Assessing the obese diabetic patient for bariatric surgery: which candidate do I choose?

Factors Determining Diabetic Remission after Sleeve Gastrectomy: A Prospective Study

Background

An exponential rise in the prevalence of obesity and the associated type 2 diabetes mellitus (T2DM) has led to an explosion in the field of bariatric surgery worldwide. It has been proposed that laparoscopic sleeve gastrectomy (LSG) not only results in excess weight loss (EWL) but also leads to excellent glycemic control.

Aims

However, not every patient benefits from the bariatric surgery. Furthermore, bariatric surgery is currently indicated based on body mass index (BMI), but BMI solely does not predict diabetes remission after the surgery. We aimed to study the outcome of LSG on the diabetic status and the factors predicting the disease remission.

Subjects and Methods

This prospective study was conducted on 104 obese patients having T2DM who underwent LSG. Following surgery, the clinical outcome on weight loss, BMI, and glycemic control was studied for 6 months. Various positive and negative predictors of diabetic remission after the surgery were also determined. Student's t-test and Chi-square tests were applied.

Results

LSG resulted in significant weight loss (P < 0.05); the percentage of EWL was 60.75 ± 6.30 at 6 months. Furthermore, surgery resulted in 78.9% remission of diabetes with fasting blood glucose and glycated hemoglobin values at 6 months being 121.13 ± 15.25 mg/dl and 6.19% ± 0.31%, respectively. Younger and heavier patients, those with lesser disease severity and shorter duration had better chances of disease remission. Gender had no correlation with disease remission.

Conclusion

LSG is a successful treatment option for T2DM and is more beneficial if offered, not as a last option, but to younger, obese patients with mild disease severity and shorter disease duration after the failure of medical treatment.

Relevance of weight in the management of patients with type 2 diabetes mellitus: towards an adipocentric approach to diabetes

In recent decades, there has been a worldwide parallel increase in the prevalence of obesity and type 2 diabetes mellitus (T2DM), which is not surprising, given that increased visceral fat is the main risk factor for the development of T2DM in genetically predisposed individuals. An intervention focused on intensive blood glucose control in T2DM with classic drugs increases the risk of weight gain and the rate of hypoglycaemia. In contrast, weight loss through lifestyle changes, drugs and/or surgery simultaneously improves most cardiovascular (CV) risk factors, including hyperglycemia. Intensive intervention on lifestyle induces an overall benefit in patients with T2DM, but long-term weight loss is modest and has not been shown to reduce CV morbidity and mortality. The emergence of new therapeutic classes for T2DM and obesity, which simultaneously improve HbA1c, weight and other CV risk factors without inducing hypoglycaemia, represents a major change in the management of patients with diabesity. A sodium-glucose cotransporter-2 inhibitor and a GLP-1 receptor agonist have recently been shown to decrease CV and total mortality in type 2 diabetic patients with CV disease. Furthermore, bariatric surgery rapidly induces remission or improvement of T2DM in a large percentage of patients and reduces diabetes-related mortality. The emergence of new therapies raises the possibility of changing the current glucose-centred therapeutic strategy for a weight-centred approach.

Effects of statin therapy on weight loss and diabetes in bariatric patients

BACKGROUND

Bariatric surgeries are considered effective treatments for weight loss and improved diabetes control. Statins increase diabetes onset in prospective clinical trials and many bariatric patients with metabolic disease are concurrently on statins.

OBJECTIVES

We retrospectively examined the relationship of statin therapy to weight loss, diabetes mellitus onset and remission, and metabolic outcomes after bariatric surgery.

SETTING

Hospital.

METHODS

A total of 1575 patients (1231 women) underwent laparoscopic adjustable gastric banding (n = 1035), Roux-en-Y gastric bypass (n = 468), or sleeve gastrectomy (n = 72) and were categorized as to statin use (n = 671 statin users) and diabetes status (n = 557 patients with diabetes) preoperatively and at one year follow-up.

RESULTS

New onset cases of diabetes did not differ between patients on and not on preoperative statins (3 versus 4 new diabetes cases, respectively), but diabetes resolved after surgery in 159 (23.7%) patients on preoperative statins and in only 124 (13.7%) patients not on preoperative statins (χ² = 26.1; P<.01). Patients ceasing statin therapy experienced more diabetes remission (n = 85 or 35.7%) than patients consistently using statin therapy at both time points (n = 57 or 17.0%; χ² = 27.3; P< .01).

CONCLUSION

In contrast to expectations, our results suggest that diabetes resolves with bariatric surgery more often in patients maintained on statin therapy than in those never on statin therapy whereas cessation of statin therapy is associated with the greatest reductions in diabetes prevalence. These results indicate an impact of statin use on metabolic outcomes following bariatric surgery; a randomized control trial is needed to examine carefully this relationship.

Development and demonstration of a state model for the estimation of incidence of partly undetected chronic diseases

Background

Estimation of incidence of the state of undiagnosed chronic disease provides a crucial missing link for the monitoring of chronic disease epidemics and determining the degree to which changes in prevalence are affected or biased by detection.

Methods

We developed a four-part compartment model for undiagnosed cases of irreversible chronic diseases with a preclinical state that precedes the diagnosis. Applicability of the model is tested in a simulation study of a hypothetical chronic disease and using diabetes data from the Health and Retirement Study (HRS).

Results

A two dimensional system of partial differential equations forms the basis for estimating incidence of the undiagnosed and diagnosed disease states from the prevalence of the associated states. In the simulation study we reach very good agreement between the estimates and the true values. Application to the HRS data demonstrates practical relevance of the methods.

Discussion

We have demonstrated the applicability of the modeling framework in a simulation study and in the analysis of the Health and Retirement Study. The model provides insight into the epidemiology of undiagnosed chronic diseases.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-015-0094-y) contains supplementary material, which is available to authorized users.