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Lenart-Lipińska M, Łuniewski M, Szydełko J, Matyjaszek-Matuszek B. Clinical and Therapeutic Implications of Male Obesity. J Clin Med 2023; 12:5354. [PMID: 37629396 PMCID: PMC10455727 DOI: 10.3390/jcm12165354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/29/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
The prevalence of obesity, a disorder linked to numerous comorbidities and metabolic complications, has recently increased dramatically worldwide and is highly prevalent in men, even at a young age. Compared to female patients, men with obesity more frequently have delayed diagnosis, higher severity of obesity, increased mortality rate, and only a minority of obese male patients are successfully treated, including with bariatric surgery. The aim of this review was to present the current state of knowledge about the clinical and therapeutic implications of obesity diagnosed in males.
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Affiliation(s)
- Monika Lenart-Lipińska
- Department of Endocrinology, Diabetology, and Metabolic Diseases, Medical University of Lublin, 20-954 Lublin, Poland; (M.Ł.); (J.S.); (B.M.-M.)
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2
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Reynolds EL, Watanabe M, Banerjee M, Chant E, Villegas-Umana E, Elafros MA, Gardner TW, Pop-Busui R, Pennathur S, Feldman EL, Callaghan BC. The effect of surgical weight loss on diabetes complications in individuals with class II/III obesity. Diabetologia 2023; 66:1192-1207. [PMID: 36917280 PMCID: PMC10011764 DOI: 10.1007/s00125-023-05899-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/25/2023] [Indexed: 03/16/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to determine the effect of bariatric surgery on diabetes complications in individuals with class II/III obesity (BMI > 35 kg/m2). METHODS We performed a prospective cohort study of participants with obesity who underwent bariatric surgery. At baseline and 2 years following surgery, participants underwent metabolic phenotyping and diabetes complication assessments. The primary outcomes for peripheral neuropathy (PN) were a change in intra-epidermal nerve fibre density (IENFD, units = fibres/mm) at the distal leg and proximal thigh, the primary outcome for cardiovascular autonomic neuropathy (CAN) was a change in the expiration/inspiration (E/I) ratio, and the primary outcome for retinopathy was a change in the mean deviation on frequency doubling technology testing. RESULTS Among 127 baseline participants, 79 completed in-person follow-up (age 46.0 ± 11.3 years [mean ± SD], 73.4% female). Participants lost a mean of 31.0 kg (SD 18.4), and all metabolic risk factors improved except for BP and total cholesterol. Following bariatric surgery, one of the primary PN outcomes improved (IENFD proximal thigh, +3.4 ± 7.8, p<0.01), and CAN (E/I ratio -0.01 ± 0.1, p=0.89) and retinopathy (deviation -0.2 ± 3.0, p=0.52) were stable. Linear regression revealed that a greater reduction in fasting glucose was associated with improvements in retinopathy (mean deviation point estimate -0.7, 95% CI -1.3, -0.1). CONCLUSIONS/INTERPRETATION Bariatric surgery may be an effective approach to reverse PN in individuals with obesity. The observed stability of CAN and retinopathy may be an improvement compared with the natural progression of these conditions; however, controlled trials are needed.
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Affiliation(s)
- Evan L Reynolds
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Maya Watanabe
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Ericka Chant
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Thomas W Gardner
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Subramaniam Pennathur
- Division of Nephrology, Department of Internal Medicine and Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Brian C Callaghan
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
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Park HS, Seo K, Kim HS, Im SI, Kim BJ, Kim BK, Heo JH. Postoperative effects of bariatric surgery on heart rate recovery and heart rate variability. KOSIN MEDICAL JOURNAL 2022. [DOI: 10.7180/kmj.22.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Several studies have reported associations between obesity and autonomic dysfunction. However, little research has investigated the effect of bariatric surgery on heart rate recovery (HRR) in the treadmill test and heart rate variability (HRV) in 24-hour Holter monitoring. We investigated the effects of bariatric surgery on HRR and HRV, which are parameters related to autonomic dysfunction. Methods: We retrospectively investigated patients who underwent bariatric surgery in 2019. The treadmill test, 24-hour Holter monitoring, and echocardiography were performed before and 6 months after surgery. We compared the changes in HRR in the treadmill test and HRV parameters such as the time domain and spectral domain in 24-hour Holter monitoring before and after surgery. Results: Of the 40 patients who underwent bariatric surgery, 25 patients had the treadmill test or 24-hour Holter monitoring both before and after surgery. Body weight and body mass index significantly decreased after surgery (112.86±24.37 kg vs. 89.10±20.26 kg, p<0.001; 39.22±5.69 kg/m2 vs. 31.00±5.09 kg/m2, p<0.001, respectively). HRR significantly increased (n=23; 43.00±20.97 vs. 64.29±18.49, p=0.001). The time domain of HRV parameters increased (n=21; standard deviation of the N-N interval 123.57±28.05 vs. 152.57±39.49, p=0.002 and mean N-N interval 791.57±88.84 vs. 869.05±126.31, p=0.002).Conclusions: Our data showed that HRR after exercise and HRV during 24-hour Holter monitoring improved after weight reduction with bariatric surgery through improved cardiac autonomic function.
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Hypoglycemia and Dysautonomia After Bariatric Surgery: a Systematic Review and Perspective. Obes Surg 2022; 32:1681-1688. [PMID: 35133603 DOI: 10.1007/s11695-022-05960-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/24/2022] [Accepted: 02/02/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION With the increasing performance of bariatric surgery, rare complications are becoming prevalent. We review the diagnosis and treatment of dysautonomia after bariatric surgery and the limited treatment options available. We summarize the suggested mechanisms and explain why a complete understanding of the etiology has yet to be determined. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed. RESULTS Of 448 studies identified in the literature search, 4 studies were reviewed, describing 87 patients diagnosed with dysautonomia. We present a patient who developed severe dysautonomia following conversion of sleeve gastrectomy to gastric bypass. CONCLUSION Treatment needs to focus on optimizing nutrition, avoiding hypoglycemia, and optimizing volume status.
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An Z, Wang H, Mokadem M. Role of the Autonomic Nervous System in Mechanism of Energy and Glucose Regulation Post Bariatric Surgery. Front Neurosci 2021; 15:770690. [PMID: 34887725 PMCID: PMC8649921 DOI: 10.3389/fnins.2021.770690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 10/15/2021] [Indexed: 01/06/2023] Open
Abstract
Even though lifestyle changes are the mainstay approach to address obesity, Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most effective and durable treatments facing this pandemic and its associated metabolic conditions. The traditional classifications of bariatric surgeries labeled them as “restrictive,” “malabsorptive,” or “mixed” types of procedures depending on the anatomical rearrangement of each one of them. This conventional categorization of bariatric surgeries assumed that the “restrictive” procedures induce their weight loss and metabolic effects by reducing gastric content and therefore having a smaller reservoir. Similarly, the “malabsorptive” procedures were thought to induce their main energy homeostatic effects from fecal calorie loss due to intestinal malabsorption. Observational data from human subjects and several studies from rodent models of bariatric surgery showed that neither of those concepts is completely true, at least in explaining the multiple metabolic changes and the alteration in energy balance that those two surgeries induce. Rather, neuro-hormonal mechanisms have been postulated to underly the physiologic effects of those two most performed bariatric procedures. In this review, we go over the role the autonomic nervous system plays- through its parasympathetic and sympathetic branches- in regulating weight balance and glucose homeostasis after SG and RYGB.
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Affiliation(s)
- Zhibo An
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Haiying Wang
- Department of Physiology, Basic Medical School of Jining Medical University, Jining, China
| | - Mohamad Mokadem
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States.,Fraternal Order of Eagles Diabetes Research Center, The University of Iowa, Iowa City, IA, United States.,Obesity Research and Education Initiative, The University of Iowa, Iowa City, IA, United States.,Iowa City Veterans Affairs Health Care System, Iowa City, IA, United States
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Al Nou'mani J, Al Alawi AM, Falhammar H, Al Qassabi A. Orthostatic intolerance after bariatric surgery: A systematic review and meta-analysis. Clin Obes 2021; 11:e12483. [PMID: 34409762 DOI: 10.1111/cob.12483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 01/03/2023]
Abstract
There have been increased reports of orthostatic intolerance post-bariatric surgery. However, the prevalence, pathophysiology and long-term outcomes have not been well described. Therefore, we sought to summarize evidence of orthostatic intolerance after bariatric surgery. We conducted a systematic review using PubMed, Scopus, CINAHL, Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify relevant articles from the date of inception until 1st April 2020. Study selection, data extraction and quality assessment of the included studies were performed independently by two reviewers. The findings of the included studies were narratively reported. When feasible, a meta-analysis was done to summarize the relevant results. We included 20 studies (n = 19 843 participants) reporting findings of 12 prospective cohort studies, 5 retrospective cohort studies, 2 cross-sectional studies and one randomized controlled trial. The 5-year cumulative incidence of orthostatic intolerance was 4.2% (one study). Common clinical presentations of orthostatic intolerance were lightheadedness, dizziness, syncope and palpitation. The pooled data suggested improvement in overall cardiac autonomic function (sympathetic and parasympathetic) post-bariatric surgery. In addition, a significant systolic blood pressure drop may reflect a reset of the balance between the sympathetic and parasympathetic nervous systems after weight loss in the pooled analysis. Existing literature on orthostatic intolerance post-bariatric surgeries was limited or of low quality, and larger studies are needed to know the true incidence of orthostatic intolerance post-bariatric surgeries and the pathophysiology. We found one study reporting the 5-years cumulative incidence of orthostatic intolerance post-bariatric surgeries as only 4.2%. This could challenge the idea of increased orthostatic intolerance prevalence post-bariatric surgeries. Registration The review protocol was registered at the International Prospective Register of Systemic Reviews PROSPERO (CRD42020170877).
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Affiliation(s)
| | - Abdullah M Al Alawi
- Oman Medical Specialty Board, Muscat, Oman
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Menzies School of Health Research, Charles Darwin University, Darwin, Northwest Territories, Australia
| | - Ahmed Al Qassabi
- Oman Medical Specialty Board, Muscat, Oman
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
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Jabbour G, Salman A. Bariatric Surgery in Adults with Obesity: the Impact on Performance, Metabolism, and Health Indices. Obes Surg 2021; 31:1767-1789. [PMID: 33454846 PMCID: PMC8012340 DOI: 10.1007/s11695-020-05182-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/09/2020] [Accepted: 12/21/2020] [Indexed: 02/07/2023]
Abstract
This systematic review summarizes current evidence on the impact of bariatric surgery (BS) on physical performance, metabolic, and health indices in adults with obesity. This systematic review suggests that BS induced significant reductions in body weight, fat mass, and fat-free mass in individuals with obesity. Additionally, BS may improve many physical fitness and health indicators. Observed improvements manifest during a distinct period of time. To date, studies on BS and performance have been small in number, nonrandomized in design, and not controlled regarding gender distribution and/or post-surgery follow-up. Future studies should further investigate concerns associated with understanding of BS outcomes to improve these outcomes with potential benefits for quality of life, disability, mortality, morbidity, and overall BS success.
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Affiliation(s)
- Georges Jabbour
- Sport Science Program, College of Arts and Sciences, Qatar University, P.O. Box 2713, Doha, Qatar.
| | - Ahmad Salman
- Sport Science Program, College of Arts and Sciences, Qatar University, P.O. Box 2713, Doha, Qatar
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Al Obeed OA, Traiki TB, Alfahad YF, Abdulla MH, AlAli MN, Alharbi AA, Alharbi R, Nouh T, Hersi A. Prevalence of vasovagal syncope following bariatric surgery. Saudi J Anaesth 2021; 15:161-164. [PMID: 34188635 PMCID: PMC8191276 DOI: 10.4103/sja.sja_922_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Obesity is a major global public health problem. Observational studies have shown an increasing incidence of syncope and pre-syncope following bariatric surgery in obese patients. However, there is paucity of the true incidence of syncope following bariatrics sugary in the literature. METHODS We have randomly surveyed 200 patients who underwent bariatric surgery between 2016-2018 using Calgary Syncope Score (CSS). RESULTS Of the 200 patients enrolled, 107 (53.5%) were female with 167 patients (83.5%) between 18 and 50 years of age. The most-reported comorbidities were diabetes mellitus 26 (13%) hypertension 25 (12.5%) and pulmonary disease 18 (9%). The majority 98 (49%) of the patients had pre-operative body mass index (BMI) of 40-50 kg/m 2, and most of them had laparoscopic sleeve gastrectomy (LSG). Sixty-two (31%) patients had vasovagal syncope (VVS), 52 (26%) patients had non-VVS and 86 (43%) had no syncope. CONCLUSION Vasovagal syncope in patients following bariatric sugary is quite common and affects 15% of bariatric patients in our series in the first year postoperatively. Further randomized controlled trials are required to prove our results.
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Affiliation(s)
- Omar A. Al Obeed
- Colorectal Research Chair, Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Thamer Bin Traiki
- Colorectal Research Chair, Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Yara F. Alfahad
- Department of Cardiac Sciences, College of Medicine, King Saud University and King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Maha-Hamadien Abdulla
- Colorectal Research Chair, Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Mohamed N. AlAli
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdulhamed A. Alharbi
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Reem Alharbi
- Department of Surgery, College of Medicine, Prince Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
| | - Thamer Nouh
- Trauma and Acute Care Surgery Unit, Department of Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ahmad Hersi
- Department of Cardiac Sciences, College of Medicine, King Saud University and King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
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9
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Gopinathannair R, Ahmed I, Akella K, Couchonnal L, Murtaza G, Lakkireddy D, Olshansky B. 'Heart Rate Deficit' from Dysautonomia in a Bariatric Surgery Patient - An Unusual Cause of Recurrent Syncope. J Atr Fibrillation 2020; 13:2390. [PMID: 34950313 DOI: 10.4022/jafib.2390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/06/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute, Overland Park, KS.,HCA Midwest Health, Kansas City, KS
| | | | - Krishna Akella
- Kansas City Heart Rhythm Institute, Overland Park, KS.,HCA Midwest Health, Kansas City, KS
| | | | - Ghulam Murtaza
- Kansas City Heart Rhythm Institute, Overland Park, KS.,HCA Midwest Health, Kansas City, KS
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute, Overland Park, KS.,HCA Midwest Health, Kansas City, KS
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Gomide Braga T, das Graças Coelho de Souza M, Maranhão PA, Menezes M, Dellatorre-Teixeira L, Bouskela E, Le Roux CW, Kraemer-Aguiar LG. Evaluation of Heart Rate Variability and Endothelial Function 3 Months After Bariatric Surgery. Obes Surg 2020; 30:2450-2453. [DOI: 10.1007/s11695-020-04397-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Delgado André L, Basso-Vanelli RP, Di Thommazo-Luporini L, Angélica Ricci P, Cabiddu R, Pilon Jürgensen S, Ricardo de Oliveira C, Arena R, Borghi-Silva A. Functional and systemic effects of whole body electrical stimulation post bariatric surgery: study protocol for a randomized controlled trial. Trials 2018; 19:597. [PMID: 30382930 PMCID: PMC6211515 DOI: 10.1186/s13063-018-2844-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/06/2018] [Indexed: 11/29/2022] Open
Abstract
Background Obesity represents a major public health problem and is the fifth leading risk factor for mortality. Morbid obesity is associated with chronic systemic inflammation which increases the risk of comorbidities. Bariatric surgery (BS) is considered an effective intervention for obese patients. However, BS is associated with dietary restriction, potentially limiting physical activity. Whole-body neuromuscular electrical stimulation (WBS) could represent an innovative option for the rehabilitation of BS patients, especially during the early postoperative phase when other conventional techniques are contraindicated. WBS is a safe and effective tool to combat sarcopenia and metabolic risk as well as increasing muscle mass, producing greater glucose uptake, and reducing the proinflammatory state. Therefore, the objective of this study is to evaluate the effects of WBS on body composition, functional capacity, muscle strength and endurance, insulin resistance, and pro- and anti-inflammatory circulating markers in obese patients undergoing BS. Methods/design The present study is a randomized, double-blind, placebo-controlled, parallel groups clinical trial approved by the Ethics Committee of our Institution. Thirty-six volunteers (body mass index (BMI) > 35 kg/m2) between 18 and 45 years of age will be randomized to the WBS group (WBSG) or control (Sham) group (ShamG) after being submitted to BS. Preoperative assessments will include maximal and submaximal exercise testing, body composition, blood inflammatory markers, and quadriceps strength and endurance. The second day after discharge, body composition will be evaluated and a 6-min walk test (6MWT) will be performed. The WBS or Sham protocol will consist of 30 daily sessions for 6 consecutive weeks. Afterwards, the same assessments that were performed in the preoperative period will be repeated. Discussion Considering the important role of WBS in skeletal muscle conditioning and its value as an aid in exercise performance, the proposed study will investigate this technique as a tool to promote early rehabilitation in these patients, and as a strategy to enhance exercise capacity, weight loss, and peripheral muscle strength with positive systemic effects. The present study is still ongoing, and data will be published after its conclusion. Trial registration REBEC, RBR-99qw5h. Registered on 20 February 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2844-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Larissa Delgado André
- Department of Physiotherapy, Federal University of São Carlos, Rod. Washington Luís, km 235, São Carlos, São Paulo, 13565-905, Brazil
| | - Renata P Basso-Vanelli
- Department of Physiotherapy, Federal University of São Carlos, Rod. Washington Luís, km 235, São Carlos, São Paulo, 13565-905, Brazil
| | - Luciana Di Thommazo-Luporini
- Department of Physiotherapy, Federal University of São Carlos, Rod. Washington Luís, km 235, São Carlos, São Paulo, 13565-905, Brazil
| | - Paula Angélica Ricci
- Department of Physiotherapy, Federal University of São Carlos, Rod. Washington Luís, km 235, São Carlos, São Paulo, 13565-905, Brazil
| | - Ramona Cabiddu
- Department of Physiotherapy, Federal University of São Carlos, Rod. Washington Luís, km 235, São Carlos, São Paulo, 13565-905, Brazil
| | - Soraia Pilon Jürgensen
- Department of Physiotherapy, Federal University of São Carlos, Rod. Washington Luís, km 235, São Carlos, São Paulo, 13565-905, Brazil
| | - Claudio Ricardo de Oliveira
- Department of Medicine, Federal University of São Carlos, Rod. Washington Luís, km 235, São Carlos, São Paulo, 13565-905, Brazil
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Audrey Borghi-Silva
- Cardiopulmonary Physiotherapy Laboratory, Department of Physiotherapy, Federal University of São Carlos, Rod. Washington Luís, km 235, São Carlos, São Paulo, 13565-905, Brazil.
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Vinik AI, Casellini C, Parson HK, Colberg SR, Nevoret ML. Cardiac Autonomic Neuropathy in Diabetes: A Predictor of Cardiometabolic Events. Front Neurosci 2018; 12:591. [PMID: 30210276 PMCID: PMC6119724 DOI: 10.3389/fnins.2018.00591] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 08/06/2018] [Indexed: 12/15/2022] Open
Abstract
Autonomic nervous system (ANS) imbalance manifesting as cardiac autonomic neuropathy in the diabetic population is an important predictor of cardiovascular events. Symptoms and signs of ANS dysfunction, such as resting heart rate elevations, diminished blood pressure responses to standing, and altered time and frequency domain measures of heart rate variability in response to deep breathing, standing, and the Valsalva maneuver, should be elicited from all patients with diabetes and prediabetes. With the recognition of the presence of ANS imbalance or for its prevention, a rigorous regime should be implemented with lifestyle modification, physical activity, and cautious use of medications that lower blood glucose. Rather than intensifying diabetes control, a regimen tailored to the individual risk of autonomic imbalance should be implemented. New agents that may improve autonomic function, such as SGLT2 inhibitors, should be considered and the use of incretins monitored. One of the central mechanisms of dysfunction is disturbance of the hypothalamic cardiac clock, a consequence of dopamine deficiency that leads to sympathetic dominance, insulin resistance, and features of the metabolic syndrome. An improvement in ANS balance may be critical to reducing cardiovascular events, cardiac failure, and early mortality in the diabetic population.
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Affiliation(s)
- Aaron I. Vinik
- Division of Endocrinology and Metabolism, Strelitz Diabetes Center and Neuroendocrine Unit, Department of Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Carolina Casellini
- Division of Endocrinology and Metabolism, Strelitz Diabetes Center and Neuroendocrine Unit, Department of Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Henri K. Parson
- Division of Endocrinology and Metabolism, Strelitz Diabetes Center and Neuroendocrine Unit, Department of Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Sheri R. Colberg
- Department of Human Movement Sciences, Old Dominion University, Norfolk, VA, United States
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Sagheer S, Sheikh AB, Alkubeysi M, Andre P, Bunn C, Inbar S. Delayed Chronotropic Response due to Autonomic Imbalance Presenting as Dyspnea on Early Exertion: A Complication of Bariatric Surgery. Cureus 2018; 10:e3212. [PMID: 30405988 PMCID: PMC6205872 DOI: 10.7759/cureus.3212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Bariatric surgery has shown promising outcomes in improving overall morbidity and mortality in morbidly obese patients. Cardiovascular risk reduction from weight loss is well known in the literature. However, little is highlighted about the cardiovascular complications of massive and rapid weight loss associated with bariatric surgery. These complications result mainly from autonomic imbalance manifesting as increased parasympathetic tone and a decrease in sympathetic response. This imbalance is a consequence of hormonal changes associated with massive weight loss. We present a unique case which is a demonstration of the aforementioned changes. Our patient presented with dyspnea during an early phase of exercise with the resolution of symptoms with the continuation of exercise.
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Affiliation(s)
- Shazib Sagheer
- Internal Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | | | | | - Paul Andre
- Internal Medicine, University of New Mexico Hospital, Albuquerque, USA
| | - Christopher Bunn
- Internal Medicine, University of New Mexico Hospital, Albuquerque, USA
| | - Shmuel Inbar
- Internal Medicine, University of New Mexico Hospital, Albuquerque, USA
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Ma J, Vella A. What Has Bariatric Surgery Taught Us About the Role of the Upper Gastrointestinal Tract in the Regulation of Postprandial Glucose Metabolism? Front Endocrinol (Lausanne) 2018; 9:324. [PMID: 29997575 PMCID: PMC6028568 DOI: 10.3389/fendo.2018.00324] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/31/2018] [Indexed: 02/06/2023] Open
Abstract
The interaction between the upper gastrointestinal tract and the endocrine system is important in the regulation of metabolism and of weight. The gastrointestinal tract has a heterogeneous cellular content and comprises a variety of cells that elaborate paracrine and endocrine mediators that collectively form the entero-endocrine system. The advent of therapy that utilizes these pathways as well as the association of bariatric surgery with diabetes remission has (re-)kindled interest in the role of the gastrointestinal tract in glucose homeostasis. In this review, we will use the changes wrought by bariatric surgery to provide insights into the various gut-pancreas interactions that maintain weight, regulate satiety, and limit glucose excursions after meal ingestion.
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Affiliation(s)
- Jing Ma
- Division of Endocrinology and Metabolism, Shanghai Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic College of Medicine, Rochester, NY, United States
| | - Adrian Vella
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic College of Medicine, Rochester, NY, United States
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Ponnusamy V, Owens AP, Purkayastha S, Iodice V, Mathias CJ. Orthostatic intolerance and autonomic dysfunction following bariatric surgery: A retrospective study and review of the literature. Auton Neurosci 2016; 198:1-7. [DOI: 10.1016/j.autneu.2016.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/29/2016] [Accepted: 05/16/2016] [Indexed: 01/24/2023]
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Casellini CM, Parson HK, Hodges K, Edwards JF, Lieb DC, Wohlgemuth SD, Vinik AI. Bariatric Surgery Restores Cardiac and Sudomotor Autonomic C-Fiber Dysfunction towards Normal in Obese Subjects with Type 2 Diabetes. PLoS One 2016; 11:e0154211. [PMID: 27137224 PMCID: PMC4854471 DOI: 10.1371/journal.pone.0154211] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 04/11/2016] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The aim was to evaluate the impact of bariatric surgery on cardiac and sudomotor autonomic C-fiber function in obese subjects with and without Type 2 diabetes mellitus (T2DM), using sudorimetry and heart rate variability (HRV) analysis. METHOD Patients were evaluated at baseline, 4, 12 and 24 weeks after vertical sleeve gastrectomy or Roux-en-Y gastric bypass. All subjects were assessed using SudoscanTM to measure electrochemical skin conductance (ESC) of hands and feet, time and frequency domain analysis of HRV, Neurologic Impairment Scores of lower legs (NIS-LL), quantitative sensory tests (QST) and sural nerve conduction studies. RESULTS Seventy subjects completed up to 24-weeks of follow-up (24 non-T2DM, 29 pre-DM and 17 T2DM). ESC of feet improved significantly towards normal in T2DM subjects (Baseline = 56.71±3.98 vs 12-weeks = 62.69±3.71 vs 24-weeks = 70.13±2.88, p<0.005). HRV improved significantly in T2DM subjects (Baseline sdNN (sample difference of the beat to beat (NN) variability) = 32.53±4.28 vs 12-weeks = 44.94±4.18 vs 24-weeks = 49.71±5.19, p<0,001 and baseline rmsSD (root mean square of the difference of successive R-R intervals) = 23.88±4.67 vs 12-weeks = 38.06±5.39 vs 24-weeks = 43.0±6.25, p<0.0005). Basal heart rate (HR) improved significantly in all groups, as did weight, body mass index (BMI), percent body fat, waist circumference and high-density lipoprotein (HDL). Glycated hemoglobin (HbA1C), insulin and HOMA2-IR (homeostatic model assessment) levels improved significantly in pre-DM and T2DM subjects. On multiple linear regression analysis, feet ESC improvement was independently associated with A1C, insulin and HOMA2-IR levels at baseline, and improvement in A1C at 24 weeks, after adjusting for age, gender and ethnicity. Sudomotor function improvement was not associated with baseline weight, BMI, % body fat or lipid levels. Improvement in basal HR was also independently associated with A1C, insulin and HOMA2-IR levels at baseline. CONCLUSION This study shows that bariatric surgery can restore both cardiac and sudomotor autonomic C-fiber dysfunction in subjects with diabetes, potentially impacting morbidity and mortality.
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Affiliation(s)
- Carolina M. Casellini
- Strelitz Diabetes Center for Endocrine and Metabolic Disorders and the Neuroendocrine Unit, Department of Medicine; Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Henri K. Parson
- Strelitz Diabetes Center for Endocrine and Metabolic Disorders and the Neuroendocrine Unit, Department of Medicine; Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Kim Hodges
- Strelitz Diabetes Center for Endocrine and Metabolic Disorders and the Neuroendocrine Unit, Department of Medicine; Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Joshua F. Edwards
- Strelitz Diabetes Center for Endocrine and Metabolic Disorders and the Neuroendocrine Unit, Department of Medicine; Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - David C. Lieb
- Strelitz Diabetes Center for Endocrine and Metabolic Disorders and the Neuroendocrine Unit, Department of Medicine; Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Stephen D. Wohlgemuth
- Sentara Comprehensive Weight Loss Solutions, Sentara Medical Group, Norfolk, Virginia, United States of America
| | - Aaron I. Vinik
- Strelitz Diabetes Center for Endocrine and Metabolic Disorders and the Neuroendocrine Unit, Department of Medicine; Eastern Virginia Medical School, Norfolk, Virginia, United States of America
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Vinik AI, Casellini C, Névoret ML. Alternative Quantitative Tools in the Assessment of Diabetic Peripheral and Autonomic Neuropathy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2016; 127:235-85. [PMID: 27133153 DOI: 10.1016/bs.irn.2016.03.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Here we review some seldom-discussed presentations of diabetic neuropathy, including large fiber dysfunction and peripheral autonomic dysfunction, emphasizing the impact of sympathetic/parasympathetic imbalance. Diabetic neuropathy is the most common complication of diabetes and contributes additional risks in the aging adult. Loss of sensory perception, loss of muscle strength, and ataxia or incoordination lead to a risk of falling that is 17-fold greater in the older diabetic compared to their young nondiabetic counterparts. A fall is accompanied by lacerations, tears, fractures, and worst of all, traumatic brain injury, from which more than 60% do not recover. Autonomic neuropathy has been hailed as the "Prophet of Doom" for good reason. It is conducive to increased risk of myocardial infarction and sudden death. An imbalance in the autonomic nervous system occurs early in the evolution of diabetes, at a stage when active intervention can abrogate the otherwise relentless progression. In addition to hypotension, many newly recognized syndromes can be attributed to cardiac autonomic neuropathy such as orthostatic tachycardia and bradycardia. Ultimately, this constellation of features of neuropathy conspire to impede activities of daily living, especially in the patient with pain, anxiety, depression, and sleep disorders. The resulting reduction in quality of life may worsen prognosis and should be routinely evaluated and addressed. Early neuropathy detection can only be achieved by assessment of both large and small- nerve fibers. New noninvasive sudomotor function technologies may play an increasing role in identifying early peripheral and autonomic neuropathy, allowing rapid intervention and potentially reversal of small-fiber loss.
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Affiliation(s)
- A I Vinik
- Eastern Virginia Medical School, Strelitz Diabetes and Neuroendocrine Center, Norfolk, VA, United States.
| | - C Casellini
- Eastern Virginia Medical School, Strelitz Diabetes and Neuroendocrine Center, Norfolk, VA, United States
| | - M-L Névoret
- Impeto Medical Inc., San Diego, CA, United States
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Celedonio JE, Arnold AC, Dupont WD, Ramirez CE, Diedrich A, Okamoto LE, Raj SR, Robertson D, Peltier AC, Biaggioni I, Shibao CA. Residual sympathetic tone is associated with reduced insulin sensitivity in patients with autonomic failure. Clin Auton Res 2015; 25:309-15. [PMID: 26359268 DOI: 10.1007/s10286-015-0307-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/18/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Parkinson disease, an α-synucleinopathy, is associated with reduced insulin sensitivity, impaired glucose tolerance, and diabetes mellitus. Importantly, these metabolic alterations have been shown to contribute to disease progression. The purpose of this study was to determine if reduced insulin sensitivity is also present in other α-synucleinopathies associated with autonomic failure. METHODS We studied 19 patients with multiple system atrophy and 26 patients with pure autonomic failure. For comparison, we studied 8 healthy controls matched for body mass index. Insulin sensitivity and beta cell function were calculated using fasting glucose and insulin levels according to the homeostatic model assessment 2. A multiple linear regression model was performed to determine factors that predict insulin sensitivity in autonomic failure. RESULTS There was a significant difference in insulin sensitivity among groups (P = 0.048). This difference was due to lower insulin sensitivity in multiple system atrophy patients: 64% [interquartile range (IQR), 43 to 117] compared to healthy controls 139% (IQR, 83 to 212), P = 0.032. The main factor that contributed to the reduced insulin sensitivity was the presence of supine hypertension and residual sympathetic tone. CONCLUSIONS Multiple system atrophy patients have reduced insulin sensitivity that is associated with residual sympathetic activation and supine hypertension. These patients may therefore be at high risk for development of impaired glucose tolerance and diabetes mellitus.
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Affiliation(s)
- Jorge E Celedonio
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Amy C Arnold
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - Claudia E Ramirez
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - David Robertson
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Amanda C Peltier
- Department of Neurology, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, USA
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA.
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Wu JM, Yu HJ, Lai HS, Yang PJ, Lin MT, Lai F. Improvement of heart rate variability after decreased insulin resistance after sleeve gastrectomy for morbidly obesity patients. Surg Obes Relat Dis 2014; 11:557-63. [PMID: 25630807 DOI: 10.1016/j.soard.2014.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 09/11/2014] [Accepted: 09/13/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Morbidly obese patients display both an autonomic nervous imbalance and impaired glucose metabolism, and both of these conditions can be partially reversed after bariatric surgery. The aim of the present study was to investigate changes in heart rate variability (HRV) and glucose metabolism in patients after laparoscopic sleeve gastrectomy (SG). METHODS Eighteen morbidly obese patients who underwent SG were examined before surgery and at 7, 30, 90, and 180 days after surgery. Indices of HRV included time-domain, frequency-domain, and nonlinear parameters. Glucose metabolism was evaluated by the measuring levels of insulin resistance, glycated hemoglobin (HbA(1c)), and gut hormones. RESULTS The study included 9 men and 9 women with a mean age of 34 years. In the HRV study, the average R-R interval, median R-R interval, standard deviation of the R-R intervals, root mean squared successive difference of the R-R intervals (RMSSD), and the number of pairs of successive normal-to-normal beat intervals that differed by>50 ms significantly increased at 180 days after surgery. Regarding the frequency-domain indices, the low frequency (LF)/high frequency (HF) ratio was more balanced at 90 days after SG compared with baseline, and increases in the total power, LF band, and HF band were observed at 180 days. The assessments of insulin resistance, glucose metabolism, and gut hormones revealed not only improvements in the homeostasis model assessment of insulin resistance and HbA1c levels but also increases in the levels of glucagon-like peptide-1 at 90 and 180 days after surgery compared with baseline. A multivariable regression model revealed significantly negative associations between the perioperative changes in HOMA-IR and changes in both the RMSSD and HF band. CONCLUSIONS SG leads to early improvements in insulin resistance and glucose metabolism that are followed by improvements in HRV indices. Improvements in insulin resistance were associated with increases in the RMSSD and HF band index, but the mechanism of these changes require further study.
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Affiliation(s)
- Jin-Ming Wu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Hwan-Jeu Yu
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
| | - Hong-Shiee Lai
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Jen Yang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Tsan Lin
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Feipei Lai
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
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Fleischer J, Yderstraede K, Gulichsen E, Jakobsen PE, Lervang HH, Eldrup E, Nygaard H, Tarnow L, Ejskjaer N. Cardiovascular autonomic neuropathy is associated with macrovascular risk factors in type 2 diabetes: new technology used for routine large-scale screening adds new insight. J Diabetes Sci Technol 2014; 8:874-80. [PMID: 24876410 PMCID: PMC4764213 DOI: 10.1177/1932296814528616] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective was to identify the presence of cardiovascular autonomic neuropathy (CAN) in a cohort of individuals with diabetes in outpatient clinics from 4 different parts of Denmark and to explore the difference between type 1 and type 2 diabetes in relation to CAN. The DAN-Study is a Danish multicenter study focusing on diabetic autonomic neuropathy. Over a period of 12 months, 382 type 1 and 271 type 2 individuals with diabetes were tested for CAN. Patients were randomly recruited and tested during normal visits to outpatient clinics at 4 Danish hospitals. The presence of CAN was quantified by performing 3 cardiovascular reflex tests (response to standing, deep breathing, and valsalva). To describe possible associations, multivariate analysis with CAN as the dependent variable was performed. The prevalence of CAN was higher among patients with type 2 diabetes (35%) compared to patients with type 1 diabetes (25%). Multivariate analysis revealed significant associations between CAN and different risk markers in the 2 populations. In type 1 diabetes patients CAN was associated with microalbuminuria (P < .001), macroalbuminuria (P = .011), simplex retinopathy (P < .001), proliferative retinopathy (P < .001), and peripheral neuropathy (P = .041). Among type 2 diabetes patients CAN was independently associated with high pulse pressure (P < .01), BMI (P = .006), and smoking (P = .025). In this cross-sectional observational study CAN was independently associated with microvascular complication in type 1, whereas in type 2 CAN was associated with macrovascular risk factors.
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Affiliation(s)
- Jesper Fleischer
- Medical Research Laboratories, Clinical Institute of Medicine, Aarhus University and Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Knud Yderstraede
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | | | - Poul Erik Jakobsen
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Ebbe Eldrup
- Department of Internal Medicine and Endocrinology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Hans Nygaard
- Clinical Institute of Medicine, Aarhus University, Aarhus, Denmark
| | - Lise Tarnow
- Steno Diabetes Center, Gentofte, Denmark Clinical Institute of Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Ejskjaer
- Medical Research Laboratories, Clinical Institute of Medicine, Aarhus University and Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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Malik MG, Franklin SM, Whigham LA, Castellanos A, Fontaine JM. Asymptomatic sinus bradycardia following bariatric surgery. Am J Cardiol 2014; 113:1049-53. [PMID: 24462072 DOI: 10.1016/j.amjcard.2013.11.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 11/23/2013] [Accepted: 11/23/2013] [Indexed: 10/25/2022]
Abstract
Approximately 121,000 bariatric surgical procedures are performed annually, and salutary effects include a reduction in cardiovascular morbidity and mortality, risk factor modification, and improvement in sympathovagal tone. There are anecdotal accounts of unexplained sinus bradycardia (SB) after significant weight loss but no systematic studies have been conducted. The purpose of this study was to determine the frequency of incident SB, its timing, and association with weight loss, clinical characteristics, and predictors. We evaluated various clinical characteristics including resting heart rate, blood pressure, body mass index (BMI), heart rate reserve (HRR), basal metabolic rate, and exercise regimen in 151 consecutive patients who underwent bariatric surgery. Multiple logistic regression analysis was performed to determine predictors of SB. Twenty-five of 137 patients (18%) experienced postoperative SB. Patients with SB had significantly greater reduction in BMI than those without bradycardia (35 ± 9.6% and 25.7 ± 13%, respectively, p = 0.002). HRR was significantly greater in patients with SB (116 ± 14 beats/min) compared with those without bradycardia (105 ± 14 beats/min, p = 0.007). Multiple logistic regression analysis revealed that the odds of developing SB were 1.96 and 1.91 and associated with the percent decrease in BMI (95% confidence interval 1.3 to 3.0, p = 0.002) or increase in HRR (95% confidence interval 1.28 to 2.85, p = 0.002), respectively. In conclusion, SB occurred 14 ± 11 months postoperatively and its predictors were the percent reduction in BMI or increase in HRR.
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A pilot study investigating the effects of continuous positive airway pressure treatment and weight-loss surgery on autonomic activity in obese obstructive sleep apnea patients. J Electrocardiol 2014; 47:364-73. [PMID: 24636793 DOI: 10.1016/j.jelectrocard.2014.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND We have previously demonstrated that severity of obstructive sleep apnea (OSA) as measured by the apnea-hypopnea index (AHI) is a significant independent predictor of readily-computed time-domain metrics of short-term heart rate variability (HRV). METHODS We aimed to assess time-domain HRV measured over 5-min while awake in a trial of obese subjects undergoing one of two OSA therapies: weight-loss surgery (n=12, 2 males, median and interquartile range (IQR) for BMI 43.7 [42.0, 51.4] kg/m2, and AHI 18.1 [16.3, 67.5] events/h) or continuous positive airway pressure (CPAP) (n=15, 11 males, median BMI 33.8 [31.3, 37.9] kg/m2, and AHI 36.5 [24.7, 77.3] events/h). Polysomnography was followed by electrocardiography during wakefulness; measurements were repeated at 6 and 12-18 months post-intervention. RESULTS Despite similar measurements at baseline, subjects who underwent surgery exhibited greater improvement in short-term HRV than those who underwent CPAP (p=0.04). CONCLUSIONS Our data suggest a possible divergence in autonomic function between the effects of weight loss resulting from bariatric surgery, and the amelioration of obstructive respiratory events resulting from CPAP treatment. Randomized studies are necessary before clinical recommendations can be made.
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Loh KP, Ogunneye O. Malignant cardioinhibitory vasovagal syncope — An uncommon cardiovascular complication of Roux-en-Y gastric bypass surgery: The fainting syndrome! Int J Cardiol 2013; 164:e38-9. [DOI: 10.1016/j.ijcard.2012.09.159] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 09/25/2012] [Indexed: 11/16/2022]
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Abstract
The vagus nerve has an important role in regulation of metabolic homeostasis, and efferent vagus nerve-mediated cholinergic signalling controls immune function and proinflammatory responses via the inflammatory reflex. Dysregulation of metabolism and immune function in obesity are associated with chronic inflammation, a critical step in the pathogenesis of insulin resistance and type 2 diabetes mellitus. Cholinergic mechanisms within the inflammatory reflex have, in the past 2 years, been implicated in attenuating obesity-related inflammation and metabolic complications. This knowledge has led to the exploration of novel therapeutic approaches in the treatment of obesity-related disorders.
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Affiliation(s)
- Valentin A Pavlov
- Center for Biomedical Science, The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA.
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Castello-Simões V, Polaquini Simões R, Beltrame T, Bassi D, Maria Catai A, Arena R, Azambuja NC, do Nascimento Ortega J, Borghi-Silva A. Effects of aerobic exercise training on variability and heart rate kinetic during submaximal exercise after gastric bypass surgery--a randomized controlled trial. Disabil Rehabil 2012; 35:334-42. [PMID: 22725971 DOI: 10.3109/09638288.2012.694575] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study aimed to determine whether morbidly obese women have an alteration of heart rate (HR) kinetics and HR variability (HRV) during the 6-min walk test (6MWT) and if an aerobic exercise training can modify these indexes after gastric bypass surgery (GBS). DESIGN AND METHODS Nineteen morbidly obese women were randomized to a trained (TG) or control group and 12 women of eutrophic group (EG) were also evaluated. The obese women were tested on two occasions: 1 week before and 4 months after GBS through record of HR and R-R intervals during 6MWT for analysis HR kinetics. The TG underwent an aerobic exercise training program on a treadmill (1-h session, totaling 36 sessions over 12-week). RESULTS Both obese groups demonstrated a significant reduction of rMSSD and slower HR kinetics during the 6MWT when compared to the EG. In addition, only the TG demonstrated a significant improvement in HRV indexes, walking distance, faster time constant and mean response time of HR during 6MWT after training (p < 0.05). CONCLUSION Morbidly obese women have slower HR kinetics and altered cardiac modulation during submaximal exercise. However, aerobic exercise training can produce beneficial adaptations in HRV and faster HR kinetics following GBS.
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Affiliation(s)
- Viviane Castello-Simões
- Cardiopulmonary Physiotherapy Laboratory, Nucleus of Research in Physical Exercise, Federal University of São Carlos, São Carlos, São Paulo, Brazil.
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Castello V, Simões RP, Bassi D, Catai AM, Arena R, Borghi-Silva A. Impact of aerobic exercise training on heart rate variability and functional capacity in obese women after gastric bypass surgery. Obes Surg 2012; 21:1739-49. [PMID: 21104041 DOI: 10.1007/s11695-010-0319-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Obesity is a major public health concern on a global scale. Bariatric surgery is among the treatment options, resulting in significant and sustainable weight loss as well as amelioration of comorbidities. The purpose of this study was to evaluate whether a 12-week aerobic exercise program positively impacts heart rate variability (HRV) and functional capacity after gastric bypass surgery (GBS) in a female cohort. METHODS Of the 52 patients initially recruited, 21 were randomized to a training group (TG) or control group and successfully completed the study. Patients were tested on two occasions: 1 week before GBS and 4 months after GBS. Anthropometric variables, body composition, record of heart rate and R-R intervals, and 6-min walk test (6MWT) were assessed at both time points. The TG underwent an aerobic exercise training program on a treadmill (1-h session, totaling 36 sessions over 12 weeks). RESULTS The main findings from this study were: (1) only the TG demonstrated a significant increase (p < 0.05) in all indexes of heart rate variability (HRV) after 12 weeks of aerobic exercise training and (2) only the TG demonstrated a significant increase (p < 0.05) in 6MWT distance and decrease in diastolic blood pressure after aerobic exercise training. CONCLUSIONS We conclude that 12 weeks of aerobic exercise training improves cardiac autonomic modulation and functional capacity 4 months after GBS.
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Affiliation(s)
- Viviane Castello
- Cardiopulmonary Physiotherapy Laboratory, Nucleus of Research in Physical Exercise, Federal University of São Carlos, Rod. Washington Luis, km 235, 13565-905, São Carlos, São Paulo, Brazil
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Chaudhuri A, Borade NG, Tirumalai J, Saldanha D, Ghosh B, Srivastava K. A study of autonomic functions and obesity in postmenopausal women. Ind Psychiatry J 2012; 21:39-43. [PMID: 23766576 PMCID: PMC3678176 DOI: 10.4103/0972-6748.110949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Easy accessibility to Medicare and better living conditions has increased life expectancy in recent years. There are over 60 million postmenopausal women above 55 years in India. Obesity, physical inactivity, and altered estrogen metabolism play an integrated role in contributing to the disease risk profile of postmenopausal women. These same risk factors also affect modulation of the autonomic nervous system. A study was undertaken to test the hypothesis whether there is indeed an alteration in autonomic functions in obese postmenopausal women. MATERIALS AND METHODS 60 postmenopausal women without any gross systemic disease whose body mass index and waist/hip ratio were recorded. Subjects were divided into two groups of 36 Non-Obese and 24 Obese. The two groups were well matched for age and menopausal duration. The physical as well as physiological parameters like valsalva ratio, heart rate variation with deep breath test, heart rate response to postural change (30:15 R-R interval ratio), orthostatic tolerance test, and isometric handgrip test were recorded. RESULTS Results of valsalva ratio, deep breath test, and 30:15 R-R interval ratios and isometric handgrip test were significantly decreased and orthostatic tolerance values were significantly increased in Obese subjects. CONCLUSION Findings show decreased sympathovagal activity with obesity in postmenopausal women.
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Affiliation(s)
- Arunima Chaudhuri
- Department of Physiology, Dr. D.Y. Patil Medical College, Kolkata, West Bengal, India
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Maser RE, Lenhard MJ, Peters MB, Irgau I, Wynn GM. Effects of surgically induced weight loss by Roux-en-Y gastric bypass on cardiovascular autonomic nerve function. Surg Obes Relat Dis 2011; 9:221-6. [PMID: 22222304 DOI: 10.1016/j.soard.2011.11.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 11/14/2011] [Accepted: 11/14/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Obesity is associated with autonomic imbalance. With respect to cardiovascular autonomic dysfunction, this is characterized by reduced heart rate variability (HRV). Our objective was to determine the effect of surgically induced weight loss on cardiovascular autonomic nerve fiber function in subjects with severe obesity and examine whether an association with reduced insulin resistance exists. The setting was a hospital and private practice in the United States. METHODS A total of 32 morbidly obese patients (body mass index 51 ± 11 kg/m(2)) underwent laparoscopic Roux-en-Y gastric bypass. Measures of HRV (e.g., power spectral analysis, RR variation during deep breathing) were used to evaluate autonomic function before and 6 months after surgery. The homeostasis model assessment of insulin resistance index (HOMA-IR) was used to assess insulin resistance. RESULTS At 6 months after bariatric surgery, the patients had lost 58% excess body mass index with improvement in the HOMA-IR (3.0 ± 1.4 versus 1.1 ± .7; P < .001). Measures of RR variation during deep breathing and total spectral power, low frequency (LF) power (influenced by sympathetic and parasympathetic activity), and high frequency (HF) power (parasympathetic activity) increased with weight loss. The LF/HF ratio was lower (1.5 ± 1.5 versus .9 ± .7, P < .05) with a reduction in weight. Spectral analysis of HRV combined with spectral analysis of respiratory activity generated the respiration frequency area (RFA) and low frequency area. The RFA was increased, and the LFA/RFA ratio was reduced with weight loss. HOMA-IR and HRV did not correlate. CONCLUSION Surgically induced weight loss has a favorable effect on autonomic function, but it does not appear to be directly attributable to reduced insulin resistance.
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Affiliation(s)
- Raelene E Maser
- Department of Medical Technology, University of Delaware, Newark, Delaware 19716, USA.
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Lind L, Zethelius B, Sundbom M, Edén Engström B, Karlsson FA. Vasoreactivity is rapidly improved in obese subjects after gastric bypass surgery. Int J Obes (Lond) 2010; 33:1390-5. [PMID: 19752874 DOI: 10.1038/ijo.2009.188] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Obesity is associated with increased risk of cardiovascular disease. We investigated vasoreactivity in conduit and resistance arteries in morbidly obese subjects, and the effect of weight loss after gastric bypass surgery. METHODS A total of 19 obese subjects (body mass index (BMI): 43.8+/-3.1 kg m(-2), 75% female, mean age 41 years) were investigated before surgery and after 1 and 12 months of surgery. Nineteen non-obese controls matched for age and gender were examined. Vasoreactivity was evaluated by ultrasound to measure flow-mediated dilation (FMD, evaluating a conduit vessel) and pulse-wave analysis with terbutaline provocation (change in reflectance index (RI), evaluating resistance vessels). RESULTS Before surgery, the obese showed a low change in RI (18+/-12 vs 37+/-15% in controls, P=0.0001), but not significantly regarding FMD (7.9+/-6.4 vs 8.9+/-5.4% in controls). Surgery resulted in a weight loss of 9% at 1 month and 30% at 1 year. Change in RI markedly improved to 36+/-12% at 1 month (P=0.0001 vs baseline) and further to 44+/-11% at 1 year (P=0.014 vs 1 month). FMD did not change significantly. Heart rate and brachial artery diameter were reduced, with no significant change in blood pressure. The improvement in resistance vessel vasodilation, estimated as change in RI, was not correlated to changes in weight or measures of glucose and lipid metabolism. CONCLUSIONS Obese patients showed impaired vasoreactivity in resistance arteries that was normalized already 1 month after gastric bypass surgery. The basis for this remarkable outcome, not significantly related to changes in body weight and metabolic variables, remains to be clarified.
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Affiliation(s)
- L Lind
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Yuen AWC, Sander JW. Can slow breathing exercises improve seizure control in people with refractory epilepsy? A hypothesis. Epilepsy Behav 2010; 18:331-4. [PMID: 20630807 DOI: 10.1016/j.yebeh.2010.05.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 05/05/2010] [Accepted: 05/19/2010] [Indexed: 11/17/2022]
Abstract
Studies on various medical conditions have shown that poor health is associated with lower parasympathetic tone. People with epilepsy appear to have decreased parasympathetic tone, with a greater decrease in those with intractable seizures than in those with well-controlled epilepsy. Slow breathing exercises have been shown to increase parasympathetic tone in healthy volunteers. Slow breathing exercises have been shown to improve a number of medical conditions including asthma, hypertension, anxiety states, and posttraumatic stress disorder. We hypothesize that slow breathing exercises in people with epilepsy can lead to an increase in parasympathetic tone and an accompanying reduction in seizure frequency. The slow breathing exercises, probably through baroreceptors, chemoreceptors, and pulmonary stretch receptors, affect cortical activity and hence seizure thresholds. It is also possible that slow breathing exercises might reduce seizure frequency by reducing anxiety. The hypothesis can be tested by employing devices and protocols that have been used to reduce breathing rates and have been shown to improve health outcomes in other medical conditions.
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Affiliation(s)
- Alan W C Yuen
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK.
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Perugini RA, Li Y, Rosenthal L, Gallagher-Dorval K, Kelly JJ, Czerniach DR. Reduced heart rate variability correlates with insulin resistance but not with measures of obesity in population undergoing laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2009; 6:237-41. [PMID: 20005785 DOI: 10.1016/j.soard.2009.09.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 09/03/2009] [Accepted: 09/14/2009] [Indexed: 12/23/2022]
Abstract
BACKGROUND Obesity is associated with a pathologic predominance of sympathetic over parasympathetic tone. With respect to the heart, this autonomic dysfunction presents as a decreased heart rate variability (HRV), which has been associated with increased cardiovascular morbidity. Gastric bypass (GB) reduces cardiovascular mortality, and, thus, could beneficially affect the HRV. We sought to identify the factors predictive of HRV in a severely obese population of undergoing GB at a university hospital in the United States. METHODS The data of all patients presenting for GB were included in a prospective database. The homeostatic model of assessment (HOMA) was used to calculate the insulin resistance and glucose disposition index. A 24-hour Holter monitor was used to assess the HRV. Measurements were repeated at 2 weeks and 6 months postoperatively. The correlations between variables were determined using linear mixed models. RESULTS We studied 30 patients undergoing GB. All exhibited some degree of reduced HRV that improved postoperatively. The HOMA-insulin resistance inversely correlated with the HRV, and the HOMA-glucose disposition index directly correlated with the parameters of HRV in our longitudinal models. Weight, body mass index, excess body weight, gender, and age did not correlate with HRV. Improvements in HRV correlated with reductions in the average heart rate, underscoring a postoperative increase in relative vagal tone. CONCLUSION HRV in the severely obese is better predicted by the degree of insulin resistance, than by the degree of obesity, age, or gender. GB led to an improvement in HRV, the magnitude of which correlated with the change in insulin resistance and glucose disposition index, but not with weight loss.
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Affiliation(s)
- Richard A Perugini
- University of Massachusetts Memorial Health Care, Worcester, Massachusetts, USA.
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Machado MB, Velasco IT, Scalabrini-Neto A. Gastric Bypass and Cardiac Autonomic Activity: Influence of Gender and Age. Obes Surg 2008; 19:332-8. [DOI: 10.1007/s11695-008-9665-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Accepted: 08/04/2008] [Indexed: 01/30/2023]
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