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Bariatric Surgery for Adults With Class I Obesity and Difficult-to-Manage Type 2 Diabetes: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2023; 23:1-151. [PMID: 38130940 PMCID: PMC10732121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Background Many individuals with type 2 diabetes are classified as either overweight or obese. A patient may be described as having difficult-to-manage type 2 diabetes if their HbA1c levels remain above recommended target levels, despite efforts to treat it with lifestyle changes and pharmacotherapy. Bariatric surgery refers to procedures that modify the gastrointestinal tract. In patients with class II or III obesity, bariatric surgery has resulted in substantial weight loss, improved quality of life, reduced mortality risk, and resolution of type 2 diabetes. There is some evidence suggesting these outcomes may also be possible for patients with class I obesity as well. We conducted a health technology assessment of bariatric surgery for adults with class I obesity and difficult-to-manage type 2 diabetes, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding bariatric surgery, and patient preferences and values. Methods We performed a systematic clinical literature review. We assessed the risk of bias of each included study, using the Cochrane Risk of Bias tool for randomized controlled trials, the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool for cohort studies, and the Risk of Bias in Systematic Reviews (ROBIS) tool for systematic reviews; we assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature review and conducted a cost-utility analysis of bariatric surgery in comparison with nonsurgical usual care over a lifetime horizon from a public payer perspective. We also analyzed the budget impact of publicly funding bariatric surgery for adults with class I obesity and difficult-to-manage type 2 diabetes in Ontario. To contextualize the potential value of bariatric surgery, we spoke with people with obesity and type 2 diabetes who had undergone or were considering this procedure. Results We included 14 studies in the clinical evidence review. There were large increases in diabetes remission rates (GRADE: Low to Very low) and large reductions in body mass index (GRADE: Low to Very low) with bariatric surgery than with medical management. Bariatric surgery may also reduce the use of medications for type 2 diabetes (GRADE: Low) and may improve quality of life for people with class I obesity and difficult-to-manage type 2 diabetes compared with medical management. (GRADE: Low)Our economic evidence review included 5 cost-effectiveness studies; none were conducted in a Canadian setting, and 4 were considered partially applicable to our research question. Most studies found bariatric surgery to be cost-effective compared to standard care for patients with class I obesity and type 2 diabetes; however, the applicability of these results to the Ontario context is uncertain due to potential differences in clinical practice, resource utilization, and unit costs.Our primary economic evaluation found that over a lifetime horizon, bariatric surgery was more costly (incremental cost: $8,151 per person) but also more effective than current usual care (led to a 0.339 quality-adjusted life-year [QALY] gain per person). The cost increase was driven by costs associated with surgery (before, after, and during surgery), and the QALY gain was due to life-years gained. Results were sensitive to the bariatric surgery cost and assumptions regarding its long-term benefits with respect to weight loss and diabetes remission.Publicly funding 50 bariatric surgeries in year 1, and gradually increasing to 250 surgeries in year 5, for people with class I obesity and difficult-to-manage type 2 diabetes would lead to budget increases of $0.55 million in year 1 to $2.45 million in year 5, for a total of $7.63 million over 5 years.The people with obesity and type 2 diabetes with whom we spoke reported that bariatric surgery was generally seen as a positive treatment option, and those who had undergone the procedure reported positively on its value as a treatment to manage their weight and diabetes. Conclusions For adults with class I obesity and difficult-to-manage type 2 diabetes, bariatric surgery may be more clinically effective and cost-effective than medical management. Compared with medical management in people with class I obesity and difficult-to-manage type 2 diabetes, bariatric surgery may result in large increases in diabetes remission rates, large reductions in BMI, and reduced medication use for type 2 diabetes, improved quality of life. Over a lifetime horizon, bariatric surgery led to a cost increase and QALY gain. Bariatric surgery can result in postsurgical complications that are not faced by those receiving medical management. The cost-effectiveness of bariatric surgery depends on its long-term impacts on obesity-related and diabetes-related complications, which could be uncertain.Our budget impact analysis suggests that publicly funding bariatric surgery in Ontario for people with class I obesity and difficult-to-manage type 2 diabetes would lead to a budget increase of $7.63 million over 5 years.For people with obesity and type 2 diabetes, bariatric surgery was seen as a potential positive treatment option to manage their weight and diabetes.
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Canakis A, Wall-Wieler E, Liu Y, Zheng F, Sharaiha RZ. Type 2 Diabetes Remission After Bariatric Surgery and Its Impact on Healthcare Costs. Obes Surg 2023; 33:3806-3813. [PMID: 37851285 PMCID: PMC10687155 DOI: 10.1007/s11695-023-06856-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE Bariatric surgery is the most effective and durable treatment of obesity and can put type 2 diabetes (T2D) into remission. We aimed to examine remission rates after bariatric surgery and the impacts of post-surgical healthcare costs. MATERIALS AND METHODS Obese adults with T2D were identified in Merative™ (US employer-based retrospective claims database). Individuals who had bariatric surgery were matched 1:1 with those who did not with baseline demographic and health characteristics. Rates of remission and total healthcare costs were compared at 6-12 and 6-36 months after the index date. RESULTS Remission rates varied substantially by baseline T2D complexity; differences in rates at 1 year ranged from 41% for those with high-complexity T2D to 66% for those with low- to mid-complexity T2D. At 3 years, those who had bariatric surgery had 56% higher remission rates than those who did not have bariatric surgery, with differences of 73%, 59%, and 35% for those with low-, mid-, and high-complexity T2D at baseline. Healthcare costs were $3401 and $20,378 lower among those who had bariatric surgery in the 6 to 12 months and 6 to 36 months after the index date, respectively, than their matched controls. The biggest cost differences were seen among those with high-complexity T2D; those who had bariatric surgery had $26,879 lower healthcare costs in the 6 to 36 months after the index date than those who did not. CONCLUSION Individuals with T2D undergoing bariatric surgery have substantially higher rates of T2D remission and lower healthcare costs.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Elizabeth Wall-Wieler
- Global Health Economics and Outcomes Research, Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086, USA
| | - Yuki Liu
- Global Health Economics and Outcomes Research, Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086, USA
| | - Feibi Zheng
- Global Health Economics and Outcomes Research, Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086, USA
- DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, 1283 York Ave, 9th Floor, New York, NY, 10065, USA.
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Mirghani H, Alamrani SAS, Alkonani AA, Al Madshush AM. The Impact of Bariatric Surgery on Weight Loss and Glycemic Control in Patients With Obesity and Type 2 Diabetes: A Systematic Review. Cureus 2023; 15:e49122. [PMID: 38125226 PMCID: PMC10732469 DOI: 10.7759/cureus.49122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Obesity and type 2 diabetes mellitus (T2DM) are global health challenges. Bariatric surgery has emerged as a potential intervention for managing these conditions, but its efficacy and impact need comprehensive evaluation. This systematic review aimed to assess the impact of bariatric surgery on weight loss and glycemic control in patients with obesity and T2DM. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in October 2023, primarily using PubMed. Studies were selected based on specific inclusion and exclusion criteria, focusing on bariatric surgery's relationship with weight loss and glycemic control. The quality of the included studies was assessed using the ROBINS-I (risk of bias in non-randomized studies of interventions) risk of bias assessment approach. Out of 272 initially identified studies, nine met the inclusion criteria. These studies, encompassing 10,445 participants from various global locations, predominantly targeted middle-aged participants. The findings consistently highlighted the benefits of bariatric surgery in weight reduction and improved glycemic control. However, the degree of benefits varied based on the type of surgical procedure, patient's BMI, and other individual factors. Bariatric surgery offers significant advantages in managing obesity and T2DM. While it consistently aids in weight reduction and glycemic control, individualized treatment approaches considering various patient and procedural factors are crucial for optimal outcomes. When applied to the right patient, bariatric surgery can offer significantly better glycemic control and weight reduction when compared to only medication control and lifestyle adjustments. However, future research should focus on long-term outcomes and the integration of surgical interventions with lifestyle and medical management.
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Liu N, Chen X, Ran J, Yin J, Zhang L, Yang Y, Cen J, Dai H, Zhou J, Gao K, Zhang J, Liu L, Chen Z, Wang H. Investigating the change in gene expression profile of blood mononuclear cells post-laparoscopic sleeve gastrectomy in Chinese obese patients. Front Endocrinol (Lausanne) 2023; 14:1049484. [PMID: 36998473 PMCID: PMC10043499 DOI: 10.3389/fendo.2023.1049484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/27/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is a sustainable technique that effectively treats morbid obesity. However, the molecular mechanisms underlying the improvement of metabolic health following this process warrants more investigation. This study investigates LSG-related molecules and uses bulk RNA-sequencing high-throughput analysis to unravel their regulatory mechanisms. METHODS Peripheral blood mononuclear cells (PBMC) were collected from ten obese patients with BMI ≥ 32.5 kg/m2 in the Department of General Surgery of Kunming First People's Hospital. After LSG, patients were followed up for one month, and blood samples were retaken. Blood samples from ten patients before and after LSG and bulk RNA-Seq data were analyzed in this study. LSG-associated gene expression was detected by weighted gene coexpression network analysis (WGCNA) and differential analysis. Subsequently, essential signature genes were identified using logistic least absolute shrinkage and selection operator (LASSO) and support vector machine-recursive feature elimination (SVM-RFE) algorithms. Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and single-sample gene set enrichment analysis (ssGSEA) were utilized to reveal the potential functions of the target genes. Furthermore, the Pearson correlation of signature genes with leptin and lipocalin was also explored. Finally, we constructed a robust endogenous RNA (ceRNA) network based on miRWalk and starBase databases. RESULTS We identified 18 overlapping genes from 91 hub genes, and 165 differentially expressed mRNAs (DE-mRNA), which were revealed to be significantly associated with immune cells, immune response, inflammatory response, lipid storage, and localization upon functional enrichment analysis. Three signature genes, IRF1, NFKBIA, and YRDC, were identified from the 18 overlapping genes by LASSO and SVM-REF algorithms. The logistic regression model based on the three signature genes highlighted how robustly they discriminated between samples. ssGSEA indicated these genes to be involved in lipid metabolism and degradation pathways. Moreover, leptin levels were significantly reduced in patients undergoing LSG, and NFKBIA significantly negatively correlated with leptin. Finally, we identified how the long non-coding RNA (lncRNA) ATP2B1-AS1 regulated the expression of the signature genes by competitively binding to six microRNAs (miRNAs), which were hsa-miR-6509-5p, hsa-miR-330-5P, hsa-miR-154-5P, hsa-miR-145-5P, hsa-miR4726-5P and hsa-miR-134-5P. CONCLUSION This study identified three critical regulatory genes significantly differentiated between patients before and after LSG treatment and highlighted their potentially crucial role after bariatric surgery. This provides novel insights to increase our understanding of the underlying mechanisms of weight loss and associated metabolic improvement after bariatric surgery.
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Affiliation(s)
- Na Liu
- Department of Endocrinology, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Xiaolei Chen
- Department of Endocrinology, The First People’s Hospital of Kunming, Kunming, Yunnan, China
- *Correspondence: Xiaolei Chen,
| | - Jianghua Ran
- Department of Endocrinology, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Jianhui Yin
- Department of General Surgery, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Lijun Zhang
- Department of General Surgery, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Yuelin Yang
- Clinical Laboratory, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Jianchang Cen
- Department of Vascular Surgery, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Hongmei Dai
- Ophthalmology, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Jiali Zhou
- Department of Endocrinology, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Kui Gao
- Department of Endocrinology, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Jihong Zhang
- Department of General Surgery, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Liyin Liu
- Department of General Surgery, The First People’s Hospital of Kunming, Kunming, Yunnan, China
| | - Zhiyuan Chen
- Faculty of Physical Education, Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Haibin Wang
- Department of Infectious Diseases, The Affiliated Hospital of YunNan University, Kunming, Yunnan, China
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Thouvenot K, Turpin T, Taïlé J, Clément K, Meilhac O, Gonthier MP. Links between Insulin Resistance and Periodontal Bacteria: Insights on Molecular Players and Therapeutic Potential of Polyphenols. Biomolecules 2022; 12:biom12030378. [PMID: 35327570 PMCID: PMC8945445 DOI: 10.3390/biom12030378] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 02/07/2023] Open
Abstract
Type 2 diabetes is a metabolic disease mainly associated with insulin resistance during obesity and constitutes a major public health problem worldwide. A strong link has been established between type 2 diabetes and periodontitis, an infectious dental disease characterized by chronic inflammation and destruction of the tooth-supporting tissue or periodontium. However, the molecular mechanisms linking periodontal bacteria and insulin resistance remain poorly elucidated. This study aims to summarize the mechanisms possibly involved based on in vivo and in vitro studies and targets them for innovative therapies. Indeed, during periodontitis, inflammatory lesions of the periodontal tissue may allow periodontal bacteria to disseminate into the bloodstream and reach tissues, including adipose tissue and skeletal muscles that store glucose in response to insulin. Locally, periodontal bacteria and their components, such as lipopolysaccharides and gingipains, may deregulate inflammatory pathways, altering the production of pro-inflammatory cytokines/chemokines. Moreover, periodontal bacteria may promote ROS overproduction via downregulation of the enzymatic antioxidant defense system, leading to oxidative stress. Crosstalk between players of inflammation and oxidative stress contributes to disruption of the insulin signaling pathway and promotes insulin resistance. In parallel, periodontal bacteria alter glucose and lipid metabolism in the liver and deregulate insulin production by pancreatic β-cells, contributing to hyperglycemia. Interestingly, therapeutic management of periodontitis reduces systemic inflammation markers and ameliorates insulin sensitivity in type 2 diabetic patients. Of note, plant polyphenols exert anti-inflammatory and antioxidant activities as well as insulin-sensitizing and anti-bacterial actions. Thus, polyphenol-based therapies are of high interest for helping to counteract the deleterious effects of periodontal bacteria and improve insulin resistance.
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Affiliation(s)
- Katy Thouvenot
- Université de La Réunion, Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), 97490 Saint-Denis de La Réunion, France; (K.T.); (T.T.); (J.T.); (O.M.)
| | - Teva Turpin
- Université de La Réunion, Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), 97490 Saint-Denis de La Réunion, France; (K.T.); (T.T.); (J.T.); (O.M.)
| | - Janice Taïlé
- Université de La Réunion, Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), 97490 Saint-Denis de La Réunion, France; (K.T.); (T.T.); (J.T.); (O.M.)
| | - Karine Clément
- Nutrition and Obesity, Systemic Approaches (NutriOmics), INSERM, Sorbonne Université, 75013 Paris, France
| | - Olivier Meilhac
- Université de La Réunion, Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), 97490 Saint-Denis de La Réunion, France; (K.T.); (T.T.); (J.T.); (O.M.)
| | - Marie-Paule Gonthier
- Université de La Réunion, Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), 97490 Saint-Denis de La Réunion, France; (K.T.); (T.T.); (J.T.); (O.M.)
- Correspondence: ; Tel.: +33-262-693-92-08-55
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