Effect of bariatric surgery on the metabolic syndrome: a population-based, long-term controlled study

Bariatric Surgery and Remission of Metabolic Syndrome: A Meta-analysis of Randomised Controlled Trials and Prospective Studies

BACKGROUND

Studies have discussed the efficacy of bariatric surgery (BS) in remission of individual components of metabolic syndrome (MS). We aimed to analyse the prevalence of MS following BS.

METHODS

On October 5, 2023, we conducted a literature search on PubMed, Scopus, Web of Science, and Cochrane. RevManv5.4 was used for the analysis.

RESULTS

MS patients who underwent BS had lower odds of MS within the first year post-BS (OR 0.14, 95%CI 0.12-0.17); patients who had a preoperative BMI < 50 showed a higher reduction in MS post-BS compared with patients who suffered from super obesity (OR 0.12 versus OR 0.17). Older patients (age > 42) had lower odds of MS post-BS compared with younger patients (OR 0.05 versus OR 0.17). There was not a difference in MS prevalence between 1 and 2 years postoperatively (OR 1.07, 95%CI 0.72-1.58). Asians reported the highest reduction in MS post-BS (OR 0.08). MS patients who received medical treatment had three times the odds of having MS compared with patients who underwent BS. Patients who had BS reported a decline in their anti-hypertensives and oral anti-diabetic drugs (OR 0.26, 95%CI 0.15-0.46, OR 0.11, 95%CI 0.07-0.16, respectively). There was not a significant difference in MS prevalence between patients who underwent RYGB and those who had SG (OR 2.16, 95%CI 0.74-6.26).

CONCLUSIONS

BS is superior to medical treatment in the remission of MS. Age, preoperative BMI, and country of origin affect the rates of MS remission. BS results in a sustainable resolution of MS across 1, 2, and 5 years post-surgery. A tailored approach is warranted to achieve the best outcomes.

Sleeve Gastrectomy and Its Impact on Insulin Resistance and Metabolic Health: A Cohort Study

BACKGROUND

Obesity is a prevalent metabolic disorder that significantly contributes to insulin resistance (IR), type 2 diabetes (T2DM), and metabolic syndrome. Sleeve gastrectomy has emerged as an effective surgical intervention for obesity, with potential benefits on metabolic health. This study investigates the impact of sleeve gastrectomy on serum insulin levels, IR (HOMA-IR), inflammatory markers, C-peptide, kidney function, and various biochemical parameters in diabetic and non-diabetic patients.

METHODS

A prospective cohort study was conducted, involving 199 patients over 18 years old who were candidates for sleeve gastrectomy at Luqman Hakim Hospital from 2021 to 2022. Data were collected using standardized questionnaires and anthropometric measurements, and biochemical assessments were performed before surgery and 6 months postoperatively. Statistical analyses included descriptive statistics, t-tests, Mann-Whitney tests, and repeated measures analysis of variances (ANOVA).

RESULTS

The study included 199 patients (84.4% female) with a mean (± standard deviation (SD)) age of 39.79 ± 11.30 years. Significant reductions were observed in weight, BMI, and abdominal circumference across all patient groups. Diabetic patients showed marked improvements in fasting blood sugar, 2-h postprandial blood sugar, and glycosylated hemoglobin levels. Insulin resistance decreased significantly, as did serum insulin and C-peptide levels. Improvements in lipid profiles and inflammatory markers were also noted. Insulin use post-surgery showed a significant inverse relationship with glycemic control improvement.

CONCLUSIONS

Sleeve gastrectomy is a safe and effective procedure for obese patients, significantly improving insulin resistance and various obesity-associated diseases within 6 months post-surgery.

Outcomes of cardiac arrest hospitalizations in patients with obesity with versus without prior bariatric surgery status:A nationwide propensity-matched analysis

Introduction

Prior bariatric surgery (PBS) status in obese patients is thought to curtail the risk of cardiovascular events, but its role in change of outcomes of patients with obesity developing new acute cardiac events such as cardiac arrests (CA) remains largely unknown.

Methods

Hospitalizations among adult patients with obesity and CA were identified retrospectively using the National Inpatient Sample (2015 October-2017 December). Propensity-matched analysis (1:1) was performed for sociodemographic/hospital characteristics to identify two cohorts, with (PBS+) or without (PBS-) status. The primary endpoint was in-hospital mortality, and the secondary endpoint was healthcare resource utilization.

Results

Both cohorts (n = 1275 each), had patients with comparable age (mean 58 years), with a higher frequency of white (>70 %), females (>60 %), and Medicare enrollees (>40 %). PBS + cohort had lower rates of diabetes (27.8 % vs 36.1 %), hyperlipidemia (33.7 % vs 48.6 %), renal failure (17.3 % vs 22.0 %), chronic pulmonary disease (11.8 % vs 21.2 %) and higher rates of anemias (18.4 % vs 12.2 %), liver disease (5.1 % vs 2.4 %) and alcohol abuse (6.7 % vs 2.4 %) than PBS- cohort (p < 0.05). All-cause mortality (46.3 % vs 45.1 %, p = 0.551) was comparable between the two cohorts. The PBS + cohort was less often transferred routinely (p<0.001) but had a shorter hospital stay (p<0.001) with equivalent hospital charges compared to the PBS- cohort.

Conclusions

The PBS status (regardless of chronology) did not increase survival in CA admissions among patients with obesity. Preventive measures are necessary to manage enduring cardiovascular disease risk factors that may limit the advantages of surgery for patients with obesity and aggravate the worse outcomes of future cardiac events.

The effect of bariatric surgery on metabolic syndrome: A retrospective cohort study in Colombia

Introduction and Objective

Metabolic syndrome (MetS) represents a group of metabolic abnormalities. It is currently a pandemic, and its prevalence is on the rise. MetS has a direct relationship with obesity, for this reason, bariatric and metabolic surgery has been proposed as a method to simultaneously control obesity and MetS. However, in Colombia the results of this intervention are unknown. This study aims to compare metabolic syndrome before and after bariatric surgery in a Colombian population.

Methods

Retrospective cohort study conducted in a highly complex institution in Colombia, where comparing the prevalence of metabolic syndrome in patients who underwent bariatric surgery during a 1-year follow-up period, between January 2015 and December 2019. Of these patients, 48 underwent Roux-en-Y gastric bypass, and 32 underwent sleeve gastrectomy by laparoscopic technique.

Results

A total of 80 patients were included, of which 67.5% were women and the mean age was 42.8 ± 12.9 years. The most frequent preprocedure comorbidities were arterial hypertension (36.2%), dyslipidemia (32.4%), and sleep apnea (20%). After bariatric surgery, the prevalence of metabolic syndrome decreased from 66.2% to 3.7% (p < 0.05). In addition, a reduction in the Homeostatic Model Assessment for Insulin Resistance score from 77.5% to 22.5% was observed during the follow-up period. HbA1c, creatinine, and thyroid-stimulating hormone, were the only parameters without significant changes.

Conclusions

Metabolic and bariatric surgery is an effective treatment for weight reduction, with a high impact in reducing the prevalence of metabolic syndrome and insulin resistance in the short and medium term in the Colombian population.

Comprehensive Analysis of Improvements in Health-Related Quality of Life and Establishment of QALY Gains in a Government-Funded Bariatric Surgical Program with 5-Year Follow-up

Purpose

Bariatric surgery is an efficacious intervention for substantial and sustained weight reduction in individuals with morbid obesity resulting in health improvements. However, the changes to a patient’s health related quality of life (HRQoL) in the medium to longer term after bariatric surgery have not been adequately characterized. Our aim was to evaluate the change to patient HRQoL 5 years following bariatric surgery in an Australian government-funded hospital system and determine the significance of relationships between change in physical and mental assessment scores and HRQoL utility scores.

Materials and Methods

We performed a longitudinal panel study of 81 adult patients who underwent primary bariatric surgery at an Australian tertiary government-funded hospital and completed multi-attribute utility (MAU), multi-attribute non-utility (MA), and disease-specific adjusted quality of life (AQoL) questionnaires before and after bariatric surgery.

Results

At a mean (SD) 5.72 (1.07) years postbariatric surgery, participants demonstrated statistically significant improvements in mean AQoL-8D utility (0.135 (0.21); P < 0.0001), yielding a mean 3.2 (1.67) QALYs gained. Beck Depression Inventory-II scores improved (baseline mean 17.35 (9.57); 5-year mean 14.7 (11.57); P = 0.037). Short Form-36 scores improved in the domains of physical functioning and role limitations due to physical health and general health. Change in depression scores and patient satisfaction with surgery were found to be significant predictors of follow up AQoL utility scores.

Conclusions

Bariatric surgery improves physical and psychological quality of life measures over 5 years. The improvement of patient QALYs provide insight to the potential cost utility of publicly funded bariatric surgery in the medium term.

Graphical abstract

Changes in adipokine levels and metabolic profiles following bariatric surgery

BACKGROUND

Bariatric surgery is considered to be the most effective treatment option for weight reduction in obese patients. Abdominal obesity is frequently accompanied by metabolic syndrome (MS). Adipokines are cell signaling proteins that have direct impact upon the metabolic homeostasis. The purpose of this analysis was to evaluate the effect of bariatric surgery, including laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB) on the adipokine levels and metabolic profile as well as MS and status of type 2 diabetes (T2D).

METHODS

We analyzed anthropometric parameters, blood levels of adipokines, vitamins, lipids and inflammatory markers in 30 bariatric surgery patients with obesity of class II or III 1 month before and 1 year after surgery as well as in 60 obese patients from general practice (GP) and 15 patients with normal body mass (control).

RESULTS

The BMI was significantly higher among patients before surgery and GP patients in comparison to control and post-surgery patients. The levels of glucose, cholesterol and LDL-cholesterol, triglyceride and hs-CRP were the highest in patients before surgery but decreased significantly after surgery, while the level of HDL-cholesterol increased after surgery. The levels of adiponectin increased and that of leptin decreased after surgery. The significant difference in the concentration of resistin was revealed between LSG and LRYGB methods. The relationship between resistin and vitamin D was also found. The patients with MS and T2D displayed significantly greater reduction in lipid markers and adipokine levels than the rest of patients.

CONCLUSION

Remarkable changes in levels of adipokines after bariatric surgery appear like increase in adiponectin and decrease in leptin levels. Significant improvement in anthropometric parameters, metabolic and inflammatory markers occurs, suggesting high potential for reduction of metabolic syndrome and risk for type 2 diabetes. We have shown for the first time ever that level of vitamin D may be involved in resistin regulation.

Changes in Antihypertensive Medication Following Bariatric Surgery

Obesity is a leading cause of hypertension (i.e., high blood pressure [BP]). While hypertension can be managed with antihypertensive medication, substantial weight loss can also lower BP, reducing the need for antihypertensive medication. Articles in this review (n = 60) presented data on antihypertensive medication use among adults pre- and postoperatively. Roux-en-Y gastric bypass was the most studied surgical approach followed by Laparoscopic Sleeve Gastrectomy. Antihypertensive medication was discontinued in a large proportion of patients after surgery, and the mean number of antihypertensive medications decreased by approximately one. In almost a third of the studies, over 75% of participants experienced hypertension remission. All articles aside from two reported a decrease in systolic BP, with about 40% reporting a decrease of ≥ 10 mm Hg.

Meal Patterns and Food Choices of Female Rats Fed a Cafeteria-Style Diet Are Altered by Gastric Bypass Surgery

After Roux-en-Y gastric bypass surgery (RYGB), rats tend to reduce consumption of high-sugar and/or high-fat foods over time. Here, we sought to investigate the behavioral mechanisms underlying these intake outcomes. Adult female rats were provided a cafeteria diet comprised of five palatable foodstuffs varying in sugar and fat content and intake was monitored continuously. Rats were then assigned to either RYGB, or one of two control (CTL) groups: sham surgery or a nonsurgical control group receiving the same prophylactic iron treatments as RYGB rats. Post-sur-gically, all rats consumed a large first meal of the cafeteria diet. After the first meal, RYGB rats reduced intake primarily by decreasing the meal sizes relative to CTL rats, ate meals more slowly, and displayed altered nycthemeral timing of intake yielding more daytime meals and fewer nighttime meals. Collectively, these meal patterns indicate that despite being motivated to consume a cafeteria diet after RYGB, rats rapidly learn to modify eating behaviors to consume foods more slowly across the entire day. RYGB rats also altered food preferences, but more slowly than the changes in meal patterns, and ate proportionally more energy from complex carbohydrates and protein and proportionally less fat. Overall, the pattern of results suggests that after RYGB rats quickly learn to adjust their size, eating rate, and distribution of meals without altering meal number and to shift their macronutrient intake away from fat; these changes appear to be more related to postingestive events than to a fundamental decline in the palatability of food choices.

Reduction of Major Adverse Cardiovascular Events (MACE) after Bariatric Surgery in Patients with Obesity and Cardiovascular Diseases: A Systematic Review and Meta-Analysis

Cardiovascular diseases (CVDs) are the leading cause of death worldwide and obesity is a major risk factor that increases the morbidity and mortality of CVDs. Lifestyle modifications (e.g., diet control, physical exercise and behavioral changes) have been the first-line managements of obesity for decades. Nonetheless, when such interventions fail, pharmacotherapies and bariatric surgery are considered. Interestingly, a sudden weight loss (e.g., due to bariatric surgery) could also increase mortality. Thus, it remains unclear whether the bariatric surgery-associated weight reduction in patients with obesity and CVDs is beneficial for the reduction of Major Adverse Cardiovascular Events (MACE). Here, we performed a systematic literature search and meta-analysis of published studies comparing MACE in patients with obesity and CVDs who underwent bariatric surgery with control patients (no surgery). Eleven studies, with a total of 1,772,305 patients, which consisted of 74,042 patients who underwent any form of bariatric surgery and 1,698,263 patients with no surgery, were included in the systematic review. Next, the studies' data, including odds ratio (OR) and adjusted hazard ratio (aHR), were pooled and analyzed in a meta-analysis using a random effect model. The meta-analysis of ten studies showed that the bariatric surgery group had significantly lower odds of MACE as compared to no surgery (OR = 0.49; 95% CI 0.40-0.60; p < 0.00001; I² = 93%) and the adjustment to confounding variables in nine studies revealed consistent results (aHR = 0.57; 95% CI 0.49-0.66; p < 0.00001; I² = 73%), suggesting the benefit of bariatric surgery in reducing the occurrence of MACE in patients with obesity and CVDs (PROSPERO ID: CRD42021274343).

The Long-Term Impact of Bariatric Surgery on Development of Atrial Fibrillation and Cardiovascular Events in Obese Patients: An Historical Cohort Study

Objective: To determine whether early Roux-en-Y gastric bypass surgery (RYGB) reduces the risk of Major adverse cardiovascular events (MACE) in patients with obesity. Patients and Methods: We conducted a study of patients with class II and III obesity [body mass index (BMI) > 35 kg/m²] from Olmsted County, Minnesota, who underwent obesity clinic consultation between the years 1993-2012, and had either RYGB surgery within 1 year (RYGB-1Y group), or medically managed (No-RYGB group). The composite endpoint of MACE (all-cause mortality, stroke, heart failure admission and acute myocardial infarction) was the primary endpoint, with new-onset AF as the secondary endpoint. Results: Of the 1,009 study patients, 308 had RYGB-1Y and 701 were medically managed (No-RYGB). Overall, the age was 44.0 ± 12.4 (mean ± SD) years; BMI was 45.0 ± 6.8 kg/m². The RYGB-1Y group had a lower rate of MACE (adjusted hazard ratio (HR), 0.62; 95% CI, 0.44-0.88; P = 0.008) and lower mortality (adjusted HR, 0.51; 95% CI, 0.26-0.96; P = 0.04) than the No-RYGB group. The RYGB-1Y surgery was not associated with lower AF occurrence (HR, 0.66; 95% CI, 0.40-1.10; P = 0.11). Conclusion: An early RYGB approach for BMI reduction was associated with lower rates of MACE.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Five-Year Outcomes in Bariatric Surgery Patients

Background and objectives: Obesity presents as a multifactorial, pandemic disease that arises as a consequence of unequal energy intake and energy consumption. Obesity adversely affects the quality of life, leading not only to disability, but also to various other disorders. Bariatric surgery is the most effective method for achieving significant and sustained weight loss in individuals with extreme obesity. The aim of this study was to examine how well surgically induced weight loss is maintained after five years of follow-up and its effects on cardiovascular risk factors and outcome. Materials and Methods: This is a retrospective cross-sectional study of 66 patients with morbid obesity, with body mass index (BMI) ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 and obesity-related health conditions, aged 20 to 61 years, mostly women (77.3%) who underwent laparoscopic Roux-en-Y gastric bypass surgery. Results: Average follow-up was 6.42 years (95% CI 6.30-6.54 years) after surgery, with survival rate of 97% in operated individuals. There was a statistically significant reduction of weight and body mass index 6 months and 5 years after surgery in comparison to the initial values (p < 0.001). Of 62 patients who presented weight loss at the end of the follow-up period, 38 were able to maintain the amount of weight loss that was attained 6 months after surgery, while 24 patients regained weight compared to their postoperative weight at 6 months. Two patients reported no weight loss after treatment. Significant weight reduction was associated with better control of diabetes and increased self-reported physical activity at 6 months and 5 years after surgery, as well as with a reduction of the use of anti-diabetic and anti-hypertensive medications. Conclusions: Our research demonstrates a positive long-term impact of bariatric surgery on patients' health conditions, significant and sustained weight loss, and decrease in BMI, which were associated with a reduction of co-morbidities and risk factors for cardiovascular diseases.

Dietary macro- and micro-nutrients intake adequacy at 6th and 12th month post-bariatric surgery

BACKGROUND

Bariatric surgery (BS) is considered as an effective solution to control morbid obesity. Food restrictions resulting from the operation may decrease dietary nutrient intakes, particularly during the first year after BS. This study mainly aimed to assess the adequacy of dietary nutrient intakes at 6th and 12th month after BS.

METHOD

Of the severely obese participants in the Tehran obesity treatment study in 2015-2016, 58 patients undergoing Roux-En-Y gastric bypass (N = 16) or sleeve gastrectomy (N = 42) were selected from Tehran Obesity Treatment Center. To assess the patients' dietary intake, a three-day, 24-h dietary recall was obtained on three unscheduled days (two non-consecutive weekdays and one weekend day) at 6th and 12th month after BS. To evaluate the adequacy of nutrient intake, the patients' intakes were compared to the current dietary reference intakes (DRIs), including estimated average requirements (EAR) or Adequate Intakes (AI).

RESULTS

The mean age of the participants (71% women) undergoing BS was 37 ± 8 years. Anthropometric parameters significantly decreased at the 12th month after BS. The percentage of energy from carbohydrate intake increased significantly between the 6th and 12th month after BS (P = 0.04). The mean ± SD of protein intake was lower than the recommended dosage with a dramatic decrease from 45 ± 30 to 31 ± 15 (g/day) between the two intervals (P = 0.001). The mean intake of saturated fatty acid (SFA) decreased dramatically (P < 0.001) from 6 to 12 month; however, the median intake of n3-polyunsaturated fatty acid (n3-PUFA) intake increased (P = 0.02). None of the participants showed nutrient intake adequacy in terms of biotin, fat soluble vitamins, pantothenic acid, potassium, and zinc. Moreover, less than 10% of the participants showed nutrient intake adequacy in terms of folate, magnesium, manganese, and calcium according to DRIs during the both intervals after BS.

CONCLUSION

Bariatric surgery can reduce dietary intakes, which is more obvious 12 months after the surgery. Out of 21 micronutrients, nearly all could not met the EAR and were received < 50%, also had significant reduction from the 6th to12th month after surgery.

Bariatric surgery and cardiovascular outcome

BACKGROUND

Obesity is recognized as a classic risk factor for atherosclerosis and subsequent cardiovascular disease (CVD). Weight loss after bariatric surgery has been associated with reduced CV mortality and total mortality in obese patients. Our aim was to study the impact of bariatric surgery on CV risk profile, cardiac structure, and function postoperatively.

RESULTS

This prospective longitudinal study included 100 morbidly obese patients at final analysis. All patients were subjected to full clinical, laboratory, and echocardiographic examination at baseline and 6 months after bariatric surgery. The mean age of study population was 37.2 ± 10.49 with BMI of 47 ± 6.82. Females represented 84%. Sleeve gastrectomy and Roux-en-Y gastric bypass were performed in 79% and 21%, respectively. Surgery-related mortality and morbidity were 0.94% and 4.7%, respectively. After 6 months, there were significant decreases in BMI, heart rate, SBP, DBP, and Framingham risk score (P < 0.0001). The prevalence of risk factors decreased as follows: hypertension 24% vs. 12%, P = 0.0005; DM 21% vs. 11%, P = 0.002; dyslipidemia 32% vs. 7%, P < 0.0001; and metabolic syndrome 54% vs. 26%, P < 0.0001. Highly significant (P < 0.0001) decrease in fasting PG and 2 h PP-PG, HbA1c, ASL, ALT, fasting total cholesterol, LDL, TG, and increase in HDL were observed after bariatric surgery. There were significant shortening in QTc interval (P = 0.009), decrease in LV dimensions and LV mass index (P < 0.0001), and increase in LV EF% (P = 0.0003). BMI at follow-up showed significant positive correlation with age, Framingham risk score, and preoperative BMI (r = 0.289, P = 0.0036; r = 0.37, P = 0.0054; and r = 0.31, P = 0.0081, respectively).

CONCLUSION

In addition to enabling patients to achieve a substantial weight loss, bariatric surgery provides a myriad of health benefits. Weight reduction was associated with a favorable improvement in cardiovascular risk profile, cardiac structure, and function.

Gender-differences in predictors for time to metabolic syndrome resolution: A secondary analysis of a randomized controlled trial study

Understanding gender differences in health-related behaviors and their impacts is a crucial aspect of effective primary care. We studied gender-based differences in predictors of metabolic syndrome (MetS) resolution among newly diagnosed MetS patients. This study was a secondary analysis of a prospective clinical trial study comprising of 637 middle-aged and older adults (226 men and 411 women) who underwent a regular health checkup and were newly diagnosed with MetS at 16 different health clinics of 14 metropolitan cities and provinces. We conducted Cox proportional hazard analysis to estimate cumulative probability of MetS resolution within a 12‐month observation period. Among the 637 patients, 47.6% of participants achieved MetS resolution. The resolution rate was similar among men and women (44.7% and 49.1%, respectively, P = 0.320). Low household income (Hazard ratio = 2.62, 95% confidence interval: 1.13–6.08) and current employment (2.29, 1.26–4.13) were associated with a higher cumulative probability of MetS resolution in men than in women. For women, however, longer sleeping hours (1.18, 1.04–1.34) and living with a partner (1.58, 1.06–2.35) were positive predictors of MetS resolution. Being overweight (0.63, 0.44–0.89) was associated with lower cumulative probability of MetS resolution in women than in men. The factors associated with cumulative probability of MetS resolution within the 12-month follow-up were different between men and women. These findings facilitate further exploration on gender-based differences in risk factors for less optimal improvements in MetS.

Lipoprotein(a) Change After Sleeve Gastrectomy Is Affected by the Presence of Metabolic Syndrome

BACKGROUND

Patients with metabolic syndrome (MetS) are at high risk of developing cardiovascular disease (CVD) and lipoprotein(a) (Lp(a)) is an independent risk factor for CVD. This study aimed to determine the effect of vertical sleeve gastrectomy (VSG)-induced weight loss on Lp(a) levels in obese individuals.

METHODS

Patients submitted to VSG from January 2011 to July 2015 were included. Anthropometric and metabolic parameters were recorded before and 12 months after surgery. Univariate analysis identified associations between Lp(a) and anthropometry and metabolic parameters, and the logistic regression predictors of Lp(a) decrease after VSG.

RESULTS

MetS was present in 47% of the 330 patients involved. Patients with MetS had higher body mass index (BMI) and triglyceride levels and were more insulin-resistant. No differences were found between groups respecting Lp(a) levels prior to surgery (15.2 mg/dL vs. 15.0 mg/dL, p = 0.795). After surgery, patients without MetS had a decrease in Lp(a) levels (14.7 mg/dL vs. 12.3 mg/dL, p = 0.006), while MetS patients showed no differences (13.9 mg/dL vs. 14.6 mg/dL, p = 0.302). The regression model evidenced that older age and Δ HDL-c were predictors of Lp(a) decrease, whereas the greater the number of MetS components and lower estimated BF% loss, the lesser odds of decreasing Lp(a) after surgery.

CONCLUSIONS

Despite a global improvement of conventional CVD risk factors, only individuals without MetS showed a decrease of Lp(a) levels after VSG. Further studies should explore not only the pathophysiological mechanisms underlying the absence of decrease of Lp(a) levels in MetS patients, but also its impact on the metabolic beneficial changes usually observed after VSG.

Laparoscopic Sleeve Gastrectomy versus Lifestyle Modification in Class I Obesity in Pakistani Population: A Prospective Cohort Study

Introduction The American Society of Metabolic and Bariatric Surgery has stated that bariatric surgery is indicated in Class I obesity patients with one or more comorbidities. However, other weight loss options, such as diet plus exercise, are available to patients with a body mass index (BMI) ranging from 30 to 35 kg/m2. This study aimed to prospectively compare the results of Class I obesity patients undergoing laparoscopic sleeve gastrectomy (LSG) or using a weight control program (WCP). Methods A prospective analysis was conducted of patients with Class I obesity and comorbid diabetes and hypertension, with follow-ups at 6, 12, and 18 months. Subjects were divided into two groups: the LSG group of patients who had undergone LSG, and the WCP group who adhered to a WCP. The percentage of excess BMI loss (%EBMIL) and comorbidity remission (diabetes mellitus and hypertension) were tracked with measurements of hemoglobin A1C (HBA1C) levels and systolic blood pressure. Self-esteem was also tracked using the Rosenberg Self-Esteem Scale (SES) at 0 and 18 months. The overall patient satisfaction score was calculated using a visual analogue scale. Results Of the 150 patients enrolled in the study, 106 were included in the LSG group, and 103 were included in the WCP group. The reduction in HBA1C was more pronounced in the LSG group, and the differences between the two were statistically significant after 6, 12, and 18 months (LSG 5.6 ± 0.47 vs. WCP 6.5 ± 0.64, CI 1.04-0.73, P < 0.05). At 12 and 18 months, there were statistically significant reductions in systolic blood pressure after LSG (LSG 134.2 ± 7.16 vs. WCP 145.63 ± 5.94, CI 13.2-9.6, P < 0.05). Self-esteem levels measured by the Rosenberg SES increased for all participants, while patient satisfaction score was higher in the LSG group than that in the WCP group (P < 0.05). The %EBMIL at 6 months in the LSG group was 35.48%, compared to the WCP group at only 7.23%. At 12 months, the %EBMIL had increased twofold in the LSG group, at 68.19%, compared to 14.53% in the WCP group. At the final 18-month follow-up, the %EBMIL in the LSG group was 99.60% but was only 25.70% in the WCP group (P < 0.05). Conclusion Our study elucidates a clear superiority of LSG over any structured WCP with regard to weight reduction, improvement in glycemic control, and reduction in blood pressure in Class I obesity patients. Additionally, patients having LSG reported markedly improved self-esteem and satisfaction when compared with those who undertook a WCP.

Cost-effectiveness Analysis of Bariatric Surgery for Patients With Nonalcoholic Steatohepatitis Cirrhosis

IMPORTANCE

Obesity is the most common risk factor for nonalcoholic steatohepatitis (NASH), the progressive form of nonalcoholic fatty liver disease that can lead to cirrhosis and hepatocellular carcinoma. Weight loss can be an effective treatment for obesity and may slow the progression of advanced liver disease.

OBJECTIVE

To assess the cost-effectiveness of bariatric surgery in patients with NASH and compensated cirrhosis.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation study used a Markov-based state-transition model to simulate the benefits and risks of laparoscopic sleeve gastrectomy (SG), laparoscopic Roux-en-Y gastric bypass (GB), and intensive lifestyle intervention (ILI) compared with usual care in patients with NASH and compensated cirrhosis and varying baseline weight (overweight, mild obesity, moderate obesity, and severe obesity). Patients faced varied risks of perioperative mortality and complications depending on the type of surgery they underwent. Data were collected on March 22, 2017.

MAIN OUTCOMES AND MEASURES

Life-years, quality-adjusted life-years (QALYs), costs (in 2017 $US), and incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

Demographic characteristics of the patient population were based on a previously published prospective study (n = 161). Patients in the model were 41.0% female, and the base case age was 54 years. Compared with usual care, SG was associated with an increase in QALYs of 0.263 to 1.180 (bounds of ranges represent overweight to severe obesity); GB, 0.263 to 1.207; and ILI, 0.004 to 0.216. Sleeve gastrectomy was also associated with an increase in life-years of 0.693 to 1.930; GB, 0.694 to 1.947; and ILI, 0.012 to 0.114. With usual care, expected life-years in overweight, mild obesity, moderate obesity, and severe obesity were 12.939, 11.949, 10.976, and 10.095, respectively. With usual care, QALY in overweight was 6.418; mild obesity, 5.790; moderate obesity, 5.186; and severe obesity, 4.577. Sleeve gastrectomy was the most cost-effective option for patients across all weight classes assessed: ICER for SG in patients with overweight was $66 119 per QALY; mild obesity, $18 716 per QALY; moderate obesity, $10 274 per QALY; and severe obesity, $6563 per QALY. A threshold analysis on the procedure cost of GB found that for GB to be cost-effective, the cost of the surgery must be decreased from its baseline value of $28 734 by $4889 for mild obesity, by $3189 for moderate obesity, and by $2289 for severe obesity. In overweight patients, GB involved fewer QALYs than SG, and thus decreasing the cost of surgery would not result in cost-effectiveness.

CONCLUSIONS AND RELEVANCE

Bariatric surgery could be highly cost-effective in patients with NASH compensated cirrhosis and obesity or overweight. The findings from this analysis suggest that it can inform clinical trials evaluating the effect of bariatric procedures in patients with NASH cirrhosis, including those with a lower body mass index.

Mitochondria as a therapeutic target for common pathologies

Although the development of mitochondrial therapies has largely focused on diseases caused by mutations in mitochondrial DNA or in nuclear genes encoding mitochondrial proteins, it has been found that mitochondrial dysfunction also contributes to the pathology of many common disorders, including neurodegeneration, metabolic disease, heart failure, ischaemia-reperfusion injury and protozoal infections. Mitochondria therefore represent an important drug target for these highly prevalent diseases. Several strategies aimed at therapeutically restoring mitochondrial function are emerging, and a small number of agents have entered clinical trials. This Review discusses the opportunities and challenges faced for the further development of mitochondrial pharmacology for common pathologies.

Glucose Metabolism Parameters and Post-Prandial GLP-1 and GLP-2 Release Largely Vary in Several Distinct Situations: a Controlled Comparison Among Individuals with Crohn's Disease and Individuals with Obesity Before and After Bariatric Surgery

BACKGROUND

This study aims to compare the post-prandial curves of glucose, insulin, GLP-1, and GLP-2 among individuals with Crohn's disease (CD), obese individuals before and after bariatric surgery, and healthy controls.

METHODS

This an exploratory cross-sectional study that involved five groups of patients (two groups of individuals with CD-active and inactive), bariatric patients (pre- and post-surgery, who were their own controls), and a distinct separated control group of healthy volunteers. C-reactive protein (CRP) levels and the post-prandial curves of glucose, insulin, GLP-1, and GLP-2 curves were assessed and compared.

RESULTS

The pre-RYGB group presented significantly higher levels of CRP than the post-RYGB (p = 0.001) and the control group (p = 0.001). The inactive CD group presented a higher post-prandial GLP-1 area under the curve (AUC) than the pre-RYGB group (p = 0.009). The post-RYGB group presented significantly higher AUCs of GLP-2 than the pre-RYGB group (p < 0.0001), both inactive and active CD groups (p < 0.0001 in both situations), and the control group (p = 0.002). The pre-RYGB group presented a significantly higher AUC of glucose than the post-RYGB (p = 0.02) and both active and inactive CD groups (p = 0.019 and p = 0.046, respectively). The pre-RYGB group presented a significantly higher AUC of insulin than the control (p = 0.005) and both CD groups (p < 0.0001).

CONCLUSIONS

Obesity is associated with an inflammatory state comparable to the one observed in CD; inflammation may also be enrolled in the blockade of GLP-2. CD individuals present a more incretin-driven pattern of glucose metabolism, as a way to prevent hypoglycemia and compensate the carbohydrate malabsorption and GLP-2 blockade.

Cytometric analysis of adipose tissue reveals increments of adipocyte progenitor cells after weight loss induced by bariatric surgery

Obesity-related comorbidities are, in large part, originated from the dysfunction of adipose tissue. Most of them revert after the normalization of body mass. Adipose tissue is essentially occupied by adipocytes. However, different populations of immunological cells and adipocyte precursor cells (AdPCs) are the main cellular components of tissue. During obesity, body fat depots acquire a low-level chronic inflammation and adipocytes increase in number and volume. Conversely, weight loss improves the inflammatory phenotype of adipose tissue immune cells and reduces the volume of adipocytes. Nevertheless, very little is known about the evolution of the human AdPCs reservoir. We have developed a flow cytometry-based methodology to simultaneously quantify the main cell populations of adipose tissue. Starting from this technical approach, we have studied human adipose tissue samples (visceral and subcutaneous) obtained at two different physiological situations: at morbid obesity and after bariatric surgery-induced weight loss. We report a considerable increase of the AdPCs reservoir after losing weight and several changes in the immune cells populations of adipose tissue (mast cells increase, neutrophils decrease and macrophages switch phenotype). No changes were observed for T-lymphocytes, which are discussed in the context of recent findings.

Does Obesity Explain the Effect of the Metabolic Syndrome on Complications Following Elective Lumbar Fusion? A Propensity Score Matched Analysis

STUDY DESIGN

Propensity score matched retrospective cohort study.

OBJECTIVES

Obesity is a major confounder in determining the independent effect of metabolic syndrome (MetS) on complications after spinal surgery. The purpose of this study is to differentiate MetS from obesity as an independent influence on perioperative outcomes after elective lumbar spine fusion.

METHODS

One- to 3-level posterior spinal fusion cases were identified from the 2011-2014 American College of Surgeons' National Surgical Quality Improvement Program. To determine the effects of MetS outside of obesity itself, patients with MetS were first compared to a no-MetS cohort and then to an obese-only no-MetS cohort. Two propensity score matches based on demographics, comorbidities, surgical complexity, and diagnosis were used to match patients in 1:1 ratios and compare outcomes. Logistic regression with propensity score adjustment was further utilized as a secondary method of reducing selection bias.

RESULTS

Out of 18 605 patients that met criteria for inclusion, 1903 (10.2%) met our definition of MetS. Patients with MetS had a higher rate of wound complications (3.8% vs 2.7% obese no MetS, P = .045; vs 2.6% no MetS, P = .035), readmissions (7.4% vs 2.2% obese no MetS, P < .001; vs 4.6% no MetS, P < .001), and extended length of stay (29.1% vs 23.9% obese no MetS, P < .001; vs 23.5% no MetS, P < .001). Patients with MetS were more likely to experience a wound complication (odds ratio = 1.47, 95% confidence interval = 1.02-2.12) or readmission (odds ratio = 1.48, 95% confidence interval = 1.22-1.80).

CONCLUSIONS

Even after controlling for obesity, MetS is an independent risk factor for adverse short-term outcomes. These findings have various implications for preoperative risk stratification and reduction strategies.

Regulation of Microbiota by Vitamin D Receptor: A Nuclear Weapon in Metabolic Diseases

Metabolic syndrome is a multi-faceted disease. The microbiota, as a newly discovered organ, contributes to the pathogenesis and progression of metabolic syndrome. Recent studies have demonstrated that nuclear receptors play critical roles in metabolic diseases. In the current review, we discuss the general role of the microbiome in health and metabolic syndrome. We summarize the functions of the nuclear receptor vitamin D receptor (VDR) in metabolism. The focus of this review is the novel roles of vitamin D/VDR signaling in regulating inflammation and the microbiome, especially in obesity. Furthermore, we extend our discussion of potential gut-liver axis mediated by VDR signaling and microbiota in obesity. Finally, we discuss the potential clinical application of probiotics and fecal microbiota transplantation in prevention and treatment of metabolic syndrome. Insights into nuclear receptors in metabolism and metabolic diseases will allow us to develop new strategies for fighting metabolic diseases.

Anxiety behavior and hypothalamic-pituitary-adrenal axis altered in a female rat model of vertical sleeve gastrectomy

Surgical weight loss results in a host of metabolic changes that culminate in net positive health benefit to the patients. However, the psychological impact of these surgeries has not been fully studied. On one hand, surgical weight loss has been reported to improve standard quality of life and resolution of symptoms of depression. But on the other hand, reports of self-harm and increased ER visits for self-harm suggest other psychological difficulties. Inability to handle anxiety following surgical weight loss has alarming potential ramifications for these gastric surgery patients. In the present study, we used models of diet-induced obesity and vertical sleeve gastrectomy (VSG) to ask whether anxiety behavior and hypothalamic-pituitary-adrenal (HPA) axis gene changes were affected by surgical weight loss under two diet regimens: i.e. low-fat diet (LFD) and high-fat diet (HFD). We show reduced exploratory behavior in the open field test but increased time in the open arms of the elevated plus maze. Furthermore, we show increased plasma levels of corticosterone in female VSG recipients in the estrus phase and increased levels of hypothalamic arginine-vasopressin (avp), pro-opiomelanocortin (pomc), and tyrosine hydroxylase (th). We report reduced dopamine receptor D1 (drd1) gene in prefrontal cortex (PFC) in VSG animals in comparison to Sham. Further we report diet-driven changes in stress-relevant gene targets in the hypothalamus (oxt, pomc, crhr1) and adrenal (nr3c1, nr3c2, mc2r). Taken together, these data suggest a significant impact of both surgical weight loss and diet on the HPA axis and further impact on behavior. Additional assessment is necessary to determine whether molecular and hormonal changes of surgical weight loss are the source of these findings.

Relationship Between Vitamin D Deficiency and the Components of Metabolic Syndrome in Patients with Morbid Obesity, Before and 1 Year After Laparoscopic Roux-en-Y Gastric Bypass or Sleeve Gastrectomy

BACKGROUND

Vitamin D deficiency (VDD) is associated with obesity and metabolic syndrome (MS). After bariatric surgery (BS), high rates of VDD often persist and some patients are refractory to the resolution of comorbidities. The aim of the present study is to analyse the relationship between the levels of vitamin D and the persistence of MS components at 12 months after BS, according to the surgical technique used.

METHODS

We performed a retrospective study of 46 patients undergoing BS: 23 underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) and 23 laparoscopic sleeve gastrectomy (LSG). These patients had an average BMI of 45 kg/m² (34-63). Levels of vitamin D were classified as deficient (<20 ng/dl), insufficient (20-30 ng/dl) or normal (>30 ng/dl) and analysed in relation to the components of MS (high blood pressure (HBP), dyslipidaemia (DL) and type 2 diabetes mellitus (T2DM) preoperatively and 12 months after surgery.

RESULTS

VDD was observed in 77% of the patients prior to surgery. There were no significant associations between predisposing factors and baseline vitamin D. After surgery, plasma levels of vitamin D increased in both groups, but only 18% of the patients achieved normal values. Both groups had achieved significant improvements in MS components. Thus, 63% of all the patients achieved complete resolution of HBP, 54% that of DL and 77% that of T2DM. Moreover, MS was present in 11% of the patients, compared to 63% at baseline, and the MS resolution rate was 83%, with no significant differences between LRYGBP and LSG.

CONCLUSIONS

There is a relationship between VDD and persistence of MS, and particularly so with T2DM. VDD could represent a predictor of MS persistence at 12 months after surgery.

Metabolic Syndrome After Roux-en-Y Gastric Bypass Surgery in Chinese Obese Patients with Type 2 Diabetes

BACKGROUND

Roux-en-Y gastric bypass (RYGB) surgery is currently the most effective treatment for substantial and sustained weight loss in morbidly obese individuals. We aim to determine the prevalence in Chinese obese patients with type 2 diabetes (T2DM) and the efficacy of surgical treatment of the metabolic syndrome (MetS) and its components with a control group in medical therapy.

METHODS

A total of 121 obese T2DM individuals who underwent RYGB and 93 nonoperative obese patients with T2DM were enrolled in the study. MetS was defined according to the criteria established by the Chinese Joint Committee for Developing Chinese Guidelines on Prevention and Treatment of Dyslipidemia in Adults (JCDCG). We determined the change in MetS and the prevalence of its components and performed logistic regression models to evaluate predictors of MetS remission.

RESULTS

One year after RYGB, all MetS components improved in the RYGB group and medication use decreased. Of the RYGB group, MetS prevalence decreased from 108 patients (83.3 %) to 20 (16.5 %), and from 88 patients (94.6 %) to 76 (81.7 %) in the control group. Multiple logistic regression analyses indicated that a shorter diabetes duration and higher percent excess weight loss (%EWL) were associated with a greater chance of MetS remission after surgery.

CONCLUSIONS

RYGB induces considerable and persistent improvement in MetS prevalence in Chinese obese patients with T2DM. Diabetes duration and %EWL might act as potential prognostic markers in predicting the MetS reversibility.

Bariatric surgery for obesity and metabolic disorders: state of the art

Obesity is one of the most important public health conditions worldwide. Bariatric surgery for severe obesity is an effective treatment that results in the improvement and remission of many obesity-related comorbidities, as well as providing sustained weight loss and improvement in quality of life. Contemporary bariatric operations include Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric band and the duodenal switch. The vast majority of these procedures are now performed using laparoscopic technique, the main advantages of which include rapid recovery, the reduction of postoperative pain and the reduction of wound-related complications, compared with open surgery. Contemporary bariatric surgery is now safe, with a mortality of three in 1,000 patients; however, all bariatric operations are associated with their own unique short-term and long-term nutritional and procedural-related complications. Type 2 diabetes mellitus (T2DM) is the most studied metabolic disorder associated with obesity, with data demonstrating that improvement and remission of T2DM in patients with obesity is superior after bariatric surgery compared with conventional medical therapy. Bariatric surgery is now a part of some treatment algorithms for the medical management of patients with T2DM and severe obesity. New, minimally invasive and endoscopic devices for the treatment of obesity have now been approved in the USA, which will expand the treatment options for individuals with obesity.

The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique

BACKGROUND

Internal hernia (IH) is a common complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Little large-volume data exist on how to handle the mesenteric defects during LRYGB. This study evaluated long-term follow-up (5.5 years) of 2443 patients with primary closure of the mesenteric defects with a stapling device at LRYGB, in comparison with a non-closed group from the same centre.

METHODS

All patients (N = 4013) undergoing LRYGB over a 10-year period (2005-2015) at a single institution were evaluated. The mesenteric defects were routinely closed starting June 2010. In total, 1570 non-closure patients and 2443 patients with stapled closure of the defects were prospectively entered and the results analysed.

RESULTS

Closure of the mesenteric defects increased surgical time by 4 min and did not affect the 30-day complication rate. IH incidence was significantly lower (2.5%) in the closure group compared with 11.7% in the non-closure group, at 60 months. The relative risk reduction by closing the mesenteric defects was 4.09-fold (95% CI = 2.97-5.62) as calculated using a survival model.

CONCLUSIONS

Internal hernia after LRYGB occurs frequently if mesenteric defects are left unclosed. Primary closure with a hernia-stapling device is safe and significantly reduces the risk of internal hernia.

Quality of life after gastric sleeve and gastric bypass for morbid obesity

Highlights

Quality-of-life measures improve as early as 3 months after bariatric surgery.There is wide variability in reporting that renders direct comparisons difficult.The available comparisons between RYGB and sleeve gastrectomy could not detect any difference.Improvement in PRO measures might be related to weight loss.Larger and better designed studies are required to achieve discrimination in PRO measures.

Background

Obesity is associated with reduced quality-of-life (QoL), which generally improves after bariatric surgery. The differential effect of each type of surgery (gastric sleeve [SG] and gastric bypass [RYGB]) on QoL is not yet fully understood.

Objectives

To understand which of these surgeries offers greatest improvement in QoL and patient satisfaction.

Methods

Systematic literature search on Pubmed in July 2014. Relevant articles were selected in a step-wise approach. The 2482 titles were scanned for relevance and 191 were selected for abstract reviewing; and 88 papers were selected for full text analysis.

Results

Only 5 papers compared the 2 techniques and only 17 more had retrievable data either on SG or RYGB. The reports were very heterogeneous, preventing a direct comparison of patient reported outcomes (PRO) among studies.Improved results have been reported as early has 3 months and SF-36 scores were improved in all domains in medium to long-term. The question remains whether the improvement in QoL is related to the weight loss and which factors are associated with improved patients' perceptions.

Conclusions

There is wide heterogeneity in the reporting of PRO measures after bariatric surgery, but data is consistent with a significant improvement after both surgeries.Larger and better-designed studies are required to understand if there are significant differences in the quality of life after SG or RYGB.

Metabolic syndrome remission after Roux-en-Y gastric bypass or sleeve gastrectomy

BACKGROUND

Bariatric surgery is known to decrease weight and the prevalence of comorbidities, but there is little evidence on the differential effect of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on the remission of the aggregate outcome, metabolic syndrome, 4 years after surgery. The purpose of this study was to determine the effectiveness of RYGB and SG on metabolic syndrome in veterans.

METHODS

We retrospectively reviewed consecutive patients who underwent SG and RYGB at the Dallas Veterans Affairs Medical Center from 2003 to 2012. We determined the effect of both the operations on the remission of metabolic syndrome, its individual components, and medium-term morbidity and mortality. A sensitivity analysis was performed using propensity matching.

RESULTS

A total of 266 patients were identified (159 RYGB and 107 SG) with 96% follow-up after 4 years. The mean age of the cohort was 51.4 years; the majority of patients were male (59%) and Caucasian (69%). RYGB patients had a greater mean body mass index and were more likely to have hypertension or hypertriglyceridemia. RYGB was associated with a similar metabolic syndrome remission to SG (37.6% vs 26.8%; P=0.09). The percentage of weight loss was 26.5% after RYGB and 10.8% after SG at 4 years post operation (P<0.01). Predictors of metabolic syndrome persistence were male gender, type 2 diabetes, and low high-density lipoprotein. While both the operations were associated with similar mortality (RYGB 4.4%, SG 2.8%; P=0.74), RYGB was associated with a greater rate of morbidity.

CONCLUSION

RYGB and SG seem to be associated with similar remission rates of metabolic syndrome at 4 years. RYGB yields greater weight loss with greater medium-term complications.

Cardiometabolic Syndrome and Increased Risk of Heart Failure

Approximately 50 % of patients with heart failure have diastolic heart failure (HFPEF) with the major predisposing risk factors age, inactivity, obesity, insulin resistance (IR), type-2 diabetes, and hypertension. The prognosis of HFPEF is comparable to that of systolic heart failure, but without any specific or effective treatment. This review presents a biomathematically corrected diagnostic approach for quantification of diastolic dysfunction (DD) via the age dependency of diastolic function. Pathophysiological mechanisms for DD in the cardiometabolic syndrome (CMS) are mainly based on downstream effects of IR including insufficient myocardial energy supply. The second section discusses therapeutic strategies for the control and therapy of CMS, IR, and the associated DD/HFPEF with a focus on dietary therapy that is independent of weight loss but improves all manifestations of the CMS and reduces cardiovascular risk.

The metabolic vascular syndrome - guide to an individualized treatment

In ancient Greek medicine the concept of a distinct syndrome (going together) was used to label 'a group of signs and symptoms' that occur together and 'characterize a particular abnormality and condition'. The (dys)metabolic syndrome is a common cluster of five pre-morbid metabolic-vascular risk factors or diseases associated with increased cardiovascular morbidity, fatty liver disease and risk of cancer. The risk for major complications such as cardiovascular diseases, NASH and some cancers develops along a continuum of risk factors into clinical diseases. Therefore we still include hyperglycemia, visceral obesity, dyslipidemia and hypertension as diagnostic traits in the definition according to the term 'deadly quartet'. From the beginning elevated blood pressure and hyperglycemia were core traits of the metabolic syndrome associated with endothelial dysfunction and increased risk of cardiovascular disease. Thus metabolic and vascular abnormalities are in extricable linked. Therefore it seems reasonable to extend the term to metabolic-vascular syndrome (MVS) to signal the clinical relevance and related risk of multimorbidity. This has important implications for integrated diagnostics and therapeutic approach. According to the definition of a syndrome the rapid global rise in the prevalence of all traits and comorbidities of the MVS is mainly caused by rapid changes in life-style and sociocultural transition resp. with over- and malnutrition, low physical activity and social stress as a common soil.

A clinical perspective of obesity, metabolic syndrome and cardiovascular disease

The metabolic syndrome is a condition characterized by a special constellation of reversible major risk factors for cardiovascular disease and type 2 diabetes. The main, diagnostic, components are reduced HDL-cholesterol, raised triglycerides, blood pressure and fasting plasma glucose, all of which are related to weight gain, specifically intra-abdominal/ectopic fat accumulation and a large waist circumference. Using internationally adopted arbitrary cut-off values for waist circumference, having metabolic syndrome doubles the risk of cardiovascular disease, but offers an effective treatment approach through weight management. Metabolic syndrome now affects 30-40% of people by age 65, driven mainly by adult weight gain, and by a genetic or epigenetic predisposition to intra-abdominal/ectopic fat accumulation related to poor intra-uterine growth. Metabolic syndrome is also promoted by a lack of subcutaneous adipose tissue, low skeletal muscle mass and anti-retroviral drugs. Reducing weight by 5-10%, by diet and exercise, with or without, anti-obesity drugs, substantially lowers all metabolic syndrome components, and risk of type 2 diabetes and cardiovascular disease. Other cardiovascular disease risk factors such as smoking should be corrected as a priority. Anti-diabetic agents which improve insulin resistance and reduce blood pressure, lipids and weight should be preferred for diabetic patients with metabolic syndrome. Bariatric surgery offers an alternative treatment for those with BMI ≥ 40 or 35-40 kg/m(2) with other significant co-morbidity. The prevalence of the metabolic syndrome and cardiovascular disease is expected to rise along with the global obesity epidemic: greater emphasis should be given to effective early weight-management to reduce risk in pre-symptomatic individuals with large waists.

Effect of bariatric surgery on cardiometabolic risk in elderly patients: A population-based study

AIM

Obesity is a major cardiovascular (CV) risk factor. Bariatric surgery (BSx) is an approved therapeutic alternative for class II-III obesity, but little evidence focuses on older adults. We assessed the effect of BSx on cardiometabolic variables and long-term CV risk in older adults.

METHODS

We carried out a population-based, observational study from 1990-2009, of 40 consecutive elderly (age ≥60 years) residents of Olmsted County, MN, USA, with class II-III obesity treated with BSx at a University-based, academic health center. Data were obtained from the Rochester Epidemiology Project. Metabolic syndrome (MetS) was defined using American Heart Association/National Heart, Lung, Blood Institute (AHA/NHLBI) criteria (increased triglycerides, low high-density lipoprotein, increased blood pressure, increased glucose and body mass index as a modified measure of obesity instead of waist circumference). Change in CV risk factors, MetS prevalence, and impact on predicted CV risk using the Framingham risk score was ascertained at 1 year postoperatively and assessed statistically.

RESULTS

Mean age and body mass index were 64.4 ± 3.7 and 45.0 ± 6.3 kg/m(2) , respectively, and 28 out of 40 (70%) were women. One participant died during the 11-month study period after BSx from respiratory complications related to BSx, and one participant died at 2 years. Percentage of excess weight loss decreased by 57.5% at 1 year. Prevalence 1 year after BSx decreased for diabetes (57.5% to 22.5%; P < 0.03), hypertension 87.5% to 73.7% (P = 0.003), dyslipidemia (80% to 42.5%; P < 0.001) and sleep apnea (62.5% to 23.7%; P < 0.001).MetS prevalence decreased from 80% to 45% (P < 0.002). Baseline risk was 14.1%, which changed at follow up at 8.2%.

CONCLUSIONS

In older adults, BSx induces considerable weight loss, improves CV risk factors, decreases MetS prevalence and is an effective treatment in this population. Geriatr Gerontol Int 2016; 16: 618-624.

Bariatric surgery for metabolic syndrome in obesity

Metabolic syndrome is closely associated with morbid obesity and leads to increased risk of cardiovascular diseases and related mortality. Bariatric surgery is considered an effective option for the management of this condition. We searched MEDLINE, Current Contents, and the Cochrane Library for papers published on bariatric surgery outcomes in English from January 1, 1990, to April 20, 2014. Bariatric surgery can significantly reduce body weight, resolve or cure many of the symptoms of metabolic syndrome, including type 2 diabetes, hypertension, hyperlipidemia, and improve long-term survival. Surgery, in addition to existing therapy, could therefore be considered as an optimal treatment for patients with metabolic syndrome and morbid obesity.

Metabolic syndrome and chronic kidney disease: Current status and future directions

Metabolic syndrome (MetS) is a term used to denote a combination of selected, widely prevalent cardiovascular disease (CVD)-related risk factors. Despite the ambiguous definition of MetS, it has been clearly associated with chronic kidney disease markers including reduced glomerular filtration rate, proteinuria and/or microalbuminuria, and histopathological markers such as tubular atrophy and interstitial fibrosis. However, the etiological role of MetS in chronic kidney disease (CKD) is less clear. The relationship between MetS and CKD is complex and bidirectional, and so is best understood when CKD is viewed as a common progressive illness along the course of which MetS, another common disease, may intervene and contribute. Possible mechanisms of renal injury include insulin resistance and oxidative stress, increased proinflammatory cytokine production, increased connective tissue growth and profibrotic factor production, increased microvascular injury, and renal ischemia. MetS also portends a higher CVD risk at all stages of CKD from early renal insufficiency to end-stage renal disease. Clinical interventions for MetS in the presence of CKD should include a combination of weight reduction, appropriate dietary modification and increase physical activity, plus targeting of individual CVD-related risk factors such as dysglycemia, hypertension, and dyslipidemia while conforming to relevant national societal guidelines.

Laparoscopic sleeve gastrectomy compared to a multidisciplinary weight loss program for obesity--effects on body composition and protein status

BACKGROUND

Optimal obesity therapy is a matter of debate. Besides weight reduction, other criteria such as safety and nutritional status are of relevance. Therefore, we compared a favored surgical intervention with the most effective conservative treatment regarding anthropometry and nutritional status.

METHODS

Fifty-four obese patients were included who underwent laparoscopic sleeve gastrectomy (LSG, n = 27) or a 52-week multidisciplinary intervention program (MIP, n = 27) for weight loss. Body weight, body composition assessed by bioelectrical impedance analysis, and serum protein levels were measured before and within 12 months after intervention.

RESULTS

After 1 year of observation, excess weight loss was more pronounced following LSG (65 %) compared to MIP (38 %, p < 0.001). In both groups, body fat was clearly reduced, but a higher reduction occurred in the LSG group. However, protein status deteriorated particularly in the LSG group. Within 1 year, body cell mass declined from 37.1 to 26.9 kg in the LSG group, but only from 35.7 to 32.2 kg in the MIP group. This resulted in an increased mean extracellular mass/body cell mass ratio (1.42 versus 1.00, p < 0.001), in a decreased mean phase angle (4.4° versus 6.6°, p < 0.001), and in a lower prealbumin level in serum (p < 0.02) in the LSG group compared to the MIP group.

CONCLUSIONS

LSG, compared to MIP, was more effective regarding excess weight loss and body fat loss within 1 year, however, induced more pronounced muscle mass and protein loss, possibly requiring particular interventions such as exercise or protein supplements.

Metabolic, behavioral, and reproductive effects of vertical sleeve gastrectomy in an obese rat model of polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting women of reproductive age. Its clinical expression is diverse, including metabolic, behavioral, and reproductive effects, with many affected by obesity and decreased quality of life. Women with PCOS who have undergone surgically induced weight loss have reported tremendous benefit, not only with weight loss, but also improvement of hyperandrogenism and menstrual cyclicity.

METHODS

In a rat model of PCOS achieved via chronic administration of dihydrotestosterone (DHT) exposure, we investigated the ability of bariatric surgery, specifically vertical sleeve gastrectomy (VSG), to ameliorate the metabolic, behavioral, and reproductive abnormalities invoked by this PCOS model.

RESULTS

We found that DHT treatment combined with exposure to a high-fat diet resulted in increased body weight and body fat, impaired fasting glucose, hirsutism, anxiety, and irregular cycles. VSG resulted in reduced food intake, body weight, and adiposity with improved fasting glucose and triglycerides. VSG induced lower basal corticosterone levels and attenuated stress responsivity. Once the DHT levels decreased to normal, regular estrous cyclicity was also restored.

CONCLUSIONS

VSG, therefore, improved PCOS manifestations in a comprehensive manner and may represent a potential therapeutic approach for specific aspects of PCOS.

Impact of Roux-en-Y gastric bypass on metabolic syndrome and insulin resistance parameters

BACKGROUND

Metabolic syndrome (MetS) is a complex association of clustering metabolic factors that increase risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease. Surgical treatment has become an important tool to achieve its control. The aim of this study was to evaluate the impact of Roux-en-Y gastric bypass (RYGB) on MetS and its individual components, clinical characteristics, and biochemical features.

SUBJECTS AND METHODS

The study is a retrospective cohort of 96 subjects with MetS who underwent RYGB and were evaluated at baseline and after surgery. Clinical and biochemical features were analyzed.

RESULTS

After surgery, significant rates of resolution for MetS (88.5%), T2DM (90.6%), hypertension (85.6%), and dyslipidemias (54.2%) were found. Significant decreases in levels of fasting glucose, fasting insulin, hemoglobin A1c, low-density lipoprotein, and triglycerides and an increase in high-density lipoprotein level were also shown. The decrease in insulin resistance evaluated by homeostasis model assessment (HOMA-IR) was consistent. MetS resolution was associated with postoperative glycemic control, decreases in levels of fasting glucose, hemoglobin A1c, HOMA-IR, and triglycerides and in antihypertensive usage, and percentage weight loss.

CONCLUSIONS

This study found high rates of resolution for MetS, T2DM, hypertension, and dyslipidemias after RYGB in obese patients. This finding was consistent with current literature. Hence RYGB should be largely indicated for this group of subjects as it is a safe and powerful tool to achieve MetS control.

Excess body mass index loss predicts metabolic syndrome remission after gastric bypass

BACKGROUND

Metabolic syndrome (MS) is a condition associated with obesity that identifies individuals with increased cardiovascular risk. Gastric bypass improves several MS components, such as glucose, lipid metabolism and hypertension. The aim of this study was to evaluate the effect of long-limb gastric bypass on the remission of MS criteria associated with morbid obesity.

METHODS

Obese patients who met the "harmonized" criteria for MS (n = 153) that underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) with a long biliopancreatic limb were prospectively evaluated with regards to body weight, body mass index (BMI), percentage of excess BMI lost (% EBMIL), fasting glucose, blood pressure and lipid profile up to 36 months after surgery.

RESULTS

Before surgery, patients had a BMI of 44.3 ± 0.5 kg/m2; 66% were under anti-diabetic treatment; 78.4% were under anti-hypertensive treatment and 44.3% were under anti-dyslipidemic treatment. After a mean follow-up time of 2.4 ± 0.1 years, MS remission rates were 32.7% at 6 months, 69.7% at 12 months, 63.4% at 24 months, and 59.2% at 36 months; when only 32.9%, 43.4% and 15.8% of patients were still under anti-diabetic, anti-hypertensive and anti-dyslipidemic treatment, respectively. The %EBMIL and BMI were the parameters that showed the highest accuracy to predict the MS remission at all-time points after the surgery.

CONCLUSIONS

Long limb gastric bypass in obese patients results in significant and sustained weight loss which predicts a high remission rate of MS and allows the discontinuation of drug therapy for several metabolic disturbances in most patients.

Metabolic syndrome prevalence and associations in a bariatric surgery cohort from the Longitudinal Assessment of Bariatric Surgery-2 study

BACKGROUND

Metabolic syndrome is associated with higher risk for cardiovascular disease, sleep apnea, and nonalcoholic steatohepatitis, all common conditions in patients referred for bariatric surgery, and it may predict early postoperative complications. The objective of this study was to determine the prevalence of metabolic syndrome, defined using updated National Cholesterol Education Program criteria, in adults undergoing bariatric surgery and compare the prevalence of baseline co-morbid conditions and select operative and 30-day postoperative outcomes by metabolic syndrome status.

METHODS

Complete metabolic syndrome data were available for 2275 of 2458 participants enrolled in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2), an observational cohort study designed to evaluate long-term safety and efficacy of bariatric surgery in obese adults.

RESULTS

The prevalence of metabolic syndrome was 79.9%. Compared to those without metabolic syndrome, those with metabolic syndrome were significantly more likely to be men, to have a higher prevalence of diabetes and prior cardiac events, to have enlarged livers and higher median levels of liver enzymes, a history of sleep apnea, and a longer length of stay after surgery following laparoscopic Roux-en-Y gastric bypass (RYGB) and gastric sleeves but not open RYGB or laparoscopic adjustable gastric banding. Metabolic syndrome status was not significantly related to duration of surgery or rates of composite end points of intraoperative events and 30-day major adverse surgical outcomes.

CONCLUSIONS

Nearly four in five participants undergoing bariatric surgery presented with metabolic syndrome. Establishing a diagnosis of metabolic syndrome in bariatric surgery patients may identify a high-risk patient profile, but does not in itself confer a higher risk for short-term adverse postsurgery outcomes.

Effects of laparoscopic sleeve gastrectomy in patients with morbid obesity and metabolic disorders

PURPOSES

Obesity and its correlation with other pathological conditions determine the onset of the metabolic syndrome, which exposes the patient to a higher risk of major cardiovascular complications. Laparoscopic sleeve gastrectomy (LSG) is a bariatric surgical procedure that appears to influence both the reduction of fat mass and the action of some gastrointestinal hormones.

PATIENTS AND METHODS

Between January 2011 and July 2013, 23 patients with morbid obesity underwent LSG and follow-up. In the evaluation of patients, the criteria for metabolic syndrome given by the International Diabetes Federation were followed. A multidisciplinary team of experts evaluated patients before surgery and in subsequent scheduled postoperative visits at 7, 30, 60, and 90 days and 4, 5, 6, 9, and 12 months. Anthropometric and metabolic parameters were analyzed.

RESULTS

The mean excess weight loss was 8.57±3.02%, 17.65±6.40%, 25.47±7.90%, 33.76±9.27%, 41.83±10.71%, 46.02±13.90%, 52.60±14.05%, 58.48±16.07%, and 62.59±21.29% at 7, 30, 60, and 90 days and 4, 5, 6, 9, and 12 months, respectively. In the same observational period there was an excellent improvement of metabolic indices. None of the patients previously taking prescribed hypoglycemic drugs restarted therapy. Mean fasting plasma glucose significantly decreased compared with the preoperative values. Blood pressure had a statistically significant improvement. Modification in the lipid profile was more variable. During the period of observation 22 of 23 patients reported in this study did not fit the criteria for metabolic syndrome.

CONCLUSIONS

Morbid obesity and related diseases may benefit from a surgical approach in selected patients. Randomized controlled trials are needed to evaluate the role of LSG.

Obesity: the 'huge' problem in cardiovascular diseases

Obesity is an epidemic in the United States. It is an independent risk factor for cardiovascular diseases and associated with reduced life expectancy. The adverse effects are related to direct impact of obesity on cardiovascular system and indirectly through its influence on risk factors. Excessive accumulation of adipose tissue in the myocardium leads to structural and functional alteration. In addition, numerous hormones secreted by adipose tissue create pro-inflammatory and prothrombotic state. This predisposes to coronary heart disease, heart failure, and sudden death. Even those with normal weight but excessive body fat are at risk. Weight reduction and exercise are the main therapeutic options.

Is obesity a risk factor for chronic kidney disease in children?

There is a rapid increase worldwide in the prevalence of obesity in adults and children. Obesity is not only a comorbidity for chronic kidney disease (CKD) but may also be a risk factor for CKD. Epidemiological correlations and pathophysiological changes have been observed associating obesity with CKD. Low birth weight may be associated with both obesity and low nephron mass, leading to CKD later in life. Elevated levels of adipokines, such as leptin and adiponectin, in obesity may be factors in CKD pathogenesis and progression. Furthermore, various other factors, such as hypertension, increased cardiovascular morbidity, insulin resistance, dyslipidemia, and lipotoxicity, may play significant roles in the pathogenesis of CKD in obesity. Reduction in obesity, which is a potentially modifiable risk factor, might help decrease the burden of CKD in the population. Apart from individualized options, community-based interventions have the potential to create a strong impact in this condition.

Early Outcomes of Roux-en-Y Gastric Bypass in a Publically Funded Obesity Program

Background. There is limited literature assessing the outcomes of bariatric surgery in a publically funded, North American, multidisciplinary bariatric program. Our objective was to assess outcomes of roux-en-Y gastric bypass (RYGB) in a publically funded bariatric program through a retrospective review of patient records. Methods. 293 patients spent a median of 13 months attending a multidisciplinary obesity clinic prior to undergoing laparoscopic RYGB surgery. The hospital was a Canadian, publically funded, level 2 trauma center with university teaching services. Results. 79% of the patients were female and the average BMI at first visit to clinic was 55.3 kg/m2. The average decrease in BMI was 19.2 ± 0.9 kg/m(2). This was an average absolute weight loss of 56.1 kg or 35.5% of initial weight. The average excess weight loss was 63.4 ± 20.4%. Improvement or resolution of obesity related comorbidities occurred in 65.9% of type 2 diabetics and in 50% of hypertensive patients. Conclusion. Despite this being an unconventional setting of a publically funded program in a large Canadian teaching hospital, early outcomes following RYGB were appropriate in severely obese patients. Ongoing work will identify areas of improvement for enhanced efficiencies within this system.

Five-year changes in psychiatric treatment status and weight-related comorbidities following bariatric surgery in a veteran population

BACKGROUND

Although bariatric surgery is an established treatment for obesity, less is known regarding the long-term effects of surgery on psychiatric function. This paper reports changes in psychiatric treatment status, weight, and weight-related comorbidities over 5 years of follow-up among a population of veterans completing bariatric surgery.

METHODS

We assessed 55 veterans undergoing bariatric surgery at a single Veteran Affairs medical center for 5 years post-surgery. Patients completed a pre-surgery clinical interview with a licensed psychologist. Using computerized medical records, we tracked pre- to post-surgery involvement with antidepressants, anxiolytics, psychotherapies, and overall psychiatric treatment visits along with changes in weight and metabolic function.

RESULTS

Rates of antidepressant use and/or involvement with psychotherapy for depression declined from 56.4 % at pre-surgery to 34.6 % at 5 years post-surgery, p = 0.01. Anxiolytic use and/or involvement with psychotherapy for anxiety, however, increased from 23.6 to 32.7 % pre- to 5 years post-surgery. Average psychiatric treatment volume remained similar to pre-surgery status across follow-up. These mixed indicators of psychiatric improvement occurred despite marked metabolic improvements from surgery. Mean percent excess weight loss = 51.7 and 41.3 (1 and 5 years post-surgery, respectively), systolic blood pressure (-6.8 mmHg (14.3)/-6.1 mmHg (12.8), respectively), glucose levels (-18.6 mg/dL (30.2)/-10.0 mg/dL (25.9), respectively), triglycerides (-78.2 mg/dL (96.7)/-69.1 mg/dL (102.2), respectively) and high-density lipoproteins (+7.1 (9.9)/+11.3 (11.3), respectively) levels each improved.

CONCLUSIONS

We report evidence of decreased antidepressant use and depression therapies following bariatric surgery, but no improvements on rates of anxiolytic use and anxiety therapies or on overall psychiatric treatment involvement. Despite metabolic improvements, bariatric patients with psychiatric histories may warrant ongoing attention to mental health.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Bariatric surgery as potential treatment for nonalcoholic fatty liver disease: a future treatment by choice or by chance?

Morbid obesity is strongly associated with nonalcoholic fatty liver disease (NAFLD) which is one of the most common causes of chronic liver disease worldwide. The current best treatment of NAFLD and NASH is weight reduction through life style modifications, antiobesity medication, and bariatric surgery. Importantly, bariatric surgery is the best alternative option for weight reduction if lifestyle modifications and pharmacological therapy have not yielded long-term success. Bariatric surgery is an effective treatment option for individuals who are grossly obese and associated with marked decrease in obesity-related morbidity and mortality. The most common performed bariatric surgery is Roux-en-Y gastric bypass (RYGB). The current evidence suggests that bariatric surgery in these patients will decrease the grade of steatosis, hepatic inflammation, and fibrosis. NAFLD per se is not an indication for bariatric surgery. Further research is urgently needed to determine (i) the benefit of bariatric surgery in NAFLD patients at high risk of developing liver cirrhosis (ii) the role of bariatric surgery in modulation of complications of NAFLD like diabetes and cardiovascular disease. The outcomes of the future research will determine whether bariatric surgery will be one of the recommended choice for treatment of the most progressive type of NAFLD.