The role of bariatric surgery to treat diabetes: current challenges and perspectives

Bettie's travels: How pigs enable new connections between human health innovations and industrial agricultural pork production in Denmark

Drawing on ethnographic fieldwork, this paper unfolds the past and present uses of pigs that structured the emergence of a pig model of gut-hormone based appetite control, leading to the current scientific breakthrough in treatment of obesity. While the hyping of next generation medications for obesity and type 2 diabetes centers on the efficacy and profits attached to these drugs, I unfold how science embedded in this development had the in-vivo and in-vitro travels of Bettie-an obese Göttingen Minipig pig-at its heart. Tracing how she became embedded in a circuit of vitality connecting industrial agriculture and science on human health, I show how both are governed by a shared valuation of pigs' fat. Bettie's fat, however, was not to be eaten. Instead, Bettie was consumed in knowledge production. For pigs to enter this new trajectory, Bettie emerged as a promissory site for extraction of molecular information made possible by new visualization technologies and representational strategies that allowed for the coupling of human-pig physiology at the cellular level. While her travels were spurred by the hope of discovery of small molecules, Bettie allows us to grasp an important shift in science, as the insights derived from her work emphasized the importance of physiology and the environment for human obesity. In doing so, she served as a visceral model. On a larger scale, Bettie's entering science on human health reflects a recursive structure of knowledge in which the present problems with obesity and type 2 diabetes derive from the solutions to previous problems associated with alleviating hunger.

Bariatric surgery and diabetes: Current challenges and perspectives

Diabetes mellitus (DM) and obesity have become public issues of global concern. Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach; however, there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM. In this review, we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM. I believe that our insights will be of great help to clinicians in their daily practice.

Pharmacotherapy as an Augmentation to Bariatric Surgery for Obesity

A global obesity pandemic is one of the most significant health threats worldwide owing to its close association with numerous comorbidities such as type 2 diabetes mellitus, arterial hypertension, dyslipidemia, heart failure, cancer and many others. Obesity and its comorbidities lead to a higher rate of cardiovascular complications, heart failure and increased cardiovascular and overall mortality. Bariatric surgery is at present the most potent therapy for obesity, inducing a significant weight loss in the majority of patients. In the long-term, a substantial proportion of patients after bariatric surgery experience a gradual weight regain that may, in some, reach up to a presurgical body weight. As a result, anti-obesity pharmacotherapy may be needed in some patients after bariatric surgery to prevent the weight regain or to further potentiate weight loss. This article provides an overview of the use of anti-obesity medications as an augmentation to bariatric surgery for obesity. Despite relatively limited published data, it can be concluded that anti-obesity medication can serve as an effective adjunct therapy to bariatric surgery to help boost post-bariatric weight loss or prevent weight regain.

Comprehensive Clinical and Genetic Analyses of Circulating Bile Acids and Their Associations With Diabetes and Its Indices

Bile acids (BAs) are cholesterol-derived compounds that regulate glucose, lipid, and energy metabolism. Despite their significance in glucose homeostasis, the association between specific BA molecular species and their synthetic pathways with diabetes is unclear. Here, we used a recently validated, stable-isotope dilution, high-performance liquid chromatography with tandem mass spectrometry method to quantify a panel of BAs in fasting plasma from 2,145 study participants and explored structural and genetic determinants of BAs linked to diabetes, insulin resistance, and obesity. Multiple 12α-hydroxylated BAs were associated with diabetes (adjusted odds ratio [aOR] range, 1.3-1.9; P < 0.05 for all) and insulin resistance (aOR range, 1.3-2.2; P < 0.05 for all). Conversely, multiple 6α-hydroxylated BAs and isolithocholic acid (iso-LCA) were inversely associated with diabetes and obesity (aOR range, 0.3-0.9; P < 0.05 for all). Genome-wide association studies revealed multiple genome-wide significant loci linked with 9 of the 14 diabetes-associated BAs, including a locus for iso-LCA (rs11866815). Mendelian randomization analyses showed genetically elevated deoxycholic acid levels were causally associated with higher BMI, and iso-LCA levels were causally associated with reduced BMI and diabetes risk. In conclusion, comprehensive, large-scale, quantitative mass spectrometry and genetics analyses show circulating levels of multiple structurally specific BAs, especially DCA and iso-LCA, are clinically associated with and genetically linked to obesity and diabetes.

ARTICLE HIGHLIGHTS

Human Gut Microbiome Before and After Bariatric Surgery in Obese Patients with and Without Type 2 Diabetes

BACKGROUND

Bariatric surgery, a significant intervention for obesity, may influence weight loss through changes in gut microbiota, particularly the Firmicutes and Bacteroidetes. This study explores these potential shifts and their metabolic implications.

MATERIALS

We conducted a cross-sectional study involving patients who had undergone bariatric surgery. Stool samples were collected at baseline, 3 months, and 6 months post-operation. We performed DNA extraction and quantified the bacterial phyla Firmicutes and Bacteroidetes to assess changes in the gut microbiota over time.

RESULTS

Our research revealed a significant alteration in the gut microbiota following bariatric surgery. In diabetic individuals, there was a marked increase in the average number of Firmicutes bacteria at both 3 and 6 months post-operation, compared to pre-surgery levels. In contrast, non-diabetic subjects experienced a notable decrease in Firmicutes during the same timeframe. Regarding Bacteroidetes bacteria, the trend was reversed; diabetic patients showed a significant reduction, while non-diabetics exhibited an increase after the surgery. These findings highlight the dynamic changes in gut microbiota composition associated with bariatric surgery and its potential link to metabolic changes post-operation.

CONCLUSION

These findings suggest that obesity alters the gut's microbial composition. The observed bacterial fluctuations, particularly in the dominant Firmicutes and Bacteroidetes groups, are likely contributors to the weight loss experienced post-surgery. This alteration in gut bacteria underscores the complex interplay between microbiota and metabolic health, highlighting potential avenues for therapeutic intervention.

Association between Dietary Pattern, Weight Loss, and Diabetes among Adults with a History of Bariatric Surgery: Results from the Qatar Biobank Study

We aimed to examine the association between weight loss, dietary patterns, diabetes, and glycemic control among Qatari adults with a history of bariatric surgery (BS). Data from 1893 adults from the Qatar Biobank study were analyzed. Diabetes was defined by blood glucose, HbA1c, and medical history, with poor glycemic control defined as HbA1c ≥ 7.0%. The dietary patterns were derived from a Food Frequency Questionnaire using factor analysis. The participants' mean age was 38.8 years, with a mean weight loss of 23.4% and a 6.1% prevalence of poor glycemic control. Weight loss was inversely associated with diabetes and poor glycemic control. The traditional dietary pattern (high intake of Biryani, chicken, meat, fish dishes, zaatar fatayer, croissant, lasagna, and Arabic bread) was inversely associated with diabetes prevalence, with an OR of 0.61 (95%CI, 0.41-0.99) when comparing extreme quartiles. No significant associations were found between prudent or sweet dietary patterns and diabetes. Among the individuals with known diabetes, the prevalence of remission was 33.4%, with an OR for remission of 5.94 (95%CI, 1.89-18.69) for the extreme quartiles of weight loss. In conclusion, weight loss and traditional dietary patterns are inversely associated with diabetes and glycemic control among adults with a history of BS, with weight loss being the main determinant.

Sex- and operation-dependent effects on 5-year weight loss results of bariatric surgery

BACKGROUND

Weight loss response after bariatric surgery is highly variable, and several demographic factors are associated with differential responses to surgery. Preclinical studies demonstrate numerous sex-specific responses to bariatric surgery, but whether these responses are also operation dependent is unknown.

OBJECTIVE

To examine sex-specific weight loss outcomes up to 5 years after laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

SETTING

Single center, university, United States.

METHODS

Retrospective, observational cohort study including RYGB (n = 5057) and vertical SG (n = 2041) patients from a single, academic health center. Percentage total weight loss (TWL) over time was examined with generalized linear mixed models to determine the main and interaction effects of surgery type on weight loss by sex.

RESULTS

TWL demonstrated a strong sex-by-procedure interaction, with women having a significant advantage with RYGB compared with SG (adjusted difference at 5 yr: 8.0% [95% CI: 7.5-8.5]; P < .001). Men also experienced greater TWL over time with RYGB or SG, but the difference was less and clinically insignificant (adjusted difference at 5 yr: 2.9% [2.0-3.8]; P < .001; P interaction between sex and procedure type = .0001). Overall, women had greater TWL than men, and RYGB patients had greater TWL than SG patients (adjusted difference at 5 yr: 3.1% [2.4-3.2] and 6.9% [6.5-7.3], respectively; both P < .0001). Patients with diabetes lost less weight compared with those without (adjusted difference at 5 yr: 3.0% [2.7-3.2]; P < .0001).

CONCLUSIONS

Weight loss after bariatric surgery is sex- and procedure-dependent. There is an association suggesting a clinically insignificant difference in weight loss between RYGB and SG among male patients at both the 2- and 5-year postsurgery time points.

Diabetes Is Associated with Worse Postoperative Mortality and Morbidity in Bariatric Surgery, Regardless of the Procedure

Background/Objectives: Bariatric surgery is a central cornerstone in obesity treatment. We aimed to assess the impact of diabetes on the postoperative outcomes of bariatric surgery and compare three techniques: sleeve gastrectomy, Roux-en-Y, and gastric banding. Methods: We extracted data from the National Inpatient Sample (2015-2019) using ICD codes. The primary outcome was postoperative mortality. Secondary outcomes were major bleeding, atrial fibrillation, and acute renal failure. Results: Among patients who underwent sleeve gastrectomy, diabetes was associated with a higher adjusted risk of mortality (aOR 2.07 [1.36-3.16]), atrial fibrillation, and acute renal failure, but a similar risk of bleeding. Among patients who underwent Roux-en-Y, diabetes did not increase mortality and bleeding risk. Still, it was associated with a higher risk of atrial fibrillation and acute renal failure. Among patients who underwent gastric banding, diabetes was only associated with a higher risk of bleeding. When comparing the three techniques in diabetes patients, Roux-en-Y was significantly associated with higher mortality and acute renal failure risk when compared to the other procedures. Bleeding was more common in Roux-en-Y than in Sleeve. Conclusions: In total, diabetes is associated with worse postoperative outcomes in bariatric surgery, regardless of the technique. Among diabetes patients, Roux-en-Y was associated with the highest mortality and morbidity.

Overnutrition, Hyperinsulinemia and Ectopic Fat: It Is Time for A Paradigm Shift in the Management of Type 2 Diabetes

The worldwide incidence of prediabetes/type 2 has continued to rise the last 40 years. In the same period, the mean daily energy intake has increased, and the quality of food has significantly changed. The chronic exposure of pancreatic β-cells to calorie excess (excessive energy intake) and food additives may increase pancreatic insulin secretion, decrease insulin pulses and/or reduce hepatic insulin clearance, thereby causing chronic hyperinsulinemia and peripheral insulin resistance. Chronic calorie excess and hyperinsulinemia may promote lipogenesis, inhibit lipolysis and increase lipid storage in adipocytes. In addition, calorie excess and hyperinsulinemia can induce insulin resistance and contribute to progressive and excessive ectopic fat accumulation in the liver and pancreas by the conversion of excess calories into fat. The personal fat threshold hypothesis proposes that in susceptible individuals, excessive ectopic fat accumulation may eventually lead to hepatic insulin receptor resistance, the loss of pancreatic insulin secretion, hyperglycemia and the development of frank type 2 diabetes. Thus, type 2 diabetes seems (partly) to be caused by hyperinsulinemia-induced excess ectopic fat accumulation in the liver and pancreas. Increasing evidence further shows that interventions (hypocaloric diet and/or bariatric surgery), which remove ectopic fat in the liver and pancreas by introducing a negative energy balance, can normalize insulin secretion and glucose tolerance and induce the sustained biochemical remission of type 2 diabetes. This pathophysiological insight may have major implications and may cause a paradigm shift in the management of type 2 diabetes: avoiding/reducing ectopic fat accumulation in the liver and pancreas may both be essential to prevent and cure type 2 diabetes.

G protein-coupled receptors driven intestinal glucagon-like peptide-1 reprogramming for obesity: Hope or hype?

'Globesity' is a foremost challenge to the healthcare system. The limited efficacy and adverse effects of available oral pharmacotherapies pose a significant obstacle in the fight against obesity. The biology of the leading incretin hormone glucagon-like-peptide-1 (GLP-1) has been highly captivated during the last decade owing to its multisystemic pleiotropic clinical outcomes beyond inherent glucoregulatory action. That fostered a pharmaceutical interest in synthetic GLP-1 analogues to tackle type-2 diabetes (T2D), obesity and related complications. Besides, mechanistic insights on metabolic surgeries allude to an incretin-based hormonal combination strategy for weight loss that emerged as a forerunner for the discovery of injectable 'unimolecular poly-incretin-agonist' therapies. Physiologically, intestinal enteroendocrine L-cells (EECs) are the prominent endogenous source of GLP-1 peptide. Despite comprehending the potential of various G protein-coupled receptors (GPCRs) to stimulate endogenous GLP-1 secretion, decades of translational GPCR research have failed to yield regulatory-approved endogenous GLP-1 secretagogue oral therapy. Lately, a dual/poly-GPCR agonism strategy has emerged as an alternative approach to the traditional mono-GPCR concept. This review aims to gain a comprehensive understanding by revisiting the pharmacology of a few potential GPCR-based complementary avenues that have drawn attention to the design of orally active poly-GPCR agonist therapy. The merits, challenges and recent developments that may aid future poly-GPCR drug discovery are critically discussed. Subsequently, we project the mechanism-based therapeutic potential and limitations of oral poly-GPCR agonism strategy to augment intestinal GLP-1 for weight loss. We further extend our discussion to compare the poly-GPCR agonism approach over invasive surgical and injectable GLP-1-based regimens currently in clinical practice for obesity.

Longitudinal Profiling of Fasting Plasma Metabolome in Response to Weight-Loss Interventions in Patients with Morbid Obesity

It is well recognized that patients with severe obesity exhibit remarkable heterogeneity in response to different types of weight-loss interventions. Those who undergo Roux-en-Y gastric bypass (RYGB) usually exhibit more favorable glycemic outcomes than those who receive adjustable gastric banding (BAND) or intensive medical intervention (IMI). The molecular mechanisms behind these observations, however, remain largely unknown. To identify the plasma metabolites associated with differential glycemic outcomes induced by weight-loss intervention, we studied 75 patients with severe obesity (25 each in RYGB, BAND, or IMI). Using untargeted metabolomics, we repeatedly measured 364 metabolites in plasma samples at baseline and 1-year after intervention. Linear regression was used to examine whether baseline metabolites or changes in metabolites are associated with differential glycemic outcomes in response to different types of weight-loss intervention, adjusting for sex, baseline age, and BMI as well as weight loss. Network analyses were performed to identify differential metabolic pathways involved in the observed associations. After correction for multiple testing (q < 0.05), 33 (RYGB vs. IMI) and 28 (RYGB vs. BAND) baseline metabolites were associated with changes in fasting plasma glucose (FPG) or glycated hemoglobin (HbA1c). Longitudinal changes in 38 (RYGB vs. IMI) and 38 metabolites (RYGB vs. BAND) were significantly associated with changes in FPG or HbA1c. The identified metabolites are enriched in pathways involved in the biosynthesis of aminoacyl-tRNA and branched-chain amino acids. Weight-loss intervention evokes extensive changes in plasma metabolites, and the altered metabolome may underlie the differential glycemic outcomes in response to different types of weight-loss intervention, independent of weight loss itself.

Evaluation of prescription medication changes following sleeve gastrectomy surgery

Objective

The increasing global prevalence of obesity, coupled with its association with chronic health conditions and rising healthcare costs, highlights the need for effective interventions; however, despite the availability of treatment options, the ongoing success of primary interventions in maintaining long-term weight loss remains limited. This study examined the prescription medication dispensing changes following sleeve gastrectomy in Australians aged 45 years and over.

Methods

In a retrospective analysis of 847 bariatric surgery patients from the New South Wales 45 and Up Study, the assessment of medication patterns categorizing into three groups: gastrointestinal, metabolic, cardiorespiratory, musculoskeletal, and nervous systems was conducted. Each drug class was analyzed, focusing on patients with dispensing records within the 12 months before surgery. This study employed interrupted time-series analysis to compare pre- and post-surgery medication usage.

Results

With a predominantly female population (76.9%) and an average age of 57.2 (standard deviation 5.71), there were statistically significant reductions in both unique medications (12.5% decrease, p = 0.004) and total medications dispensed (15.9% decrease, p = 0.003) from 12 months before surgery to 13-24 months after bariatric surgery. All medication categories, except opioids, showed reductions. Notably, the most significant reductions were observed in diabetes (38.6%), agents acting on the renin-angiotensin system (40.4%), lipid modifying agents (26.5%), anti-inflammatory products (46.3%), and obstructive airway diseases (53.3%) medications during this time frame.

Conclusion

These findings suggest that sleeve gastrectomy provides an effective therapeutic intervention for patients with comorbidities requiring multiple medications, especially for obesity-related diseases such as diabetes, cardiovascular, respiratory and musculoskeletal disorders.

Postprandial Triglyceride, Glucose and Insulin Levels 10 Years After Bariatric Surgery in Women With Severe Obesity - A Pilot Study: Part 1 - Laparoscopic Greater Curvature Plication

The long-term effects of bariatric surgery on postprandial profiles in patients with obesity and type 2 diabetes (T2D) have not yet been investigated. Therefore, this study examined postprandial profiles before laparoscopic greater curvature plication (LGCP), and then at 2 and 10 years after surgery.The studied cohort included 10 women (mean age= 54.4±5 years) with obesity (mean BMI= 42.5±7.8 kg/m?) and T2D who underwent LGCP. All subjects underwent a standardized liquid mixed-meal test. For statistical evaluation, ANOVA with Bonferroni multiple comparison was used. Mean postprandial levels were significantly decreased 2 years after surgery. Responses 10 years after the surgery also remained significantly lower than before surgery. Changes observed during the follow-up were significant: glucose: F=34.5, p<0.001; insulin: F=49.3, p<0.001; triglycerides F=9.2, p<0.001. The long-term favorable effects of bariatric surgery on cardiometabolic health may be partly mediated by reductions in postprandial glucose, insulin, and triglyceride levels.

Bariatric Surgery for Adults With Class I Obesity and Difficult-to-Manage Type 2 Diabetes: A Health Technology Assessment

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.

Bikini-line Hiatal Hernia Repair (BLHHR) During Sleeve Gastrectomy

BACKGROUND

To preserve the aesthetic benefits achieved with Bikini line sleeve gastrectomy (BLSG), we have devised a novel approach for simultaneous hiatal hernia repair (HHR), known as bikini-line hiatal hernia repair (BLHHR). This manuscript presents our initial experience with BLHHR and assesses its feasibility and outcomes.

METHODS

A prospective preliminary study was conducted on patients who underwent BLHHR between September 2020 and October 2022. Patient demographics, preoperative assessments, operative details, postoperative outcomes, and aesthetic evaluations were recorded. Feasibility and safety were assessed.

RESULTS

Among 891 BLSG patients, 89 (9.9%) underwent BLHHR. The mean distances between the xiphoid process and the umbilicus, symphysis pubis, and anterior superior iliac spine (ASIS) were 28.8 ± 2.2, 33.9 ± 3.1, and 31.2 ± 1.8 cm, respectively. Optimal visualization and accessibility of the gastroesophageal junction (GEJ) were achieved without compromising HHR repair or sleeve gastrectomy. The mean operative time was 76.5 ± 11 min, longer than the 58 ± 10 min required for BLSG alone. Patient scar satisfaction ranged from 87.5 to 97.9%, and the mean pain score was 2.9 ± 0.8. No major complications were reported. At 6 months, %EWL (percentage of excess weight loss) was 53.3 ± 13.7%, GERD (gastroesophageal reflux disease) remission was achieved in 62.8% of patients and comorbidities were improved.

CONCLUSION

BLHHR was potentially feasible and safe. Outcomes related to patient scar satisfaction, weight loss, improvement of associated comorbidities, and GERD symptoms were not compromised. The aesthetic benefits achieved by BLSG were maintained.

Research progress on the relationship between bile acid metabolism and type 2 diabetes mellitus

Bile acids, which are steroid molecules originating from cholesterol and synthesized in the liver, play a pivotal role in regulating glucose metabolism and maintaining energy balance. Upon release into the intestine alongside bile, they activate various nuclear and membrane receptors, influencing crucial processes. These bile acids have emerged as significant contributors to managing type 2 diabetes mellitus, a complex clinical syndrome primarily driven by insulin resistance. Bile acids substantially lower blood glucose levels through multiple pathways: BA-FXR-SHP, BA-FXR-FGFR15/19, BA-TGR5-GLP-1, and BA-TGR5-cAMP. They also impact blood glucose regulation by influencing intestinal flora, endoplasmic reticulum stress, and bitter taste receptors. Collectively, these regulatory mechanisms enhance insulin sensitivity, stimulate insulin secretion, and boost energy expenditure. This review aims to comprehensively explore the interplay between bile acid metabolism and T2DM, focusing on primary regulatory pathways. By examining the latest advancements in our understanding of these interactions, we aim to illuminate potential therapeutic strategies and identify areas for future research. Additionally, this review critically assesses current research limitations to contribute to the effective management of T2DM.

Weight Loss Effect of GLP-1 RAs With Endoscopic Bariatric Therapy and Bariatric Surgeries

Background

Different treatment modalities are available for obesity management, including lifestyle changes, pharmacotherapy, endoscopic interventions, and surgeries. Limited evidence is available on the weight loss effect of combining glucagon-like peptide 1 receptor agonists (GLP-1 RAs) with endoscopic bariatric therapy (EBT) and bariatric surgeries (BS).

Objectives

In this systematic review, we compared the weight loss effect and metabolic changes of combining GLP-1 RAs with EBT and BS.

Methods

Literature searches were performed in the Cochrane Database of Systematic Review, Cochrane Central Register of Controlled Trials, Embase, PubMed, Google Scholar, and PRISMA databases. Only randomized control trials and retrospective studies were included.

Results

A total of 11 studies was included. Nine studies compared BS with and without liraglutide and 2 compared EBT with and without liraglutide. Adding liraglutide to EBT or BS provided significant weight loss when compared with EBT or BS alone. When changes in weight were compared across the studies, EBT with liraglutide showed a weight loss effect comparable to the net weight loss (ie, nadir weight loss after BS-regained weight) achieved following BS alone.

Conclusion

This review showcases a promising approach for managing obesity that combines GLP-1 RAs with EBT. This approach is expected to achieve shorter hospital stays, fewer side effects, and longer term weight loss benefits than BS alone. However, additional prospective studies with higher quality, more consistent outcome measures for weight loss and metabolic changes are needed to further evaluate the approach.

Factors contributing to whether or not people with obesity undergo bariatric surgery

BACKGROUND

Bariatric surgery has been suggested as a safe and effective way to treat obesity by facilitating weight loss, but factors that predict the likelihood of bariatric surgery are unknown. The objective of this study was to describe factors associated with individuals with obesity that influence their decision to undergo bariatric surgery.

SUBJECTS AND METHODS

The study design was a cross-sectional study and participants were recruited via a survey link posted on the Obesity Action Coalition website. Demographic data, medical data, weight loss program data, and reports of personal experiences were gathered via an online survey. A multivariate logistic regression model was conducted to examine predictors associated with bariatric surgery (N = 4192).

RESULTS

Participants who took phentermine (OR=2.983), Phentermine-topiramate (Qsymia) (OR=2.863), Naltrexone-bupropion (Contrave) (OR=3.246), or Liraglutide (Saxenda) (OR=2.144) had a higher likelihood of undergoing bariatric surgery for weight loss. Participants with type 2 diabetes (OR=1.728), post-traumatic stress disorder (PTSD) (OR=1.489), or COVID-19 (OR=3.852) had a higher likelihood of undergoing bariatric surgery while sleep apnea (OR=0.760) was associated with a lower likelihood of receiving surgery. Those who used MyFitnessPal™ (OR=2.232), Noom™ (OR=1.400), Jenny Craig™ (OR=1.533), or Keto (OR=1.664) for weight loss had a higher likelihood of obtaining bariatric surgery. Personal trauma experiences of sexual abuse (OR=1.982) and physical abuse (OR=1.490) were more associated with participants who underwent surgery.

CONCLUSIONS

A variety of characteristics were associated with decisions to undergo bariatric surgery. These findings may help to determine ways to support individuals who are considering bariatric surgery.

Pharmacotherapy before and after bariatric surgery

Diabetes is a chronic disease that affects a vast number of individuals globally, and without optimal treatment, can lead to significant health complications. Moreover, obesity is another chronic disease with several complications, which includes type 2 diabetes. Bariatric surgery is a viable long-term choice for managing diseases such as obesity and type 2 diabetes. However, the impact of pharmacotherapy before and after surgery remains unclear. In this review, we assessed the use of pharmacotherapy in patients with obesity with or without diabetes before and after bariatric surgery, focusing on weight loss, glycemic control, and the risk of postoperative complications. We showed that anti-obesity medication has become increasingly important in managing obesity and type 2 diabetes, both before and after bariatric surgery. The use of preoperative pharmacotherapy can optimize patients for surgery and reduce perioperative complications. Meanwhile, postoperative pharmacotherapy can maximize weight loss, improve metabolic outcomes, and lower the risk of weight regain. Medications such as sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, and combination therapies, are now very effective for treating obesity and type 2 diabetes mellitus. However, optimal timing, duration, and which combinations of pharmacotherapy to use with bariatric surgery remain unclear. Additionally, the long-term safety and efficacy of these treatments should be assessed. Integrating pharmacotherapy with bariatric surgery is a promising approach to managing obesity and type 2 diabetes, providing patients with additional options for achieving sustainable weight loss and improving their metabolic health.

Bariatric surgery and calcifediol treatment, Gordian knot of severe-obesity-related comorbidities treatment

Background

Obesity (OB) is a chronic metabolic disease with important associated comorbidities and mortality. Vitamin D supplementation is frequently administered after bariatric surgery (BS), so as to reduce OB-related complications, maybe including chronic inflammation.

Aim

This study aimed to explore relations between vitamin D metabolites and components of the inflammasome machinery in OB before and after BS and their relations with the improvement of metabolic comorbidities.

Patients and methods

Epidemiological/clinical/anthropometric/biochemical evaluation was performed in patients with OB at baseline and 6 months after BS. Evaluation of i) vitamin-D metabolites in plasma and ii) components of the inflammasome machinery and inflammatory-associated factors [NOD-like-receptors (NLRs), inflammasome-activation-components, cytokines and inflammation/apoptosis-related components, and cell-cycle and DNA-damage regulators] in peripheral blood mononuclear cells (PBMCs) was performed at baseline and 6 months after BS. Clinical and molecular correlations/associations were analyzed.

Results

Significant correlations between vitamin D metabolites and inflammasome-machinery components were observed at baseline, and these correlations were significantly reduced 6 months after BS in parallel to a decrease in inflammation markers, fat mass, and body weight. Treatment with calcifediol remarkably increased 25OHD levels, despite 24,25(OH)2D3 remained stable after BS. Several inflammasome-machinery components were associated with improvement in metabolic comorbidities, especially hypertension and dyslipidemia.

Conclusion

The beneficial effects of vitamin D on OB-related comorbidities after BS patients are associated with significant changes in the molecular expression of key inflammasome-machinery components. The expression profile of these inflammasome components can be dynamically modulated in PBMCs after BS and vitamin D supplementation, suggesting that this profile could likely serve as a sensor and early predictor of the reversal of OB-related complications after BS.

Effectiveness of Bariatric Surgery in the Management of Type 2 Diabetes Mellitus: A Case Report and Literature Review

Type 2 diabetes (T2DM) and obesity represent major global health burdens and economic costs to healthcare systems. T2DM management is challenging due to multiple comorbidities and limited drug efficacy. Bariatric surgery has emerged as an effective treatment approach. A 65-year-old man with refractory obesity (BMI > 35 kg/m2) and poorly controlled T2DM underwent gastric bypass surgery in 2018. Prior to surgery, medication noncompliance and dietary measures failed to achieve adequate glycemic control or weight loss. Postoperatively, the patient lost 20 kg and achieved improved T2DM control (HbA1C reduction), allowing complete cessation of diabetic medications. The patient's case demonstrates bariatric surgery's potential to significantly alter the clinical course of obesity and T2DM versus standard care. National guidelines outline eligibility criteria for bariatric referral; however, utilization rates remain low (<1%) despite over two million eligible individuals in the United Kingdom. Improved access could reduce disease burden and healthcare costs from diabetes complications over the long term. This case report provides a real-world example supporting bariatric surgery as an effective intervention for appropriately selected patients with obesity and uncontrolled T2DM, with the potential to improve clinical outcomes and lower costs associated with diabetes management.

The role of weight control in the management of type 2 diabetes mellitus: Bariatric surgery

Diabetes mellitus is one of the major epidemics in the United States. It is heavily associated with obesity and multiple metabolic derangements that lead to long term morbidity, mortality as well as financial burden. Although medical therapy has been the mainstay in the management of diabetes mellitus, there remains a large portion of this patient population which struggles to obtain adequate glycemic control and long-term weight control with medical management alone. Bariatric surgery is a powerful tool in combating diabetes mellitus and affects glucose homeostasis through a variety of pathways. While it does provide a durable pathway for weight loss, improvement in glucose homeostasis is not only affected by the weight loss seen after bariatric surgery. Changes in gut hormone secretion, insulin regulation, and gut microbial composition also affect how these operations improve glucose homeostasis. Through improvement in the management of diabetes mellitus, comorbidities including cardiovascular disease, in turn demonstrate improvement. In this article, we will discuss the role of bariatric (metabolic) surgery as it relates to long term weight loss and the impact that weight loss has on improvement in diabetes mellitus.

The BARI-hoods Project: neighborhood social determinants of health and postoperative weight loss using integrated electronic health record, census, and county data

BACKGROUND

While social determinants of health (SDoH) have gained attention for their role in weight loss following bariatric surgery, electronic health record (EHR) data provide limited information beyond demographics associated with disparities in weight loss.

OBJECTIVE

To integrate EHR, census, and county data to explore disparities in SDoH and weight loss among patients in the largest populous county of Ohio.

SETTING

Seven hundred seventy-two patients (82.1% female; 37.0% Black) who had primary bariatric surgery (48.7% gastric bypass) from 2015 to 2019 at Ohio State University.

METHODS

EHR variables included race, insurance, procedure, and percent total weight lost (%TWL) at 2/3, 6, 12, and 24 months. Census variables included poverty and unemployment rates. County variables included food stores, fitness/recreational facilities, and open area within a 5- and 10-minute walk from home. Two mixed multilevel models were conducted with %TWL over 24 months, with visits as the between-subjects factor; race, census, county, insurance, and procedure variables were covariates. Two additional sets of models determined within-group differences for Black and White patients.

RESULTS

Access to more food stores within a 10-minute walk was associated with greater %TWL over 24 months (P = .029). Black patients with access to more food stores within a 10-minute (P = .017) and White patients with more access within a 5-minute walk (P = .015) had greater %TWL over 24 months. Black patients who lived in areas with higher poverty rates (P = .036) experienced greater %TWL over 24 months. No significant differences were found for unemployment rate or proximity to fitness/recreational facilities and open areas.

CONCLUSIONS

Close proximity to food stores is associated with better weight loss 2 years after bariatric surgery. Lower poverty levels did not negatively affect weight loss in Black patients.

Effects of weight loss after bariatric surgery on the median and ulnar nerves conduction studies

BACKGROUND

The aim of the present study was to compare the nerve conduction study (NCS) of median and ulnar nerves before and after bariatric surgery.

METHODS

This prospective cross-sectional study included 32 patients with BMI≥35 who were candidate for Sleeve gastrectomy. NCS of median and ulnar nerves were evaluated before and 3 months after surgery. In CTS cases, Boston Carpal Tunnel Questionnaire (BCTQ) was completed.

RESULTS

Eligible participants were 32 patients aged between 19 and 64 years. 20 patients including 34 hands had CTS. Severity of CTS and BCTQ scores were significantly different after surgery. Moreover, sensory amplitude, and motor NCV for both median and ulnar nerves in hands without CTS as well as sensory amplitude of ulnar nerve in hands with CTS were significantly different after bariatric surgery (P value < 0.05).

CONCLUSIONS

The results of this study suggest that three months after the bariatric surgery, the clinical and electrophysiological severity of CTS shows a significant improvement.

ETHICAL CODE OF STUDY

IR.IUMS.FMD.REC.1396.15008.

Health outcomes of patients with type 2 diabetes following bariatric surgery: Results from a publicly funded initiative

OBJECTIVE

Bariatric surgery is an effective treatment for type 2 diabetes and morbid obesity. This paper analyses the clinical and patient-reported outcomes of patients treated through the Bariatric Surgery Initiative, a health system collaboration providing bariatric surgery as a state-wide public service in Queensland, Australia.

RESEARCH DESIGN AND METHODS

A longitudinal prospective cohort study was undertaken. Eligible patients had type 2 diabetes and morbid obesity (BMI ≥ 35 kg/m2). Following referral by specialist outpatient clinics, 212 patients underwent Roux-en-Y gastric bypass or sleeve gastrectomy. Outcomes were tracked for a follow-up of 12-months and included body weight, BMI, HbA1c, comorbidities, health-related quality of life, eating behaviour, and patient satisfaction.

RESULTS

Following surgery, patients' average body weight decreased by 23.6%. Average HbA1c improved by 24.4% and 48.8% of patients were able to discontinue diabetes-related treatment. The incidence of hypertension, non-alcoholic steatohepatitis, and renal impairment decreased by 37.1%, 66.4%, and 62.3%, respectively. Patients' emotional eating scores, uncontrolled eating and cognitive restraint improved by 32.5%, 20.7%, and 6.9%, respectively. Quality of life increased by 18.8% and patients' overall satisfaction with the treatment remained above 97.5% throughout the recovery period.

CONCLUSIONS

This study confirmed previous work demonstrating the efficacy of publicly funded bariatric surgery in treating obesity, type 2 diabetes and related comorbidities, and improving patients' quality of life and eating behaviour. Despite the short follow-up period, the results bode well for future weight maintenance in this cohort.

Twelve-Month Outcomes in Patients with Obesity Following Bariatric Surgery-A Single Centre Experience

BACKGROUND

As obesity rates continue to rise worldwide, many surgeons consider bariatric procedures as a possible cure for the upcoming obesity pandemic. Excess weight represents a risk factor for multiple metabolic disorders, especially for type 2 diabetes mellitus (T2DM). There is a strong correlation between the two pathologies. The aim of this study is to highlight the safety and short-term results of laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB, laparoscopic gastric plication (LGP) and intragastric balloon (IGB) as methods used in the treatment of obesity. We followed the remission or amelioration of comorbidities, tracked metabolic parameters, weight loss curves and hoped to outline the profile of the obese patient in Romania.

METHODS

The target population of this study was represented by patients (n = 488) with severe obesity who qualified for the metabolic surgery criteria. Starting from 2013 to 2019, patients underwent four types of bariatric procedures and were subsequently monitored over the course of 12 months in the 3rd Surgical Clinic at "Sf. Spiridon" Emergency Hospital Iași. Descriptive evaluation indicators, as well as those of analytical evaluation were used as statistical processing methods.

RESULTS

A significant decrease in body weight was recorded during monitoring and was more pronounced for patients who underwent LSG and RYGB. T2DM was identified in 24.6% of patients. Partial remission of T2DM was present in 25.3% of cases, and total remission was identified in 61.4% of patients. Mean blood glucose levels, triglycerides, LDL and total cholesterol levels decreased significantly during monitoring. Vitamin D increased significantly regardless of the type of surgery performed, while mean levels of vitamin B12 decreased significantly during monitoring. Post-operative intraperitoneal bleeding occurred in 6 cases (1.22%) and a reintervention for haemostasis was required.

CONCLUSIONS

All procedures performed were safe and effective methods of weight loss and improved associated comorbidities and metabolic parameters.

Pregnancy as an opportunity to prevent type 2 diabetes mellitus: FIGO Best Practice Advice

Gestational diabetes (GDM) impacts approximately 17 million pregnancies worldwide. Women with a history of GDM have an 8-10-fold higher risk of developing type 2 diabetes and a 2-fold higher risk of developing cardiovascular disease (CVD) compared with women without prior GDM. Although it is possible to prevent and/or delay progression of GDM to type 2 diabetes, this is not widely undertaken. Considering the increasing global rates of type 2 diabetes and CVD in women, it is essential to utilize pregnancy as an opportunity to identify women at risk and initiate preventive intervention. This article reviews existing clinical guidelines for postpartum identification and management of women with previous GDM and identifies key recommendations for the prevention and/or delayed progression to type 2 diabetes for global clinical practice.

[Endoscopic intragastric injection of botulinum toxin in the treatment of patients with morbid obesity: opportunities and prospects]

The authors consider modern epidemiological and demographic data on morbid obesity. Literature review is devoted to non-surgical treatment of patients with morbid obesity. The authors analyze the results of experimental and clinical studies on endoscopic intragastric injection of botulinum toxin and bariatric efficacy of this approach. The indications for endoscopic intragastric injection of botulinum toxin and advantages of this technique are clearly formulated. The authors identified the most significant criteria for objective assessment of clinical effectiveness of endoscopic intragastral injection of botulinum toxin, as well as scientific and methodological principles necessary for this technique. Clinical efficacy of intragastric injection of botulinum toxin including overweight loss, anorexigenic and gastroparetic effects indicates inconsistent results and certain unresolved problems. Thus, large-scale multiple-center randomized controlled trials and multivariate analysis are required to determine the role of endoscopic intragastric injection of botulinum toxin in complex treatment of patients with morbid obesity.

Primary Care Physicians' Knowledge, Attitude, and Potential Referral Barriers towards Bariatric Surgery: A Northern Saudi Study

Introduction: Bariatric surgery is the most effective procedure for sustained weight loss and control of obesity-associated comorbidities among morbidly obese patients. Successful bariatric surgery depends on a multidisciplinary approach involving all healthcare workers, including the primary care physicians, from the referral of patients to long-term follow-up. The present study assessed the knowledge, attitude, and potential referral barriers of primary care physicians to bariatric surgery and associated sociodemographic factors. Materials and methods: The present analytical cross-sectional study was conducted among 280 randomly selected primary care physicians using a standard and validated data collection tool. We performed an independent t-test and one-way ANOVA to find the association between sociodemographic characteristics and knowledge, attitude, and referral barrier scores. Furthermore, multilinear regression analysis was executed to determine the association among knowledge, attitude, and barriers. Results: The current study found that 52.9%, 19.3%, and 59.3% had a low score in the knowledge, attitude, and barriers categories. The attitude scores were significantly associated with the education status (p = 0.005) and current position at primary health centers (p = 0.012), and the referral barriers score was significantly associated with the work experience duration (p = 0.004). We found a positive relationship between knowledge and attitude (regression coefficient (β) [95% CI]:0.389 [0.154 to 0.585], p = 0.001) and a negative relationship between knowledge and referral barriers (β [95% CI]: -0.291 [-0.127 to -0.058], p = 0.007). Conclusions: Our survey findings suggest that a lack of knowledge regarding bariatric surgery led to several concerns and referral barriers among the physicians. Therefore, the recommendation is to improve the primary care physicians' knowledge through continuing medical education, symposium, and other suitable training methods with a special focus on obesity care in the curriculum. Furthermore, a mixed-method survey involving other provinces of the KSA is warranted to formulate the region-specific training needs.

Remission as an Emerging Therapeutic Target in Type 2 Diabetes in the Era of New Glucose-Lowering Agents: Benefits, Challenges, and Treatment Approaches

Type 2 diabetes mellitus (T2DM) is a progressive disease with a growing prevalence, associated with an increased risk of complications. The introduction of new classes of antidiabetic drugs into clinical practice has dramatically changed the landscape of diabetes therapy. However, despite the progress made in the pharmacotherapy of T2DM, mitigating the burden of the disease on individuals, societies and health care systems remains a challenge. Remission has recently emerged as a therapeutic target in T2DM, achievable through a wide range of interventions. Recent studies have shown that extensive lifestyle changes, such as weight reduction, bariatric surgery, and intensive glucose lowering therapy, can prompt the remission of diabetes, but some unanswered questions remain regarding its long-term effects on diabetic complications. Metabolic surgery and novel classes of glucose-lowering medications are currently the most effective interventions to induce weight loss and by extension remission in patients with diabetes; however, the ideal strategy to achieve the long-term maintenance of remission remains doubtful. In this narrative review, we discuss the available therapeutic approaches to target the remission of diabetes through personalized multimodal care, based on the latest evidence.

The role of obesity and bariatric surgery-induced weight loss in breast cancer

Obesity is a complex metabolic condition considered a worldwide public health crisis, and a deeper mechanistic understanding of obesity-associated diseases is urgently needed. Obesity comorbidities include many associated cancers and are estimated to account for 20% of female cancer deaths in the USA. Breast cancer, in particular, is associated with obesity and is the focus of this review. The exact causal links between obesity and breast cancer remain unclear. Still, interactions have emerged between body mass index, tumor molecular subtype, genetic background, and environmental factors that strongly suggest obesity influences the risk and progression of certain breast cancers. Supportive preclinical research uses various diet-induced obesity models to demonstrate that weight loss, via dietary interventions or changes in energy expenditure, reduces the onset or progression of breast cancers. Ongoing and future studies are now aimed at elucidating the underpinning mechanisms behind weight-loss-driven observations to improve therapy and outcomes in patients with breast cancer and reduce risk. This review aims to summarize the rapidly emerging literature on obesity and weight loss strategies with a focused discussion of bariatric surgery in both clinical and preclinical studies detailing the complex interactions between metabolism, immune response, and immunotherapy in the setting of obesity and breast cancer.

Methodological appraisal of the evidence about efficacy of metabolic surgery in adults with non-morbid obesity and hypertension: An overview of systematic reviews

BACKGROUND

Nowadays, the high morbimortality of obesity is mainly related to diabetes, cancer, and hypertension. It is reported that obesity in patients with hypertension can lead to resistance to pressure reduction through pharmacological therapy and lifestyle changes, so bariatric surgery emerges as a proposed treatment for obesity.

METHODS

We performed an umbrella review that included systematic reviews of clinical trials that evaluated patients with hypertension and non-morbid obesity. The quality and certainty of the evidence was evaluated with the AMSTAR-II and GRADE tools.

RESULTS

677 systematic reviews were identified, of which only three were included for analysis. We considered the outcomes addressed by the reviews on hypertension, identifying that 5 RCTs evaluated pressure reduction at 1 year of follow-up and 5 RCTs at more than 1 year, 5 RCTs evaluated hypertension rate, 6 RCTs analyzed changes in systolic pressure and 5 RCTs changes in diastolic pressure. Likewise, when assessing the methodological quality, it was concluded that the three reviews have critically low quality.

CONCLUSIONS

We found only three systematic reviews that evaluated the topic with critically low methodological quality. They reported results in favor of metabolic surgery, but with very low certainty of evidence.

A Changed Gut Microbiota Diversity Is Associated With Metabolic Improvements After Duodenal Mucosal Resurfacing With Glucagon-Like-Peptide-1 Receptor Agonist in Type 2 Diabetes in a Pilot Study

Introduction

The gut microbiota influences and interacts with the host metabolism through effects on nutrient metabolism and digestion. Duodenal Mucosal Resurfacing (DMR) is a novel endoscopic procedure involving duodenal mucosal ablation by the use of hydrothermal energy. DMR, when combined with a glucagon-like peptide-1 receptor agonist (GLP-1RA), resulted in discontinuation of exogenous insulin treatment in 69% of patients with insulin dependent type 2 diabetes mellitus (T2DM) in the INSPIRE study. These patients also experienced improved glycaemic control and metabolic health. We thus investigated if these clinical effects were associated with a change in gut microbiota alpha and beta diversity.

Methods

Faecal samples from the 16 patients were obtained for Illumina shotgun sequencing at baseline and 3 months after DMR. We assessed alpha and beta diversity of the gut microbiota in these samples and analysed its correlations with changes in HbA1c, body weight, and liver MRI proton density fat fraction (PDFF).

Results

HbA1c correlated negatively with alpha diversity (p=0.011, rho: -0.62) whereas changes in PDFF correlated significantly with beta diversity (p=0.036, rho: 0.55) 3 months after initiation of the combined intervention. These correlations with metabolic parameters were observed despite finding no change in gut microbiota diversity at 3 months post DMR.

Discussion

The correlation between gut microbiota richness (alpha diversity) and HbA1c as well as the change in PDFF and changed microbiota composition (beta diversity) suggests that changed gut microbiota diversity is associated with metabolic improvements after DMR in combination with glucagon-like-peptide-1 receptor agonist in type 2 diabetes. Larger controlled studies are however needed to find causal links between DMR with GLP-1RA, the gut microbiota, and improvements in metabolic health.

The Neuro-Endo-Microbio-Ome Study: A Pilot Study of Neurobiological Alterations Pre- Versus Post-Bariatric Surgery

BACKGROUND

Plausible phenotype mechanisms following bariatric surgery include changes in neural and gastrointestinal physiology. This pilot study aims to investigate individual and combined neurologic, gut microbiome, and plasma hormone changes pre- versus post-vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RYGB), and medical weight loss (MWL). We hypothesized post-weight loss phenotype would be associated with changes in central reward system brain connectivity, differences in postprandial gut hormone responses, and increased gut microbiome diversity.

METHODS

Subjects included participants undergoing VSG, n = 7; RYGB, n = 9; and MWL, n = 6. Ghrelin, glucagon-like peptide-1, peptide-YY, gut microbiome, and resting state functional magnetic resonance imaging (rsfMRI; using fractional amplitude of low-frequency fluctuations [fALFF]) were measured pre- and post-intervention in fasting and fed states. We explored phenotype characterization using clustering on gut hormone, microbiome, and rsfMRI datasets and a combined analysis.

RESULTS

We observed more widespread fALFF differences post-bariatric surgery versus post-MWL. Decreased post-prandial fALFF was seen in food reward regions post-RYGB. The highest number of microbial taxa that increased post-intervention occurred in the RYGB group, followed by VSG and MWL. The combined hormone, microbiome, and MRI dataset most accurately clustered samples into pre- versus post-VSG phenotypes followed by RYGB subjects.

CONCLUSION

The data suggest surgical weight loss (VSG and RYGB) has a bigger impact on brain and gut function versus MWL and leads to lesser post-prandial activation of food-related neural circuits. VSG subjects had the greatest phenotype differences in interactions of microbiome, rsfMRI, and gut hormone features, followed by RYGB and MWL. These results will inform future prospective research studying gut-brain changes post-bariatric surgery.

Goals of cure: Perspectives on the concept of cure in type 2 diabetes

RATIONALE, AIMS AND OBJECTIVES: Type 2 diabetes (T2D) is an archetypical chronic condition of significant prevalence. Yet the concept of cure in the context of T2D reveals an interplay between the medical imagination and clinical realities that can shift the course of a patient's care. There are two domains in which cure is sociologically constructed: the professional domain occupied by clinicians treating people with T2D, and the lay domain occupied by T2D patients. Lay epistemologies of cure tend to be focused on modifying the experience of having T2D, while professional epistemologies tend to focus on modifying the disease through medical treatment. The objective of this study is to explore the role of the concept of cure in the context of type 2 diabetes, a model for chronic disease.

METHODS

Through surveys and interviews of T2D patients, providers and researchers at an urban academic medical centre, I explore the perspectives and attitudes each group have towards the concept of cure in T2D. Semi-structured interviews of T2D professionals and patient surveys consisting of free response questions and Likert scale items were thematically analysed for perspectives on cure in T2D.

RESULTS

Sixteen T2D patients met inclusion criteria and consented to the survey and ten T2D professionals were interviewed. Cure is conceived of heterogeneously both within and between epistemologies. Patients carry hopes of cure predicated on eliminating the unpleasant experiences of T2D and its treatments, while T2D professionals tend to avoid invoking the concept of cure, at least to patients, on grounds of clinical uncertainty. However, the concept of cure is a significant motivator of treatment in both lay and professional epistemologies.

CONCLUSION

Different viewpoints on cure in T2D present an opportunity for shared meaning and decision making between patients and their providers that can frame the best possible outcome for patient care.

Changes in gut microbiota, metabolite SCFAs, and GPR43 expression in obese diabetic mice after sleeve gastrectomy

AIMS

To evaluate changes in short-chain fatty acid levels and G protein-coupled receptor 43 expression and distribution in gut microbiota and explore their relationships in obese diabetic mice after sleeve gastrectomy.

METHODS AND RESULTS

Diet-induced obese mice and obese diabetic ob/ob mice were established. Changes in glucose metabolism, lipid metabolism, gut microbiota, metabolite short-chain fatty acids, and G protein-coupled receptor 43 expression were assessed in both models 10 weeks postoperatively. Mice that underwent sleeve gastrectomy exhibited sustained weight loss and reduced glucose, insulin, leptin, and cholesterol levels. Metagenomic sequencing revealed significant characteristic alterations in gut microbiota after sleeve gastrectomy, which were correlated with changes in fecal short-chain fatty acid levels. Postoperatively, G protein-coupled receptor 43 expression in the colon tissue was upregulated in both models, whereas its expression in the adipose tissue was downregulated in the diet-induced obese mouse model.

CONCLUSIONS

Metabolic improvement in obese and diabetic mice after sleeve gastrectomy is associated with alterations in gut microbiota, short-chain fatty acid levels, and G protein-coupled receptor 43 expression.

SIGNIFICANCE AND IMPACT OF STUDY

Our findings reveal a possible mechanism through which sleeve gastrectomy improves obesity and diabetes via changes in bacteria producing short-chain fatty acids and G protein-coupled receptor 43.

Is Sleeve Gastrectomy as Effective in Older Patients as in Younger Patients? A Comparative Analysis of Weight Loss, Related Comorbidities, and Medication Requirements

Background

Bariatric surgery in the older population has been the subject of ongoing debate but several studies have recently demonstrated its short-term advantages in this age group. It is not yet clear, however, whether these benefits are long-lasting.

Methods

We retrospectively analyzed patients with morbid obesity who underwent laparoscopy sleeve gastrectomy (LSG). These patients were divided into two groups: those above 60 years of age (older group) and those of 60 years or under (younger group). Variables evaluated included demographics and anthropometrics data, comorbidities, and daily medication requirements.

Results

Two hundred fifty-two patients underwent LSG, 57 in the older group and 195 in the younger group. Outcomes related to weight loss in the older subjects were modest compared to those in the younger population (older group %EWL 41.6 vs younger group %EWL 51.1, p < 0.05, older group %TWL 24.9% vs younger group %TWL 25.2%, p < 0.05). During follow-up, both older and younger patients showed an improvement in all the comorbidities: hypertension (older 82.5% vs 38.1%, younger 52.6% vs 29.2%, p < 0.05), type 2 diabetes mellitus (older 38.6% vs 27.3%, 34.9% vs 23.9%, p < 0.05), hyperlipidemia (older 75.4% vs 42.9%, younger 35.9% vs 21.1%, p < 0.05), and OSAHS (older 57.9% vs 30%, younger 40.4% vs 7.1%, p < 0.05). The average number of daily medications used to manage comorbidities decreased in both groups.

Conclusion

LSG in older patients is effective in terms of weight loss, improvement of comorbidities, and lower daily medication requirements up to 5 years of follow-up.

Graphical abstract

European Society of Cardiology: cardiovascular disease statistics 2021

AIMS

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries.

METHODS AND RESULTS

Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures.

CONCLUSION

Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

Bariatric surgery for the management of type 2 diabetes mellitus-current trends and challenges: a review article

Obesity has become an epidemic and has emerged as a serious ailment of global concern. Longstanding obesity may lead to several complications, including type 2 diabetes mellitus (T2DM). Considering the role of the gastrointestinal tract (GIT) in glycemic control, altering it would be relevant to the T2DM management algorithm. Bariatric surgery is a well-known surgical procedure that alters the GIT for managing T2DM among moderate to severely obese patients. T2DM remissions (adequate glycemic control without any other antidiabetic drugs) among the post-bariatric patients are due to weight loss related and weight loss unrelated pathophysiological mechanisms, including caloric intake restriction, increased insulin secretion, sensitivity, and malabsorption. Evidence suggests that bariatric surgeries among T2DM patients improved micro and macrovascular complications. Bariatric surgical procedures have more advantages of post-operative weight loss and glycemic control in biliopancreatic diversions than other available bariatric surgical procedures. Several concerns raised on the short and long-term risks associated with the bariatric surgery were nutritional deficiencies, psychological issues, GIT ulcers, and survival rates. Data related to follow-up of complications related to the above-stated risk are still elusive. According to some of the recently published studies, relapse of T2DM after remission is a worrying phenomenon among post-bariatric surgery patients, requiring more clinical trials and long-term follow-up on the relapsed patients. The effectiveness of reoperation among the relapsed patients also needs to be evaluated. Other unresolved issues related to bariatric surgery are patient compliance, cost-effectiveness, quality of life among post-bariatric patients, and the effectiveness of the post-operative holistic approach to avoid relapse. Future studies, especially randomized controlled trials, are recommended to resolve the existing controversies associated with bariatric surgery.

Duodenal mucosal resurfacing with a GLP-1 receptor agonist increases postprandial unconjugated bile acids in patients with insulin-dependent type 2 diabetes

Duodenal mucosal resurfacing (DMR) is a new endoscopic ablation technique aimed at improving glycemia and metabolic control in patients with type 2 diabetes mellitus (T2DM). DMR appears to improve insulin resistance, which is the root cause of T2DM, but its mechanism of action is largely unknown. Bile acids function as intestinal signaling molecules in glucose and energy metabolism via the activation of farnesoid X receptor and secondary signaling [e.g., via fibroblast growth factor 19 (FGF19)], and are linked to metabolic health. We investigated the effect of DMR and glucagon-like peptide-1 (GLP-1) on postprandial bile acid responses in 16 patients with insulin-dependent T2DM, using mixed meal tests performed at the baseline and 6 mo after the DMR procedure. The combination treatment allowed discontinuation of insulin treatment in 11/16 (69%) of patients while improving glycemic and metabolic health. We found increased postprandial unconjugated bile acid responses (all P < 0.05), an overall increased secondary bile acid response (P = 0.036) and a higher 12α-hydroxylated:non-12α-hydroxylated ratio (P < 0.001). Total bile acid concentrations were unaffected by the intervention. Postprandial FGF19 and 7-α-hydroxy-4-cholesten-3-one (C4) concentrations decreased postintervention (both P < 0.01). Our study demonstrates that DMR with GLP-1 modulates the postprandial bile acid response. The alterations in postprandial bile acid responses may be the result of changes in the microbiome, ileal bile acid uptake and improved insulin sensitivity. Controlled studies are needed to elucidate the mechanism linking the combination treatment to metabolic health and bile acids.NEW & NOTEWORTHY Glycemic and metabolic improvements are seen in patients with type 2 diabetes after replacing their insulin therapy with DMR and GLP-1. These changes are accompanied by changes in postprandial bile acid concentrations: increased unconjugated and secondary bile acids.

Novel Insight into the Mechanism of Metabolic Surgery Causing the Diversity in Glycemic Status in Type 2 Diabetes

Metabolic surgery results in diverse glycemic status in patients with type 2 diabetes (T2D), including hyperglycemia without remission, significant amelioration of hyperglycemia with partial remission, complete restoration of euglycemia, or with prolonged remission, hyperglycemia recurrence in relapses after remission, or post-bariatric hypoglycemia. Unfortunately, it is not known how metabolic surgery leads to this diverse consequence. Here, we discuss the diversity of glycemic status associated with metabolic surgery and the potential mechanisms of T2D remission. We also highlight the relationship between the change in low-grade inflammation and T2D remission after metabolic surgery. We hypothesize that the level of inflammatory and anti-inflammatory cytokines controls the efficacy of metabolic surgery in patients with T2D. This hypothesis may provide further insight into the mechanism of the beneficial effects of metabolic surgery patients with T2D.

Five-Year Outcomes of Sleeve Gastrectomy in Patients with Class I Obesity and Type 2 Diabetes Mellitus

BACKGROUND

Several studies have reported short and medium-term outcomes of laparoscopic sleeve gastrectomy (LSG) in patients with class I obesity and type 2 diabetes mellitus (T2DM). However, literature on outcomes beyond three years is scarce. The present study discusses the 5-year results of a previously reported cohort of 20 patients with class I obesity and T2DM, who had undergone LSG between March 2012 and March 2015.

MATERIALS AND METHODS

Patients were followed up in the bariatric clinic at yearly intervals as per institute protocol. Primary outcome was proportion of patients with a glycated haemoglobin (HbA1c) level of 6.5% or less, 5 years after LSG. Secondary outcomes were percentage total weight loss (%TWL), excess weight loss (EWL), weight regain and complications.

RESULTS

Out of 20 patients, 9 (45%) were male and 11 (55%) were female. Mean age was 41.6 ± 9.5 years. Mean pre-operative weight and BMI were 94.8 ± 14.4 kg and 33.4 ± 1.2 kg/m2, respectively. Median duration of diabetes was 42 months. Mean pre-operative fasting plasma glucose (FPG) and HbA1c were 171.1 ± 56.8 mg/dL and 8.7 ± 1.6%, respectively. Of the 17 patients available for follow-up at 5 years, 9 (52.9%) achieved HbA1c < 6.5% without medication, while 7 (41.2%) patients had improvement of their glycaemic status. One patient had recurrence of diabetes after initial remission. Mean %TWL and %EWL were 18% and 65.1%, respectively.

CONCLUSION

Laparoscopic sleeve gastrectomy is a reasonable option as a metabolic procedure for patients with T2DM and class I obesity.

Personalized Type 2 Diabetes Management: An Update on Recent Advances and Recommendations

Previous guidelines for the treatment of people with type 2 diabetes mellitus (T2D) have relied heavily upon rigid algorithms for the sequential addition of pharmacotherapies to achieve target glycemic control. More recent guidelines advocate a personalized approach for diabetes treatment, to improve patient satisfaction, quality of life, medication adherence and overall health outcomes. Clinicians should work with patients to develop personalized goals for their treatment, including targeted glycemic control, weight management, prevention and treatment of associated comorbidities and avoidance of complications such as hypoglycemia. Factors that affect the intensity of treatment and choice of pharmacotherapy should include medical and patient influences. Medical considerations include the diabetes phenotype, biomarkers including genetic tests, and the presence of comorbidities such as cardiovascular, renal, or hepatic disease. Patient factors include their treatment preference, age and life expectancy, diabetes duration, hypoglycemia fear and unawareness, psychological and social circumstances. The use of a personalized approach in the management of people with T2D can reduce the cost and failure associated with the algorithmic "one-size-fits-all" approach, to anticipate disease progression, improve the response to diabetes pharmacotherapy and reduce the incidence of diabetes-associated complications. Ultimately, the use of personalized medicine in people with T2D should improve medication adherence, patient satisfaction and quality of life to reduce diabetes distress and improve physical health outcomes.

Olfaction in the context of obesity and diabetes: Insights from animal models to humans

The olfactory system is at the crossroad between sensory processing and metabolic sensing. In addition to being the center of detection and identification of food odors, it is a sensor for most of the hormones and nutrients responsible for feeding behavior regulation. The consequences of modifications in body homeostasis, nutrient overload and alteration of this brain network in the pathological condition of food-induced obesity and type 2 diabetes are still not elucidated. The aim of this review was first to use both humans and animal studies to report on the current knowledge of the consequences of obesity and type 2 diabetes on odorant threshold and olfactory perception including identification discrimination and memory. We then discuss how olfactory processing can be modified by an alteration of the metabolic homeostasis of the organism and available elements on pharmacological treatments that regulate olfaction. We focus on data within the olfactory system but also on the interactions between the olfactory system and other brain networks impacted by metabolic diseases.

Factors affecting relapse of type 2 diabetes after bariatric surgery in Sweden 2007-2015: a registry-based cohort study

BACKGROUND

Although a large proportion of patients with type 2 diabetes (T2DM) who have undergone metabolic surgery experience initial remission some patients later suffer from relapse. While several factors associated with T2D remission are known, less is known about factors that may influence relapse.

OBJECTIVES

To identify possible risk factors for T2D relapse in patients who initially experienced remission.

SETTING

Nationwide, registry-based study.

METHODS

We conducted a nationwide registry-based retrospective cohort study including all adult patients with T2D and body mass index ≥35 kg/m² who received primary metabolic surgery with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in Sweden between 2007 and 2015. Patients who achieved complete diabetes remission 2 years after surgery was identified and analyzed. Main outcome measure was postoperative relapse of T2D, defined as reintroduction of diabetes medication.

RESULTS

In total, 2090 patients in complete remission at 2 years after surgery were followed for a median of 5.9 years (interquartile range [IQR] 4.3-7.2 years) after surgery. The cumulative T2D relapse rate was 20.1%. Duration of diabetes (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.05-1.14; P < .001), preoperative glycosylated hemoglobin A1C (HbA1C) level (HR, 1.01; 95% CI, 1.00-1.02; P = .013), and preoperative insulin treatment (HR, 2.67; 95% CI, 1.84-3.90; P < .001) were associated with higher rates for relapse, while postoperative weight loss (HR, .93; 95% CI, .91-.96; P < .001), and male sex (HR, .65; 95% CI, .46-.91; P = .012) were associated with lower rates.

CONCLUSION

Longer duration of T2D, higher preoperative HbA1C level, less postoperative weight loss, female sex, and insulin treatment prior to surgery are risk factors for T2D relapse after initial remission.