Impact of weight change, secular trends and ageing on cardiovascular risk factors: 10-year experiences from the SOS study

Bariatric surgery post-liver transplantation: A Belgian nationwide study

Weight gain poses a rising concern post-liver transplantation (LT), and metabolic dysfunction-associated steatotic liver disease might impair graft health. The timing is crucial when considering bariatric surgery (BS) in a population with liver disease or transplantation. BS can be considered for post-LT weight gain, although the evidence is limited and the long-term outcome still uncertain. We conducted a national retrospective analysis in 5 Belgian transplant centers and included 25 patients with an LT followed by a bariatric procedure. A total of 187 LT patients without BS were included for comparison. Clinical, biochemical, and outcome data were retrospectively retrieved. In our nationwide cohort, 25 patients had undergone BS post-LT, at a median 3.5 years after LT. Twenty-one (84.0%) patients received a sleeve gastrectomy (SG). Patients were predominantly male (72.0%), with a lower age at time of transplantation compared with the non-BS population (54.5 vs. 60.6, p <0.001). Weight loss was significant and sustained, with a decrease in body mass index from 41.0±4.5 pre-BS to 32.6±5.8 1-3 years post-BS ( p <0.001) and 31.1±5.8 3-5 years post-BS ( p <0.001). Three pre-BS (12.0%) patients presented with recurrent and one (4.0%) de novo metabolic dysfunction-associated steatotic liver disease after LT, with 100% resolution post-BS ( p =0.016). Notable reductions were observed in alanine transaminase levels (40.5±28.5 U/L to 27.1±25.1 U/L post-BS, p =0.05) and HbA1c levels (6.9±1.6 to 6.0±1.4 post-BS, p <0.001). Three patients were re-transplanted, and eight patients died, of which five (20.0%) due to a nonhepatic malignancy and one (4.0%) due to liver failure. SG is the favored BS post-LT and has proven to be safe and feasible in a post-LT setting with favorable metabolic consequences. SG post-LT is a valid treatment for de novo and recurrent metabolic dysfunction-associated steatotic liver disease post-LT. Although we report on the largest cohort to date, there is still a need for larger cohorts to examine the effect of BS on patient and graft survival.

Cardiovascular Protective Properties of GLP-1 Receptor Agonists: More than Just Diabetic and Weight Loss Drugs

Owing to their potent glucose-lowering efficacy and substantial weight loss effects, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are now considered part of the frontline therapeutic options to treat both type 2 diabetes mellitus and nondiabetic overweight/obesity. Stemming from successful demonstration of their cardiometabolic modulation and reduction of major adverse cardiovascular events in clinical outcome trials, GLP-1 RAs have since been validated as agents with compelling cardiovascular protective properties. Studies spanning from the bench to preclinical and large-scale randomised controlled trials have consistently corroborated the cardiovascular benefits of this pharmacological class. Most notably, there is converging evidence that they exert favourable effects on atherosclerotic ischaemic endpoints, with preclinical data indicating that they may do so by directly modifying the burden and composition of atherosclerotic plaques. This narrative review examines the underlying pharmacology and clinical evidence behind the cardiovascular benefits of GLP-1 RAs, with particular focus on atherosclerotic cardiovascular disease. It also delves into the mechanisms that underpin their putative plaque-modifying actions, addresses existing knowledge gaps and therapeutic challenges and looks to future developments in the field, including the use of combination incretin agents for diabetes and weight loss management.

Early Postoperative Weight Loss Predicts Weight Loss up to 5 Years After Roux-En-Y Gastric Bypass, Banded Roux-En-Y Gastric Bypass, and Sleeve Gastrectomy

Purpose

Previous studies showed that patients with lower weight loss after bariatric surgery could be identified based on early postoperative weight loss. However, these studies had only 12–36-month follow-up. This study aimed to explore whether patients in the lowest weight loss quartile at 3 months had lower weight loss trajectories up to 5 years after Roux-en-Y gastric bypass (RYGB), banded Roux-en-Y gastric bypass (BRYGB), and sleeve gastrectomy (SG) surgery.

Methods

Weight was assessed preoperatively, and 3, 6, 9, 12, 24, 36, 48, and 60 months postoperatively. Patients were grouped into four categories based on quartiles of percentage total weight loss (%TWL) at 3-month follow-up. Results were compared between the lowest %TWL quartile group and other quartile groups.

Results

Patients underwent either RYGB (n=13,106; 72%), SG (n=3585; 20%), or BRYGB (n=1391, 8%) surgery. Weight loss trajectories of patients in the lowest %TWL quartile group remained lower than that of other quartile groups throughout a 5-year follow-up, for all three types of surgery. Patients in the lowest %TWL quartile group had higher age at surgery, higher baseline BMI, and were more likely to be male (in the SG group), and to suffer from diabetes, hypertension, dyslipidemia, and osteoarthritis.

Conclusion

This study showed a positive association between weight loss at 3 and 12 to 60 months after bariatric surgery. Weight loss at 3 months after surgery could be used to identify patients whose anticipated weight loss trajectories are below average, to potentially improve their outcomes through early behavioral or medical interventions.

Graphical Abstract

Relation of Bariatric Surgery to Inpatient Cardiovascular Outcomes (from the National Inpatient Sample)

Approximately one in 3 patients in the United States are obese. There is a strong association between obesity and an increased rate of cardiovascular disease (CVD)-related mortality. Bariatric surgery (BS) has emerged as an effective strategy to achieve reduction of excess weight. Our study aims to explore the relationship between BS and major adverse cardiovascular events (MACE) among obese hospitalized patients in the United States. This is a retrospective study of all obese adult patients with BMI ≥35 kg/m² (n= 1,700,943) in the National Inpatient Sample between 2012 and 2016. Differences in the clinical characteristics of obese patients with a history of BS versus obese patients without a history of BS were analyzed as well as the association between BS and MACE after adjusting for CVD risk factors. Among 50,296 obese patients with a history of BS (2.96%), the mean age was 53 ± 12 years with the majority being female (75.32%) and Caucasian (71.85%). Multivariate analysis revealed that obese patients with a history of BS had a1.6-fold decrease odds of MACE compared with patients without BS (OR 0.62; 95% CI, 0.60 to 0.65; p <0.001). In conclusion, this study illustrates that among obese patients with BMI ≥35 kg/m², history of BS was associated with a significantly lower odds of inpatient MACE, after adjusting for CVD risk factors.

Weight loss in adults following bariatric surgery, a systematic review of preoperative behavioural predictors

Bariatric surgery is effective in treating obesity in many cases, yet as many as 50% of patients may not achieve the desired weight reduction. Preoperative modifiable behavioural factors could help patient selection and intervention design to improve outcomes. Medline, EMBASE, Cochrane Library and PsychINFO were searched to identify studies published between 1 January 2008 and 14 February 2019 reporting on preoperative modifiable behavioural factors associated with postoperative weight loss, with minimum 2 years follow-up. A total of 6888 articles were screened, 34 met the inclusion criteria. Maladaptive eating behaviours (MEB), preoperative weight loss (PWL), and tobacco use were reported 21, 18, and 3 times respectively. Physical activity and substance abuse were each reported once. Most articles on PWL (72.2%) and MEB (52.4%) reported no association. Positive associations were reported in 22.2% and 14.3% of articles for PWL and MEB respectively. Negative associations were reported in 5.6% and 33.3% of articles for PWL and MEB, respectively. Marked heterogeneity in outcome reporting hindered quantitative synthesis. The current paucity of evidence amenable to synthesis leads to ongoing uncertainty regarding the size and direction of association between PWL and MEB with outcomes following bariatric surgery. Long-term studies with common reporting of outcomes are needed.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The Role of Bariatric Surgery on Diabetes and Diabetic Care Compliance

PURPOSE OF REVIEW

Bariatric surgery is a durable and long-term solution to treat both obesity and its associated comorbidities, specifically type 2 diabetes mellitus (T2DM). Many studies have demonstrated the benefits of bariatric surgery on T2DM, but weight recidivism along with recurrence of comorbidities can be seen following these procedures. Patient compliance post-bariatric surgery is linked to weight loss outcomes and comorbidity improvement/resolution. The role of compliance with respect to T2DM medication in bariatric patients specifically has not recently been examined. This article seeks to review the role of bariatric surgery on short- and long-term resolution of T2DM, recurrence, and compliance with T2DM medication following bariatric surgery.

RECENT FINDINGS

Seven randomized control trials have examined metabolic surgery versus medical therapy in glycemic control in patients meeting criteria for severe obesity. Six out of seven studies demonstrate a significant advantage in the surgical arms with regards to glycemic control, as well as secondary endpoints such as weight loss, serum lipid levels, blood pressure, renal function, and other parameters. While patient compliance with lifestyle modifications post-bariatric surgery is linked to weight loss outcomes, there are no studies to date that directly evaluate the role of lifestyle modifications and T2DM medication adherence in the management of T2DM post-bariatric surgery. Bariatric surgery is an effective treatment option to achieve long-term weight loss and resolution of obesity-related medical comorbidities, specifically T2DM. Patient compliance to lifestyle modifications post-bariatric surgery is linked to weight loss outcomes and comorbidity resolution. The role of diabetic care compliance in bariatric patient outcomes, however, is poorly understood. Further studies are needed to elucidate the predictors and associated risk factors for non-compliance in this patient population.

Older Age Confers a Higher Risk of 30-Day Morbidity and Mortality Following Laparoscopic Bariatric Surgery: an Analysis of the Metabolic and Bariatric Surgery Quality Improvement Program

INTRODUCTION

There is a paucity of literature describing the association of age with the risk of adverse events following bariatric surgery. The purpose of this study is to investigate the association of age with 30-day morbidity and mortality following laparoscopic bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

All adult patients undergoing laparoscopic Roux-en-Y gastric bypass (RNGYB) or sleeve gastrectomy (SG) were identified within the MBSAQIP database. Patients were divided into five equal age quintiles. Binary outcomes of interest, including cardiac, pulmonary, wound, septic, clotting, and renal events, in addition to the incidence of related 30-day unplanned reintervention, related 30-day mortality, and a composite morbidity and mortality outcome were compared across the age quintiles and procedures.

RESULTS

A total of 266,544 patients met inclusion criteria. Older age was associated with an increased risk of all morbidity outcomes except venous thromboembolism events, 30-day mortality, and the composite morbidity and mortality outcome. Patients who underwent Roux-en-Y gastric bypass had worse outcomes per quintile for almost every outcome of interest when compared to patients who underwent sleeve gastrectomy.

CONCLUSION

Older patients and patients who undergo Roux-en-Y gastric bypass are at an increased risk of perioperative morbidity and mortality following laparoscopic bariatric surgery. Additional studies are needed to determine the association of age with long-term weight loss and cardiometabolic comorbidity resolution following bariatric surgery in order to determine if the increased perioperative risk is offset by improved long-term outcomes in older patients undergoing bariatric surgery.

Obesity and cardiovascular risk: a call for action from the European Society of Hypertension Working Group of Obesity, Diabetes and the High-risk Patient and European Association for the Study of Obesity: part A: mechanisms of obesity induced hypertension, diabetes and dyslipidemia and practice guidelines for treatment

: Obesity is a key factor for cardiovascular diseases and complications. Obesity is associated with hypertension, dyslipidemia and type II diabetes, which are the major predictors of cardiovascular disease in the future. It predisposes for atrial fibrillation, heart failure, sudden cardiac death, renal disease and ischemic stroke that are the main causes of cardiovascular hospitalization and mortality. As obesity and the cardiovascular effects on the vessels and the heart start early in life, even from childhood, it is important for health policies to prevent obesity very early before the disease manifestation emerge. Key roles in the prevention are strategies to increase physical exercise, reduce body weight and to prevent or treat hypertension, lipids disorders and diabetes earlier and efficiently to prevent cardiovascular complications.Epidemiology and mechanisms of obesity-induced hypertension, diabetes and dyslipidemia will be reviewed and the role of lifestyle modification and treatment strategies in obesity will be updated and analyzed. The best treatment options for people with obesity, hypertension, diabetes and dyslipidemia will discussed.

Arterial Hypertension

BACKGROUND

Essential arterial hypertension is one of the main treatable cardiovascular risk factors. In Germany, approximately 13% of women and 18% of men have uncontrolled high blood pressure (≥ 140/90 mmHg).

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed.

RESULTS

Arterial hypertension is diagnosed when repeated measurements in a doctor's office yield values of 140/90 mmHg or higher. The diagnosis should be confirmed by 24-hour ambulatory blood pressure monitoring or by home measurement. Further risk factors and end-organ damage should be considered as well. According to the current European guidelines, the target blood pressure for all patients, including those with diabetes mellitus or renal failure, is <140/90 mmHg. If the treatment is well tolerated, further lowering of blood pressure, with a defined lower limit, is recommended for most patients. The main non-pharmacological measures against high blood pressure are reduction of salt in the diet, avoidance of excessive alcohol consumption, smoking cessation, a balanced diet, physical exercise, and weight loss. The first-line drugs for arterial hypertension include long-acting dihydropyridine calcium channel blockers, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and thiazide-like diuretics. Mineralocorticoid-receptor blockers are effective in patients whose blood pressure cannot be brought into acceptable range with first-line drugs.

CONCLUSION

In most patients with essential hypertension, the blood pressure can be well controlled and the cardiovascular risk reduced through a combination of lifestyle interventions and first-line antihypertensive drugs.

Early blood pressure response to isometric exercise is attenuated in obese individuals who have undergone bariatric surgery

Blood pressure (BP) reactivity is predictive of the development of cardiovascular disease. We hypothesized that the BP response at the onset of isometric handgrip exercise would occur earlier and to a lesser degree in individuals who underwent bariatric surgery compared with obese adults and that the reliance on total peripheral resistance (TPR) would be attenuated. Twenty-six individuals (7 nonobese, 11 obese, 8 postbariatric surgery) completed isometric handgrip exercise (40% maximum voluntary contraction) to exhaustion. Heart rate (HR, ECG) and arterial BP (brachial catheter) were measured continuously. Stroke volume was estimated from the pressure waveform, and cardiac output (CO) and TPR were calculated. Peak change, time to peak, and rate of rise in BP were assessed during the first 30 s of exercise. Obese adults exhibited a slower rise in BP and higher peak BP at exercise onset compared with nonobese controls ( P < 0.05). Peak BP and the rate of rise were not different between individuals who underwent bariatric surgery and nonobese controls ( P > 0.05). Nonobese controls exhibited an exercise-mediated increase in CO, whereas obese adults increased TPR ( P < 0.05). The increases in CO and TPR were less apparent in individuals who underwent bariatric surgery ( P > 0.05). In contrast to obese adults, individuals who underwent bariatric surgery exhibit a rapid rise in BP at exercise onset. This rapid increase in BP is associated with a fall in TPR and results in lower peak BP at the onset of isometric exercise. These data suggest that bariatric surgery improves BP reactivity via changes in the time course of hemodynamic responses. NEW & NOTEWORTHY Bariatric surgery has been shown to reduce the blood pressure (BP) response to isometric handgrip exercise. By examining the time course of the BP response to exercise, we found, in contrast to obese adults, individuals who underwent bariatric surgery exhibit a rapid rise in BP at exercise onset, which is associated with a fall in total peripheral resistance and results in lower peak BP at the onset of isometric exercise. These data suggest that bariatric surgery improves BP reactivity via reflex autonomic adjustments.

Hypertension

Systemic arterial hypertension is the most important modifiable risk factor for all-cause morbidity and mortality worldwide and is associated with an increased risk of cardiovascular disease (CVD). Fewer than half of those with hypertension are aware of their condition, and many others are aware but not treated or inadequately treated, although successful treatment of hypertension reduces the global burden of disease and mortality. The aetiology of hypertension involves the complex interplay of environmental and pathophysiological factors that affect multiple systems, as well as genetic predisposition. The evaluation of patients with hypertension includes accurate standardized blood pressure (BP) measurement, assessment of the patients' predicted risk of atherosclerotic CVD and evidence of target-organ damage, and detection of secondary causes of hypertension and presence of comorbidities (such as CVD and kidney disease). Lifestyle changes, including dietary modifications and increased physical activity, are effective in lowering BP and preventing hypertension and its CVD sequelae. Pharmacological therapy is very effective in lowering BP and in preventing CVD outcomes in most patients; first-line antihypertensive medications include angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, dihydropyridine calcium-channel blockers and thiazide diuretics.

Sleeve Gastrectomy Decreases Body Weight, Whole-Body Adiposity, and Blood Pressure Even in Aged Diet-Induced Obese Rats

BACKGROUND

Aging and obesity are two conditions associated with increased risk of cardiovascular disease. Our aim was to analyze whether an advanced age affects the beneficial effects of sleeve gastrectomy on weight loss and blood pressure in an experimental model of diet-induced obesity (DIO).

METHODS

Young (6-month-old) and old (18-month-old) male Wistar DIO rats (n = 101) were subjected to surgical (sham operation and sleeve gastrectomy) or dietary interventions (pair-fed to the amount of food eaten by sleeve gastrectomized animals). Systolic (SBP), diastolic (DBP), and mean (MBP) blood pressure values and heart rate (HR) were recorded in conscious, resting animals by non-invasive tail-cuff plethysmography before and 4 weeks after surgical or dietary interventions.

RESULTS

Aging was associated with higher (P < 0.05) body weight and subcutaneous and perirenal fat mass as well as mild cardiac hypertrophy. Sleeve gastrectomy induced a reduction in body weight, whole-body adiposity, and serum total ghrelin in both young and old DIO rats. The younger group achieved a higher excess weight loss than the older group (164 ± 60 vs. 82 ± 17 %, P < 0.05). A significant (P < 0.05) decrease in insulin resistance, SBP, DBP, MBP, and HR without changes in heart weight was observed after sleeve gastrectomy independently of age.

CONCLUSION

Our results provide evidence for the effectiveness of sleeve gastrectomy without increased operative risk in body weight and blood pressure reduction even in aged animals via endocrine changes that go beyond the mere caloric restriction.

Diabetes mellitus and stroke: A clinical update

Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus (DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke.

Lipid changes 8 years post gastric bypass in adolescents with severe obesity (FABS-5+ study)

OBJECTIVE

Severe obesity in adolescents is increasing and few effective treatments exist. Bariatric surgery is one option, but the extent to which surgery influences cardiovascular risk factors over time in youth is not clear. We hypothesized that Roux-en Y gastric bypass (RYGB) would be associated with sustained improvements in lipids over time (>5 years).

PARTICIPANTS/METHODS

Youth who underwent RYGB from 2001 to 2007 were recruited for the Follow-up of Adolescent Bariatric Surgery-5+ (FABS-5+) in 2011-2014. Baseline body mass index (BMI) and lipids were abstracted from medical records. Follow-up data were obtained at a research visit. Analyses included paired t-tests to assess changes in BMI and lipids over time. General linear models were used to evaluate predictors of high-density lipoprotein (HDL) and non-HDL-cholesterol at follow-up. A non-operative group was recruited for comparison.

RESULTS

Surgical participants (n=58) were a mean±s.d. age of 17±2 years at baseline and 25±2 years at long-term follow-up. Eighty-six percent were Caucasian and 64% were female. At long-term follow-up BMI decreased by 29% and all lipids (except total cholesterol) significantly improved (P<0.01). Female sex was a significant predictor of non-HDL-cholesterol level at 1 year, while change in BMI from 1 year to long-term follow-up was a significant predictor of non-HDL-cholesterol and HDL-cholesterol during the same interval (P<0.05). In the non-operative group, BMI increased by 8% and lipid parameters were unchanged.

CONCLUSIONS

This is the longest and most complete follow-up of youth following RYGB. Weight loss maintenance over time was significantly associated with improvements in lipid profile over 5 years.

Bariatric surgery versus lifestyle interventions for severe obesity: 5-year changes in body weight, risk factors and comorbidities

Changes in body weight (BW), risk factors and comorbidities 5 years after Roux-en-Y gastric bypass (RYGB) or different lifestyle interventions are compared. A total of 209 (75% women) severe obese adults were non-randomly allocated to: (A) RYGB (n = 58), (B) weight loss (WL) camp (n = 30), (C) residential intermittent programme (n = 64) or (D) hospital outpatient programme (n = 57). Body weight, risk factors and comorbidities were assessed at baseline, 1 and 5 years. A total of 89 and 54% completed the 1- and 5-year follow-up. The RYGB group experienced more WL at 5 years (-23.9%, 95% CI [-27.7, -20.0]) compared with lifestyle groups: (B) (-9.2%, 95% CI [-16.9, -1.5]), (C) (-4.1%, 95% CI [-8.0, -0.1]) and (D) (-4.1 kg, 95% CI [-10.0, 1.8]) (all P < 0.001). No differences were observed between lifestyle groups, although groups B and C had significant WL after 5 years (all P < 0.05). Plasma glucose and high-density lipoprotein cholesterol were improved in the RYGB group at 5 years compared with lifestyle groups (all P < 0.05). More patients in the RYGB group experienced remission of hypertension (P < 0.05). RYGB was associated with a lower BW, improved blood parameters and hypertension remission compared with lifestyle interventions at 5 years. However, significant WL was also achieved with lifestyle interventions.

Prevalence of coronary heart disease risk factors in physical education students

Abstract To establish the prevalence of coronary risk in physical education students, and compare risk between the genders and the years of course. We evaluated 246 physical education students using RISKO questionnaire to determine eight risk factors: age, heredity, body weight, smoking, physical inactivity, hypercholesterolemia, hypertension and sex. Students had mean coronary risk score of 16.03 ± 3.52 points, rated "below-average risk." Men had significantly greater risk compared to women. No difference was found between the years of course. The prevalence of risk factors were heritability (58.37%), physical inactivity (32.65%), hypercholesterolemia (32.24%), overweight (27.35%), smoking (3.67%) and hypertension (2.45%). The coronary risk of physical education students was rated as below average, being higher among men than women, and no difference in risk between years of course. The most prevalent risk factors were heredity, physical inactivity, overweight and hypercholesterolemia.

Dapagliflozin-induced weight loss affects 24-week glycated haemoglobin and blood pressure levels

The aim of this study was to investigate the associations between dapagliflozin-mediated reductions in body weight and reductions in glycated haemoglobin (HbA1c) and blood pressure. Data were pooled from seven studies evaluating dapagliflozin 10 mg as monotherapy or combination therapy over 24 weeks. Using linear regression to estimate the contribution of weight loss to HbA1c and blood pressure reductions, the β-value estimate for HbA1c (%)/kg was 0.028 (p < 0.0001). Weight loss of 2 kg with dapagliflozin contributed to 6% of the total HbA1c reduction. For systolic (SBP) and diastolic blood pressure (DBP), the β-value (mmHg/kg) estimates were 0.606 (p < 0.0001) and 0.253 (p < 0.0001), respectively. Weight loss of 2 kg contributed to 28% of the overall SBP reduction, and 24% of the overall DBP reduction. In conclusion, dapagliflozin-mediated weight loss may contribute to overall reductions in HbA1c and blood pressure.

Predictors of weight loss are different in men and women after sleeve gastrectomy

BACKGROUND

Weight loss following bariatric surgery varies according to patient factors before the intervention. However, whether predictors of weight loss differ between men and women is, to our knowledge, unknown. We therefore aimed to investigate baseline predictors for overall weight loss and identify potential sex-specific baseline predictors in bariatric surgery patients.

METHODS

In this prospective cohort study, 160 patients (117 women and 43 men) who underwent sleeve gastrectomy were followed up for 2 years. Weight loss was defined as percent excess body mass index loss (%EBMIL). To investigate whether %EBMIL differed between men and women, we included all two-way interactions with sex by incorporating the product term sex and predictors using multiple linear regression analysis.

RESULTS

The overall mean ± standard deviation of %EBMIL after 2 years was 78.3 ± 23.5. Predictors for lower %EBMIL in a regression model with no interactions were female sex (P = 0.003), higher body mass index before surgery (P = 0.001), and nonsmoking (P = 0.029). When examining sex-specific predictors for %EBMIL, higher age (P = 0.027) and not having diabetes (P = 0.007) predicted lower %EBMIL in men. In women, unemployment (P = 0.006) and anxiety and/or depression (P = 0.009) predicted lower %EBMIL.

CONCLUSIONS

This study suggests that weight loss and predictors for weight loss 2 years after sleeve gastrectomy are sex-specific. These findings may be useful for the surgical strategy used to treat these patients.

Should we wait for metabolic complications before operating on obese patients? Gastric bypass outcomes in metabolically healthy obese individuals

BACKGROUND

A subgroup of obese patients without metabolic disorders has been identified and defined as metabolically healthy but morbidly obese (MHMO).

OBJECTIVES

To compare Roux-en-Y gastric bypass (RYGB) outcomes between MHMO and metabolically unhealthy morbidly obese (MUMO) patients to assess whether the obesity phenotype could affect the results.

SETTING

A university-affiliated tertiary care center.

METHODS

One hundred nineteen consecutive patients underwent RYGB; 102 completed the 2-year follow-up and were divided into 2 groups (MHMO and MUMO) according to Wildman criteria, including blood pressure, triglycerides, high-density lipoprotein cholesterol (HDL-C), fasting blood sugar, C-reactive protein (CRP), and homeostasis model assessment of insulin resistance (HOMA-IR). Weight loss and metabolic parameter changes were analyzed.

RESULTS

Twenty-one of 102 (20.6%) patients were identified as MHMO; they were mostly women (90.5%) and were significantly younger than MUMO patients (39.4 ± 9.1 yr versus 47.2 ± 10, P = .001); 12.6% were lost to follow-up. MHMO phenotype was significantly associated with a greater percentage of excess body mass index loss (P = .03), independent of gender, age, and redo procedures. All metabolic parameters were significantly improved 2 years after surgery in the MUMO group. HOMA-IR, CRP, and triglycerides were significantly lower 2 years after surgery in the MHMO group, whereas fasting blood sugar and HDL-C were unchanged. At 2 years of follow-up, 92.3% of the population was metabolically healthy.

CONCLUSIONS

RYGB is an effective procedure to achieve weight loss and had a strong positive metabolic effect in both MHMO and MUMO phenotypes. RYGB led to an increase of the metabolically healthy status and may prevent or delay the onset of metabolic disorders.

Sympathetic activity and markers of cardiovascular risk in nondiabetic severely obese patients: the effect of the initial 10% weight loss

BACKGROUND

Obesity is associated with elevated cardiovascular mortality, which may be attributed, in part, to sympathetic nervous system (SNS) activation and an associated poor metabolic profile. We examined the effects of laparoscopic adjustable gastric band (LAGB) on SNS activity and cardiovascular profile when the initial weight loss of 10%, corresponding to the recommendation of clinical guidelines, was reached.

METHODS

Direct muscle sympathetic nerve activity (MSNA, microneurography), baroreflex function, and cardiovascular profile were examined before and after a predetermined weight loss of 10% in 23 severely obese nondiabetic individuals.

RESULTS

The 10% weight loss was achieved at an average of 7.3 ± 1.4 months (range = 1.3-23.3 months). This was associated with significant improvement in office systolic and diastolic blood pressure (BP) (-12 mm Hg and -5 mm Hg, respectively), a decrease in MSNA (33 ± 3 to 22 ± 3 bursts per minute), improvement in cardiac (16 ± 3 to 31 ± 4 ms/mm Hg) and sympathetic (-2.23 ± 0.39 to -4.30 ± 0.96 bursts/100 heartbeats/mm Hg) baroreflex function, total cholesterol (5.33 ± 0.13 to 4.97 ± 0.16 mmol/L), fasting insulin (29.3 ± 2.4 to 19.6 ± 1.1 mmol/L), and creatinine clearance (172 ± 11 to 142 ± 8 ml/min). None of the cardiovascular risk improvement related to the rate of weight loss. The change in systolic and diastolic BP correlated with change in waist circumference (r = 0.46, P = 0.04; r = 0.50, P = 0.02, respectively).

CONCLUSIONS

The initial 10% weight loss induced by LAGB was associated with substantial hemodynamic, metabolic, SNS, and renal function improvements. Changes in waist circumference appear to be an important factor contributing to BP adaptation after LAGB surgery.

Greater short-term weight loss in women 20-45 versus 55-65 years of age following bariatric surgery

BACKGROUND

Whether and how sex and age affect bariatric-surgery outcome is poorly understood. Estrogens regulate body composition in women and animals, and increase weight loss in a rodent model of gastric bypass, suggesting that premenopausal women may lose more weight following bariatric surgery.

METHODS

One thousand three hundred fifty-six female gastric-bypass or gastric-banding patients were retrospectively grouped as 20-45 years old (presumptively premenopausal; n = 1,199) and 55-65 years old (presumptively postmenopausal; n = 157). Mixed-model ANCOVA followed by Bonferroni-corrected t tests were used to categorically test the effect of age on percent excess body weight loss (%EBWL) at 1 and 2 years post-surgery, controlling for preoperative EBW and surgery type. Age effects were also tested dimensionally in all women and in 289 male patients.

RESULTS

Twenty- to forty-five-year-old women showed greater %EBWL 1 and 2 years post-surgery than 55-65-year-old women (p's < 0.0005). No age effect was detected in 20-25- vs. 30-35-, 30-35- vs. 40-45-, or 20-25- vs. 40-45-year-old women (p's > 0.2) This age effect was detected only after gastric banding, with 20-45-year-old women losing ∼7 kg more than 55-65-year-old women after 2 years. Dimensional analysis confirmed a significant inverse effect of age on bariatric surgery outcome in women, but did not detect any effect in men.

CONCLUSIONS

Results indicate that 55-65-year-old women lose less weight than 20-45-year-old women in the initial 2 years after bariatric surgery, especially gastric banding; this may be mediated by age- or menopause-associated changes in physical activity, energy expenditure, or energy intake.

Impact of 5-year weight change on blood pressure: results from the Weight Loss Maintenance trial

In this secondary analysis of the Weight Loss Maintenance trial, the authors assessed the relationship between blood pressure (BP) change and weight change in overweight and obese adults with hypertension and/or dyslipidemia who were randomized to 1 of 3 weight loss maintenance strategies for 5 years. The participants were grouped (N=741) based on weight change from randomization to 60 months as: (1) weight loss, (2) weight stable, or (3) weight gain. A significant positive correlation between weight change and systolic BP (SBP) change at 12, 30, and 60 months and between weight change and diastolic BP (DBP) change at 30 months was observed. From randomization to 60 months, mean SBP increased to a similar degree for the weight gain group (4.2±standard error=0.6 mm Hg; P<.001) and weight stable group (4.6±1.1 mm Hg; P<.001), but SBP did not rise in the weight loss group (1.0±1.7 mm Hg, P=.53). DBP was unchanged for all groups at 60 months. Although aging may have contributed to rise in BP at 60 months, it does not appear to fully account for observed BP changes. These results suggest that continued modest weight loss may be sufficient for long-term BP lowering.

Treatment of hypertension in obese patients

Obesity is a global pandemic and with its rise, its associated co-morbidities are increasing in prevalence, particularly uncontrolled hypertension. Lifestyle changes should be an anchor for the management of obesity-related hypertension; however, they are difficult to sustain. Drug therapy is often necessary to achieve blood pressure control. Diuretics, inhibitors of the renin-angiotensin system, and dihydropyridine calcium channel blockers are often used as first trio, with subsequent additions of mineralocorticoid receptor antagonists and/or dual alpha/beta blocking agents. While a number of agents are currently available, 50 % of hypertensive patients remain uncontrolled. A number of novel drug and invasive therapies are in development and hold significant potential for the effective management of obesity-related hypertension.

Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery

Obesity is a risk factor for diabetes, cardiovascular disease events, cancer and overall mortality. Weight loss may protect against these conditions, but robust evidence for this has been lacking. The Swedish Obese Subjects (SOS) study is the first long-term, prospective, controlled trial to provide information on the effects of bariatric surgery on the incidence of these objective endpoints. The SOS study involved 2010 obese subjects who underwent bariatric surgery [gastric bypass (13%), banding (19%) and vertical banded gastroplasty (68%)] and 2037 contemporaneously matched obese control subjects receiving usual care. The age of participants was 37-60 years and body mass index (BMI) was ≥34 kg m(-2) in men and ≥38 kg m(-2) in women. Here, we review the key SOS study results published between 2004 and 2012. Follow-up periods varied from 10 to 20 years in different reports. The mean changes in body weight after 2, 10, 15 and 20 years were -23%, -17%, -16% and -18% in the surgery group and 0%, 1%, -1% and -1% in the control group respectively. Compared with usual care, bariatric surgery was associated with a long-term reduction in overall mortality (primary endpoint) [adjusted hazard ratio (HR) = 0.71, 95% confidence interval (CI) 0.54-0.92; P = 0.01] and decreased incidences of diabetes (adjusted HR=0.17; P < 0.001), myocardial infarction (adjusted HR = 0.71; P = 0.02), stroke (adjusted HR=0.66; P = 0.008) and cancer (women: adjusted HR = 0.58; P = 0.0008; men: n.s.]. The diabetes remission rate was increased severalfold at 2 years [adjusted odds ratio (OR) = 8.42; P < 0.001] and 10 years (adjusted OR = 3.45; P < 0.001). Whereas high insulin and/or high glucose at baseline predicted favourable treatment effects, high baseline BMI did not, indicating that current selection criteria for bariatric surgery need to be revised.

Insulin sparing action of adenovirus 36 and its E4orf1 protein

Additional drugs are required to effectively manage diabetes and its complications. Recent studies have revealed protective effects of Ad36, a human adenovirus, and its E4orf1 protein on glucose disposal, which may be creatively harnessed to develop novel anti-diabetic agents. Experimental Ad36 infection improves hyperglycemia in animal models and natural Ad36 infection in humans is associated with better glycemic control. Available data indicate distinctive advantages for a drug that may mimic the action of Ad36/E4orf1. The key features of such a potential drug include the ability to increase glucose uptake by adipose tissue and skeletal muscle, to reduce hepatic glucose output independent of proximal insulin signaling, and to up-regulate adiponectin and its hepatic action. The effect of Ad36/E4orf1 on hepatocyte metabolism suggests a role for treating hepatic steatosis. Despite these potential advantages, considerable research is required before such a drug is developed. The in vivo efficacy and safety of E4orf1 in improving hyperglycemia remain unknown, and an appropriate drug delivery system is required. Nonetheless, Ad36 E4orf1 offers a research opportunity to develop a new anti-diabetic agent with multiple potential advantages and conceptually advances the use of a rather unconventional source, microbial proteins, for anti-diabetic drug development.

Effect of preoperative body mass index on weight loss after obesity surgery

BACKGROUND

Previous studies suggest that individuals with body mass index (BMI) above versus below 60 kg/m(2) attain lower percentage of excess weight loss (%EWL) after bariatric surgery. The objectives of this study were to (1) test whether conclusions drawn about the effect of preoperative BMI on postoperative weight loss depend on the outcome measure, (2) test for evidence of a threshold effect at BMI = 60 kg/m(2), and (3) test the effect from surgery to 12-month follow-up, relative to 12- to 36-month follow-up.

METHODS

Retrospective analyses of participants grouped according to preoperative BMI: 35-39.9 (n = 232); 40-49.9 (n = 1166); 50-59.9 (n = 429);≥60 (n = 166).

RESULTS

As anticipated, individuals with higher versus lower preoperative BMI had greater total weight loss but lower %EWL at all postoperative time points (all, P<.0005). However, these individuals also had lower percentage of initial weight loss (%IWL) at all time points beyond 1 month postsurgery (all, P<.0005). From 12- to 36-months, individuals with BMI 35-39.9 had 3.2±14.3 %IWL (P<.0001); 40-49.9 had 1.0±8.9 %IWL (P<.0005); 50-59.9 had-2.4±10.0 %IWL (P<.0005); and≥60 had-3.6±11.5 %IWL (P<.0005). Overall F3,1989 = 20.2, P< .0005.

CONCLUSIONS

Conclusions drawn about the effect of preoperative BMI may depend on the outcome measure. A dosage effect of preoperative BMI was apparent, with heavier individuals showing lower percentages of initial and excess weight loss, regardless of BMI above or below 60 kg/m(2). Finally, this effect was particularly apparent after the initial 12-month rapid weight loss phase, when less obese (BMI<50) individuals continued losing weight, while heavier individuals (BMI≥50) regained significant weight.

Cardiovascular events after bariatric surgery in obese subjects with type 2 diabetes

OBJECTIVE

Obese individuals with type 2 diabetes have an increased risk of cardiovascular disease. The effect of bariatric surgery on cardiovascular events in obese individuals with type 2 diabetes remains to be determined. The Swedish Obese Subjects (SOS) study is a prospective, controlled intervention study that examines the effects of bariatric surgery on hard end points. The aim of the present study was to examine the effect of bariatric surgery on cardiovascular events in the SOS study participants with type 2 diabetes.

RESEARCH DESIGN AND METHODS

All SOS study participants with type 2 diabetes at baseline were included in the analyses (n = 345 in the surgery group and n = 262 in the control group). Mean follow-up was 13.3 years (interquartile range 10.2-16.4) for all cardiovascular events.

RESULTS

Bariatric surgery was associated with a reduced myocardial infarction incidence (38 events among the 345 subjects in the surgery group vs. 43 events among the 262 subjects in the control group; log-rank P = 0.017; adjusted hazard ratio [HR] 0.56 [95% CI 0.34-0.93]; P = 0.025). No effect of bariatric surgery was observed on stroke incidence (34 events among the 345 subjects in the surgery group vs. 24 events among the 262 subjects in the control group; log-rank P = 0.852; adjusted HR 0.73 [0.41-1.30]; P = 0.29). The effect of surgery in reducing myocardial infarction incidence was stronger in individuals with higher serum total cholesterol and triglycerides at baseline (interaction P value = 0.02 for both traits). BMI (interaction P value = 0.12) was not related to the surgery outcome.

CONCLUSIONS

Bariatric surgery reduces the incidence of myocardial infarction in obese individuals with type 2 diabetes. Preoperative BMI should be integrated with metabolic parameters to maximize the benefits of bariatric surgery.

Meal Replacement Beverage Twice a Day in Overweight and Obese Adults (MDRC2012-001)

This open label, single arm, prospective, interventional, weight loss trial evaluated a meal replacement beverage (Right Size^® Smoothie) used to replace breakfast and lunch each day for 12 weeks (7 clinic visits) as part of a calorie-restricted diet in overweight and obese adults. A total of 155 individuals were screened, 55 enrolled and 28 completed this 12 week study. Subjects were obese (mean weight: 206 pounds and BMI: 32.7 kg/m²) and the mean age was 40 years including 42 (76.4%) female and 13 (23.6%) male volunteers. The modified Intent to Treat and Completer groups lost an average of 10.6 and 13.8 pounds and reduced their average BMI by 1.7 and 2.2 kg/m² respectively during this 12 week trial. The Per Protocol group lost 15.2 pounds and 2.4 kg/m² and the Optimal Weight Loss group lost 18.5 pounds and 2.9 kg/m². Using the Satiety Labeled Intensity Magnitude scale (SLIM) questionnaire, subjects reported feeling relatively hungry before they consumed the beverage, then feeling relatively full 15 minutes following the beverage with the sensation of some fullness lasting more than 2 hours and then feeling relatively hungry again at 3 hours after consuming the beverage. Study subjects reported significant improvements in physical functioning, general health, vitality and mental health as well as increased cognitive restraint of eating, reduced disinhibition and reduced hunger during the trial. The study beverages were well tolerated and no Serious Adverse Events (SAE) reported. This study suggests the study beverage aids in weight loss by helping to curb hunger during a reduced calorie diet program.

Long-term remission of type 2 diabetes in morbidly obese patients after sleeve gastrectomy

BACKGROUND

The aim of this study was to evaluate the long-term effects of laparoscopic sleeve gastrectomy (LSG) on type 2 diabetes mellitus (T2DM) and other related co-morbidities in severely obese patients.

METHODS

From May 2003 to July 2008, 33 morbidly obese diabetic patients (20 with body mass index [BMI]>50 kg/m(2)) underwent LSG. A total of 23 females and 10 males participated, with a mean age of 49.3±8 years, mean preoperative BMI of 52.1±8.5 kg/m(2), mean fasting plasma glucose (FPG) of 143.2±47.9 mg/dL, mean glycosylated hemoglobin (HbA1c) of 7.3%±1.4%, and a mean T2DM duration of 7 years. All patients had a 36-month follow-up, and 13 had a 60-month follow-up.

RESULTS

Twenty-nine patients (87.8%) discontinued antidiabetic medications 3 months after LSG, (mean BMI of 42.8±7.8 kg/m(2); FPG of 104.5±22.1 mg/dL; HbA1c of 5.3%±.4%). At 36 months, 22 of 26 LSG patients (84.6%) had normal FPG and HbA1c values without antidiabetic therapy. At the 60-month follow-up, 10 of 13 patients (76.9%) had normal FPG and HbA1c values without antidiabetic therapy. The Framingham risk score decreased significantly from 9.7% preoperatively to 4.7% postoperatively. No new diabetic retinopathy occurred during the whole period of observation.

CONCLUSIONS

This study confirms the efficacy of LSG in the treatment of T2DM and indicates that, at both 36- and 60-month follow-ups, LSG can provide a significant percentage of treated patients with a prolonged remission of T2DM, with diminished cardiac risk factors and no development of diabetic retinopathy. These results compare favorably with those reported after standard medical therapy.

Joint statement of the European Association for the Study of Obesity and the European Society of Hypertension: obesity and difficult to treat arterial hypertension

Obese patients are prone to arterial hypertension, require more antihypertensive medications, and have an increased risk of treatment-resistant arterial hypertension. Obesity-induced neurohumoral activation appears to be involved. The association between obesity and hypertension shows large inter-individual variability, likely through genetic mechanisms. Obesity affects overall cardiovascular and metabolic risk; yet, the relationship between obesity and cardiovascular risk is complex and not sufficiently addressed in clinical guidelines. The epidemiological observation that obesity may be protective in patients with established cardiovascular disease is difficult to translate into clinical experience and practice. Weight loss is often recommended as a means to lower blood pressure. However, current hypertension guidelines do not provide evidence-based guidance on how to institute weight loss. In fact, weight loss influences on blood pressure may be overestimated. Nevertheless, weight loss through bariatric surgery appears to decrease cardiovascular risk in severely obese patients. Eventually, most obese hypertensive patients will require antihypertensive medications. Data from large-scale studies with hard clinical endpoints on antihypertensive medications specifically addressing obese patients are lacking and the morbidity from the growing population of severely obese patients is poorly recognized or addressed. Because of their broad spectrum of beneficial effects, renin-angiotensin system inhibitors are considered to be the most appropriate drugs for antihypertensive treatment of obese patients. Most obese hypertensive patients require two or more antihypertensive drugs. Finally, how to combine weight loss strategies and antihypertensive treatment to achieve an optimal clinical outcome is unresolved.

Drug treatment of obesity in cardiovascular disease

Obesity is a significant health problem worldwide and is associated with a number of co-morbidities including type 2 diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnea, and cardiovascular disease. A number of different pathophysiologic mechanisms including increased inflammation, oxidative stress, and insulin resistance have been associated with initiation and progression of atherosclerotic disease in obese individuals. Lifestyle modifications have provided modest results in weight reduction and the focus of interest has now shifted towards drug development to treat severely obese individuals with a body mass index (BMI) >30 kg/m(2) or those with a BMI >27 kg/m(2) who have additional co-morbidities. Different regimens focusing on dietary absorption or acting centrally to control hunger and food intake have been developed. However, their weight loss effect is, in most cases, modest and this effect is lost once the medication is discontinued. In addition, long-term use of these drugs is limited by significant side effects and lack of long-term safety and efficacy data. Orlistat is the only US FDA-approved medication for long-term use. A number of new medications are currently under investigation in phase III trials with promising preliminary results. This review comments on available anti-obesity pharmacologic regimens, their weight-loss benefit, and their impact on cardiovascular risk factors.

A systematic review and mixed treatment comparison of pharmacological interventions for the treatment of obesity

The study aims to compare anti-obesity interventions in a single evidence synthesis framework. Electronic databases were searched for randomized controlled trials of orlistat, rimonabant or sibutramine reporting weight or body mass index (BMI) change from baseline at 3, 6 or 12 months. A mixed treatment comparison was used to combine direct and indirect trial evidence. Ninety-four studies involving 24,808 individuals were included; 83 trials included data on weight change and 41 on BMI change. All results are in comparison with placebo. The active drugs were all effective at reducing weight and BMI. At 3 months, orlistat reduced weight by -2.65 kg (95% credibility interval -4.00 kg, -1.31 kg). For sibutramine, 15 mg gave a greater reduction than 10 mg at 12 months, -6.35 kg versus -5.42 kg, respectively. Rimonabant reduced weight by -11.23 kg at 3 months and -4.55 kg at 12 months. Lifestyle advice alone also reduced weight at 6 and 12 months, but was less effective than the pharmacological interventions. In conclusion, modest weight reductions were seen for all pharmacological interventions. Those interventions which have now been withdrawn from use (sibutramine and rimonabant) seem to be the most effective, implying that there may be a place in clinical practice for similar drugs if side effects could be avoided.

A randomised study on the effects of fish protein supplement on glucose tolerance, lipids and body composition in overweight adults

The popularity of high-protein diets for weight reduction is immense. However, the potential benefits from altering the source of dietary protein rather than the amount is scarcely investigated. In the present study, we examined the effects of fish protein supplement on glucose and lipid metabolism in overweight adults. A total of thirty-four overweight adults were randomised to 8 weeks' supplementation with fish protein or placebo tablets (controls). The intake of fish protein supplement was 3 g/d for the first 4 weeks and 6 g/d for the last 4 weeks. In this study, 8 weeks of fish protein supplementation resulted in lower values of fasting glucose (P< 0·05), 2 h postprandial glucose (P< 0·05) and glucose-area under the curve (AUC) (five measurements over 2 h, P< 0·05) after fish protein supplementation compared to controls. Glucose-AUC was decreased after 8 weeks with fish protein supplement compared to baseline (P< 0·05), concomitant with increased 30 min and decreased 90 min and 2 h insulin C-peptide level (P< 0·05), and reduced LDL-cholesterol (P< 0·05). Body muscle % was increased (P< 0·05) and body fat % was reduced (P< 0·05) after 4 weeks' supplementation. Physical activity and energy and macronutrients intake did not change during the course of the study. In conclusion, short-term daily supplementation with a low dose of fish protein may have beneficial effects on blood levels of glucose and LDL-cholesterol as well as glucose tolerance and body composition in overweight adults. The long-term effects of fish protein supplementation is of interest in the context of using more fish as a protein source in the diet, and the effects of inclusion of fish in the diet of individuals with low glucose tolerance should be evaluated.