (86 vs 96.7 kg) was significantly lower in patients who relapsed/no-remission. Patients with sustained remission had statistically significant low glycosylated haemoglobin (P < .030), plasma glucose (120 minutes) (P < .002) on OGTT, area under curve glucose (P < .011) values and more C-peptide (P < .006) on univariate analysis. Only duration of diabetes (OR 2.78, 95% CI 1.56-4.97, P < .001) was found to be independent preoperative factor associated with early relapse/no-remission. Two years of diabetes duration was the cut-off point to predict relapse/no-remission (sensitivity 78.9, specificity 63.4, receiver operating characteristic curve 0.71). Duration of diabetes is the most probable, independent preoperative predictor of early T2DM relapse/no-remission in patient with obesity and diabetes undergoing metabolic surgery.
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Affiliation(s)
- Hemant K Nautiyal
- Department of General Surgery, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India
| | - Wei Guan
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
| | - Shibo Lin
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
| | - Hui Liang
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
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Craig S, Perry R, Vyavahare S, Ng M, Gault V, Flatt P, Irwin N. A GIP/xenin hybrid in combination with exendin-4 improves metabolic status in db/db diabetic mice and promotes enduring antidiabetic benefits in high fat fed mice. Biochem Pharmacol 2020; 171:113723. [DOI: 10.1016/j.bcp.2019.113723] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/15/2019] [Indexed: 12/23/2022]
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Akalestou E, Genser L, Rutter GA. Glucocorticoid Metabolism in Obesity and Following Weight Loss. Front Endocrinol (Lausanne) 2020; 11:59. [PMID: 32153504 PMCID: PMC7045057 DOI: 10.3389/fendo.2020.00059] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/30/2020] [Indexed: 01/08/2023] Open
Abstract
Glucocorticoids are steroid hormones produced by the adrenal cortex and are essential for the maintenance of various metabolic and homeostatic functions. Their function is regulated at the tissue level by 11β-hydroxysteroid dehydrogenases and they signal through the glucocorticoid receptor, a ligand-dependent transcription factor. Clinical observations have linked excess glucocorticoid levels with profound metabolic disturbances of intermediate metabolism resulting in abdominal obesity, insulin resistance and dyslipidaemia. In this review, we discuss the physiological mechanisms of glucocorticoid secretion, regulation and function, and survey the metabolic consequences of excess glucocorticoid action resulting from elevated release and activation or up-regulated signaling. Finally, we summarize the reported impact of weight loss by diet, exercise, or bariatric surgery on circulating and tissue-specific glucocorticoid levels and examine the therapeutic possibility of reversing glucocorticoid-associated metabolic disorders.
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Affiliation(s)
- Elina Akalestou
- Section of Cell Biology and Functional Genomics, Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial Centre for Translational and Experimental Medicine, Imperial College London, London, United Kingdom
| | - Laurent Genser
- Section of Cell Biology and Functional Genomics, Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial Centre for Translational and Experimental Medicine, Imperial College London, London, United Kingdom
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver Transplantation, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Institut Hospitalo-Universitaire ICAN, Sorbonne Université, Paris, France
| | - Guy A. Rutter
- Section of Cell Biology and Functional Genomics, Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial Centre for Translational and Experimental Medicine, Imperial College London, London, United Kingdom
- *Correspondence: Guy A. Rutter
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Karras SN, Koufakis T, Mustafa OG, Kotsa K. Anti-incretin effect: The other face of Janus in human glucose homeostasis. Obes Rev 2019; 20:1597-1607. [PMID: 31347774 DOI: 10.1111/obr.12917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/26/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023]
Abstract
The provocative idea that type 2 diabetes (T2D) may be a surgically treated disorder is based on accumulating evidence suggesting impressive remission rates of obesity and diabetes following bariatric surgery interventions. According to the "anti-incretin" theory, ingestion of food in the gastrointestinal (GI) tract, apart from activating the well-described incretin effect, also results in the parallel stimulation of a series of negative feedback mechanisms (anti-incretin effect). The primary goal of these regulations is to counteract the effects of incretins and other postprandial glucose-lowering adaptive mechanisms. Disruption of the equilibrium between incretins and anti-incretins could be an additional pathway leading to the development of insulin resistance and hyperglycemia. This theory provides an alternative theoretical framework to explain the mechanisms behind the optimal effects of metabolic surgery on T2D and underlines the importance of the GI tract in the homeostatic regulation of energy balance in humans. The anti-incretin concept is currently based on a limited amount of evidence and certainly requires further validation by additional studies. The aim of the present review is to discuss and critically evaluate recent evidence on the anti-incretin theory, providing an insight into current state and future perspectives.
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Affiliation(s)
- Spyridon N Karras
- Division of Endocrinology and Metabolism and Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Omar G Mustafa
- Department of Diabetes, King's College Hospital, London, UK
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Ferraz ÁAB, de Sá VCT, Santa-Cruz F, Siqueira LT, Silva LB, Campos JM. Roux-en-Y gastric bypass for nonobese patients with uncontrolled type 2 diabetes: a long-term evaluation. Surg Obes Relat Dis 2019; 15:682-687. [PMID: 31005458 DOI: 10.1016/j.soard.2019.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is growing evidence that the impact of Roux-en-Y gastric bypass (RYGB) on type 2 diabetes (T2D) occurs regardless of the amount of weight loss. Taking this background into consideration, it is plausible to study this procedure in individuals with lower body mass index (BMI) under clinical treatment failure for uncontrolled T2D. OBJECTIVES To elucidate the long-term impact of RYGB on T2D regression in a non-obese population. SETTING Hospital das Clínicas, Federal University of Pernambuco, Brazil. METHODS Twelve patients with BMI 25 to 30 kg/m2 and inadequately controlled T2D underwent RYGB and were followed up for 6 years. Fasting plasma glucose, glycated hemoglobin, BMI, and the use of insulin and/or oral hypoglycemic agents were assessed. Each variable was analyzed in 3 distinct moments: preoperative evaluation, 2-year postoperative follow-up (2-PO), and 6-year postoperative follow-up (6-PO). RESULTS There were no cases of early or late mortality. Mean BMI at preoperative evaluation, 2-PO, and 6-PO were 28.1 ± 1.2; 23.2 ± 2.4; and 24.7 ± 3.1, respectively. The lowest BMI at 6-PO was 19.1 kg/m2. Complete remission of T2D was achieved in 16.7%, partial remission in another 16.7%, glycemic control in 25%, and glycemic improvement in 25% of the sample at 6-PO; 16.7% did not present positive glycemic outcomes. Only 1 patient needed to resume insulin administration between 2-PO and 6-PO. CONCLUSIONS RYGB was found to be safe and effective in treating uncontrolled T2D in non-obese patients, providing improvements in the glycemic patterns in 83.4% of our sample.
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Affiliation(s)
- Álvaro A B Ferraz
- Department of Surgery, Hospital das Clínicas, Federal University of Pernambuco, Recife, PE, Brazil.
| | - Vladimir C T de Sá
- Department of Surgery, Hospital das Clínicas, Federal University of Pernambuco, Recife, PE, Brazil
| | | | - Luciana T Siqueira
- Department of Surgery, Hospital das Clínicas, Federal University of Pernambuco, Recife, PE, Brazil
| | - Lyz B Silva
- Department of Surgery, Hospital das Clínicas, Federal University of Pernambuco, Recife, PE, Brazil
| | - Josemberg M Campos
- Department of Surgery, Hospital das Clínicas, Federal University of Pernambuco, Recife, PE, Brazil
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Murad AJ, Cohen RV, de Godoy EP, Scheibe CL, Campelo GP, Ramos AC, de Lima RC, Pinto LEV, Coelho D, Costa HBF, Pinto ÍMP, Pereira T, Teófilo FRS, Valadão JA. A Prospective Single-Arm Trial of Modified Long Biliopancreatic and Short Alimentary Limbs Roux-En-Y Gastric Bypass in Type 2 Diabetes Patients with Mild Obesity. Obes Surg 2018; 28:599-605. [PMID: 28933045 DOI: 10.1007/s11695-017-2933-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Type-2 diabetes (T2D) patients with body mass index (BMI) below 35 kg/m2 carry lower remission rates than severely obese T2D individuals submitted to "standard limb lengths" Roux-en-Y gastric bypass (RYGB). Mild-obese patients appear to have more severe forms of T2D, where the mechanisms of glycemic control after a standard-RYGB may be insufficient. The elongation of the biliopancreatic limb may lead to greater stimulation of the distal intestine, alterations in bile acids and intestinal microbiota, among other mechanisms, leading to better metabolic outcomes. The aim of this study is to evaluate the safety and efficacy of the RYGB with a biliopancreatic limb of 200 cm in the control of T2D in patients with BMI 30-35 kg/m2. METHODS From January 2011 to May 2015, 102 T2D patients with BMI from 30 to 34.9 kg/m2 underwent laparoscopic RYGB with the biliopancreatic-limb of 200 cm and the alimentary-limb of 50 cm. RESULTS There were no deaths or reoperations. The mean follow-up was 28.1 months. The mean BMI dropped from 32.5 to 25.1 kg/m2, while the mean fasting glucose decreased from 182.9 to 89.8 mg/dl and the mean glycated hemoglobin (HbA1c) went from 8.7 to 5.2%. During follow-up, 92.2% had their T2D under complete control (HbA1c < 6%, no anti-diabetic medications), while 7.8% were under partial control. Control of hypertension and dyslipidemia were 89.4 and 85.5%, respectively. No patient developed hypoalbuminemia, and there were mild micronutrient deficiencies. CONCLUSIONS RYGB with long-biliopancreatic and short-alimentary limbs is safe and seems effective in achieving complete control of T2D in patients with BMIs between 30 and 35 kg/m2.
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Affiliation(s)
- Abdon José Murad
- Center for Bariatric and Metabolic Surgery, São Domingos Hospital, São Luís, Brazil.
| | - Ricardo Vitor Cohen
- The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | | | | | | | - Almino Cardoso Ramos
- Gastro-Obeso-Center Advanced Institute for Digestive and Bariatric Surgery, São Paulo, Brazil
| | | | | | - Daniel Coelho
- Service for Obesity and Related Diseases Surgery, Surgical Clinic Unit, Onofre Lopes University Hospital, Natal, Brazil
| | | | - Ígor Marreiros Pereira Pinto
- Service for Obesity and Related Diseases Surgery, Surgical Clinic Unit, Onofre Lopes University Hospital, Natal, Brazil
| | - Tiago Pereira
- Technology and Healthcare Unit, Oswaldo Cruz German Hospital, São Paulo, Brazil
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Pop LM, Mari A, Zhao TJ, Mitchell L, Burgess S, Li X, Adams-Huet B, Lingvay I. Roux-en-Y gastric bypass compared with equivalent diet restriction: Mechanistic insights into diabetes remission. Diabetes Obes Metab 2018; 20. [PMID: 29532631 PMCID: PMC5999551 DOI: 10.1111/dom.13287] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To investigate the physiological mechanisms leading to rapid improvement in diabetes after Roux-en-Y gastric bypass (RYGB) and specifically the contribution of the concurrent peri-operative dietary restrictions, which may also alter glucose metabolism. MATERIALS AND METHODS In order to assess the differential contributions of diet and surgery to the mechanisms leading to the rapid improvement in diabetes after RYGB we enrolled 10 patients with type 2 diabetes scheduled to undergo RYGB. All patients underwent a 10-day inpatient supervised dietary intervention equivalent to the peri-operative diet (diet-only period), followed by, after a re-equilibration (washout) period, an identical period of pair-matched diet in conjunction with RYGB (diet and RYGB period). We conducted extensive metabolic assessments during a 6-hour mixed-meal challenge test, with stable isotope glucose tracer infusion performed before and after each intervention. RESULTS Similar improvements in glucose levels, β-cell function, insulin sensitivity and post-meal hepatic insulin resistance were observed with both interventions. Both interventions led to significant reductions in fasting and postprandial acyl ghrelin. The diet-only intervention induced greater improvements in basal hepatic glucose output and post-meal gastric inhibitory polypeptide (GIP) secretion. The diet and RYGB intervention induced significantly greater increases in post-meal glucagon-like peptide-1 (GLP-1), peptide YY (PYY) and glucagon levels. CONCLUSIONS Strict peri-operative dietary restriction is a main contributor to the rapid improvement in glucose metabolism after RYGB. The RYGB-induced changes in the incretin hormones GLP-1 and PYY probably play a major role in long-term compliance with such major dietary restrictions through central and peripheral mechanisms.
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Affiliation(s)
- Laurentiu M. Pop
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrea Mari
- National Research Council, Institute of Neuroscience, Padua, Italy
| | - Tong-Jin Zhao
- Department of Molecular Genetics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, Xiamen University, Xiamen, Fujian, China (current affiliation)
| | - Lori Mitchell
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatrics, University of Texas Medical Branch at Galveston, Texas, USA
| | - Shawn Burgess
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Xilong Li
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Beverley Adams-Huet
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Internal Medicine, Division of Mineral Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ildiko Lingvay
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Zhai H, Li Z, Peng M, Huang Z, Qin T, Chen L, Li H, Zhang H, Zhang W, Xu G. Takeda G Protein-Coupled Receptor 5-Mechanistic Target of Rapamycin Complex 1 Signaling Contributes to the Increment of Glucagon-Like Peptide-1 Production after Roux-en-Y Gastric Bypass. EBioMedicine 2018; 32:201-214. [PMID: 29859856 PMCID: PMC6020750 DOI: 10.1016/j.ebiom.2018.05.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 05/20/2018] [Accepted: 05/21/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The mechanism by which Roux-en-Y Gastric Bypass (RYGB) increases the secretion of glucagon-like peptide-1 (GLP-1) remains incompletely defined. Here we investigated whether TGR5-mTORC1 signaling mediates the RYGB-induced alteration in GLP-1 production in mice and human beings. METHODS Circulating bile acids, TGR5-mTORC1 signaling, GLP-1 synthesis and secretion were determined in lean or obese male C57BL/6 mice with or without RYGB operation, as well as in normal glycemic subjects, obese patients with type 2 diabetes before and after RYGB. RESULTS Positive relationships were observed among circulating bile acids, ileal mechanistic target of rapamycin complex 1 (mTORC1) signaling and GLP-1 during changes in energy status in the present study. RYGB increased circulating bile acids, ileal Takeda G protein-coupled receptor 5 (TGR5) and mTORC1 signaling activity, as well as GLP-1 production in both mice and human subjects. Inhibition of ileal mTORC1 signaling by rapamycin significantly attenuated the stimulation of bile acid secretion, TGR5 expression and GLP-1 synthesis induced by RYGB in lean and diet-induced obese mice. GLP-1 production and ileal TGR5-mTORC1 signaling were positively correlated with plasma deoxycholic acid (DCA) in mice. Treatment of STC-1 cells with DCA stimulated the production of GLP-1. This effect was associated with a significant enhancement of TGR5-mTORC1 signaling. siRNA knockdown of mTORC1 or TGR5 abolished the enhancement of GLP-1 synthesis induced by DCA. DCA increased interaction between mTOR-regulatory-associated protein of mechanistic target of rapamycin (Raptor) and TGR5 in STC-1 cells. INTERPRETATION Deoxycholic acid-TGR5-mTORC1 signaling contributes to the up-regulation of GLP-1 production after RYGB.
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Affiliation(s)
- Hening Zhai
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China; Endoscopy Center, The First Affiliated Hospital of Jinan University, 613 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510630, China
| | - Zhi Li
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China
| | - Miao Peng
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China
| | - Zhaoqi Huang
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China
| | - Tingfeng Qin
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China
| | - Linxi Chen
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China
| | - Hanbing Li
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China
| | - Heng Zhang
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China
| | - Weizhen Zhang
- Shenzhen University Diabetes Center, Shenzhen University Health Science Center, Shenzhen, Guangdong 518060, China; Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109-0346, USA.
| | - Geyang Xu
- Department of Physiology, School of Medicine, Jinan University, 601 Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510632, China.
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Jerlhag E. GLP-1 signaling and alcohol-mediated behaviors; preclinical and clinical evidence. Neuropharmacology 2018; 136:343-349. [PMID: 29337226 DOI: 10.1016/j.neuropharm.2018.01.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/18/2017] [Accepted: 01/09/2018] [Indexed: 12/20/2022]
Abstract
Alcohol addiction, affecting approximately four percent of the population, contributes significantly to the global burden of diseases and is a substantial cost to the society. The neurochemical mechanisms regulating alcohol mediated behaviors is complex and in more recent years a new physiological role of the gut-brain peptides, traditionally known to regulate appetite and food intake, have been suggested. Indeed, regulators of alcohol-mediated behaviors. One of these gut-brain peptides is the annorexigenic peptide glucagon-like peptide-1 (GLP-1), Preclinical studies show that GLP-1 receptor activation, either by GLP-1 or analogues, attenuate the ability of alcohol to activate the mesolimbic dopamine system as well as decrease alcohol consumption and operant self-administration. In further support for the endogenous GLP-1 system in addiction processes are the experimental data showing that a GLP-1 receptor antagonist increases alcohol intake. Moreover, GLP-1 receptor agonists prevent the ability of other addictive drugs to activate the mesolimbic dopamine system. The number of clinical studies is limited, but show i) that genetic variation in the GLP-1 receptor gene is associated with alcohol addiction as well as increased alcohol infusion in humans, ii) that plasma levels of GLP-1 are associated with the subjective experience of cocaine and iii) that a GLP-1 receptor agonist reduces alcohol intake in patients with type-2 diabetes mellitus. These experimental and clinical studies raises the concern that clinically available GLP-1 receptor agonists deserves to be tested as potential treatments of patients with addictive disorders including alcohol addiction. This article is part of the Special Issue entitled 'Metabolic Impairment as Risk Factors for Neurodegenerative Disorders.'
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Affiliation(s)
- Elisabet Jerlhag
- Department of Pharmacology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Medicinaregatan 13A, SE-405 30 Gothenburg, Sweden.
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Glaysher MA, Mohanaruban A, Prechtl CG, Goldstone AP, Miras AD, Lord J, Chhina N, Falaschetti E, Johnson NA, Al-Najim W, Smith C, Li JV, Patel M, Ahmed AR, Moore M, Poulter N, Bloom S, Darzi A, Le Roux C, Byrne JP, Teare JP. A randomised controlled trial of a duodenal-jejunal bypass sleeve device (EndoBarrier) compared with standard medical therapy for the management of obese subjects with type 2 diabetes mellitus. BMJ Open 2017; 7:e018598. [PMID: 29146657 PMCID: PMC5695522 DOI: 10.1136/bmjopen-2017-018598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The prevalence of obesity and obesity-related diseases, including type 2 diabetes mellitus (T2DM), is increasing. Exclusion of the foregut, as occurs in Roux-en-Y gastric bypass, has a key role in the metabolic improvements that occur following bariatric surgery, which are independent of weight loss. Endoscopically placed duodenal-jejunal bypass sleeve devices, such as the EndoBarrier (GI Dynamics, Lexington, Massachusetts, USA), have been designed to create an impermeable barrier between chyme exiting the stomach and the mucosa of the duodenum and proximal jejunum. The non-surgical and reversible nature of these devices represents an attractive therapeutic option for patients with obesity and T2DM by potentially improving glycaemic control and reducing their weight. METHODS AND ANALYSIS In this multicentre, randomised, controlled, non-blinded trial, male and female patients aged 18-65 years with a body mass index 30-50 kg/m2 and inadequately controlled T2DM on oral antihyperglycaemic medications (glycosylated haemoglobin (HbA1c) 58-97 mmol/mol) will be randomised in a 1:1 ratio to receive either the EndoBarrier device (n=80) for 12 months or conventional medical therapy, diet and exercise (n=80). The primary outcome measure will be a reduction in HbA1c by 20% at 12 months. Secondary outcome measures will include percentage weight loss, change in cardiovascular risk factors and medications, quality of life, cost, quality-adjusted life years accrued and adverse events. Three additional subgroups will investigate the mechanisms behind the effect of the EndoBarrier device, looking at changes in gut hormones, metabolites, bile acids, microbiome, food hedonics and preferences, taste, brain reward system responses to food, eating and addictive behaviours, body fat content, insulin sensitivity, and intestinal tissue gene expression. TRIAL REGISTRATION NUMBER ISRCTN30845205, ClinicalTrials.gov Identifier NCT02459561.
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Affiliation(s)
- Michael Alan Glaysher
- Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, Hampshire, UK
| | | | | | - Anthony P Goldstone
- PsychoNeuroEndocrinology Research Group, Neuropsychopharmacology Unit, Centre for Psychiatry and Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, London, UK
| | - Alexander Dimitri Miras
- Division of Diabetes, Endocrinology and Metabolic Medicine, Hammersmith Hospital, London, UK
| | - Joanne Lord
- Southampton HTA Centre, University of Southampton, University of Southampton Science Park, Southampton, UK
| | - Navpreet Chhina
- Computational Cognitive and Clinical Neuroimaging Group, Hammersmith Hospital, Imperial College London, London, UK
| | | | | | - Werd Al-Najim
- Department of Investigative Medicine, Imperial College London, London, UK
- Diabetes Complications Research Centre, Conway Institute, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Claire Smith
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Jia V Li
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Mayank Patel
- Department of Diabetes and Endocrinology, Southampton General Hospital, Southampton, UK
| | - Ahmed R Ahmed
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Michael Moore
- Primary Care Medical Group, University of Southampton Medical School, Southampton, UK
| | - Neil Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Stephen Bloom
- North West London Pathology, Head of Division of Diabetes, Endocrinology and Metabolism, Imperial College London, Hammersmith Hospital, London, UK
| | - Ara Darzi
- Division of Surgery, Imperial College London, London, UK
| | - Carel Le Roux
- Head of Pathology, University College Dublin, Dublin, Ireland
| | - James P Byrne
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Julian P Teare
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
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Stefanidis A, Oldfield BJ. Neuroendocrine mechanisms underlying bariatric surgery: Insights from human studies and animal models. J Neuroendocrinol 2017; 29. [PMID: 28887853 DOI: 10.1111/jne.12534] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 02/06/2023]
Abstract
Obesity has reached epidemic proportions and, to date, bariatric surgery remains the only effective treatment for morbid obesity in terms of its capacity to achieve durable weight loss. Bariatric surgery procedures, including Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB) and sleeve gastrectomy (SG), have been the primary procedures conducted over the past decade, with SG increasing in popularity over the past 5 years at the expense of both RYGB and AGB. Although these procedures were initially proposed to function via restrictive or malabsorptive mechanisms, it is now clear that profound physiological changes underlie the metabolic improvements in patients who undergo bariatric surgery. Data generated in human patients and animal models highlight the rapid and sustained changes in gut hormones that coincide with these procedures. Furthermore, recent studies highlight the involvement of the nervous system, specifically the vagus nerve, in mediating the reduction in appetite and food intake following bariatric surgery. What is unclear is where these pathways converge and interact within the gut-brain axis and whether vagally-mediated circuits are sufficient to drive the metabolic sequalae following bariatric surgery.
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Affiliation(s)
- A Stefanidis
- Department of Physiology, Monash University, Clayton, VIC, Australia
| | - B J Oldfield
- Metabolic Disease and Obesity Program, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
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Effects of Laparoscopic Roux-en-Y Gastric Bypass on Chinese Type 2 Diabetes Mellitus Patients with Different Levels of Obesity: Outcomes After 3 Years’ Follow-Up. Obes Surg 2017; 28:702-711. [DOI: 10.1007/s11695-017-2903-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zaveri H, Dallal RM, Cottam D, Surve A, Kartiko S, Bonnani F, Cottam A, Cottam S. Indications and Operative Outcomes of Gastric Bypass Reversal. Obes Surg 2017; 26:2285-90. [PMID: 26883929 DOI: 10.1007/s11695-016-2105-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is one of the best-known and most commonly performed bariatric procedures. However, this procedure carries infrequent but serious long-term complications, which may require revisional procedures. This study reports the indications and outcomes of gastric bypass reversal that have not been described well in the literature. METHODS A multicenter retrospective study of 50 patients who underwent reversal of RYGB conducted between 2006 and 2015 was reviewed to describe the usual indications and outcomes of gastric bypass reversal surgeries. RESULTS Of 50 patients, 7 (14 %) were males and 43 (86 %) were females. The mean age of the patient population was 40.4 ± 11.6 years (range 19-66). Reasons for reversal included anastomotic ulcers (n = 27), anastomotic complications (n = 9), malnutrition (n = 2), and functional disorder (n = 12). The mean BMI before the reversal was 29 ± 9.4 kg/m(2) (range 16-60). The mean time between the primary procedure and reversal was 60 ± 65.5 months (range 2-300). Fourteen of the reversals were done via laparotomy. Mean hospital stay was 8.4 ± 7.3 days (range 3-34 days). There was no peri-operative death 30 days after reversal. Following gastric bypass reversal, 92.6 % (n = 25) of the patient population had resolution from ulcers, 77.8 % (n = 7) of the patient population had resolution from anatomic complications, 100 % (n = 2) of the patient population had resolution from malnutrition, and 66.7 % (n = 8) of the patient population had resolution from functional disorders. CONCLUSIONS Gastric bypass reversal is a reasonable and safe treatment for complications arising from the GBP surgery. A laparoscopic approach is feasible in select patients.
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Affiliation(s)
- Hinali Zaveri
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
| | - Ramsey M Dallal
- Einstein Healthcare Network, 60 Township Line Road, Elkins Park, PA, 19027, USA
| | - Daniel Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA.
| | - Amit Surve
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
| | - Susan Kartiko
- Einstein Healthcare Network, 60 Township Line Road, Elkins Park, PA, 19027, USA
| | - Fernando Bonnani
- Abington Memorial Hospital, 225 Newtown Rd, 2nd Flr-Main Bldg, Warminster, PA, 18974, USA
| | - Austin Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
| | - Samuel Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT, 84102, USA
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Weiss CR, Akinwande O, Paudel K, Cheskin LJ, Holly B, Hong K, Fischman AM, Patel RS, Shin EJ, Steele KE, Moran TH, Kaiser K, Park A, Shade DM, Kraitchman DL, Arepally A. Clinical Safety of Bariatric Arterial Embolization: Preliminary Results of the BEAT Obesity Trial. Radiology 2017; 283:598-608. [PMID: 28195823 PMCID: PMC5410948 DOI: 10.1148/radiol.2016160914] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose To conduct a pilot prospective clinical trial to evaluate the feasibility, safety, and short-term efficacy of bariatric embolization, a recently developed endovascular procedure for the treatment of obesity, in patients with severe obesity. Materials and Methods This is an institutional review board- and U.S. Food and Drug Administration-approved prospective physician-initiated investigational device exemption study. This phase of the study ran from June 2, 2014, to August 4, 2015. Five severely obese patients (four women, one man) who were 31-49 years of age and who had a mean body mass index of 43.8 kg/m2 ± 2.9 with no clinically important comorbidities were enrolled in this study. Transarterial embolization of the gastric fundus with fluoroscopic guidance was performed with 300-500-μm Embosphere microspheres. The primary end point was 30-day adverse events (AEs). The secondary end points included short-term weight loss, serum obesity-related hormone levels, hunger and satiety assessments, and quality of life (QOL) surveys, reported up to 3 months. Simple statistics of central tendencies and variability were calculated. No hypothesis testing was performed. Results The left gastric artery, with or without the gastroepiploic artery, was embolized in five patients, with a technical success rate of 100%. There were no major AEs. There were two minor AEs-subclinical pancreatitis and a mucosal ulcer that had healed by the time of 3-month endoscopy. A hospital stay of less than 48 hours for routine supportive care was provided for three patients. Mean excess weight loss of 5.9% ± 2.4 and 9.0% ± 4.1 was noted at 1 month and at 3 months, respectively. Mean change in serum ghrelin was 8.7% ± 34.7 and -17.5% ± 29 at 1 month and 3 months, respectively. Mean changes in serum glucagon-like peptide 1 and peptide YY were 106.6% ± 208.5 and 17.8% ± 54.8 at 1 month. There was a trend toward improvement in QOL parameters. Hunger/appetite scores decreased in the first 2 weeks after the procedure and then rose without reaching preprocedure levels. Conclusion Bariatric embolization is feasible and appears to be well tolerated in severely obese patients. In this small patient cohort, it appears to induce appetite suppression and may induce weight loss. Further expansion of this study will provide more insight into the long-term safety and efficacy of bariatric embolization. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Clifford R. Weiss
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Olaguoke Akinwande
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Kaylan Paudel
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Lawrence J. Cheskin
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Brian Holly
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Kelvin Hong
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Aaron M. Fischman
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Rahul S. Patel
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Eun J. Shin
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Kimberley E. Steele
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Timothy H. Moran
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Kristen Kaiser
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Amie Park
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - David M. Shade
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Dara L. Kraitchman
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
| | - Aravind Arepally
- From the Departments of Radiology (C.R.W., O.A., K.P., B.H., K.H., D.L.K.), Gastroenterology and Hepatology (E.J.S.), Surgery (K.E.S.), and Psychiatry (T.H.M.), Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7203, 1800 Orleans St, Baltimore, MD 21287; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md (L.J.C.); Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.M.F., R.S.P.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (K.K., A.P., D.M.S.); and Department of Radiology, Piedmont Healthcare, Atlanta, Ga (A.A.)
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Mazidi M, Gao HK, Li L, Hui H, Zhang Ye. Effects of Roux-en-Y gastric bypass on insulin secretion and sensitivity, glucose homeostasis, and diabetic control: A prospective cohort study in Chinese patients. Surgery 2017; 161:1423-1429. [DOI: 10.1016/j.surg.2016.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/04/2016] [Accepted: 11/19/2016] [Indexed: 02/06/2023]
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Campos J, Ramos A, Szego T, Zilberstein B, Feitosa H, Cohen R. THE ROLE OF METABOLIC SURGERY FOR PATIENTS WITH OBESITY GRADE I AND TYPE 2 DIABETES NOT CONTROLLED CLINICALLY. ACTA ACUST UNITED AC 2017; 29 Suppl 1:102-106. [PMID: 27409057 PMCID: PMC5064276 DOI: 10.1590/0102-6720201600s10025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/19/2016] [Indexed: 12/13/2022]
Abstract
Introduction Even considering the advance of the medical treatment in the last 20 years with new and more effective drugs, the outcomes are still disappointing as the control of obesity and type 2 Diabetes Mellitus (T2DM) with a large number of patients under the medical treatment still not reaching the desired outcomes. Objective: To present a Metabolic Risk Score to better guide the surgical indication for T2DM patients with body mass index (BMI) where surgery for obesity is still controversial. Method: Research was conducted in Pubmed, Medline, Pubmed Central, Scielo and Lilacs between 2003-2015 correlating headings: metabolic surgery, obesity and type 2 diabetes mellitus. In addition, representatives of the societies involved, as an expert panel, issued opinions. Results: Forty-five related articles were analyzed by evidence-based medicine criteria. Grouped opinions sought to answer the following questions: Why metabolic and not bariatric surgery?; Mechanisms involved in glycemic control; BMI as a single criterion for surgical indication for uncontrolled T2DM; Results of metabolic surgery studies in BMI<35 kg/m2; Safety of metabolic surgery in patients with BMI<35 kg/m2; Long-term effects of surgery in patients with baseline BMI<35 kg/m2 and Proposal for a Metabolic Risk Score. Conclusion: Metabolic surgery has well-defined mechanisms of action both in experimental and human studies. Gastrointestinal interventions in T2DM patients with IMC≤35 kg/m2 has similar safety and efficacy when compared to groups with greater BMIs, leading to the improvement of diabetes in a superior manner than clinical treatment and lifestyle changes, in part through weight loss independent mechanisms . There is no correlation between baseline BMI and weight loss in the long term with the success rate after any surgical treatment. Gastrointestinal surgery treatment may be an option for patients with T2DM without adequate clinical control, with a BMI between 30 and 35, after thorough evaluation following the parameters detailed in Metabolic Risk Score defined by the surgical societies. Roux-en-Y gastric bypass (RYGB), because of its well known safety and efficacy and longer follow-up studies, is the main surgical technique indicated for patients eligible for surgery through the Metabolic Risk Score. The vertical sleeve gastrectomy may be considered if there is an absolute contraindication for the RYGB. T2DM patients should be evaluated by the multiprofessional team that will assess surgical eligibility, preoperative work up, follow up and long term monitoring for micro and macrovascular complications.
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Affiliation(s)
- Josemberg Campos
- Inter Societary guideline bythe Brazilian Society for Bariatric and Metabolic Surgery (SBCBM), Brazilian College of Surgeons (CBC) and Brazilian College of Digestive Surgery (CBCD), São Paulo, SP, Brazil
| | - Almino Ramos
- Inter Societary guideline bythe Brazilian Society for Bariatric and Metabolic Surgery (SBCBM), Brazilian College of Surgeons (CBC) and Brazilian College of Digestive Surgery (CBCD), São Paulo, SP, Brazil
| | - Thomaz Szego
- Inter Societary guideline bythe Brazilian Society for Bariatric and Metabolic Surgery (SBCBM), Brazilian College of Surgeons (CBC) and Brazilian College of Digestive Surgery (CBCD), São Paulo, SP, Brazil
| | - Bruno Zilberstein
- Inter Societary guideline bythe Brazilian Society for Bariatric and Metabolic Surgery (SBCBM), Brazilian College of Surgeons (CBC) and Brazilian College of Digestive Surgery (CBCD), São Paulo, SP, Brazil
| | - Heládio Feitosa
- Inter Societary guideline bythe Brazilian Society for Bariatric and Metabolic Surgery (SBCBM), Brazilian College of Surgeons (CBC) and Brazilian College of Digestive Surgery (CBCD), São Paulo, SP, Brazil
| | - Ricardo Cohen
- Inter Societary guideline bythe Brazilian Society for Bariatric and Metabolic Surgery (SBCBM), Brazilian College of Surgeons (CBC) and Brazilian College of Digestive Surgery (CBCD), São Paulo, SP, Brazil
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Bunt JC, Blackstone R, Thearle MS, Vinales KL, Votruba S, Krakoff J. Changes in glycemia, insulin and gut hormone responses to a slowly ingested solid low-carbohydrate mixed meal after laparoscopic gastric bypass or band surgery. Int J Obes (Lond) 2017; 41:706-713. [PMID: 28119531 DOI: 10.1038/ijo.2017.22] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 12/22/2016] [Accepted: 01/11/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate early changes in glycemia, insulin physiology and gut hormone responses to an easily tolerated and slowly ingested solid, low-carbohydrate mixed meal test (MMT) following laparoscopic adjustable gastric banding (LAGB) or Roux-en-Y gastric bypass (RYGB) surgery. SUBJECTS/METHODS This was a prospective non-randomized study. Plasma glucose, insulin and c-peptide (to estimate hepatic insulin extraction; %HIE), incretins (GIP, aGLP-1) and pancreatic polypeptide (PP) responses to the MMT were measured at 4-8 weeks before and after surgery in obese, metabolically healthy patients (RYGB=10F or LAGB =7F/1M). Supplementary clamp data on basal endogenous glucose production (EGP) and peripheral insulin action (Rd=rate of glucose disposal) and metabolic clearance rates of insulin (MCR-INS) were available in five of the RYGB patients. Repeated measures were appropriately accounted for in the analyses. RESULTS Following LAGB surgery, C-peptide and insulin MMT profiles (P=0.004 and P=0.0005, respectively) were lower with no change in %HIE (P=0.98). In contrast, in RYGB subjects, both fasting glucose and insulin (Δ=-0.66 mmol l-1, P⩽0.05 and Δ=-44.4 pmol l-1, P⩽0.05, respectively) decreased, and MMT glucose (P<0.0001) and insulin (P=0.001) but not c-peptide (P= 0.69) decreased. Estimated %HIE increased at fasting (Δ=8.4%, P⩽0.05) and during MMT (P=0.0005). Early (0-20 min) prandial glucose (0.27±0.26 versus 0.006±0.21 mmol l-1, P⩽0.05) and insulin (63(48, 66) versus 18(12, 24) pmol l-1, P⩽0.05) responses increased after RYGB. RYGB altered the trajectory of prandial aGLP-1 responses (treatment × trajectory P=0.02), and PP was lower (P<0.0001). Clamp data in a subset of RYGB patients showed early improvement in basal EGP (P=0.001), and MCR-INS (P=0.015). CONCLUSION RYGB results in distinctly different changes in plasma glucose, insulin and gut hormone response patterns to a solid, slowly ingested low-carbohydrate MMT versus LAGB. Altered nutrient delivery, along with indirect evidence for changes in hepatic and peripheral insulin physiology, are consistent with the greater early improvement in glycemia observed after RYGB versus LAGB surgery.
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Affiliation(s)
- J C Bunt
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, NIDDK, NIH, DHHS, Phoenix, AZ, USA
| | - R Blackstone
- Scottsdale Healthcare Bariatric Center, Scottsdale, AZ, USA.,Department of Surgery, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - M S Thearle
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, NIDDK, NIH, DHHS, Phoenix, AZ, USA
| | - K L Vinales
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, NIDDK, NIH, DHHS, Phoenix, AZ, USA
| | - S Votruba
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, NIDDK, NIH, DHHS, Phoenix, AZ, USA
| | - J Krakoff
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, NIDDK, NIH, DHHS, Phoenix, AZ, USA
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Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European survey. Obes Surg 2016; 26:933-40. [PMID: 26341086 DOI: 10.1007/s11695-015-1865-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts). METHODS Eight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62%). In 175/313 patients, 55.9% underwent MGB/OAGB, while in 138/313 patients, 44.1% received SG between January 2006 and December 2014. RESULTS Two hundred six out of 313 (63.7 %) pts reached 1 year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1 ± 6.6, and the mean BMI for SG pts was 35.9 ± 5.9 (p < 0.001). Eighty-two out of 96 (85.4%) MGB/OAGB pts vs. 67/110 (60.9%) SG pts are in remission (p < 0.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR) = 0.623, 95% confidence interval (CI) 0.419-0.925, p = 0.01], preoperative consumption of insulin or oral antidiabetic agents (OR = 0.256, 95% CI 0.137-0.478, p = <0.001), and T2DM duration >10 years (OR = 0.752, 95% CI 0.512-0.976, p = 0.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (OR = 3.888, 95% CI 1.654-9.143, p = 0.002) of diabetes remission. CONCLUSIONS A significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12 months have been identified.
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Abstract
Diabetes mellitus and obesity are closely interrelated and pose a major burden on health care in terms of morbidity and mortality. Weight loss has favorable metabolic benefits for glycemic control and improvement of metabolic syndrome. Bariatric surgery (BS) is the most effective treatment for weight loss with durable results as compared to lifestyle modification. BS procedures have been associated with significant reduction in abdominal obesity, metabolic syndrome components, and glycemic control requiring fewer medications. Long-term risks of surgery include nutritional deficiencies, osteoporosis, bone fractures, and hyperinsulinemic hypoglycemia, which need to be carefully balanced with metabolic benefits for individual patients.
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Affiliation(s)
- Sidra Azim
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, 9500 Euclid Avenue (F-20), Cleveland, OH 44195, USA
| | - Sangeeta R Kashyap
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, 9500 Euclid Avenue (F-20), Cleveland, OH 44195, USA.
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Selective beneficial cardiometabolic effects of vertical sleeve gastrectomy are predominantly mediated through glucagon-like peptide (GLP-1) in Zucker diabetic fatty rats. Ann Med Surg (Lond) 2016; 12:65-74. [PMID: 27900077 PMCID: PMC5123065 DOI: 10.1016/j.amsu.2016.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 12/12/2022] Open
Abstract
Background Glucagon-like peptide-1 (GLP-1) level was significantly increased post Vertical Sleeve Gastrectomy (VSG), an effect believed to contribute to its beneficial cardiometabolic effects. Objective To validate the beneficial GLP-1 mediated cardiometabolic effects post VSG using GLP-1 antagonist (exendin 9-39) in Zucker diabetic fatty rats. Methods Animals were divided into three (n = 5) groups: (i) sham, (ii) VSG, and (iii) VSG received exendin 9–39 (GLP-1 receptor antagonist). The study was performed over 12 weeks and parameters were measured 12 weeks post-surgery. Results and discussion As expected, fasting blood glucose and insulin levels were improved post VSG due to enhanced GLP-1 secretion. However, both fasting glucose and insulin levels were impaired in the presence of GLP-1 antagonist. Baseline total cholesterol level pre-surgery was 100±1 mg/dl which remained unchanged in the VSG group but significantly increased to 140±8 mg/dl in the presence of antagonist. Interestingly, post-surgery there was a nearly 70% reduction in triglyceride level in the VSG group compared to sham which was overcome in the presence of antagonist. Myographic studies using aortic rings showed no significant change between groups. Additionally, blood pressure and heart rate also remained unchanged in all groups. Serum bile acid and L-PGDS levels increased post VSG but significantly decreased in the presence of antagonist, suggesting a strong association with GLP-1 and a novel mechanism of action. Conclusion Enhanced GLP-1 secretion post VSG imparted beneficial cardiometabolic effects on blood glucose, insulin, total cholesterol, triglyceride, bile acids and L-PGDS levels which were abated in the presence of GLP-1 antagonist. GLP-1 increases post-VSG 30 min after glucose load. Post-VSG GLP-1 secretion is associatged with lower cholesterol and triglycerides. Bile acids and L-PGDS increase post-VSG and are inhibited in the presence of GLP-1 antagonist. Heart rate, blood pressure and myograph profile remain unchanged.
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Sala P, Belarmino G, Machado NM, Cardinelli CS, Al Assal K, Silva MM, Fonseca DC, Ishida RK, Santo MA, de Moura EGH, Sakai P, Guarda IFMS, da Silva IDCG, Rodrigues AS, Pereira CADB, Heymsfield S, Doré J, Torrinhas RSMDM, Giannella-Neto D, Waitzberg DL. The SURMetaGIT study: Design and rationale for a prospective pan-omics examination of the gastrointestinal response to Roux-en-Y gastric bypass surgery. J Int Med Res 2016; 44:1359-1375. [PMID: 27834300 PMCID: PMC5536762 DOI: 10.1177/0300060516667862] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Objective To describe the protocol of the SURgically induced Metabolic effects on the Human GastroIntestinal Tract (SURMetaGIT) study, a clinical pan-omics study exploring the gastrointestinal tract as a central organ driving remission of type 2 diabetes mellitus (T2DM) after Roux-en-Y gastric bypass (RYGB). The main points considered in the study’s design and challenges faced in its application are detailed. Methods This observational, longitudinal, prospective study involved collection of gastrointestinal biopsy specimens, faeces, urine, and blood from 25 obese women with T2DM who were candidates for RYGB (20 patients for omics assessment and 5 for omics validation). These collections were performed preoperatively and 3 and 24 months postoperatively. Gastrointestinal transcriptomics; faecal metagenomics and metabolomics; plasma proteomics, lipidomics, and metabolomics; and biochemical, nutritional, and metabolic data were assessed to identify their short- and long-term correlations with T2DM remission. Results Data were collected from 20 patients before and 3 months after RYGB. These patients have nearly completed the 2-year follow-up assessments. The five additional patients are currently being selected for omics data validation. Conclusion The multi-integrated pan-omics approach of the SURMetaGIT study enables integrated analysis of data that will contribute to the understanding of molecular mechanisms involved in T2DM remission after RYGB.
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Affiliation(s)
- Priscila Sala
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
- Priscila Sala - Av. Dr. Arnaldo, 455, 2° andar, sala 2208 – Cerqueira César - CEP: 01246-903, São Paulo – SP, Brazil.
| | - Giliane Belarmino
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | - Natasha Mendonça Machado
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | - Camila Siqueira Cardinelli
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | - Karina Al Assal
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | - Mariane Marques Silva
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | - Danielle Cristina Fonseca
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | - Robson Kiyoshi Ishida
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | - Marco Aurélio Santo
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | | | - Paulo Sakai
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Steven Heymsfield
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, LA, USA
| | - Joel Doré
- Institut National de la Recherche Agronomique INRA, France
| | | | | | - Dan Linetzky Waitzberg
- Department of Gastroenterology, Digestive Surgery Discipline, School of Medicine, FMUSP – University of São Paulo, São Paulo, Brazil
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Fenger M, Hansen DL, Worm D, Hvolris L, Kristiansen VB, Carlsson ER, Madsbad S. Gastric bypass surgery reveals independency of obesity and diabetes melitus type 2. BMC Endocr Disord 2016; 16:59. [PMID: 27829412 PMCID: PMC5103622 DOI: 10.1186/s12902-016-0140-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 10/21/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Roux-en-Y gastric bypass surgery is widely applied to ameliorate morbid obesity, including diabetes in people with type 2 diabetes. The latter vanish a few days after surgery for many, but not in all patients before any weight reduction has occurred. The explanation for this change in metabolic status is poorly understood, but the observation may suggest that the fate obesity and diabetes is only partly linked after surgery. METHODS The trajectories of weight reduction measured as reduced body mass index (BMI) in 741obese subjects with and without diabetes were evaluated. Evaluation was performed on three groups: 1) subjects that were non-diabetic before and after surgery; 2) subjects that were diabetics before surgery but non-diabetics after surgery; and 3) subjects that were diabetics before surgery and remained diabetics after surgery. The diabetic state was established at HbA1c above 48 mmol/mol. RESULTS The trajectories differ significantly between groups and any sub-populations of groups, the latter identified by the distance between individual trajectories using a k-means procedure. The results suggest that different domains in the enormous genetic network governing basic metabolism are perturbed in obesity and diabetes, and in fact some of the patients are affected by two distinct diseases: obesity and diabetes mellitus type 2. CONCLUSION Although RYGB "normalized" many glycaemic parameters in some of the diabetic subjects apparently converting to a non-diabetics state, other diabetic subjects stay diabetic in the context of the new gut anatomy after surgery. Thus, the obesity part of the glycaemic derangement may have been ameliorated, but some defects of the diabetic state had not.
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Affiliation(s)
- Mogens Fenger
- Department of Clinical Biochemistry, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
| | | | - Dorte Worm
- Department of Clinical Medicine, University Hospital of Zeeland, Køge, Denmark
| | - Lisbeth Hvolris
- Department of Surgical Gastroenterology, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
| | - Viggo B. Kristiansen
- Department of Surgical Gastroenterology, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
| | - Elin Rebecka Carlsson
- Department of Clinical Biochemistry, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
| | - Sten Madsbad
- Department of Endocrinology, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
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Kaska L, Sledzinski T, Chomiczewska A, Dettlaff-Pokora A, Swierczynski J. Improved glucose metabolism following bariatric surgery is associated with increased circulating bile acid concentrations and remodeling of the gut microbiome. World J Gastroenterol 2016; 22:8698-8719. [PMID: 27818587 PMCID: PMC5075546 DOI: 10.3748/wjg.v22.i39.8698] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/23/2016] [Accepted: 09/14/2016] [Indexed: 02/06/2023] Open
Abstract
Clinical studies have indicated that circulating bile acid (BA) concentrations increase following bariatric surgery, especially following malabsorptive procedures such as Roux-en-Y gastric bypasses (RYGB). Moreover, total circulating BA concentrations in patients following RYGB are positively correlated with serum glucagon-like peptide-1 concentrations and inversely correlated with postprandial glucose concentrations. Overall, these data suggest that the increased circulating BA concentrations following bariatric surgery - independently of calorie restriction and body-weight loss - could contribute, at least in part, to improvements in insulin sensitivity, incretin hormone secretion, and postprandial glycemia, leading to the remission of type-2 diabetes (T2DM). In humans, the primary and secondary BA pool size is dependent on the rate of biosynthesis and the enterohepatic circulation of BAs, as well as on the gut microbiota, which play a crucial role in BA biotransformation. Moreover, BAs and gut microbiota are closely integrated and affect each other. Thus, the alterations in bile flow that result from anatomical changes caused by bariatric surgery and changes in gut microbiome may influence circulating BA concentrations and could subsequently contribute to T2DM remission following RYGB. Research data coming largely from animal and cell culture models suggest that BAs can contribute, via nuclear farnezoid X receptor (FXR) and membrane G-protein-receptor (TGR-5), to beneficial effects on glucose metabolism. It is therefore likely that FXR, TGR-5, and BAs play a similar role in glucose metabolism following bariatric surgery in humans. The objective of this review is to discuss in detail the results of published studies that show how bariatric surgery affects glucose metabolism and subsequently T2DM remission.
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Kaválková P, Mráz M, Trachta P, Kloučková J, Cinkajzlová A, Lacinová Z, Haluzíková D, Beneš M, Vlasáková Z, Burda V, Novák D, Petr T, Vítek L, Pelikánová T, Haluzík M. Endocrine effects of duodenal-jejunal exclusion in obese patients with type 2 diabetes mellitus. J Endocrinol 2016; 231:11-22. [PMID: 27474690 DOI: 10.1530/joe-16-0206] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/29/2016] [Indexed: 01/20/2023]
Abstract
Duodenal-jejunal bypass liner (DJBL) is an endoscopically implantable device designed to noninvasively mimic the effects of gastrointestinal bypass operations by excluding the duodenum and proximal jejunum from the contact with ingested food. The aim of our study was to assess the influence of DJBL on anthropometric parameters, glucose regulation, metabolic and hormonal profile in obese patients with type 2 diabetes mellitus (T2DM) and to characterize both the magnitude and the possible mechanisms of its effect. Thirty obese patients with poorly controlled T2DM underwent the implantation of DJBL and were assessed before and 1, 6 and 10months after the implantation, and 3months after the removal of DJBL. The implantation decreased body weight, and improved lipid levels and glucose regulation along with reduced glycemic variability. Serum concentrations of fibroblast growth factor 19 (FGF19) and bile acids markedly increased together with a tendency to restoration of postprandial peak of GLP1. White blood cell count slightly increased and red blood cell count decreased throughout the DJBL implantation period along with decreased ferritin, iron and vitamin B12 concentrations. Blood count returned to baseline values 3months after DJBL removal. Decreased body weight and improved glucose control persisted with only slight deterioration 3months after DJBL removal while the effect on lipids was lost. We conclude that the implantation of DJBL induced a sustained reduction in body weight and improvement in regulation of lipid and glucose. The increase in FGF19 and bile acids levels could be at least partially responsible for these effects.
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Affiliation(s)
- Petra Kaválková
- Institute of Medical Biochemistry and Laboratory DiagnosticsFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Miloš Mráz
- Third Department of Medicine - Department of Endocrinology and MetabolismFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Pavel Trachta
- Third Department of Medicine - Department of Endocrinology and MetabolismFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Jana Kloučková
- Institute of Medical Biochemistry and Laboratory DiagnosticsFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Anna Cinkajzlová
- Institute of Medical Biochemistry and Laboratory DiagnosticsFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Zdeňka Lacinová
- Institute of Medical Biochemistry and Laboratory DiagnosticsFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic Third Department of Medicine - Department of Endocrinology and MetabolismFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Denisa Haluzíková
- Department of Sports MedicineFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Marek Beneš
- Department of Gastroenterology and HepatologyInstitute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Zuzana Vlasáková
- Department of DiabetesInstitute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Václav Burda
- Department of CyberneticsFaculty of Electrical Engineering, Czech Technical University, Prague, Czech Republic
| | - Daniel Novák
- Department of CyberneticsFaculty of Electrical Engineering, Czech Technical University, Prague, Czech Republic
| | - Tomáš Petr
- Institute of Medical Biochemistry and Laboratory DiagnosticsFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Libor Vítek
- Institute of Medical Biochemistry and Laboratory DiagnosticsFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic Fourth Department of Internal MedicineFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Terezie Pelikánová
- Department of DiabetesInstitute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martin Haluzík
- Institute of Medical Biochemistry and Laboratory DiagnosticsFirst Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic Department of ObesitologyInstitute of Endocrinology, Prague, Czech Republic
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Roux-en-Y gastric bypass augments the feeding responses evoked by gastrin-releasing peptides. J Surg Res 2016; 206:517-524. [PMID: 27884350 DOI: 10.1016/j.jss.2016.08.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/03/2016] [Accepted: 08/11/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most effective method for the treatment of obesity, and metabolic disease RYGB may reduce body weight by altering the feeding responses evoked by the short-term satiety peptides. MATERIALS AND METHODS Here, we measured meal size (MS, chow), intermeal interval (IMI) length, and satiety ratio (SR, IMI/MS; food consumed per a unit of time) by the small and the large forms of gastrin-releasing peptide (GRP) in rats, GRP-10 and GRP-29 (0, 0.1, 0.5 nmol/kg) infused in the celiac artery (CA, supplies stomach and upper duodenum) and the cranial mesenteric artery (CMA, supplies small and large intestine) in an RYGB rat model. RESULTS GRP-10 reduced MS, prolonged the IMI, and increased the SR only in the RYGB group, whereas GRP-29 evoked these responses by both routes and in both groups. CONCLUSIONS The RYGB procedure augments the feeding responses evoked by exogenous GRP, possibly by decreasing total food intake, increasing latency to the first meal, decreasing number of meals or altering the sites of action regulating MS and IMI length by the two peptides.
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Lipocalin-type prostaglandin D 2 synthase (L-PGDS) modulates beneficial metabolic effects of vertical sleeve gastrectomy. Surg Obes Relat Dis 2016; 12:1523-1531. [PMID: 27425837 DOI: 10.1016/j.soard.2016.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 03/23/2016] [Accepted: 04/04/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Vertical sleeve gastrectomy (VSG) ameliorates metabolic complications in obese and diabetic patients through unknown mechanisms. OBJECTIVE The objective of this study was to investigate the role of lipocalin-type prostaglandin D2 synthase (L-PGDS) in glucose regulation in response to VSG using L-PGDS knock-out (KO), knock-in (KI), and C57BL/6 (wild type) mice. SETTING Winthrop University Hospital Research Institute. METHODS Animals were divided into 6 groups: L-PGDS KO sham/VSG (n = 5), L-PGDS KI sham/VSG (n = 5), and C57BL/6 (wild type) sham/VSG (n = 5). Related parameters were measured in fasting animals after 10 weeks. RESULTS Our intraperitoneal glucose tolerance tests and homeostatic model assessment insulin resistance results showed significant glycemic improvement 10 weeks post-VSG in both C57BL/6 and KI groups compared with the sham group. In contrast, the KO group developed glucose intolerance and insulin resistance similar to or greater than the sham group 10 weeks post-VSG. Interestingly, weight gain was insignificant 10 weeks post-VSG in all the groups and even trended higher in the KO group compared with sham. Peptide YY levels in the KO group post-VSG were slightly increased but significantly less than other groups. Similarly, the KO group showed significantly less leptin sensitivity in response to VSG compared with the KI group. Total cholesterol level remained unchanged in all groups irrespective of sham or surgery but interestingly, the KO group had significantly higher cholesterol levels. In parallel, adipocyte size was also found to be significantly increased in the KO group post-VSG compared with the sham group. CONCLUSION Our findings propose that L-PGDS plays an important role in the beneficial metabolic effects observed after VSG.
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Effects of various gastrointestinal procedures on β-cell function in obesity and type 2 diabetes. Surg Obes Relat Dis 2016; 12:1213-9. [DOI: 10.1016/j.soard.2016.02.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/23/2016] [Indexed: 12/18/2022]
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Adams TD, Arterburn DE, Nathan DM, Eckel RH. Clinical Outcomes of Metabolic Surgery: Microvascular and Macrovascular Complications. Diabetes Care 2016; 39:912-23. [PMID: 27222549 PMCID: PMC5562446 DOI: 10.2337/dc16-0157] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/10/2016] [Indexed: 02/03/2023]
Abstract
Understanding of the long-term clinical outcomes associated with bariatric surgery has recently been advanced. Research related to the sequelae of diabetes-in particular, long-term microvascular and macrovascular complications-in patients who undergo weight-loss surgery is imperative to this pursuit. While numerous randomized control trials have assessed glucose control with bariatric surgery compared with intensive medical therapy, bariatric surgery outcome data relating to microvascular and macrovascular complications have been limited to observational studies and nonrandomized clinical trials. As a result, whether bariatric surgery is associated with a long-term reduction in microvascular and macrovascular complications when compared with current intensive glycemic control therapy cannot be determined because the evidence is insufficient. However, the consistent salutary effects of bariatric surgery on diabetes remission and glycemic improvement support the opportunity (and need) to conduct high-quality studies of bariatric surgery versus intensive glucose control. This review provides relevant background information related to the treatment of diabetes, hyperglycemia, and long-term complications; reports clinical findings (to date) with bariatric surgery; and identifies ongoing research focusing on long-term vascular outcomes associated with bariatric surgery.
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Affiliation(s)
- Ted D Adams
- Intermountain LiVe Well Center, Intermountain Healthcare, and Division of Cardiovascular Genetics, University of Utah, Salt Lake City, UT
| | | | - David M Nathan
- Diabetes Center, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Robert H Eckel
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, CO
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Lee CJ, Craig Wood G, Lazo M, Brown TT, Clark JM, Still C, Benotti P. Risk of post-gastric bypass surgery hypoglycemia in nondiabetic individuals: A single center experience. Obesity (Silver Spring) 2016; 24:1342-8. [PMID: 27225597 PMCID: PMC4919116 DOI: 10.1002/oby.21479] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/28/2015] [Accepted: 01/07/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The epidemiology of post-gastric bypass surgery hypoglycemia (PGBH) is incompletely understood. This study aimed to evaluate the risk of PGBH among nondiabetic patients and associated factors. METHODS A cohort study of nondiabetic patients who underwent Roux-en-Y gastric bypass (RYGB) was conducted. PGBH was defined by any postoperative record of glucose < 60 mg/dL, diagnosis of hypoglycemia, or any medication use for treatment of PGBH. Kaplan-Meier analysis was used to describe PGBH occurrence, log-rank tests, and Cox regression to examine associated factors. RESULTS Of the 1,206 eligible patients, 86% were female with mean age of 43.7 years, mean preoperative BMI of 48.7 kg/m(2) , and a mean follow-up of 4.8 years. The cumulative incidence of hypoglycemia at 1 and 5 years post-RYGB was 2.7% and 13.3%, respectively. Incidence of PGBH was identified in 158 patients and was associated with lower preoperative BMI (P = 0.048), lower preoperative HbA1c (P = 0.012), and higher 6-month percent of excess body weight loss (%EWL) (P = 0.001). A lower preoperative HbA1c (HR = 1.73, P = 0.0034) and higher 6-month %EWL (HR = 1.96, P = 0.0074) remained independently correlated with increased risk for PGBH in multi-regression analysis. CONCLUSIONS The 5-year incidence of PGBH among nondiabetic individuals was 13.3% and was associated with a lower preoperative HbA1c and greater weight loss at 6 months following surgery.
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Affiliation(s)
- Clare J. Lee
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, the Johns Hopkins University, Baltimore, Maryland, USA
| | - G. Craig Wood
- Geisinger Obesity Research Institute, Geisinger Clinic, Danville, Pennsylvania, USA
| | - Mariana Lazo
- Division of General Internal Medicine, Department of Medicine, the Johns Hopkins University, Baltimore, Maryland, USA
| | - Todd T. Brown
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, the Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeanne M. Clark
- Division of General Internal Medicine, Department of Medicine, the Johns Hopkins University, Baltimore, Maryland, USA
| | - Christopher Still
- Geisinger Obesity Research Institute, Geisinger Clinic, Danville, Pennsylvania, USA
| | - Peter Benotti
- Geisinger Obesity Research Institute, Geisinger Clinic, Danville, Pennsylvania, USA
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