Bariatric Surgery for Type 2 Diabetes Mellitus in Patients with BMI <30 kg/m2: A Systematic Review and Meta-Analysis

Mid-Long-Term Effect of Metabolic Surgery on Type 2 Diabetes in Nonobese Patients: a Meta-analysis

BACKGROUND

This study aimed to perform a meta-analysis regarding the mid-long-term effect (≥ 2-year follow-up) of metabolic surgery on T2DM in non-obese patients.

METHODS

PubMed, EMBASE and CENTRAL databases were searched for clinical studies from inception to March 2023. Stata 12.0 was used for data aggregation. Sensitivity, subgroup, and meta-regression analyses were performed when feasible.

RESULTS

This meta-analysis included 18 articles involving 548 patients. A pooled rate of 47.5% of T2DM remission was found after metabolic surgery. To be more specific, 83.5% was obtained for hemoglobin A1c (HbA1c) < 7.0%, 45.1% for HbA1c < 6.5%, and 40.4% for HbA1c < 6.0%. Subgroup analysis showed that one-anastomosis gastric bypass (OAGB) had a higher remission rate (93.9%) than other surgeries. Studies conducted in America had a higher remission rate (61.4%) than in Asia (43.6%). Meta-regression analysis displayed that publication year, number of patients, study design, preoperative age, BMI, and quality assessment score were not significantly associated with T2DM remission rate. Additionally, metabolic surgery could result in significant reductions in BMI (-4.133 kg/m2), weight (-9.874 kg), HbA1c (-1.939%), fasting blood glucose, fasting C-peptide, and fasting insulin. However, metabolic surgery seemed to have poorer glycemic control in non-obese than obese T2DM patients.

CONCLUSION

A moderate mid-long-term effect of T2DM remission was observed after metabolic surgery in non-obese patients. However, we still need more prospective multi-institutional studies using the same definitions for diabetes and the same surgical technique for the surgery. Without this, the exact role of bariatric surgery in non-obese patients is unanswered.

Calorie restriction ameliorates hyperglycemia, modulates the disordered gut microbiota, and mitigates metabolic endotoxemia and inflammation in type 2 diabetic rats

PURPOSE

The effects of calorie restriction (CR) on gut microbiota and the mechanism of CR ameliorating hyperglycemia in streptozotocin (STZ)-induced T2DM model rats were explored.

METHODS

High-fat diet and STZ injection were applied to induce T2DM model rats. Rats were divided into the following three groups: the control-diet ad libitum group, the T2DM model group fed with ad libitum diet, and the T2DM group fed with 30% restriction diet. 16S rRNA sequencing was used to determine the bacterial communities. Lipopolysaccharide (LPS)-binding protein (LBP), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) were measured.

RESULTS

Glucose tolerance and insulin sensitivity were improved by CR, as well as the levels of fasting and random plasma glucose. Besides, CR not only modulated the overall structure of gut microbiota but also had selective enrichment in anti-inflammatory bacteria such as Lachnospiraceae_NK4A136_group, Ruminococcaceae_9, Allobaculum, Alistipes, and Oscillibacter, and decreased pro-inflammatory pathogenic bacteria such as Bacteroides, Lachnoclostridium, and Bifidobacterium. Tax4Fun indicated that CR could regulate related functional pathways such as lipopolysaccharide biosynthesis, and the plasma levels of LBP, IL-6, and TNF-α were markedly reduced by CR, suggesting the mechanism of CR ameliorating hyperglycemia may associate with the modulation of disordered gut microbiota and the reduction of metabolic endotoxemia and inflammation.

CONCLUSION

CR could ameliorate hyperglycemia, the mechanism of which may associate with the alteration of the overall structure of gut microbiota, restoration of disordered microbiota function, and the downregulation of metabolic endotoxemia and inflammation in diabetic rats.

The Effect of Bariatric Surgery upon Diabetes Mellitus: A Proof of Concept by Using the Case of the Mid-Term Effect of Lap Adjustable Gastric Banding (LAGB) on Patients with Diabetes

Obesity is a worldwide epidemic, with numbers on the rise in the world. Obesity is strongly correlated with increased morbidity and mortality. One of the major factors affecting this increase is comorbid diseases such as diabetes mellitus (DM), which is strongly associated with and dependent on the degree of obesity. Thus, it is not surprising that when efficient surgical treatments were found to battle obesity, researchers soon found them to be relevant and effective for battling DM as well. Laparoscopic Adjustable Gastric Banding (LAGB) is a common surgical treatment for morbid obesity. LAGB has the potential to improve control of the comorbidities of morbid obesity, primarily diabetes mellitus (DM). Our hypothesis was that patients treated with LAGB would have a long-term improvement in the control of DM and that due to its unique mechanism of action, this can lend us a better understanding of how to battle diabetes in an efficient and effective way. This was a cohort study based on patients who underwent LAGB surgery in our institution 4 to 7 years previously and had DM type 2 at the time of surgery. Data were collected from patient’s charts and a telephone interview-based questionnaire including demographics, health status, and quality-of-life assessment (Bariatric Analysis and Reporting Outcome System [BAROS]). Seventy patients participated in the current study. The average follow-up time was 5.1 ± 0.9 years post-surgery. The average weight prior to surgery was 122.0 ± 20.2 kg, and on the day of the interview it was 87.0 ± 17.6 kg (p < 0.001). The average body mass index before surgery was 43.8 ± 5.1, and on the day of the interview it was 31.2 ± 4.8 (p < 0.001). On the day of the interview, 47.1% of the participants were cured of DM (not receiving treatment, whether dietary or pharmacologic). The sum of ranks for diabetes was lower after the surgery (p < 0.001), as was HTN and its treatment (p < 0.001). We have shown in this study that LAGB is an effective treatment for morbid obesity, as well as two comorbidities that come with it—DM type 2 and Hypertension (HTN)—in a longer period than previously shown, and with a unique look at the underlying mechanism of action of this procedure. There is a need for further studies to consolidate our findings and characterize which patients are more prone to enjoy these remarkable surgical benefits.

Impact of Weight Loss on the Severity of Albuminuria in Obese Diabetic Patients Undergoing Laparoscopic Sleeve Gastrectomy and One-Anastomosis Gastric Bypass

Aim

To examine the effect of weight-loss induced bariatric procedures on albuminuria levels among diabetic patients suffering from obesity.

Methods

Adults patients who suffer from morbid obesity and type 2 diabetes mellitus (T2DM) were included in a prospective cohort study. Subjects were scheduled to undergo laparoscopic sleeve gastrectomy (LSG) or one-anastomosis gastric bypass (OAGB). The albumin-to-creatinine ratio (ACR) was adopted to assess the degree of albuminuria. Microalbuminuria was determined as a ratio of >2.5-30 mg/mmol and >3.5-30 mg/mmol for males and females, respectively, while macroalbuminuria was diagnosed when the ACR exceeded >30 mg/mmol.

Results

The mean uACR decreased significantly from 20.95±16.89 to 9.92±12.69mg/mmol in LSG cohort (p <0.001), and from 19.52±16.65 to 9.34±11.77mg/mmol in the OAGB cohort, with no statistically considerable differences between both cohorts at the end of follow-up (p = 0.78). Twelve months after the procedures, the percentages of cases with microalbuminuria decreased significantly to 23.8% and 23.9%, respectively (p < 0.001); likewise, the percentages of cases with macroalbuminuria significantly decreased to 7.9% and 7.5% in the LSG and OAGB groups, respectively (p < 0.001). There were no statistically considerable differences between LSG and OAGB regarding the percentages of patients with micro or macroalbuminuria at the end of follow-up. Besides, there were no significant associations between the degree of weight loss and improvement (p = 0.959) or remission (p = 0.73) of microalbuminuria.

Conclusion

Bariatric surgery significantly reduced the severity of albuminuria 1-year after the procedure, with no preference for one procedure over the other.

Lipid Accumulation Product Predicts Diabetes Remission After Bariatric Surgery in Chinese Patients with BMI < 35 kg/m2: a Multicenter Cohort Study

PURPOSE

To evaluate whether preoperative visceral fat-related indexes, such as visceral adiposity index (VAI), lipid accumulation product (LAP), Chinese visceral adiposity index (CVAI), and metabolic score for visceral fat (METS-VF), are useful for predicting diabetes remission in Chinese patients with a BMI < 35 kg/m² after bariatric surgery.

MATERIALS AND METHODS

A retrospective, multicenter cohort study enrolled 177 patients. Binary logistic regression and receiver operating characteristic (ROC) curves were used to identify predictors and clinically useful cutoff values, respectively. The correlation between the visceral fat-related index and body fat percentage was assessed.

RESULTS

Complete remission of type 2 diabetes (T2DM) was observed in 66 patients (37.29%) 1 year after surgery. The VAI, LAP, CVAI, and METS-VF showed downward trends postsurgery. Patients with complete remission had a significantly shorter duration of diabetes and higher CVAI, VAI, LAP, and BMI values than those without complete remission. Binary logistic regression and ROC analysis confirmed that diabetes duration and LAP can predict diabetes remission after bariatric surgery, and a LAP of 67.725 is a useful threshold for predicting surgical efficacy. LAP was significantly positively correlated with VAT/total (%) (p < 0.05).

CONCLUSION

Preoperative LAP is a feasible tool for predicting T2DM remission in patients with a BMI < 35 kg/m² after bariatric surgery, and a LAP of 67.725 is a useful threshold for predicting surgical outcomes. LAP was significantly positively correlated with VAT content.

Impact of the different biliopancreatic limb length on diabetes and incretin hormone secretion following distal gastrectomy in gastric cancer patients

The present study aimed to investigate changes in glucose metabolism and incretin hormone response following longer intestinal bypass reconstruction after distal gastrectomy (DG) in low BMI patients with gastric cancer and type 2 diabetes. A total of 20 patients were prospectively recruited and underwent either conventional Billroth I (BI), Billroth II with long-biliopancreatic limb (BII), or Roux-en-Y anastomosis with long-Roux limb (RY) after DG. A 75g-oral glucose tolerance test (OGTT) was given preoperatively; and at 5 days, 3 months, and 6 months postoperatively. Serum glucose, insulin, glucagon, glucagon-like peptide-1 (GLP-1), and glucose-dependent insulinotropic polypeptide (GIP) were serially measured. At 6 months after surgery, complete diabetes remission was achieved in 57.1% of the BII group but in no patients in the other two groups (p = 0.018). BII group showed a significant reduction in glucose concentration during OGTT at 6 months in contrast to the other 2 groups. In the BII group, a significant increase in GLP-1 secretion was observed after surgery but not maintained at 6 months, while postoperative hyperglucagonemia was alleviated along with a reduction in GIP. BII gastrojejunostomy with long biliopancreatic limb achieved better diabetes control with favorable incretin response after DG compared to BI or RY reconstruction.

Time Course of Metabolic, Neuroendocrine, and Adipose Effects During 2 Years of Follow-up After Gastric Bypass in Patients With Type 2 Diabetes

CONTEXT

Roux-en-Y gastric bypass surgery (RYGB) markedly improves glycemia in patients with type 2 diabetes (T2D), but underlying mechanisms and changes over time are incompletely understood.

OBJECTIVE

Integrated assessment of neuroendocrine and metabolic changes over time in T2D patients undergoing RYGB.

DESIGN AND SETTING

Follow-up of single-center randomized study.

PATIENTS

Thirteen patients with obesity and T2D compared to 22 healthy subjects.

INTERVENTIONS

Blood chemistry, adipose biopsies, and heart rate variability were obtained before and 4, 24, and 104 weeks post-RYGB.

RESULTS

After RYGB, glucose-lowering drugs were discontinued and hemoglobin A1c fell from mean 55 to 41 mmol/mol by 104 weeks (P < 0.001). At 4 weeks, morning cortisol (P < 0.05) and adrenocorticotropin (P = 0.09) were reduced by 20%. Parasympathetic nerve activity (heart rate variability derived) increased at 4 weeks (P < 0.05) and peaked at 24 weeks (P < 0.01). C-reactive protein (CRP) and white blood cells were rapidly reduced (P < 0.01). At 104 weeks, basal and insulin-stimulated adipocyte glucose uptake increased by 3-fold vs baseline and expression of genes involved in glucose transport, fatty acid oxidation, and adipogenesis was upregulated (P < 0.01). Adipocyte volume was reduced by 4 weeks and more markedly at 104 weeks, by about 40% vs baseline (P < 0.01).

CONCLUSIONS

We propose this order of events: (1) rapid glucose lowering (days); (2) attenuated cortisol axis activity and inflammation and increased parasympathetic tone (weeks); and (3) body fat and weight loss, increased adipose glucose uptake, and whole-body insulin sensitivity (months-years; similar to healthy controls). Thus, neuroendocrine pathways can partly mediate early glycemic improvement after RYGB, and adipose factors may promote long-term insulin sensitivity and normoglycemia.

Outcomes of Diabetic Retinopathy Post-Bariatric Surgery in Patients with Type 2 Diabetes Mellitus

Bariatric surgery is an emerging therapeutic approach for obese type 2 diabetes mellitus (T2DM) patients, with proven benefits for achieving target glucose control and even remission of diabetes. However, the effect of bariatric surgery upon diabetic retinopathy is still a subject of debate as some studies show a positive effect while others raise concerns about potential early worsening effects. We performed a systematic review, on PubMed, Science Direct, and Web of Science databases regarding the onset and progression of diabetic retinopathy in obese T2DM patients who underwent weight-loss surgical procedures. A total of 6375 T2DM patients were analyzed. Most cases remained stable after bariatric surgery (89.6%). New onset of diabetic retinopathy (DR) was documented in 290 out of 5972 patients (4.8%). In cases with DR at baseline, progression was documented in 50 out of 403 (12.4%) and regression in 90 (22.3%). Preoperative careful preparation of hemoglobin A1c (HbA1c), blood pressure, and lipidemia should be provided to minimize the expectation of DR worsening. Ophthalmologic follow-up should be continued regularly in the postoperative period even in the case of diabetic remission. Further randomized trials are needed to better understand the organ-specific risk factors for progression and provide personalized counseling for T2DM patients planned for bariatric surgery.

Hepatic-Metabolite-Based Intermittent Fasting Enables a Sustained Reduction in Insulin Resistance in Type 2 Diabetes and Metabolic Syndrome

Insulin resistance is the hallmark of Type 2 Diabetes and is still an unmet medical need. Insulin resistance lies at the crossroads of non-alcoholic fatty liver disease, obesity, weight loss and exercise resistance, heart disease, stroke, depression, and brain health. Insulin resistance is purely nutrition related, with a typical molecular disease food intake pattern. The insulin resistant state is accessible by TyG as the appropriate surrogate marker, which is found to lead the personalized molecular hepatic nutrition system for highly efficient insulin resistance remission. Treating insulin resistance with a molecular nutrition-centered approach shifts the treatment paradigm of Type 2 Diabetes from management to cure. This allows remission within five months, with a high efficiency rate of 85%. With molecular intermittent fasting a very efficient treatment for prediabetes and metabolic syndrome is possible, improving the non-alcoholic fatty liver disease (NAFL) state and enabling the body to lose weight in a sustainable manner.

Predictors of Type 2 Diabetes Mellitus Remission After Metabolic Surgery in Asian Patients with a BMI < 32.5 kg/m2

BACKGROUND

Metabolic surgery is an effective treatment for type 2 diabetes mellitus (T2DM) in patients with obesity. However, the efficacy in patients with body mass index (BMI) < 32.5 kg/m², especially in Asian populations, has not been widely reported, and there are few studies on the prediction of diabetes remission.

METHODS

We evaluated 112 patients with T2DM who underwent metabolic surgery between October 2008 and November 2019. The basic data of the patients were collected, and clinical variables were measured at 6 months, 1 year, and 2 years after metabolic surgery. Four independent predictors of surgical outcomes were identified to construct the prediction score.

RESULTS

Diabetes remission occurred for 38 of the 112 patients. Ninety patients underwent Roux-en-Y gastric bypass, while the remaining 22 patients underwent sleeve gastrectomy. Weight, glucose, and lipid metabolism parameters were improved significantly after metabolic surgery. Age, BMI, insulin use, and duration were independent predictors of T2DM remission. The above four factors were defined with scores and developed ABID (age, BMI, insulin use, duration) scoring system. Patients with greater ABID scores had a greater probability of diabetes remission (from 0% at score 0 to 100% at score 4).

CONCLUSIONS

The ABID score is a simple and easy-to-implement prediction score system of diabetes remission after metabolic surgery for T2DM patients with a BMI < 32.5 kg/m².

Protective effects of calorie restriction on insulin resistance and islet function in STZ-induced type 2 diabetes rats

Background

Caloric restriction (CR) has become increasingly attractive in the treatment of type 2 diabetes mellitus (T2DM) because of the increasingly common high-calorie diet and sedentary lifestyle. This study aimed to evaluate the role of CR in T2DM treatment and further explore its potential molecular mechanisms.

Methods

Sixty male Sprague–Dawley rats were used in this study. The diabetes model was induced by 8 weeks of high-fat diet (HFD) followed by a single dose of streptozotocin injection (30 mg/kg). Subsequently, the diabetic rats were fed HFD at 28 g/day (diabetic control) or 20 g/day (30% CR regimen) for 20 weeks. Meanwhile, normal rats fed a free standard chow diet served as the vehicle control. Body mass, plasma glucose levels, and lipid profiles were monitored. After diabetes-related functional tests were performed, the rats were sacrificed at 10 and 20 weeks, and glucose uptake in fresh muscle was determined. In addition, western blotting and immunofluorescence were used to detect alterations in AKT/AS160/GLUT4 signaling.

Results

We found that 30% CR significantly attenuated hyperglycemia and dyslipidemia, leading to alleviation of glucolipotoxicity and thus protection of islet function. Insulin resistance was also markedly ameliorated, as indicated by notably improved insulin tolerance and homeostatic model assessment for insulin resistance (HOMA-IR). However, the improvement in glucose uptake in skeletal muscle was not significant. The upregulation of AKT/AS160/GLUT4 signaling in muscle induced by 30% CR also attenuated gradually over time. Interestingly, the consecutive decrease in AKT/AS160/GLUT4 signaling in white adipose tissue was significantly reversed by 30% CR.

Conclusion

CR (30%) could protect islet function from hyperglycemia and dyslipidemia, and improve insulin resistance. The mechanism by which these effects occurred is likely related to the upregulation of AKT/AS160/GLUT4 signaling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12986-021-00575-y.

Metabolic Surgery and Class 1 Obesity (< 35 kg/m2): a Prospective Study with Short-, Mid-, and Long-term Results Among Latinos

INTRODUCTION

Metabolic surgery for managing class 1 obesity and type 2 diabetes mellitus has recently gained popularity. The Latino population presents high rates of these diseases. Reports on surgical outcomes in this population are scarce.

METHODS

Prospective study with Mexican patients diagnosed with diabetes and class 1 obesity submitted to Roux-en-Y gastric bypass. The objective was to determine short-, mid-, and long-term outcomes (weight loss, metabolic, morbidity, and diabetes remission). Sub-analysis was included, based on preoperative usage of one (group A) or more (group B) oral hypoglycemic agents ± insulin.

RESULTS

Fifty-one patients with a mean body mass index of 33.1 ± 1.9 kg/m², and glycated hemoglobin 7.2 ± 1.7% were included. Significant improvements were observed in almost every parameter. At 24, 36, and 60 months, complete diabetes remission was achieved in 73.8%, 52.2%, and 50% of patients with glycated hemoglobin levels of 5.7% ± 0.8%, 5.8% ± 0.5%, and 6.1% ± 0.8%, respectively. At 24, 36, and 60 months, patients in group A (N=28) showed 90.9%, 69.2%, and 75% remission, respectively, versus patients in group B (N=23), who had remission rates of 50%, 30%, and 25% during the same period. Diabetes relapse was higher in patients using ≥ 2 oral hypoglycemic agents ± insulin before surgery.

CONCLUSION

Gastric bypass is a safe and effective metabolic surgery that results in excellent mid- and long-term results among Mexicans. Patients using one drug preoperatively showed improved results and remission rates, which underscores the importance of intervening in the early stages of the disease.

TRIAL REGISTRATION

Clinical Trials identifier: NCT04595396 ( www.ClinicalTrials.gov ).

The Use of Visceral Adiposity Index to Predict Diabetes Remission in Low BMI Chinese Patients After Bariatric Surgery

BACKGROUND

Visceral Adiposity Index (VAI) is considered to be a reliable indicator for evaluation of visceral adipose dysfunction and cardiovascular disease risk. However, no previous studies have reported the VAI variation after bariatric surgery and the predictive effect of preoperative VAI on diabetes remission. The aim of this study is to evaluate whether preoperative VAI is useful to predict diabetes remission in low BMI Chinese patients after bariatric surgery.

METHODS

Eighty-seven type 2 diabetes mellitus patients with BMI < 35 kg/m² underwent bariatric surgery from May 2010 to March 2018 in our hospital. VAI, glycolipid metabolic parameters, and anthropometric variables were measured before and 4 years after surgery. Complete remission was defined as follows: HbA1c < 6%, FPG < 5.6 mmol/L, achieved without anti-diabetic medication. Analysis included using binary logistic regression to identify predictors and ROC curves to determine clinically useful cutoff values.

RESULTS

Seventy-four patients (85.1%) underwent Roux-en-Y gastric bypass (RYGB), while the remaining 13 patients (14.9%) underwent sleeve gastrectomy (SG). Patients' weight, glycemic control, and lipid profiles were improved significantly after surgery (p < 0.05). Complete remission of T2DM was found in 35 patients (40.2%) 1 year after surgery. VAI decreased from baseline 4.41 to 1.74 in 3 months after surgery (p < 0.05) and showed a downward trend over the period from 6 months to 4 years. Patients with complete remission had a significantly shorter duration of diabetes, lower HbA1c level, and higher VAI, in comparison to those without remission. Binary logistics regression and ROC curves analysis confirm that VAI, HbA1c, and duration of diabetes can predict diabetes remission after bariatric surgery, and the VAI of 4.46 is a useful threshold for predicting surgical efficacy.

CONCLUSION

VAI is a significant predictor of diabetes remission for lower BMI patients with T2DM following bariatric surgery in China. The VAI of 4.46 is a useful threshold for predicting surgical efficacy. Multi-center and larger prospective studies are needed to confirm our findings.

Weight Loss and Changes in Adipose Tissue and Skeletal Muscle Volume after Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: a Prospective Study with 12-Month Follow-Up

BACKGROUND

This study aimed to evaluate changes in body tissue composition with obesity surgery regarding visceral fat, subcutaneous fat, and skeletal muscle.

DESIGN

Prospective non-randomized single-center cohort study METHODS: Whole-body magnetic resonance imaging (MRI) measured volumes of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and skeletal muscle (SM) in 31 patients with laparoscopic sleeve gastrectomy (LSG, 20) or Roux-en-Y gastric bypass (RYGB, 11) preoperatively, at three- and 12-months follow-up.

RESULTS

Body mass index (BMI) went down from 45.2 ± 6.5 preoperatively to 37.2 ± 5.6 (p < 0.001) at three months and 32.2 ± 5.3 kg/m² (p < 0.001) at 12 months. SAT went down from 55.0 ± 14.0 L (liter) to 42.2 ± 13.3 L (p < 0.001) at three months and 31.7 ± 10.5 L (p < 0.001) at 12 months (- 42.3%). VAT went down from 6.5 ± 2.3 to 4.5 ± 1.7 (p < 0.001) at three months and 3.1 ± 1.7 L (p < 0.001) at 12 months (- 52.3%). SM went down from 22.7 ± 4.8 to 20.4 ± 3.6 (p = 0.008) at three months and remained 20.2 ± 4.6 L at 12 months (p = 0.17 relative three-month; p = 0.04 relative preop, - 11.1%). Relative loss was higher for VAT than that for SAT (52.3 ± 18.2% vs. 42.3 ± 13.8%; p = 0.03). At 12 months, there was no difference between LSG and RYGB for relative changes in BMI or body tissue composition.

CONCLUSION

Postoperatively, there was higher net loss of SAT but higher relative loss of VAT with weight loss. SM was lost only during the first three months. MRI provides accurate evaluation of surgeries' effect on individual patients' tissue composition. This can benefit risk assessment for related cardiovascular and metabolic health but cost-related factors will likely reserve the used methods for research.

Emerging Pharmacological Targets for the Treatment of Nonalcoholic Fatty Liver Disease, Insulin Resistance, and Type 2 Diabetes

Type 2 diabetes (T2D) is characterized by persistent hyperglycemia despite hyperinsulinemia, affects more than 400 million people worldwide, and is a major cause of morbidity and mortality. Insulin resistance, of which ectopic lipid accumulation in the liver [nonalcoholic fatty liver disease (NAFLD)] and skeletal muscle is the root cause, plays a major role in the development of T2D. Although lifestyle interventions and weight loss are highly effective at reversing NAFLD and T2D, weight loss is difficult to sustain, and newer approaches aimed at treating the root cause of T2D are urgently needed. In this review, we highlight emerging pharmacological strategies aimed at improving insulin sensitivity and T2D by altering hepatic energy balance or inhibiting key enzymes involved in hepatic lipid synthesis. We also summarize recent research suggesting that liver-targeted mitochondrial uncoupling may be an attractive therapeutic approach to treat NAFLD, nonalcoholic steatohepatitis, and T2D.

Measuring quality of life in bariatric surgery: a multicentre study

BACKGROUND

Current studies mainly focus on total weight loss and comorbidity reduction. Only a few studies compare Quality of Life (QoL) after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). This study was conducted to examine the extent of improvement in QoL on different domains after primary bariatric surgery and compare these results to Dutch reference values.

METHODS

The study included prospectively collected data from patients who underwent primary bariatric surgery in five Dutch hospitals. The RAND-36 questionnaire was used to measure the patient's QoL; preoperatively and twelve months postoperatively. Postoperative scores were compared to Dutch reference values, standardized for age, using t-test. A difference of more than 5% was considered a minimal important difference. A multivariate linear regression analysis was used to compare SG and RYGB on the extent of improvement, adjusted for case-mix factors.

RESULTS

In total, 4864 patients completed both the pre- and postoperative questionnaire. Compared with Dutch reference values, patients postoperatively reported clinically relevant better physical functioning (RYGB + 6.8%), physical role limitations (SG + 5.6%; RYGB + 6.2%) and health change (SG + 77.1%; RYGB + 80.0%), but worse general health perception (SG - 22.8%; RYGB - 17.0%). Improvement in QoL was similar between SG and RYGB, except for physical functioning (β 2.758; p-value 0.008) and general health perception (β 2.607; p-value < 0.001) for which RYGB patients improved more.

CONCLUSIONS

SG and RYGB patients achieved a better postoperative score in physical functioning, physical role limitations and health change compared to Dutch reference values, and a worse score in general health perception.

Does Metabolic Surgery Lead to Diabetes Remission in Patients with BMI < 30 kg/m2?: a Meta-analysis

BACKGROUND

Bariatric surgery has demonstrated to be effective in remission of type 2 diabetes in obese patients, but it is unclear in non-obese patients. The aim of this study is to investigate if metabolic surgery is effective in diabetes resolution in patients with BMI < 30 kg/m².

MATERIALS AND METHODS

A systematic review was performed and the content of the PubMed, Ovid, and the Cochrane Library databases covering the period January 2008 to April 2018 was searched. Studies with metabolic surgery performed in patients with type 2 diabetes, BMI < 30 kg/m² and a follow-up ≥ 6 months were included. Type 2 diabetes remission rate and metabolic parameters changes were measured. A meta-analysis was conducted with the selected studies.

RESULTS

Twenty-six studies were included in the meta-analysis (1105 patients). The mixed-effects meta-analysis model for overall diabetes remission rate produced an estimate of 43% (95% IC 34-53%, p < 0.001). Moderator effects of the variables race, preoperative HbA1c, BMI, months of follow-up, duration of diabetes, and age on diabetes remission were also assessed, with no significant effects being found in any of them. A reduction in BMI (- 3.57 kg/m²), fasting blood glucose (- 55.93 mg/dL) and HbA1c (- 2.08%) was observed after surgery.

CONCLUSIONS

Metabolic surgery could be effective in remission of type 2 diabetes in BMI < 30 kg/m² patients but randomized and long-term studies are necessary. The scientific community should agree in a single definition of type 2 diabetes remission, in order to know the real effect of metabolic surgery in this group of patients.

Quality Assessment of Systematic Review of the Bariatric Surgery for Diabetes Mellitus

OBJECTIVE

Using the AMSTAR tool, this study evaluated the quality of systematic reviews (SRs) that assessed the efficacy of bariatric surgery in diabetic patients. We aimed to identify studies that can be used as clinical references.

METHODS

Medline (via PubMed), EMBASE, Epistemonikos, Web of Science, Cochrane Library, CBM, CNKI, and Wanfang Data were systematically searched from inception to December 31, 2017. Two reviewers independently selected SRs and extracted data. Disagreements were solved by discussions or through consultation with a third reviewer. Reviewers extracted data (characteristics of included SRs, e.g., publication year, language, and number of authors) into the predefined tables in the Microsoft Excel 2013 sheet. Data were visualized using the forest plot in RevMan 5.3 software.

RESULTS

A total of 64 SRs were included. The average AMSTAR score was 7.4 ± 1.7. AMSTAR scores of 7 (n = 21, 32.8%) and 8 (n = 14, 28.1%) were most common. The AMSTAR scores of SRs published before 2016 (n = 46, 71.9%) were compared with SRs published after 2016 (n = 18, 28.1%), and no significant differences were observed (MD = -0.79, 95% confidence interval (CI) -1.65-0.07, P = 0.07). For SRs published in Chinese (n = 17, 26.6%) compared to those published in English (n = 47, 73.4%), the AMSTAR scores significantly differed (MD = 0.21, 95% CI (-0.55, 0.97), P = 0.59). For SRs published in China (n = 33, 51.6%) compared to those published outside of China (n = 31, 48.4%), significant differences in the AMSTAR scores were observed (MD = 1.10, 95% CI (0.29, 1.91), P = 0.008). For SRs with an author number ≤ 6 (n = 31, 48.4%) compared to SRs with authors ≥ 6 (n = 33, 51.6%), no significant differences were observed (MD = -0.36, 95% CI (-1.22, 0.50), P = 0.41). For high-quality SRs published after 2016 (n = 11, 17.2%) compared to other SRs (n = 53, 82.8%), statistically significant differences were noted (MD = 1.75, 95% CI (1.01, 2.49), P < 0.00001).

CONCLUSIONS

The number of SRs assessing the efficacy of bariatric surgery in diabetic patients is increasing by year, but only a small number meet the criteria to support guideline recommendations. Study protocols not being registered, grey literature not retrieved, incorporation of grey literature as exclusion criteria, and failure to evaluate publication bias and report a conflict of interest were the main causes of low AMSTAR scores.

Multicenter results of long-limb bypass reconstruction after gastrectomy in patients with gastric cancer and type II diabetes

BACKGROUND/OBJECTIVE

The number of gastric cancer and type II diabetes mellitus is increasing in Korea. Metabolic surgery could be extended to gastric cancer patients with type II diabetes, especially those who are expected to achieve long-term survival. This study aimed to investigate change of diabetic status in patients undergoing long-limb Roux-en-Y bypass reconstruction compared with conventional Billroth II after curative gastrectomy. In total, 130 patients from five university hospital centers underwent long-limb Roux-en Y reconstruction after radical distal gastrectomy.

METHODS

In the long-limb group, the length of biliopancreatic limbs was more than 80 cm, and the length of the Roux limb was more than 80 cm. The control group comprised 96 patients who underwent conventional Billroth II reconstruction after distal gastrectomy. Follow-up data at three, six, nine, and 12 months were compared between the two groups.

RESULTS

Fasting blood sugar (FBS) and hemoglobin (Hb) A1c levels decreased more significantly in the long-limb Roux-en-Y group (FBS: 28.8 mg/dL; HbA1c: 0.72%). However, decreases in body mass index, albumin, and hemoglobin did not differ significantly between the two groups. Diabetes control significantly improved in the long-limb group. In multivariate analysis, long-limb bypass reconstruction was the significant factor for glycemic outcomes.

CONCLUSION

Roux-en-Y bypass with increased length of limbs after gastrectomy shows a favorable glycemic control for gastric cancer patients with type II diabetes without nutritional deficit and anemia. To obtain future perspectives, large-scale prospective studies with long-term outcomes are needed.

Prediction of Type 2 Diabetes Remission after Bariatric or Metabolic Surgery

Bariatric surgery has evolved from a surgical measure for treating morbid obesity to an epochal remedy for treating metabolic syndrome as a whole, which is represented by type 2 diabetes mellitus. Numerous clinical trials have advocated bariatric or metabolic surgery over nonsurgical interventions because of markedly superior metabolic outcomes in morbidly obese patients who satisfy traditional criteria for bariatric surgery (body mass index [BMI] >35 kg/m2) and in less obese or simply overweight patients. Nevertheless, not all diabetes patients achieve the most desirable outcomes; i.e., diabetes remission after metabolic surgery. Thus, candidates for metabolic surgery should be carefully selected based on comprehensive preoperative assessments of the risk-benefit ratio. Predictors for diabetes remission after metabolic surgery may be classified into two groups based on mechanism of action. The first is indices for preserved pancreatic beta-cell function, including younger age, shorter duration of diabetes, and higher C-peptide level. The second is the potential for an insulin resistance reduction, including higher baseline BMI and visceral fat area. Several prediction models for diabetes remission have been suggested by merging these two to guide the joint decision-making process between clinicians and patients. Three such models, DiaRem, ABCD, and individualized metabolic surgery scores, provide an intuitive scoring system and have been validated in an independent external cohort and can be utilized in routine clinical practice. These prediction models need further validation in various ethnicities to ensure universal applicability.

Metabolic surgery ameliorates cardiovascular risk in obese diabetic patients: Influence of different surgical procedures

BACKGROUND

In recent years, bariatric surgery was found to have therapeutic potential for the treatment of type 2 diabetes (T2D) in severely obese patients (body mass index [BMI] ≥35 kg/m²) and to reduce cardiovascular disease (CVD) risk and mortality. However, the benefit of CVD risk reduction after metabolic surgery in nonseverely obese T2D patients (BMI <35 kg/m²) remained to be proven.

OBJECTIVE

To evaluate the CVD risk after metabolic surgery in T2D patients using The UK Prospective Diabetes Study score.

SETTING

Tertiary referral general hospital, Taiwan, Republic of China.

METHODS

Outcomes of 392 patients (235 women and 147 men) who had undergone sleeve gastrectomy (87) or gastric bypass (305) for treatment of T2D with 1-year follow-up were assessed. Data were prospectively collected for study, and cerebral and coronary heart disease risk was calculated by using The UK Prospective Diabetes Study risk engine. Outcomes of patients who had undergone different surgical procedures were assessed.

RESULTS

One year after surgery, weight and glycemic control with complete and partial remission of T2D were significant in most of the patients. The 10-year coronary heart disease risk and fatal coronary heart disease risk were also reduced from 8.8% to 4.6% and from 4.6% to 2.1%, respectively (both P < .001). Similar CVD risk reduction was seen in both patients with BMI ≥35 and BMI <35. Multivariable analysis confirmed that surgical procedure of sleeve gastrectomy was a negative independent predictor of CVD risk reduction after metabolic surgery.

CONCLUSION

The present study confirms the efficacy of metabolic surgery for the T2D treatment and reduction of CVD risk up to 50% 1 year after surgery. Gastric bypass surgery has more power on CVD risk reduction than sleeve gastrectomy.

Reversibility of diabetes mellitus: Narrative review of the evidence

The global disease burden of diabetes mellitus is high. It is well-established that prediabetes is reversible but it is unclear whether diabetes is reversible once it has been diagnosed. The objective of this narrative review is to review the evidence of reversibility of diabetes mellitus and stimulate interest in prolonged remission as a treatment target. The current evidence for bariatric surgery is stronger than intensive medical management and the evidence is stronger for type 2 diabetes patients compared with type 1 diabetes patients. It is also unclear whether non obese diabetes patients would benefit from such interventions and the duration of diabetes before diabetes become irreversible. Further research is needed in this area especially with regards to the subgroup of diabetes patient who will benefit from these interventions and the long term safety and efficacy remains unknown especially with intensive medical management.

Comparative Characteristics of Patients with Type 2 Diabetes Mellitus Treated by Bariatric Surgery Versus Medical Treatment: a Multicentre Analysis of 277,862 Patients from the German/Austrian DPV Database

INTRODUCTION

Bariatric surgery is a well-established treatment option for serious obesity and concomitant type 2 diabetes mellitus (T2DM). In this analysis, we investigated predictors for bariatric surgery in everyday clinical practice.

MATERIALS AND METHODS

In the DPV-registry, patients with T2DM from Germany and Austria treated by bariatric surgery were compared to non-surgery controls by descriptive statistics and regression analysis.

RESULTS

Among 277,862 patients with T2DM, 0.07% underwent bariatric surgery. Surgery patients were predominantly female [61.20%], younger [median age (Q1;Q3) 54.74(47.40;61.61) vs. 70.04 (60.36;77.58) years] and had a longer diabetes duration [11.21 (7.15;17.93) vs. 8.36 (2.94;14.91) years]. They had a higher BMI [40.02 vs. 30.61 kg/m², adjusted p < 0.0001] and a slightly lower HbA1c [7.25 vs. 7.56%, adjusted p < 0.05]. There was a trend using more often insulin therapy (52.79 vs.50.08%, n.s.) with no difference in insulin dose/kg × day [0.56 vs. 0.58, n.s.]. Sleeve gastrectomy was performed most frequently, followed by Roux-en-Y gastric bypass, gastric banding, gastric balloon and others. A 2-year follow-up data in 29 patients demonstrated significant reductions in BMI [45.23 to 38.00 kg/m², p < 0.005] and HbA1c [7.98 to 6.98%, p < 0.005], and a trend for reduced insulin requirements [62.07 vs. 44.83%, n.s.].

CONCLUSION

Despite favourable 2-year outcomes, bariatric surgery is still used rarely in patients with T2DM and obesity. BMI rather than metabolic control seems to represent the major selector for or against bariatric surgery in T2DM.

Surgical treatment of obesity

Obesity prevalence continues to increase worldwide, as do the numerous chronic diseases associated with obesity, including diabetes, non-alcoholic fatty liver disease, dyslipidemia, and hypertension. The prevalence of bariatric surgery also continues to increase and remains the most effective and sustainable treatment for obesity. Over the last several years, numerous prospective and longitudinal studies have demonstrated the benefits of bariatric surgery on weight loss, mortality, and other chronic diseases. Even though the mechanisms underlying many of these beneficial effects remain poorly understood, surgical management of obesity continues to increase given its unmatched efficacy. In this commentary, we discuss recent clinical advancements as well as several areas needed for future research, including indications for bariatric and metabolic surgery, determination of responders and non-responders, metabolic surgery in non-obese individuals, and the evolving role of bariatric surgery in adolescents.

The Role of Laboratory Testing in Differentiating Type 1 Diabetes from Type 2 Diabetes in Patients Undergoing Bariatric Surgery

BACKGROUND

It may be difficult to distinguish between adults with type 1 diabetes and type 2 diabetes by clinical assessment. In patients undergoing bariatric surgery, it is critical to correctly classify diabetes subtype to prevent adverse perioperative outcomes including diabetic ketoacidosis. This study aimed to determine whether testing for C-peptide and islet cell antibodies during preoperative evaluation for bariatric surgery could improve the classification of type 1 versus type 2 diabetes compared to clinical assessment alone.

METHODS

This is a retrospective analysis of the Improving Diabetes through Lifestyle and Surgery trial, which randomized patients with clinically diagnosed type 2 diabetes and BMI 30-40 kg/m² to medical weight loss or bariatric surgery; one participant was discovered to have type 1 diabetes after experiencing postoperative diabetic ketoacidosis. Using blood samples collected prior to study interventions, we measured islet cell antibodies and fasting/meal-stimulated C-peptide in all participants.

RESULTS

The participant with type 1 diabetes was similar to the 11 participants with type 2 diabetes in age at diagnosis, adiposity, and glycemic control but had the lowest C-peptide levels. Among insulin-treated participants, fasting and stimulated C-peptide correlated strongly with the C-peptide area-under-the-curve on mixed meal tolerance testing (R = 0.86 and 0.88, respectively). Three participants, including the one with type 1 diabetes, were islet cell antibody positive.

CONCLUSIONS

Clinical characteristics did not correctly identify type 1 diabetes in this study. Preoperative C-peptide testing may improve diabetes classification in patients undergoing bariatric surgery; further research is needed to define the optimal C-peptide thresholds.

Effects of Laparoscopic Roux-en-Y Gastric Bypass for Type 2 Diabetes Mellitus: Comparison of BMI > 30 and < 30 kg/m2

Background

Recently, many studies focused on type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) < 30 kg/m² and suggested that those patients might benefit from Roux-en-Y gastric bypass (RYGB). However, evidence on its effectiveness to improve T2DM patients with BMI < 30 kg/m² is still lacking. The aim of this study is to explore whether T2DM patients with BMI < 30 kg/m² get similar surgical effect from RYGB compared with those patients with BMI > 30 kg/m².

Methodology

Seventy patients with uncontrolled T2DM underwent laparoscopic RYGB from May 2010 to December 2015 in the GI Department of Daping Hospital. Weight, BMI, waist circumference, glucose, and lipid metabolic parameters were collected and evaluated at baseline and 1, 3, 6, 12, and 24 months postsurgery. Patients with BMI < 30 kg/m² were compared with those with BMI > 30 kg/m².

Results

Among the 70 patients, 47 (67.1%) BMI < 30 kg/m², and 23 (32.9%) BMI > 30 kg/m². Patients with BMI < 30 kg/m² are significantly older; they are female predominant and have longer duration of diabetes. The complete remission of T2DM was 28.2% of the BMI < 30 kg/m² group and 57.9% of the BMI > 30 kg/m² group (p = 0.029). There was no significant difference in the change of glucose and lipid metabolic parameters of both groups. FPG, 2hPG, and HbA1c% levels were significantly improved after 1 month (p < 0.05), and then remained essentially stable from the sixth month in both groups.

Conclusions

The 2-year study has shown that RYGB is a safe and effective procedure in treating T2DM with BMI < 30 kg/m², although the complete remission of T2DM in the BMI < 30 kg/m² group is lower than the BMI > 30 kg/m² group.

The effect of metabolic surgery on nonobese patients (BMI<30 kg/m2) with type 2 diabetes: a systematic review

BACKGROUND

The influence of metabolic surgery on the glucose and lipid profiles of nonobese body mass index<30 kg/m² patients with type 2 diabetes, particularly the effect ≥1 year, remains unknown.

METHODS

PubMed and Ovid Embase were used.

SETTING

University hospitals.

RESULTS

In total, 21 studies including 921 patients were examined in this systematic review, the results of which revealed decrease in body mass index, waist circumference, fasting plasma glucose, glycosylated hemoglobin A1C, fasting C-peptide, fasting insulin, homeostasis model of assessment for insulin resistance index, triglycerides, total cholesterol, and low-density lipoprotein cholesterol. An increase in high-density lipoprotein cholesterol was also observed. The diabetes remission rates ranged from 13.3% to 90.2% according to 20 studies. The incidence of gastrointestinal bleeding ranged from 1% to 10% according to 9 studies. Four studies reported anemia after Roux-en-Y gastric bypass or one-anastomosis gastric bypass, with the incidence ranging from 8% to 33%.

CONCLUSIONS

Nonobese patients can achieve improvements in weight-related indices and glucose and lipid profiles in the short and medium term after metabolic surgery; however, the complications of metabolic surgery warrant further attention.

Mechanisms by which a Very-Low-Calorie Diet Reverses Hyperglycemia in a Rat Model of Type 2 Diabetes

Caloric restriction rapidly reverses type 2 diabetes (T2D), but the mechanism(s) of this reversal are poorly understood. Here we show that 3 days of a very-low-calorie diet (VLCD, one-quarter their typical intake) lowered plasma glucose and insulin concentrations in a rat model of T2D without altering body weight. The lower plasma glucose was associated with a 30% reduction in hepatic glucose production resulting from suppression of both gluconeogenesis from pyruvate carboxylase (V_PC), explained by a reduction in hepatic acetyl-CoA content, and net hepatic glycogenolysis. In addition, VLCD resulted in reductions in hepatic triglyceride and diacylglycerol content and PKCɛ translocation, associated with improved hepatic insulin sensitivity. Taken together, these data show that there are pleotropic mechanisms by which VLCD reverses hyperglycemia in a rat model of T2D, including reduced DAG-PKCɛ-induced hepatic insulin resistance, reduced hepatic glycogenolysis, and reduced hepatic acetyl-CoA content, PC flux, and gluconeogenesis.

Clinical Practice Recommendations for the Management of Obesity in the United Arab Emirates

With rapid urbanisation and improved living conditions as a result of rising incomes in Gulf Cooperation Council (GCC) countries, obesity has become a major and growing health problem for the region. The United Arab Emirates (UAE) has a resident population of 9.3 million (in 2016), many of whom (85.5%) lived in urban areas and led sedentary lifestyles. Based on the World Health Organisation (WHO) estimates for 2010, 25% of Emirati men and 40% of the women were obese. Obesity rates in this country has doubled from 16 to 34% compared to the year 2000, and severe obesity (BMI > 40 kg/m2) has risen dramatically from 2 to 11%. While a number of international guidelines for the management of obesity are already available in public domain, local guidelines for the UAE and the region, which are structured and individualized for the management of obesity, are sorely needed to help the family physician to provide affordable treatment for the patient at the point-of-care and to reduce the burden on the local healthcare system. A multi-disciplinary panel of international and regional experts who treat patients with overweight and obesity was convened with the aim of developing consensus recommendations for the UAE. The objective is to have a simple and easy-to-refer set of recommendations for busy clinicians as there were already many comprehensive international guidelines available. The panel reviewed and streamlined these recommendations in its entirety for relevance, coherence and usability in the local context. These recommendations for overweight and obesity management were circulated and endorsed by the local practising family medicine community, namely, the Emirates Medical Association and Family Medicine Society. We believe these recommendations would also be of interest to clinicians in other GCC countries. A summary and algorithm of these recommendations are provided.

Long-term Follow-up for Type 2 Diabetes Mellitus after Gastrectomy in Non-morbidly Obese Patients with Gastric Cancer: the Legitimacy of Onco-metabolic Surgery

Purpose

This study primarily aimed to investigate the short- and long-term remission rates of type 2 diabetes (T2D) in patients who underwent surgical treatment for gastric cancer, especially patients who were non-obese, and secondarily to determine the potential factors associated with remission.

Materials and Methods

We retrospectively reviewed the clinical records of patients with T2D who underwent radical gastrectomy for gastric cancer, from January 2008 to December 2012.

Results

T2D improved in 39 out of 70 (55.7%) patients at the postoperative 2-year follow-up and 21 of 42 (50.0%) at the 5-year follow-up. In the 2-year data analysis, preoperative body mass index (BMI) (P=0.043), glycated hemoglobin (A1C) level (P=0.039), number of anti-diabetic medications at baseline (P=0.040), reconstruction method (statistical difference was noted between Roux-en-Y reconstruction and Billroth I; P=0.035) were significantly related to the improvement in glycemic control. Unlike the results at 2 years, the 5-year data analysis revealed that only preoperative BMI (P=0.043) and A1C level (P=0.039) were statistically significant for the improvement in glycemic control; however, the reconstruction method was not.

Conclusions

All types of gastric cancer surgery can be effective in short- and long-term T2D control in non-obese patients. In addition, unless long-limb bypass is considered in gastric cancer surgery, the long-term glycemic control is not expected to be different between the reconstruction methods.

Laparoscopic sleeve gastrectomy for diabetics - 5-year outcomes

OBJECTIVE

Although the laparoscopic sleeve gastrectomy (SG) is increasingly performed for morbid obesity, gastric bypass is still considered by many to be the gold standard procedure for obese diabetic patients. The aim of this study was to assess the long-term results of SG in morbidly obese patients with type 2 diabetes.

METHODS

Diabetic patients who underwent SG at a single center between 2009 and 2011 were included. Outcomes assessed included postoperative complications, weight loss, and resolution or improvement in co-morbidities with an emphasis on diabetes, including glycated hemoglobin (HbA1C) and medication status.

RESULTS

Fifty-one diabetic patients underwent SG, 35 females and 16 males, with a collective mean age of 49 years and a mean body mass index of 43.2 kg/m². On average, patients had had diabetes for 5.4 ± 7.3 years before surgery. Mean HbA1C and fasting glucose levels were 7.9 ± 1.6% and 166.9 ± 63 mg/dL, respectively. Eleven patients (22%) were insulin dependent at the time of surgery. Average body mass index at a mean follow-up of 5 years after surgery was 34.4 ± 5.8 kg/m², with an average HbA1C of 6.6 ± 1% and an average fasting glucose of 123 ± 60 mg/dL. Only 3 patients remained insulin dependent.

CONCLUSION

SG offers retainable weight loss results, accompanied by longstanding resolution or improvement of diabetes. Prospective, randomized controlled studies are warranted to better compare long-term outcomes between SG and gastric bypass.

Bariatric surgery for nonalcoholic steatohepatitis: A clinical and cost-effectiveness analysis

Nonalcoholic steatohepatitis (NASH) affects 2%-3% of the US population and is expected to become the leading indication for liver transplantation in the next decade. Bariatric surgery may be an effective but expensive treatment for NASH. Using a state-transition model, our analysis assessed the effectiveness and cost-effectiveness of surgery to manage NASH. We simulated the benefits and harms of laparoscopic Roux-en-Y gastric bypass surgery in patients defined by weight class (overweight, mild obesity, moderate obesity, and severe obesity) and fibrosis stage (F0-F3). Comparators included intensive lifestyle intervention (ILI) and no treatment. Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios were calculated. Our results showed that surgery and ILI in obese patients (with F0-F3) increased QALYs by 0.678-2.152 and 0.452-0.618, respectively, compared with no treatment. Incremental cost-effectiveness ratios for surgery in all F0-F3 patients with mild, moderate, or severe obesity were $48,836/QALY, $24,949/QALY, and $19,222/QALY, respectively. In overweight patients (with F0-F3), surgery increased QALYs by 0.050-0.824 and ILI increased QALYs by 0.031-0.164. In overweight patients, it was cost-effective to reserve treatment only for F3 patients; the incremental cost-effectiveness ratios for providing surgery or ILI only to F3 patients were $30,484/QALY and $25,367/QALY, respectively.

CONCLUSIONS

Surgery was both effective and cost-effective for obese patients with NASH, regardless of fibrosis stage; in overweight patients, surgery increased QALYs for all patients regardless of fibrosis stage, but was cost-effective only for patients with F3 fibrosis; our results highlight the promise of bariatric surgery for treating NASH and underscore the need for clinical trials in this area. (Hepatology 2017;65:1156-1164).

Effect of Endoscopic Gastroplication on the Genome-Wide Transcriptome in the Upper Gastrointestinal Tract

BACKGROUND

Bariatric surgery is an effective intervention strategy in obesity, resulting in sustained weight loss and a reduction of comorbidities. Gastroplication, using the articulating circular endoscopic stapler, was recently introduced as a transoral bariatric technique. This procedure reduces gastric volume and induced 34.9 % of excess weight loss in the first year (Paulus et al. Gastrointest Endosc. 81(2):312-20, 3). The aim of the present study was to gain insight in the long-term effects and underlying mechanisms of gastroplication by investigating differences in the genome-wide gastric and duodenal transcriptome before and 1 year after intervention.

METHODS

Ten morbidly obese patients (BMI 39.8 ± 0.9 kg/m2 (mean ± SEM)) underwent gastroplication. Previous to the procedure and after 1 year, blood samples were taken, and mucosal biopsies were collected from the fundus, antrum and duodenum. Gene expression was measured using microarray analysis. Plasma adiponectin, HbA1c, IL-1β, IL-6, IL-7, TNF-α, IFN-γ, MCP-1, IL-8, TGF-1 and CRP levels were determined.

RESULTS

Downregulation of inflammatory genes and gene sets was observed in the fundus and duodenum 1 year after surgery. Gene expression of ghrelin and its activating enzyme GOAT were downregulated in the upper gastrointestinal tract. Patients showed a reduction in plasma HbA1c levels (from 6.17 ± 0.51 to 5.32 ± 0.14 %, p = 0.004) and an increase of plasma adiponectin (from 16.87 ± 3.67 to 27.67 ± 5.92 μg/ml, p = 0.002).

CONCLUSIONS

Individuals undergoing gastroplication displayed a downregulation of inflammatory tone in the stomach and duodenum, which coincided with improved HbA1c and adiponectin levels. The reduction of inflammatory tone in the upper gastrointestinal tract may be a consequence of an improved metabolic health status or alternatively caused by the procedure itself.

[Treatment of type 2 diabetes]

New glucose-lowering drugs have raised the complexity of diabetes treatment in recent years. While metformin is still the first choice in monotherapy for most cases, various options exist for dual combination therapy. In addition, combinations of three different oral glucose-lowering drugs are increasingly used. Insulin therapy is typically initiated using once daily administration of a long-acting insulin. If basal insulin alone is no longer sufficient, treatment can be intensified by adding short-acting insulin at mealtime or by combining basal insulin with oral glucose-lowering drugs or a glucagon-like peptide (GLP)-1 analogue. The choice of the most appropriate glucose-lowering drug should take into account not only the glucose-lowering efficacy, but also the side effect profile of the respective agents; economic factors must be considered as well. Modern treatment of type 2 diabetes should aim for near-normal glucose control.

New Approaches to Feline Diabetes Mellitus: Glucagon-like peptide-1 analogs

CLINICAL RELEVANCE

Incretin-based therapies are revolutionizing the field of human diabetes mellitus (DM) by replacing insulin therapy with safer and more convenient long-acting drugs.

MECHANISM OF ACTION

Incretin hormones (glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic peptide [GIP]) are secreted from the intestinal tract in response to the presence of food in the intestinal lumen. GLP-1 delays gastric emptying and increases satiety. In the pancreas, GLP-1 augments insulin secretion and suppresses glucagon secretion during hyperglycemia in a glucose-dependent manner. It also protects beta cells from oxidative and toxic injury and promotes expansion of beta cell mass.

ADVANTAGES

Clinical data have revealed that GLP-1 analog drugs are as effective as insulin in improving glycemic control while reducing body weight in people suffering from type 2 DM. Furthermore, the incidence of hypoglycemia is low with these drugs because of their glucose-dependent mechanism of action. Another significant advantage of these drugs is their duration of action. While insulin injections are administered at least once daily, long-acting GLP-1 analogs have been developed as once-a-week injections and could potentially be administered even less frequently than that in diabetic cats.

OUTLINE

This article reviews the physiology of incretin hormones, and the pharmacology and use of GLP-1 analogs, with emphasis on recent research in cats. Further therapies that are based on incretin hormones, such as DPP-4 inhibitors, are also briefly discussed, as are some other treatment modalities that are currently under investigation.

Bariatric Surgery in Type 1 Diabetes Mellitus: A Systematic Review

Bariatric surgery is recognised as an effective treatment strategy for obese patients with type 2 diabetes mellitus. An increasing number of patients with type 1 diabetes mellitus also suffer with obesity and obesity-associated comorbidities but the role of bariatric and metabolic surgery in this group of patients is unclear. This systematic review investigates published English language scientific literature to understand the results of bariatric surgery in obese patients with type 1 diabetes mellitus. We found that these patients can experience significant weight loss and comorbidity resolution with bariatric surgery. Though most patients also see a decline in total insulin requirement, glycaemic control remains difficult. Most of the patients reported in literature have undergone gastric bypass but data is insufficient to recommend any particular procedure.

Surgical cure for type 2 diabetes by foregut or hindgut operations: a myth or reality? A systematic review

BACKGROUND

Bariatric surgery results in remission of type 2 diabetes mellitus in a significant proportion of patients. Animal research has proposed the foregut and hindgut hypotheses as possible mechanisms of remission of T2DM independent of weight loss. These hypotheses have formed the basis of investigational procedures designed to treat T2DM in non-obese (in addition to obese) patients. The aim of this study was to review the procedures that utilise the foregut and hindgut hypotheses to treat T2DM in humans.

METHODS

A systematic review was conducted to identify the investigational procedures performed in humans that are based on the foregut and hindgut hypotheses and then to assess their outcomes.

RESULTS

Twenty-four studies reported novel procedures to treat T2DM in humans; only ten utilised glycated haemoglobin A1c (HbA1c) in their definition of remission. Reported remission rates were 20-40 % for duodenal-jejunal bypass (DJB), 73-93 % for duodenal-jejunal bypass with sleeve gastrectomy (DJB-SG), 62.5-100 % for duodenal-jejunal bypass sleeve (DJBS) and 47-95.7 % for ileal interposition with sleeve gastrectomy (II-SG). When using a predetermined level of HbA1c to define remission, the remission rates were lower (27, 63, 0 and 65 %) for DJB, DJB-SG, DJBS and II-SG.

CONCLUSIONS

The outcomes of the foregut- and hindgut-based procedures are not better than the outcomes of just one of their components, namely sleeve gastrectomy. The complexity of these procedures in addition to their comparable outcomes to a simpler operation questions their utility.

Energy balance and metabolic changes with sodium-glucose co-transporter 2 inhibition

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are the latest addition to the class of oral glucose-lowering drugs. They have been rapidly adopted into clinical practice because of therapeutic advantages, including weight loss and reduction in blood pressure, in addition to glycaemic benefits and a low intrinsic risk of hypoglycaemia. Although there are extensive data on the clinical effects of SGLT2 inhibition, the metabolic effects of inhibiting renal glucose reabsorption have not been fully described. Recent studies have identified compensatory metabolic effects, such as an increase in endogenous glucose production, and have also shown an increase in glucagon secretion during SGLT2 inhibition. In addition, there is a discrepancy between the expected and observed weight loss found in clinical studies on SGLT2 inhibitors, probably as a result of changes in energy balance with this treatment approach. SGLT2 inhibition is likely to have intriguing effects on whole body metabolism which have not been fully elucidated, and which, if explained, might help optimize the use of this new class of medicines.