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Stupalkowska W, Tavakkoli A. Invited commentary to "shedding more than weight: metabolic and bariatric surgery and the journey to insulin independence in insulin-treated type 2 diabetes" by Abi K. Mosleh et al. for the Journal of Gastrointestinal Surgery. J Gastrointest Surg 2024:S1091-255X(24)00630-9. [PMID: 39303905 DOI: 10.1016/j.gassur.2024.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Accepted: 09/16/2024] [Indexed: 09/22/2024]
Affiliation(s)
- Weronika Stupalkowska
- Division of General and Gastrointestinal Surgery, Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Boston, MA, United States
| | - Ali Tavakkoli
- Division of General and Gastrointestinal Surgery, Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Boston, MA, United States.
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Ekberg NR, Catrina SB, Spégel P. A protein-rich meal provides beneficial glycemic and hormonal responses as compared to meals enriched in carbohydrate, fat or fiber, in individuals with or without type-2 diabetes. Front Nutr 2024; 11:1395745. [PMID: 39027659 PMCID: PMC11257041 DOI: 10.3389/fnut.2024.1395745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/13/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction Diet stands as a pivotal modifiable risk factor influencing weight gain and the onset of type-2 diabetes (T2D). This study delves into the variation in glucose and regulatory pancreatic hormone levels subsequent to the consumption of meals with differing macronutrient compositions. Methods The cohort comprised 20 individuals diagnosed with T2D and 21 without diabetes. Participants underwent a cross-over design, consuming four isocaloric meals (600 kcal) enriched in carbohydrate, fiber, fat and protein. Plasma glucose, insulin and glucagon levels were measured at -30, and -5 min, followed by subsequent measurements every 30 min for 240 min post meal intake. Quantification of alterations in the postprandial state was accomplished through the incremental area under the curve (iAUC) and the incremental peak height for the insulin:glucagon ratio (IGR) and plasma glucose levels. The meal demonstrating the lowest responses across these variables was deemed the optimal meal. Results Meals rich in protein and fat, and consequently low in carbohydrate, exhibited reduced incremental peak and iAUC for both glucose and the IGR in comparison to the other meals. While the protein-enriched meal neared optimal standards, it proved less efficient for individuals without T2D and possessing a low BMI, as well as in those with T2D and poor glycemic control. Conclusion Our findings endorse the adoption of protein-enriched, low-carbohydrate meals to curtail the meal-induced anabolic hormonal response while averting excessive fluctuations in glucose levels.
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Affiliation(s)
- Neda Rajamand Ekberg
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Center for Diabetes, Academic Specialist Center, Stockholm, Sweden
| | - Sergiu-Bogdan Catrina
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Center for Diabetes, Academic Specialist Center, Stockholm, Sweden
| | - Peter Spégel
- Center for Analysis and Synthesis, Department of Chemistry, Lund University, Lund, Sweden
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Terenzi DC, Bakbak E, Teoh H, Krishnaraj A, Puar P, Rotstein OD, Cosentino F, Goldenberg RM, Verma S, Hess DA. Restoration of blood vessel regeneration in the era of combination SGLT2i and GLP-1RA therapy for diabetes and obesity. Cardiovasc Res 2024; 119:2858-2874. [PMID: 38367275 DOI: 10.1093/cvr/cvae016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/20/2022] [Accepted: 01/05/2023] [Indexed: 02/19/2024] Open
Abstract
Ischaemic cardiovascular diseases, including peripheral and coronary artery disease, myocardial infarction, and stroke, remain major comorbidities for individuals with type 2 diabetes (T2D) and obesity. During cardiometabolic chronic disease (CMCD), hyperglycaemia and excess adiposity elevate oxidative stress and promote endothelial damage, alongside an imbalance in circulating pro-vascular progenitor cells that mediate vascular repair. Individuals with CMCD demonstrate pro-vascular 'regenerative cell exhaustion' (RCE) characterized by excess pro-inflammatory granulocyte precursor mobilization into the circulation, monocyte polarization towards pro-inflammatory vs. anti-inflammatory phenotype, and decreased pro-vascular progenitor cell content, impairing the capacity for vessel repair. Remarkably, targeted treatment with the sodium-glucose cotransporter-2 inhibitor (SGLT2i) empagliflozin in subjects with T2D and coronary artery disease, and gastric bypass surgery in subjects with severe obesity, has been shown to partially reverse these RCE phenotypes. SGLT2is and glucagon-like peptide-1 receptor agonists (GLP-1RAs) have reshaped the management of individuals with T2D and comorbid obesity. In addition to glucose-lowering action, both drug classes have been shown to induce weight loss and reduce mortality and adverse cardiovascular outcomes in landmark clinical trials. Furthermore, both drug families also act to reduce systemic oxidative stress through altered activity of overlapping oxidase and antioxidant pathways, providing a putative mechanism to augment circulating pro-vascular progenitor cell content. As SGLT2i and GLP-1RA combination therapies are emerging as a novel therapeutic opportunity for individuals with poorly controlled hyperglycaemia, potential additive effects in the reduction of oxidative stress may also enhance vascular repair and further reduce the ischaemic cardiovascular comorbidities associated with T2D and obesity.
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Affiliation(s)
- Daniella C Terenzi
- UCD School of Medicine, University College Dublin, Belfield, Dublin 4 D04 V1W8, Ireland
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Ehab Bakbak
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
| | - Hwee Teoh
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Division of Endocrinology and Metabolism, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Aishwarya Krishnaraj
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
| | - Pankaj Puar
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Ori D Rotstein
- Division of General Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Surgery, University of Toronto, Stewart Building, 149 College Street, 5th floor, Toronto, ON M5T 1P5, Canada
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Solnavagen 1, 171 77 Solna, Sweden
| | | | - Subodh Verma
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
- Department of Surgery, University of Toronto, Stewart Building, 149 College Street, 5th floor, Toronto, ON M5T 1P5, Canada
| | - David A Hess
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
- Molecular Medicine Research Laboratories, Krembil Centre for Stem Cells Biology, Robarts Research Institute, University of Western Ontario, 1151 Richmond Street North, London, ON N6H 0E8, Canada
- Department of Physiology and Pharmacology, University of Western Ontario, 1151 Richmond Street North, London, ON N6H 0E8, Canada
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Jabbour G, Ibrahim R, Bragazzi N. Preoperative Physical Activity Level and Exercise Prescription in Adults With Obesity: The Effect on Post-Bariatric Surgery Outcomes. Front Physiol 2022; 13:869998. [PMID: 35874538 PMCID: PMC9301048 DOI: 10.3389/fphys.2022.869998] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/16/2022] [Indexed: 01/06/2023] Open
Abstract
This systematic review summarizes current evidence on the relation between preoperative physical activity (PA) levels with bariatric surgery (BS) outcomes and on the beneficial role of preoperative exercise/PA program among BS candidates. This systematic review suggests that candidate patients accumulating the preoperative PA level improved several BS outcomes. These improvements were reported mainly for anthropometric and cardiometabolic parameters and physical function. Observed improvements manifested during a distinct period of time in response to a wide variety of exercise programs. Evidence on the preoperative PA level as well as on preoperative exercise implementation on BS outcomes is advocated despite the small number of participants and lack of control. Thus, further studies are required to explore the most effective and suitable form of exercise prescription prior to BS while considering physical and psychological limitations of obese patients.
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Affiliation(s)
- Georges Jabbour
- Physical Education Department, College of Education, Qatar University, Doha, Qatar
- *Correspondence: Georges Jabbour, ,
| | - Rony Ibrahim
- Physical Education Department, College of Education, Qatar University, Doha, Qatar
| | - Nicola Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON, Canada
- Department of Health Sciences (DISSAL), Postgraduate School of Public Health, University of Genoa, Genoa, Italy
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Shibib L, Al-Qaisi M, Ahmed A, Miras AD, Nott D, Pelling M, Greenwald SE, Guess N. Reversal and Remission of T2DM - An Update for Practitioners. Vasc Health Risk Manag 2022; 18:417-443. [PMID: 35726218 PMCID: PMC9206440 DOI: 10.2147/vhrm.s345810] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/10/2022] [Indexed: 01/04/2023] Open
Abstract
Over the past 50 years, many countries around the world have faced an unchecked pandemic of obesity and type 2 diabetes (T2DM). As best practice treatment of T2DM has done very little to check its growth, the pandemic of diabesity now threatens to make health-care systems economically more difficult for governments and individuals to manage within their budgets. The conventional view has been that T2DM is irreversible and progressive. However, in 2016, the World Health Organization (WHO) global report on diabetes added for the first time a section on diabetes reversal and acknowledged that it could be achieved through a number of therapeutic approaches. Many studies indicate that diabetes reversal, and possibly even long-term remission, is achievable, belying the conventional view. However, T2DM reversal is not yet a standardized area of practice and some questions remain about long-term outcomes. Diabetes reversal through diet is not articulated or discussed as a first-line target (or even goal) of treatment by any internationally recognized guidelines, which are mostly silent on the topic beyond encouraging lifestyle interventions in general. This review paper examines all the sustainable, practical, and scalable approaches to T2DM reversal, highlighting the evidence base, and serves as an interim update for practitioners looking to fill the practical knowledge gap on this topic in conventional diabetes guidelines.
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Affiliation(s)
- Lina Shibib
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mo Al-Qaisi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ahmed Ahmed
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alexander D Miras
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - David Nott
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Marc Pelling
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephen E Greenwald
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Nicola Guess
- School of Life Sciences, Westminster University, London, UK
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Vahibe A, Livia C, Portela R, Shah M, McKenzie T, Kellogg T, Ghanem OM. Diabetes Remission After Bariatric Surgery in Patients on Glucocorticoids: A Pilot Study. Surg Laparosc Endosc Percutan Tech 2021; 32:236-240. [PMID: 34966151 DOI: 10.1097/sle.0000000000001028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/03/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Diabetes mellitus type 2 (DM2) remission after bariatric surgery has long been reported in the medical literature. Glucocorticoid use is associated with weight gain and could theoretically affect diabetes remission post bariatric surgery. OBJECTIVES The aim is to identify remission rates of DM2 among patients using glucocorticoids after bariatric surgery and assess long-term postsurgical follow-up. METHODS A retrospective analysis was performed on patients who used glucocorticoids and underwent bariatric surgery at the Mayo Clinic between 2008 and 2020. Data were analyzed for 3-month, 6-month, 1-year, 2-year, and 5-year intervals for factors indicative of diabetes remission. RESULTS Within our retrospective search, we identified 92 patients who were on any immunosuppressant medication before surgery. Of those, 22 patients had a diagnosis of DM2 while 18 of them were concurrently on glucocorticoids. Diabetes remission occurred in 11 of the 18 DM2 patients (61.11%). There was a statistically significant negative correlation between diabetes remission and combination therapy with glucocorticoids and tacrolimus (P=0.016); patients with a longer duration of DM2 diagnosis (P=0.024), and patients who used insulin three months after the procedure (P=0.001). However, percent total weight loss and the number of preoperative oral DM2 medications were not associated with worse outcomes. CONCLUSIONS Patients who use systemic glucocorticoids are able to achieve diabetes remission after bariatric surgery. Concurrent therapy with tacrolimus is associated with worse remission outcomes.
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Wolver S, Fadel K, Fieger E, Aburish Z, O'Rourke B, Chandler TM, Shimotani D, Clingempeel N, Jain S, Jain A, Puri P. Clinical Use of a Real-World Low Carbohydrate Diet Resulting in Reduction of Insulin Dose, Hemoglobin A1c, and Weight. Front Nutr 2021; 8:690855. [PMID: 34458301 PMCID: PMC8385129 DOI: 10.3389/fnut.2021.690855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/06/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction: Type 2 Diabetes Mellitus (T2DM) is increasing in epidemic proportions. In addition to the morbidity and mortality, for those treated with insulin, the physical, psychological, and financial tolls are often greater. Our real-world study evaluated a Low Carbohydrate Diet (LCD) in patients with T2DM on insulin with respect to glycemic control, insulin reduction, and weight loss. Materials and Methods: A prospective cohort study was conducted via an Electronic Medical Record search for patients attending the Virginia Commonwealth University Medical Weight Loss Program from 2014 to 2020 with Type 2 Diabetes Mellitus who initially presented on insulin. Data was extracted for 1 year after enrollment. The weight loss program focuses on a LCD. Results: Of 185 participants, the mean (± SD) age was 56.1 (9.9) years. Seventy percent were female and 63% were black. Eighty-five completed 12 months (45.9%), reduced their median (25-75% interquartile range, IQR) insulin dose from 69 to 0 units (0-18, p < 0.0001), HbA1c from 8 to 6.9% (6.2-7.8, p < 0.0001), and weight from 116 to 99 kg (85-120, p < 001). Eighty six percent who completed 12 months were able to reduce or discontinue insulin, with 70.6% completely discontinuing. Among all participants who completed 3, 6, or 12 months, 97.6% were able to reduce or eliminate insulin use. Conclusion: In patients with T2DM on a LCD, it is possible to reduce and even discontinue insulin use while facilitating weight loss and achieving glycemic control. A Low Carbohydrate Diet should be offered to all patients with diabetes, especially those using insulin.
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Affiliation(s)
- Susan Wolver
- Virginia Commonwealth University, Medical Center, Richmond, VA, United States
| | - Kristen Fadel
- School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Ethan Fieger
- School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Zein Aburish
- School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Brennen O'Rourke
- School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Toni-Marie Chandler
- School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Dorian Shimotani
- School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Natasha Clingempeel
- Virginia Commonwealth University, Medical Center, Richmond, VA, United States
| | - Shuchi Jain
- Virginia Commonwealth University, Richmond, VA, United States
| | - Aashish Jain
- Independent Researcher, Richmond, VA, United States
| | - Puneet Puri
- Virginia Commonwealth University, Medical Center, Richmond, VA, United States
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Lee JH, Jaung R, Beban G, Evennett N, Cundy T. Insulin use and new diabetes after acceptance for bariatric surgery: comparison of outcomes after completion of surgery or withdrawal from the program. BMJ Open Diabetes Res Care 2020; 8:8/2/e001837. [PMID: 33268449 PMCID: PMC7712440 DOI: 10.1136/bmjdrc-2020-001837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/16/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION In people accepted onto a bariatric surgery program we compared diabetes-related outcomes in those who completed surgery with those who withdrew before having surgery-examining rates of insulin use in people with type 2 diabetes (T2D), and rates of incident diabetes in people without pre-existing T2D. RESEARCH DESIGN AND METHODS 771 people were accepted onto the program. 463 people (60%) had T2D at referral, of which 48% completed surgery and 52% withdrew. Of 308 people without T2D at referral, 49% completed surgery, and 51% withdrew. Rates of insulin use and incident diabetes were compared by Kaplan-Meier analyses. Among those with pre-existing T2D, we examined rates of remission and relapse after surgery. RESULTS People without T2D who withdrew from the program had higher mean body mass index and glycated hemoglobin levels than those completing surgery (p<0.005). The rate of incident diabetes at 5 years was 19% in those who withdrew versus 0% in those completing surgery (p<0.001). 30% of people with T2D were taking insulin at referral and all stopped insulin after surgery. During follow-up, the rate of insulin (re)introduction was lower in those who completed surgery (8% vs 26% at 5 years, p<0.001). Of those with T2D who completed surgery, 80% had remission, but 34% had relapsed by 5 years. Diabetes relapse was associated with less weight loss after surgery, a longer duration of T2D and previous insulin use. CONCLUSIONS Despite a high relapse rate, people with T2D who completed surgery had lower insulin use at 5 years than those withdrawing from the program. In people without T2D, bariatric surgery prevented incident diabetes. People without T2D who withdrew from the program were at greater risk of diabetes, suggesting those who could benefit the most in terms of T2D prevention are not completing bariatric surgery.
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Affiliation(s)
- Jessica H Lee
- Auckland Diabetes Centre, Auckland City Hospital, Auckland, Aotearoa-New Zealand
| | - Rebekah Jaung
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, Aotearoa-New Zealand
| | - Grant Beban
- Hepatobiliary and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, Aotearoa-New Zealand
| | - Nicholas Evennett
- Hepatobiliary and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, Aotearoa-New Zealand
| | - Tim Cundy
- Auckland Diabetes Centre, Auckland City Hospital, Auckland, Aotearoa-New Zealand
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, Aotearoa-New Zealand
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Gilbertson NM, Gaitán JM, Osinski V, Rexrode EA, Garmey JC, Mehaffey JH, Hassinger TE, Kranz S, McNamara CA, Weltman A, Hallowell PT, Malin SK. Pre-operative aerobic exercise on metabolic health and surgical outcomes in patients receiving bariatric surgery: A pilot trial. PLoS One 2020; 15:e0239130. [PMID: 33006980 PMCID: PMC7531806 DOI: 10.1371/journal.pone.0239130] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 08/31/2020] [Indexed: 12/13/2022] Open
Abstract
Objective Examine if adding aerobic exercise to standard medical care (EX+SC) prior to bariatric surgery improves metabolic health in relation to surgical outcomes. Methods Fourteen bariatric patients (age: 42.3±2.5y, BMI: 45.1±2.5 kg/m2) met inclusion criteria and were match-paired to pre-operative SC (n = 7) or EX+SC (n = 7; walking 30min/d, 5d/wk, 65–85% HRpeak) for 30d. A 120min mixed meal tolerance test was performed pre- and post-intervention (~2d prior to surgery) to assess insulin sensitivity (Matsuda Index) and metabolic flexibility (indirect calorimetry). Aerobic fitness (VO2peak), body composition (BodPod), and adipokines (adiponectin, leptin) were also measured. Omental adipose tissue was collected during surgery to quantify gene expression of adiponectin and leptin, and operating time and length of hospital stay were recorded. ANOVA and Cohen’s d effect size (ES) was used to test group differences. Results SC tended to increase percent body fat (P = 0.06) after the intervention compared to EX+SC. Although SC and EX+SC tended to raise insulin sensitivity (P = 0.11), EX+SC enhanced metabolic flexibility (P = 0.01, ES = 1.55), reduced total adiponectin (P = 0.01, ES = 1.54) with no change in HMW adiponectin and decreased the length of hospital stay (P = 0.05) compared to SC. Albeit not statistically significant, EX+SC increased VO2peak 2.9% compared to a 5.9% decrease with SC (P = 0.24, ES = 0.91). This increased fitness correlated to shorter operating time (r = -0.57, P = 0.03) and length of stay (r = -0.58, P = 0.03). Less omental total adiponectin (r = 0.52, P = 0.09) and leptin (r = 0.58, P = 0.05) expression correlated with shorter operating time, and low leptin expression was linked to shorter length of stay (r = 0.70, P = 0.01), and low leptin expression was linked to shorter length of stay (r = 0.70, P = 0.01). Conclusion Adding pre-operative aerobic exercise to standard care may improve surgical outcomes through a fitness and adipose tissue derived mechanism.
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Affiliation(s)
- Nicole M. Gilbertson
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Julian M. Gaitán
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Victoria Osinski
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, Virginia, United States of America
| | - Elizabeth A. Rexrode
- Department of Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - James C. Garmey
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, Virginia, United States of America
| | - J. Hunter Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Taryn E. Hassinger
- Department of Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Sibylle Kranz
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Coleen A. McNamara
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - Arthur Weltman
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - Peter T. Hallowell
- Department of Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Steven K. Malin
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
- * E-mail: ,
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Dang JT, Sheppard C, Kim D, Switzer N, Shi X, Tian C, de Gara C, Karmali S, Birch DW. Predictive factors for diabetes remission after bariatric surgery. Can J Surg 2019; 62:315-319. [PMID: 31550092 PMCID: PMC7006352 DOI: 10.1503/cjs.014516] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2018] [Indexed: 12/19/2022] Open
Abstract
Background Bariatric surgery has been shown to induce type 2 diabetes mellitus (T2DM) remission in severely obese patients. After laparoscopic Roux-en-Y gastric bypass (LRYGB), diabetes remission occurs early and independently of weight loss. Previous research has identified preoperative factors for remission, such as duration of diabetes and HbA1c. Understanding factors that predict diabetes remission can help to select patients who will benefit most from bariatric surgery. Methods We retrospectively reviewed all T2DM patients who underwent laparoscopic sleeve gastrectomy (LSG) or LRYGB between January 2008 and July 2014. The primary outcome was diabetes remission, defined as the absence of hypoglycemic medications, fasting blood glucose < 7.0 mmol/L and HbA1c < 6.5%. Data were analyzed using multivariable logistic regression analysis to identify predictive factors of diabetes remission. Results We included 207 patients in this analysis; 84 (40.6%) had LSG and 123 (59.4%) had LRYGB. Half of the patients (49.8%) achieved diabetes remission at 1 year. Multivariable logistic analysis showed that LRYGB had higher odds of diabetes remission than LSG (odds ratio [OR] 6.58, 95% confidence interval [CI] 2.79–15.50, p < 0.001). Shorter duration of diabetes (OR 0.91, 95% CI 0.83–0.99, p = 0.032) and the absence of long-acting insulin (OR 0.0011, 95% CI < 0.000–0.236, p = 0.013) predicted remission. Conclusion Type of bariatric procedure (LRYGB v. LSG), shorter duration of diabetes and the absence of long-acting insulin were independent predictors of diabetes remission after bariatric surgery.
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Affiliation(s)
- Jerry T. Dang
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
| | - Caroline Sheppard
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
| | - David Kim
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
| | - Noah Switzer
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
| | - Xinzhe Shi
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
| | - Chunhong Tian
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
| | - Christopher de Gara
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
| | - Shahzeer Karmali
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
| | - Daniel W. Birch
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Dang, Switzer); the Department of Surgery, University of British Columbia, Vancouver, BC (Kim); and the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Alta. (Sheppard, Shi, Tian, Karmali, Birch)
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11
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Johnston SS, Ammann EM, Kashyap SR, Stokes A, Hsiao CCW, Daskiran M, Scamuffa R. Body mass index and insulin use as identifiers of high-cost patients with type 2 diabetes: A retrospective analysis of electronic health records linked to insurance claims data. Diabetes Obes Metab 2019; 21:1419-1428. [PMID: 30768824 DOI: 10.1111/dom.13671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/14/2018] [Accepted: 01/02/2019] [Indexed: 12/19/2022]
Abstract
AIMS To study the association of body mass index (BMI) and insulin use with type 2 diabetes-related healthcare expenditures (T2D-HE). MATERIALS AND METHODS Retrospective study using de-identified electronic health records linked to insurance claims data. Study included a prevalence-based sample of overweight or obese patients with antihyperglycaemic-treated T2D. Patients had ≥1 A1c measurement in 2014 (last observed = index A1c), ≥1 BMI measurement within ±90 days of index (average BMI = baseline BMI), and continuous enrolment for 180 days before (baseline) through 395 days after index (day 30-395 = follow-up). BMI was categorized as: 25 to 29.9 kg/m2 = overweight; 30 to 34.9 kg/m2 = obese class I (OCI); 35 to 39.9 kg/m2 = OCII; ≥40 kg/m2 = OCIII. Multivariable regressions were used to examine one-year follow-up T2D-HE as a function of BMI, insulin use, an interaction term between BMI and insulin use, and patient demographics. RESULTS Study included 13 026 patients (mean age = 63.6 years; 48.1% female; 29.5% overweight, 31.6% OCI, 20.3% OCII, 18.6% OCIII; 25.3% insulin users). Baseline insulin use rates monotonically ranged from 19.7% in overweight patients to 33.0% in OCIII patients (P < 0.001). Together, BMI and insulin use were jointly associated with one-year follow-up T2D-HE, which monotonically ranged from $5842 in overweight patients with no insulin to $17 700 OCIII insulin users, P < 0.001. Within each BMI category, insulin users' one-year T2D-HE was at least double that of non-users. Additional analyses of all-cause healthcare expenditures yielded consistent results. CONCLUSIONS BMI and insulin use represent simple stratifiers for identifying high-cost patients. OCIII insulin users incurred the greatest annual healthcare expenditures; these patients may be an ideal group for targeted interventions.
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Affiliation(s)
- Stephen S Johnston
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, New Jersey
| | - Eric M Ammann
- Epidemiology, Medical Devices, Johnson & Johnson, Titusville, New Jersey
| | | | - Andrew Stokes
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - Carine Chia-Wen Hsiao
- Franchise Health Economics and Market Access, Ethicon Inc., Johnson & Johnson, Somerville, New Jersey
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12
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Terenzi DC, Trac JZ, Teoh H, Gerstein HC, Bhatt DL, Al-Omran M, Verma S, Hess DA. Vascular Regenerative Cell Exhaustion in Diabetes: Translational Opportunities to Mitigate Cardiometabolic Risk. Trends Mol Med 2019; 25:640-655. [PMID: 31053416 DOI: 10.1016/j.molmed.2019.03.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 12/17/2022]
Abstract
Ischemic cardiovascular complications remain a major cause of mortality in people with type 2 diabetes (T2D). Individuals with T2D may have a reduced ability to revascularize ischemic tissues due to abnormal production of circulating provascular progenitor cells. This 'regenerative cell exhaustion' process is intensified by increasing oxidative stress and inflammation and during T2D progression. Chronic exhaustion may be mediated by changes in the bone marrow microenvironment that dysregulate the wingless related integration site network, a central pathway maintaining the progenitor cell pool. Restoration of vascular regenerative cell production by reducing glucotoxicity with contemporary antihyperglycemic agents, by reducing systemic inflammation postbariatric surgery, or by modulating progenitor cell provascular functions using exosomal manipulation, may provide unique approaches for mitigating ischemic disease.
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Affiliation(s)
- Daniella C Terenzi
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, M5 B 1W8, Canada; Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A1, Canada
| | - Justin Z Trac
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, M5 B 1W8, Canada; Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, M5 B 1W8, Canada; Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Division of Endocrinology and Metabolism, St. Michael's Hospital Medical Centre, Toronto, ON, M5C 2T2, Canada
| | - Hertzel C Gerstein
- Division of Endocrinology and Metabolism, McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, ON, L8S 4K1, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Heart and Vascular Center, Harvard Medical School, Boston, MA 02115, USA
| | - Mohammed Al-Omran
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A1, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, M5S 1A8, Canada; Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, M5 B 1W8, Canada; Department of Surgery, University of Toronto, Toronto, ON, M5T 1P5, Canada; Department of Surgery, King Saud University, Riyadh, 11451, Saudi Arabia
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, M5 B 1W8, Canada; Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, M5 B 1T8, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A1, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, M5S 1A8, Canada; Department of Surgery, University of Toronto, Toronto, ON, M5T 1P5, Canada
| | - David A Hess
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, M5S 1A8, Canada; Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, M5 B 1W8, Canada; Department of Physiology and Pharmacology, Western University, London, ON, N6A 5C1, Canada; Robarts Research Institute, Western University, London, ON, N6A 5B7, Canada.
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13
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Heshmati K, Harris DA, Aliakbarian H, Tavakkoli A, Sheu EG. Comparison of early type 2 diabetes improvement after gastric bypass and sleeve gastrectomy: medication cessation at discharge predicts 1-year outcomes. Surg Obes Relat Dis 2019; 15:2025-2032. [PMID: 31711946 DOI: 10.1016/j.soard.2019.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/11/2019] [Accepted: 04/06/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Although weight loss-dependent type 2 diabetes (T2D) improvement after sleeve gastrectomy (SG) is well documented, whether SG has a weight-independent impact on T2D is less studied. OBJECTIVES To evaluate early, weight-independent T2D improvement after SG and Roux-en-Y gastric bypass (RYGB) and its relationship to longer-term T2D outcomes. SETTING University Hospital, United States. METHODS We completed a retrospective cohort study of patients with T2D who underwent SG (n = 187) or RYGB (n = 246) from 2010 to 2015. Pre- and postoperative parameters, including demographic characteristics, T2D characteristics, and T2D medication requirements, blood glucose, glycosylated hemoglobin, weight, and body mass index, were reviewed. RESULTS T2D improved within days after both SG and RYGB, with more patients off T2D medications after SG than RYGB (39% versus 25%, respectively; P < .01) at the time of discharge (2.5 ± .8 versus 2.7 ± 1 d; P = .04). Over the initial postoperative 12 months, T2D medication cessation rates remained relatively stable after SG but continued to improve after RYGB (at 12 mo: 52% versus 68%, respectively; P < .05). T2D medication cessation at discharge predicts 12-month T2D medication cessation (92% [RYGB] and 78% [SG] positive predictive value). In a mixed-effects regression model adjusting for weight loss and severity of diabetes, discharge T2D medication cessation remained a significant predictor of T2D outcomes after both RYGB (odds ratio, 51; 95% confidence interval, 16.1-161; P < .0001) and SG (6.4; 95% confidence interval, 2.8-14.7; P < .0001). CONCLUSIONS Both SG and RYGB lead to high rates of T2D medication cessation within days of surgery, suggesting both operations activate weight loss-independent anti-T2D pathways. T2D medication cessation at discharge is predictive of 12-month T2D outcomes, particularly in noninsulin requiring patients. By 1 year after the surgery, RYGB leads to more weight loss and higher rates of T2D medication cessation than SG.
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Affiliation(s)
- Keyvan Heshmati
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David A Harris
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hassan Aliakbarian
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ali Tavakkoli
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric G Sheu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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14
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Impact of calorie restriction on glycemic control in overweight patients with type 2 diabetes mellitus. Int J Diabetes Dev Ctries 2018. [DOI: 10.1007/s13410-018-0706-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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15
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Panagiotou OA, Markozannes G, Adam GP, Kowalski R, Gazula A, Di M, Bond DS, Ryder BA, Trikalinos TA. Comparative Effectiveness and Safety of Bariatric Procedures in Medicare-Eligible Patients: A Systematic Review. JAMA Surg 2018; 153:e183326. [PMID: 30193303 DOI: 10.1001/jamasurg.2018.3326] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance The prevalence of obesity in patients older than 65 years is increasing. A substantial number of beneficiaries covered by Medicare meet eligibility criteria for bariatric procedures. Objective To assess the comparative effectiveness and safety of bariatric procedures in the Medicare-eligible population. Evidence Review This systematic review was conducted according to the PRISMA guidelines. Articles were identified through searches of PubMed, Embase, CINAHL, PsycINFO, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and scientific information packages from manufacturers, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and US Food and Drug Administration drugs and devices portals from January 1, 2000, to June 31, 2017. Randomized and nonrandomized comparative studies that evaluated bariatric procedures in the Medicare-eligible population were eligible. Six researchers extracted data on design, interventions, outcomes, and study quality. Findings were synthesized qualitatively; a planned meta-analysis was not undertaken owing to clinical heterogeneity. Findings A total of 11 455 citations were screened for eligibility. Of those, 16 met the eligibility criteria. Compared with no surgery or conventional weight-loss treatment, bariatric surgery results in greater weight loss. Overall mortality after 30 days is lower among bariatric patients (hazard ratio, HR, 0.50; 95% CI, 0.31-0.79, in the study with the longest follow-up of 5.9 years), although, based on 1 study, mortality within 30 days of surgery was higher than in nonsurgically treated controls (1.55% vs 0.53%; P < .001). Bariatric surgery is associated with lower risk of cardiovascular disease (HR, 0.59; 95% CI, 0.44-0.79 in the largest study comparison) and with improvements in respiratory, musculoskeletal, metabolic, and renal outcomes (increase in estimated glomerular filtration rate, 9.84; 95% CI, 8.05-11.62 mL/min/1.73m2). Compared with sleeve gastrectomy (SG) and adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGB) appears to be associated with greater weight loss (percent excess weight loss, 23.8% [95% CI, 16.2%-31.4%] at the longest follow-up of 4 years) but the 3 procedures have similar associations with most non-weight loss outcomes. Overall postoperative complications are not statistically significantly different between RYGB and SG, although major and/or serious complications are more common after RYGB. However, these associations are susceptible to at least moderate risk of confounding, selection, or measurement biases. Conclusions and Relevance In the Medicare population, there is low to moderate strength of evidence that bariatric surgery as a weight loss treatment improves non-weight loss outcomes. Well-designed comparative studies are needed to credibly determine the treatment effects for bariatric procedures in this patient population.
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Affiliation(s)
- Orestis A Panagiotou
- Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island.,Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Georgios Markozannes
- Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island.,Department of Hygiene & Epidemiology, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Gaelen P Adam
- Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Rishi Kowalski
- Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island.,Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - Abhilash Gazula
- Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Mengyang Di
- Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Dale S Bond
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island.,The Miriam Hospital Weight Control and Diabetes Research Center, Providence, Rhode Island
| | - Beth A Ryder
- Department of General Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Thomas A Trikalinos
- Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island.,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
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16
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Young L, Nor Hanipah Z, Brethauer SA, Schauer PR, Aminian A. Long-term impact of bariatric surgery in diabetic nephropathy. Surg Endosc 2018; 33:1654-1660. [DOI: 10.1007/s00464-018-6458-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/18/2018] [Indexed: 12/31/2022]
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17
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Hariri K, Guevara D, Jayaram A, Kini SU, Herron DM, Fernandez-Ranvier G. Preoperative insulin therapy as a marker for type 2 diabetes remission in obese patients after bariatric surgery. Surg Obes Relat Dis 2018; 14:332-337. [DOI: 10.1016/j.soard.2017.11.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/12/2017] [Accepted: 11/14/2017] [Indexed: 12/13/2022]
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18
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Poher AL, Tschöp MH, Müller TD. Ghrelin regulation of glucose metabolism. Peptides 2018; 100:236-242. [PMID: 29412824 PMCID: PMC5805851 DOI: 10.1016/j.peptides.2017.12.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/15/2017] [Accepted: 12/16/2017] [Indexed: 02/07/2023]
Abstract
The a 28-amino acid peptide ghrelin was discovered in 1999 as a growth hormone (GH) releasing peptide. Soon after its discovery, ghrelin was found to increase body weight and adiposity by acting on the hypothalamic melanocortinergic system. Subsequently, ghrelin was found to exert a series of metabolic effects, overall testifying ghrelin a pleiotropic nature of broad pharmacological interest. Ghrelin acts through the growth hormone secretagogue-receptor (GHS-R), a seven transmembrane G protein-coupled receptor with high expression in the anterior pituitary, pancreatic islets, thyroid gland, heart and various regions of the brain. Among ghrelins numerous metabolic effects are the most prominent the stimulation of appetite via activation of orexigenic hypothalamic neurocircuits and the food-intake independent stimulation of lipogenesis, which both together lead to an increase in body weight and adiposity. Ghrelin effects beyond the regulation of appetite and GH secretion include the regulation of gut motility, sleep-wake rhythm, taste sensation, reward seeking behaviour, and the regulation of glucose metabolism. The latter received recently increasing recognition because pharmacological inhibition of ghrelin signaling might be of therapeutic value to improve insuin resistance and type 2 diabetes. In this review we highlight the multifaceted nature of ghrelin and summarize its glucoregulatory action and discuss the pharmacological value of ghrelin pathway inhibition for the treatment of glucose intolerance and type 2 diabetes.
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Affiliation(s)
- Anne-Laure Poher
- Institute for Diabetes and Obesity, Helmholtz Diabetes Center (HDC), Helmholtz Zentrum München and German National Diabetes Center (DZD), 85764, Neuherberg, Germany
| | - Matthias H Tschöp
- Institute for Diabetes and Obesity, Helmholtz Diabetes Center (HDC), Helmholtz Zentrum München and German National Diabetes Center (DZD), 85764, Neuherberg, Germany; Division of Metabolic Diseases, Department of Medicine, Technische Universität München, 80333, Munich, Germany
| | - Timo D Müller
- Institute for Diabetes and Obesity, Helmholtz Diabetes Center (HDC), Helmholtz Zentrum München and German National Diabetes Center (DZD), 85764, Neuherberg, Germany.
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19
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Atkin SL, Ramachandran V, Yousri NA, Benurwar M, Simper SC, McKinlay R, Adams TD, Najafi-Shoushtari SH, Hunt SC. Changes in Blood microRNA Expression and Early Metabolic Responsiveness 21 Days Following Bariatric Surgery. Front Endocrinol (Lausanne) 2018; 9:773. [PMID: 30687230 PMCID: PMC6338028 DOI: 10.3389/fendo.2018.00773] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 12/10/2018] [Indexed: 12/13/2022] Open
Abstract
Background: Early metabolic responses following bariatric surgery appear greater than expected given the initial weight loss and coincide with improvement in diabetes. We hypothesized that small non-coding microRNA changes might contribute to regulating mechanisms for metabolic changes and weight loss in patients with severe obesity and diabetes. Methods: Twenty-nine type 2 patients with severe obesity (mean BMI 46.2 kg/m2) and diabetes underwent Roux-en-Y gastric bypass (RYGB) surgery. Clinical measurements and fasting blood samples were taken preoperatively and at day 21 postoperatively. Normalization of fasting glucose and HbA1c following bariatric surgery (short-term diabetes remission) was defined as withdrawal of anti-diabetic medication and fasting glucose < 100 mg/dL (5.6 mmol/L) or HbA1c < 6.0%. MicroRNA expression was determined by quantitative polymerase chain reaction and tested for significant changes after surgery. Results: BMI decreased by 3.8 kg/m2 21 days postoperatively. Eighteen of 29 RYGB (62%) had short-term diabetes remission. Changes from pre- to post-surgery in 32 of 175 microRNAs were nominally significant (p < 0.05). Following multiple comparison adjustment, changes in seven microRNAs remained significant: miR-7-5p, let-7f-5p, miR-15b-5p, let-7i-5p, miR-320c, miR-205-5p, and miR-335-5p. Four pathways were over-represented by these seven microRNAs, including diabetes and insulin resistance pathways. Conclusion: Seven microRNAs showed significant changes 21 days after bariatric surgery. Functional pathways of the altered microRNAs were associated with diabetes-, pituitary-, and liver-related disease, with expression in natural killer cells, and pivotal intestinal pathology suggesting possible mechanistic roles in early diabetes responses following bariatric surgery.
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Affiliation(s)
- Stephen L. Atkin
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
- *Correspondence: Stephen L. Atkin
| | - Vimal Ramachandran
- Department of Cell and Developmental Biology, Weill Cornell Medicine, Doha, Qatar
- MicroRNA Core Laboratory, Weill Cornell Medicine, Doha, Qatar
| | - Noha A. Yousri
- Department of Genetic Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Manasi Benurwar
- Department of Cell and Developmental Biology, Weill Cornell Medicine, Doha, Qatar
- MicroRNA Core Laboratory, Weill Cornell Medicine, Doha, Qatar
| | - Steven C. Simper
- Rocky Mountain Associated Physicians, Inc., Salt Lake City, UT, United States
| | - Rodrick McKinlay
- Rocky Mountain Associated Physicians, Inc., Salt Lake City, UT, United States
| | - Ted D. Adams
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
- Intermountain LiveWell Center, Intermountain Healthcare, Salt Lake City, UT, United States
| | - S. Hani Najafi-Shoushtari
- Department of Cell and Developmental Biology, Weill Cornell Medicine, Doha, Qatar
- MicroRNA Core Laboratory, Weill Cornell Medicine, Doha, Qatar
| | - Steven C. Hunt
- Department of Genetic Medicine, Weill Cornell Medicine, Doha, Qatar
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
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20
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Brown A, Guess N, Dornhorst A, Taheri S, Frost G. Insulin-associated weight gain in obese type 2 diabetes mellitus patients: What can be done? Diabetes Obes Metab 2017; 19:1655-1668. [PMID: 28509408 DOI: 10.1111/dom.13009] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/06/2017] [Accepted: 05/11/2017] [Indexed: 12/11/2022]
Abstract
Insulin therapy (IT) is initiated for patients with type 2 diabetes mellitus when glycaemic targets are not met with diet and other hypoglycaemic agents. The initiation of IT improves glycaemic control and reduces the risk of microvascular complications. There is, however, an associated weight gain following IT, which may adversely affect diabetic and cardiovascular morbidity and mortality. A 3 to 9 kg insulin-associated weight gain (IAWG) is reported to occur in the first year of initiating IT, predominantly caused by adipose tissue. The potential causes for this weight gain include an increase in energy intake linked to a fear of hypoglycaemia, a reduction in glycosuria, catch-up weight, and central effects on weight and appetite regulation. Patients with type 2 diabetes who are receiving IT often have multiple co-morbidities, including obesity, that are exacerbated by weight gain, making the management of their diabetes and obesity challenging. There are several treatment strategies for patients with type 2 diabetes, who require IT, that attenuate weight gain, help improve glycaemic control, and help promote body weight homeostasis. This review addresses the effects of insulin initiation and intensification on IAWG, and explores its potential underlying mechanisms, the predictors for this weight gain, and the available treatment options for managing and limiting weight gain.
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Affiliation(s)
- Adrian Brown
- Department of Medicine, Faculty of Medicine, Nutrition and Dietetic Research Group, Imperial College, London, UK
| | - Nicola Guess
- Department of Medicine, Faculty of Medicine, Nutrition and Dietetic Research Group, Imperial College, London, UK
- Division of Diabetes and Nutritional Sciences, Kings College London, London, UK
| | - Anne Dornhorst
- Department of Metabolic Medicine, Imperial College London, London, UK
| | - Shahrad Taheri
- Department of Metabolic Medicine, Imperial College London, London, UK
- Department of Medicine and Clinical Research Core, Weill Cornell Medicine, New York, New York
- Department of Medicine and Clinical Research Core, Weill Cornell Medicine, Doha, Qatar
| | - Gary Frost
- Department of Medicine, Faculty of Medicine, Nutrition and Dietetic Research Group, Imperial College, London, UK
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21
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Effects of bariatric surgery on glycemic and lipid metabolism, surgical complication and quality of life in adolescents with obesity: a systematic review and meta-analysis. Surg Obes Relat Dis 2017; 13:2037-2055. [DOI: 10.1016/j.soard.2017.09.516] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/28/2017] [Accepted: 09/12/2017] [Indexed: 12/20/2022]
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22
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Midterm effects of bariatric surgery in patients with insulin-treated type 2 diabetes. Surg Obes Relat Dis 2017; 13:2004-2009. [DOI: 10.1016/j.soard.2016.12.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 12/09/2016] [Accepted: 12/27/2016] [Indexed: 02/05/2023]
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23
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Foster D, Sanchez-Collins S, Cheskin LJ. Multidisciplinary Team-Based Obesity Treatment in Patients With Diabetes: Current Practices and the State of the Science. Diabetes Spectr 2017; 30:244-249. [PMID: 29151714 PMCID: PMC5687103 DOI: 10.2337/ds17-0045] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IN BRIEF Rates of obesity and diabetes are growing, as are their costs. Because the two diseases share many key determinants, the paradigms for their treatment overlap. For both, optimal treatment involves a multidisciplinary team following the Chronic Care Model of health care delivery. Combined treatment programs that include 1) a low-calorie diet individualized to patients' preferences, 2) structured exercise that is also tailored to each patient, and 3) psychotherapy induce the largest weight changes in patients with diabetes. Although diet alone can achieve weight loss, exercise and cognitive behavioral therapy components can enhance the effects of dietary modification. A multidisciplinary team that includes a physician with expertise in pharmacotherapy, a nurse and/or nurse practitioner, a dietitian, an exercise physiologist, and a psychologist can provide a comprehensive weight loss program combining the most effective interventions from each discipline.
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24
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The impact of bariatric surgery on insulin-treated type 2 diabetes patients. Surg Endosc 2017; 32:990-1001. [DOI: 10.1007/s00464-017-5777-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/22/2017] [Indexed: 12/19/2022]
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Schwoerer A, Kasten K, Celio A, Pories W, Spaniolas K. The effect of close postoperative follow-up on co-morbidity improvement after bariatric surgery. Surg Obes Relat Dis 2017; 13:1347-1352. [DOI: 10.1016/j.soard.2017.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/13/2017] [Accepted: 03/27/2017] [Indexed: 11/25/2022]
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Gastric Bypass Surgery Leads to Long-term Remission or Improvement of Type 2 Diabetes and Significant Decrease of Microvascular and Macrovascular Complications. Ann Surg 2017; 263:1138-42. [PMID: 26599565 DOI: 10.1097/sla.0000000000001509] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of the study was to compare long-term outcomes of 2 groups of morbidly obese patients with type 2 diabetes mellitus-1 managed by Roux-en-Y gastric bypass surgery and a comparable group managed medically. METHODS The present study was a single-institution retrospective study. Of the 173 obese patients with type 2 diabetes mellitus undergoing gastric bypass surgery between January 2000 and July 2004, 78 patients (45%) were followed for at least 10 years. The control group consisted of 80 diabetic obese patients from the same period with similar body mass index, age, race, and severity of diabetes. The median follow-up was 11 years for both the groups. RESULTS The group undergoing gastric bypass surgery had greater percentage of excess weight loss than the control group-66% versus -1.6%, respectively. Forty-one patients (52.6%) in the surgery group had complete remission of diabetes and 5 (6.4%) had partial remission. Twelve patients (15.4%) had diabetes recurrence after initial remission. No patient in the control group had remission of diabetes. Compared with the control group, the group undergoing gastric bypass surgery had a significantly reduced incidence of microvascular complications-46.3% versus 11.5%, and macrovascular complications-20.3% versus 5%, respectively (P < 0.01). CONCLUSIONS In this study, we demonstrated that after 10 years of follow-up, Roux-en-Y gastric bypass surgery, compared with nonsurgical medical management, resulted in significantly greater weight loss, reduction in hemoglobin A1c, and use of antidiabetic medications, and very importantly a lower incidence of both microvascular and macrovascular complications in obese patients with type 2 diabetes.
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Vidal J, Corcelles R, Jiménez A, Flores L, Lacy AM. Metabolic and Bariatric Surgery for Obesity. Gastroenterology 2017; 152:1780-1790. [PMID: 28193516 DOI: 10.1053/j.gastro.2017.01.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/26/2017] [Accepted: 01/26/2017] [Indexed: 01/06/2023]
Abstract
Metabolic and bariatric surgery (MBS) leads to weight loss in obese individuals and reduces comorbidities such as type 2 diabetes. MBS is superior to medical therapy in reducing hyperglycemia in persons with type 2 diabetes, and has been associated with reduced mortality and incidences of cardiovascular events and cancer in obese individuals. New guidelines have been proposed for the use of MBS in persons with type 2 diabetes. We review the use of MBS as a treatment for obesity and obesity-related conditions and, based on recent evidence, propose that health care systems make the appropriate changes to increase accessibility for eligible patients.
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Affiliation(s)
- Josep Vidal
- Obesity Unit, Endocrinology and Nutrition Department, Hospital Clinic Universitari, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain.
| | - Ricard Corcelles
- Obesity Unit, Gastrointestinal Surgery Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Amanda Jiménez
- Obesity Unit, Endocrinology and Nutrition Department, Hospital Clinic Universitari, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Lílliam Flores
- Obesity Unit, Endocrinology and Nutrition Department, Hospital Clinic Universitari, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
| | - Antonio M Lacy
- Obesity Unit, Endocrinology and Nutrition Department, Hospital Clinic Universitari, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; Obesity Unit, Gastrointestinal Surgery Department, Hospital Clinic Universitari, Barcelona, Spain
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Shantavasinkul PC, Omotosho P, Corsino L, Portenier D, Torquati A. Predictors of weight regain in patients who underwent Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2016; 12:1640-1645. [PMID: 27989521 DOI: 10.1016/j.soard.2016.08.028] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is a highly effective treatment for obesity and results in long-term weight loss and resolution of co-morbidities. However, weight regain may occur as soon as 1-2 years after surgery. OBJECTIVES This retrospective study aimed to investigate the prevalence of weight regain and possible preoperative predictors of this phenomenon after RYGB. SETTING An academic medical center in the United States. METHODS A total of 1426 obese patients (15.8% male) who underwent RYGB during January 2000 to 2012 and had at least a 2-year follow-up were reviewed. We included only patients who were initially successful, having achieved at least 50% excess weight loss at 1 year postoperatively. Patients were then categorized into either the weight regain group (WR) or sustained weight loss (SWL) group based upon whether they gained≥15% of their 1-year postoperative weight. RESULTS Weight regain was observed in 244 patients (17.1%). Preoperative body mass index was similar between groups. Body mass index was significantly higher and percent excess weight loss was significantly lower in the WR group (P<.001). Average weight regain was 19.5±9.3 kg and-.8±8.5 in the WR and SWL groups, respectively (P<.001). Time elapsed since RYGB was significantly longer in the WR group (WR 6.0±2.4 years versus SWL 3.3±1.8 years; P<.001; range 2-12 yr). Patients in the WR group were significantly younger (WR 42.3±9.8 yr versus SWL 45.7±10.8 years; P<.001), had fewer co-morbidities, and were less likely to have type 2 diabetes with insulin dependence preoperatively. Univariate analysis found that older age, male gender, having hypertension, dyslipidemia, and insulin-treated type 2 diabetes were all factors associated with sustained weight loss. Moreover, a longer duration after RYGB was associated with weight regain. Multivariate analysis revealed that younger age was a significant predictor of weight regain even after adjusting for time since RYGB. CONCLUSION The present study confirmed that a longer interval after RYGB was associated with weight regain. Younger age was a significant predictor of weight regain even after adjusting for time since RYGB. The findings of this study underscore the complexity of the mechanisms underlying weight loss and regain after RYGB. Future prospective studies are needed to further explore the prevalence, predictors, and mechanisms of weight regain after RYGB.
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Affiliation(s)
- Prapimporn Chattranukulchai Shantavasinkul
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Center for Weight Loss and Bariatric Surgery, Department of General Surgery, Rush University Medical Center, Chicago, IL
| | - Philip Omotosho
- Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Leonor Corsino
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | - Dana Portenier
- Center for Weight Loss and Bariatric Surgery, Department of General Surgery, Rush University Medical Center, Chicago, IL
| | - Alfonso Torquati
- Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Chow A, Switzer NJ, Dang J, Shi X, de Gara C, Birch DW, Gill RS, Karmali S. A Systematic Review and Meta-Analysis of Outcomes for Type 1 Diabetes after Bariatric Surgery. J Obes 2016; 2016:6170719. [PMID: 27375900 PMCID: PMC4916288 DOI: 10.1155/2016/6170719] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/10/2016] [Indexed: 01/06/2023] Open
Abstract
Background. The utility of bariatric surgery in type 1 diabetes remains controversial. The aim of the present study is to evaluate glycemic control outcomes in obese patients with type 1 diabetes after bariatric surgery. Methods. A comprehensive search of electronic databases was completed. Inclusion criteria included human adult subjects with BMI ≥35 kg/m(2) and a confirmed diagnosis of type 1 diabetes who underwent a bariatric surgical procedure. Results. Thirteen primary studies (86 patients) were included. Subjects had a mean age of 41.16 ± 6.76 years with a mean BMI of 42.50 ± 2.65 kg/m(2). There was a marked reduction in BMI postoperatively at 12 months and at study endpoint to 29.55 ± 1.76 kg/m(2) (P < 0.00001) and 30.63 ± 2.09 kg/m(2) (P < 0.00001), respectively. Preoperative weighted mean total daily insulin requirement was 98 ± 26 IU/d, which decreased significantly to 36 ± 15 IU/d (P < 0.00001) and 42 ± 11 IU/d (P < 0.00001) at 12 months and at study endpoint, respectively. An improvement in HbA1c was also seen from 8.46 ± 0.78% preoperatively to 7.95 ± 0.55% (P = 0.01) and 8.13 ± 0.86% (P = 0.03) at 12 months and at study endpoint, respectively. Conclusion. Bariatric surgery in patients with type 1 diabetes leads to significant reductions in BMI and improvements in glycemic control.
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Affiliation(s)
- Alexandra Chow
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2R7
| | - Noah J. Switzer
- Department of Surgery, University of Alberta, Edmonton, AB, Canada T6G 2B7
| | - Jerry Dang
- Department of Surgery, University of Alberta, Edmonton, AB, Canada T6G 2B7
| | - Xinzhe Shi
- Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, AB, Canada T5H 3V9
| | - Christopher de Gara
- Department of Surgery, University of Alberta, Edmonton, AB, Canada T6G 2B7
- Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, AB, Canada T5H 3V9
| | - Daniel W. Birch
- Department of Surgery, University of Alberta, Edmonton, AB, Canada T6G 2B7
- Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, AB, Canada T5H 3V9
| | - Richdeep S. Gill
- Department of Surgery, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta, Edmonton, AB, Canada T6G 2B7
- Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, AB, Canada T5H 3V9
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Abstract
Bariatric surgery in patients with type 2 diabetes has been shown to improve glycemic control and reduce need for glucose-lowering medications. Some of these improvements occur in the early postoperative period prior to any weight loss. These early reductions in circulating glucose can be attributed to primarily perioperative caloric restriction and prolonged fasting. Inpatient glycemic targets for patients undergoing bariatric surgery are similar to those recommended for other surgical procedures as a way of minimizing risk for complications. There is evidence that achieving perioperative and postoperative glycemic targets can improve the ability to achieve remission of type 2 diabetes following gastric bypass surgery. This review provides recommendations regarding glycemic goals, strategies for achieving these goals with minimal risk for hypoglycemia, and an examination of the data suggesting an association between perioperative glycemic management and diabetes remission following bariatric surgery.
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Affiliation(s)
- David Rometo
- Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15213, USA.
| | - Mary Korytkowski
- Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15213, USA.
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Abstract
BACKGROUND Bariatric surgery is a recommended treatment for diabetes in severely obese patients. Their immediate post-operative anti-hyperglycemic requirements differ from other hospitalized diabetics, yet no standardized protocols addressing glycemic control for this group exist. OBJECTIVE We aimed to create a safe, easily implemented protocol for immediate post-operative glycemic control, which we defined as the first 30 days. METHODS The protocol was designed by an interdisciplinary workgroup using review of available literature, approved institutional glycemic guidelines, and team members' experience with caring for bariatric surgery patients. RESULTS Patients are offered post-discharge recommendations using the inpatient glycemic protocol. CONCLUSION We designed a protocol with low risk of hypoglycemia that addresses the unique glycemic needs of diabetic bariatric population in the immediate post-operative period.
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Cavin JB, Couvelard A, Lebtahi R, Ducroc R, Arapis K, Voitellier E, Cluzeaud F, Gillard L, Hourseau M, Mikail N, Ribeiro-Parenti L, Kapel N, Marmuse JP, Bado A, Le Gall M. Differences in Alimentary Glucose Absorption and Intestinal Disposal of Blood Glucose After Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy. Gastroenterology 2016; 150:454-64.e9. [PMID: 26481855 DOI: 10.1053/j.gastro.2015.10.009] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 09/16/2015] [Accepted: 10/07/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Bariatric procedures, such as Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG), are the most effective approaches to resolve type 2 diabetes in obese individuals. Alimentary glucose absorption and intestinal disposal of blood glucose have not been directly compared between individuals or animals that underwent RYGB vs VSG. We evaluated in rats and humans how the gut epithelium adapts after surgery and the consequences on alimentary glucose absorption and intestinal disposal of blood glucose. METHODS Obese male rats underwent RYGB, VSG, or sham (control) operations. We collected intestine segments from all rats; we performed histologic analyses and measured levels of messenger RNAs encoding the sugar transporters SGLT1, GLUT1, GLUT2, GLUT3, GLUT4, and GLUT5. Glucose transport and consumption were assayed using ex vivo jejunal loops. Histologic analyses were also performed on Roux limb sections from patients who underwent RYGB 1-5 years after surgery. Roux limb glucose consumption was assayed after surgery by positron emission and computed tomography imaging. RESULTS In rats and humans that underwent RYGB, the Roux limb became hyperplasic, with an increased number of incretin-producing cells compared with the corresponding jejunal segment of controls. Furthermore, expression of sugar transporters and hypoxia-related genes increased and the nonintestinal glucose transporter GLUT1 appeared at the basolateral membrane of enterocytes. Ingested and circulating glucose was trapped within the intestinal epithelial cells of rats and humans that underwent RYGB. By contrast, there was no hyperplasia of the intestine after VSG, but the intestinal absorption of alimentary glucose was reduced and density of endocrine cells secreting glucagon-like peptide-1 increased. CONCLUSIONS The intestine adapts differently to RYGB vs VSG. RYGB increases intestinal glucose disposal and VSG delays glucose absorption; both contribute to observed improvements in glycemia.
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Affiliation(s)
| | - Anne Couvelard
- INSERM U1149, DHU Unity, Paris Diderot University, Paris, France; Department of Pathology, Bichat Hospital, Paris, France
| | - Rachida Lebtahi
- Department of Nuclear Medicine, Bichat Hospital, Paris, France
| | - Robert Ducroc
- INSERM U1149, DHU Unity, Paris Diderot University, Paris, France
| | - Konstantinos Arapis
- INSERM U1149, DHU Unity, Paris Diderot University, Paris, France; Department of General and Digestive Surgery, Bichat Hospital, Paris, France
| | | | | | - Laura Gillard
- INSERM U1149, DHU Unity, Paris Diderot University, Paris, France
| | | | - Nidaa Mikail
- Department of Nuclear Medicine, Bichat Hospital, Paris, France
| | | | - Nathalie Kapel
- Functional Coprology Service, Pitié Salpétrière Hospital Group, Paris, France
| | | | - André Bado
- INSERM U1149, DHU Unity, Paris Diderot University, Paris, France
| | - Maude Le Gall
- INSERM U1149, DHU Unity, Paris Diderot University, Paris, France.
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Abstract
Obesity is one of the most pervasive and costly public health problems. Clinicians need effective tools to address weight management in primary care, including evaluation and communication methods, guideline-based weight management interventions and safe and effective weight loss medications and surgery. The objective of this Grand Rounds presentation is to provide practicing clinicians with the latest information regarding effective ways to care for and communicate with patients about weight loss; evidence-based guidelines for selecting weight management therapies and safety, efficacy and adverse effects of weight loss medications and surgery.
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Affiliation(s)
- Christy Boling Turer
- Division of General Internal Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Brinks R, Bardenheier BH, Hoyer A, Lin J, Landwehr S, Gregg EW. Development and demonstration of a state model for the estimation of incidence of partly undetected chronic diseases. BMC Med Res Methodol 2015; 15:98. [PMID: 26560517 PMCID: PMC4642685 DOI: 10.1186/s12874-015-0094-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 11/06/2015] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Ralph Brinks
- German Diabetes Center, Institute for Biometry and Epidemiology, Auf'm Hennekamp 65, Düsseldorf, 40225, Germany.
| | - Barbara H Bardenheier
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
| | - Annika Hoyer
- German Diabetes Center, Institute for Biometry and Epidemiology, Auf'm Hennekamp 65, Düsseldorf, 40225, Germany.
| | - Ji Lin
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
| | - Sandra Landwehr
- University Hospital, Department for Statistics in Medicine, Düsseldorf, Germany.
| | - Edward W Gregg
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
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