Three-Year Outcomes of Bariatric Surgery in Patients With Obesity and Hypertension : A Randomized Clinical Trial

Assessment and Management of Patients with Obesity and Hypertension in European Society of Hypertension Excellence Centres. A survey from the ESH Working Group on Diabetes and Metabolic Risk Factors

BACKGROUND

Healthcare providers are faced with an increasing number of patients with obesity and arterial hypertension. Preventing obesity-associated hypertension and appropriately managing patients with established disease are both important. Hence, the aim of our study was to evaluate the clinical care of patients with obesity and hypertension among ESH Excellence Centres (ECs).

METHODS

We conducted a cross-sectional, international 30-item survey through e-mails.

RESULTS

In total, 70 representatives of ECs participated (78% men) with 66% of them practicing medicine for more than 30 years and working in well-equipped clinics. Most were internists (41%) and cardiologists (37%) and 73% reported training on the management of obese patients with hypertension. A majority weigh their patients (77%) and evaluate patients for sleep disorders (93%). However, only 47% spend more than 5min to advise for lifestyle modification in general, 59% for weight loss, 56% for salt intake and 64% for exercise. Finally, a minority of participants ask patients if they like their body (6%) or about previous attempts to lose weight (28%), evaluate 24h urinary sodium excretion rate (22%) and provide written (15%) or personalized (10%) dietary advices. If the patient suffers also from type 2 diabetes mellitus, 66% switch treatment to GLP1 receptor agonists and 60% to SGLT2 inhibitors.

CONCLUSION

Most clinicians in ESH ECs are well educated regarding obesity-associated hypertension, and clinics are sufficiently equipped to manage these patients, as well. However, several deficits were reported regarding efforts to address and implement obesity specific aspects and interventions to improve care in patients with obesity and hypertension.

Antihypertensive Medication Use Trajectories After Bariatric Surgery: A Matched Cohort Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the most effective and durable treatment for obesity. We aimed to compare the trajectories of antihypertensive medication (AHM) use among obese individuals treated and not treated with MBS.

METHODS

Adults with a body mass index of ≥35 kg/m2 were identified in the Merative Database (US employer-based claims database). Individuals treated with versus without MBS were matched 1:1 using baseline demographic and clinical characteristics as well as AHM utilization. Monthly AHM use was examined in the 3 years after the index date using generalized estimating equations. Subanalyses investigated rates of AHM discontinuation, AHM initiation, and apparent treatment-resistant hypertension.

RESULTS

The primary cohort included 43 206 adults who underwent MBS matched with 43 206 who did not. Compared with no MBS, those treated with MBS had sustained, markedly lower rates of AHM use (31% versus 15% at 12 months; 32% versus 17% at 36 months). Among patients on AHM at baseline, 42% of patients treated with MBS versus 7% treated medically discontinued AHM use (P<0.01). The risk of apparent treatment-resistant hypertension was 3.41× higher (95% CI, 2.91-4.01; P<0.01) 2 years after the index date in patients who did not undergo MBS. Among those without hypertension treated with MBS versus no MBS, 7% versus 21% required AHM at 2 years.

CONCLUSIONS

MBS is associated with lower rates of AHM use, higher rates of AHM discontinuation, and lower rates of AHM initiation among patients not taking AHM. These findings suggest that MBS is both an effective treatment and a preventative measure for hypertension.

Gastric Bypass vs Diet and Cardiovascular Risk Factors: A Nonrandomized Controlled Trial

Importance

Roux-en-Y gastric bypass (RYGB) is associated with reduced cardiovascular (CV) risk factors, morbidity, and mortality. Whether these effects are specifically induced by the surgical procedure or the weight loss is unclear.

Objective

To compare 6-week changes in CV risk factors in patients with obesity undergoing matching caloric restriction and weight loss by RYGB or a very low-energy diet (VLED).

Design, Setting, and Participants

This nonrandomized controlled study (Impact of Body Weight, Low Calorie Diet, and Gastric Bypass on Drug Bioavailability, Cardiovascular Risk Factors, and Metabolic Biomarkers [COCKTAIL]) was conducted at a tertiary care obesity center in Norway. Participants were individuals with severe obesity preparing for RYGB or a VLED. Recruitment began February 26, 2015; the first patient visit was on March 18, 2015, and the last patient visit (9-week follow-up) was on August 9, 2017. Data were analyzed from April 30, 2021, through June 29, 2023.

Interventions

VLED alone for 6 weeks or VLED for 6 weeks after RYGB; both interventions were preceded by 3-week LED.

Main Outcomes and Measures

Between-group comparisons of 6-week changes in CV risk factors.

Results

Among 78 patients included in the analyses, the mean (SD) age was 47.5 (9.7) years; 51 (65%) were women, and 27 (35%) were men. Except for a slightly higher mean (SD) body mass index of 44.5 (6.2) in the RYGB group (n = 41) vs 41.9 (5.4) in the VLED group (n = 37), baseline demographic and clinical characteristics were similar between groups. Major atherogenic blood lipids (low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein B, lipoprotein[a]) were reduced after RYGB in comparison with VLED despite a similar fat mass loss. Mean between-group differences were -17.7 mg/dL (95% CI, -27.9 to -7.5), -17.4 mg/dL (95% CI, -29.8 to -5.0) mg/dL, -9.94 mg/dL (95% CI, -15.75 to -4.14), and geometric mean ratio was 0.55 U/L (95% CI, 0.42 to 0.72), respectively. Changes in glycemic control and blood pressure were similar between groups.

Conclusions and Relevance

This study found that clinically meaningful reductions in major atherogenic blood lipids were demonstrated after RYGB, indicating that RYGB may reduce CV risk independent of weight loss.

Trial Registration

ClinicalTrials.gov Identifier: NCT02386917.

[Latest Findings on the Role of α-Ketoglutarate in Metabolic Syndrome]

Alpha-ketoglutarate (α-KG), an endogenous intermediate of the tricarboxylic acid cycle, is involved in a variety of cellular metabolic pathways. It serves as an energy donor, a precursor of amino acid biosynthesis, and an epigenetic regulator. α-KG plays physiological functions in immune regulation, oxidative stress, and anti-aging as well. In recent years, it has been reported that the level of α-KG in the body is closely associated with metabolic syndrome, including obesity, hyperglycemia, and other pathological factors. Exogenous supplementation of α-KG improves obesity, blood glucose levels, and cardiovascular disease risks associated with metabolic syndrome. Furthermore, α-KG regulates the common pathological mechanisms of metabolic syndrome, suggesting the potential application prospect of α-KG in metabolic syndrome. In order to provide a theoretical basis for further exploration of the application of α-KG in metabolic syndrome, we focused on α-KG and metabolic syndrome in this article and summarized the latest research progress in the role of α-KG in improving the pathological condition and disease progression of metabolic syndrome. For the next step, researchers may focus on the co-pathogenesis of metabolic syndrome and investigate whether α-KG can be used to achieve the therapeutic goal of "homotherapy for heteropathy" in the treatment of metabolic syndrome.

Surgery is associated with better long-term outcomes than pharmacological treatment for obesity: a systematic review and meta-analysis

Obesity is a highly prevalent disease with numerous complications. Both intensive medical treatment with the use of pharmacological drugs and bariatric surgery are current options. The objective of this meta-analysis was to compare, in the long-term, intensive medical treatment and surgery based on twelve parameters related to weight loss, cardiovascular and endocrine changes. A review of the literature was conducted in accordance with the PRISMA guidelines (PROSPERO: CRD42021265637). The literature screening was done from inception to October 2023 through PubMed, EMBASE and Web of Science databases. We included randomized clinical trials that had separate groups for medical treatment and bariatric surgery as an intervention for obesity. The risk of bias was assessed through RoB2. A meta-analysis was performed with measures of heterogeneity and publication bias. Subgroup analysis for each surgery type was performed. Data is presented as forest-plots. Reviewers independently identified 6719 articles and 6 papers with a total 427 patients were included. All studies were randomized controlled trials, three had a follow up of 5 years and two had a follow up of 10 years. Both groups demonstrated statistical significance for most parameters studied. Surgery was superior for weight loss (- 22.05 kg [- 28.86; - 15.23), total cholesterol (- 0.88 [- 1.59; - 0.17]), triglycerides (- 0.70 [- 0.82; - 0.59]), HDL (0.12 [0.02; 0.23]), systolic pressure (- 4.49 [- 7.65; - 1.33]), diastolic pressure (- 2.28 [- 4.25; - 0.31]), Hb glycated (- 0.97 [- 1.31; - 0.62]), HOMA IR (- 2.94; [- 3.52; - 2.35]) and cardiovascular risk (- 0.08; [- 0.10; - 0.05]). Patient in the surgical treatment group had better long term outcomes when compared to the non-surgical group for most clinical parameters.

Diagnosis, Treatment and Long-Term Management of Vitamin B12 Deficiency in Adults: A Delphi Expert Consensus

Background/Objectives: Vitamin B12 deficiency can cause variable symptoms, which may be irreversible if not diagnosed and treated in a timely manner. We aimed to develop a widely accepted expert consensus to guide the practice of diagnosing and treating B12 deficiency. Methods: We conducted a scoping review of the literature published in PubMed since January 2003. Data were used to design a two-round Delphi survey to study the level of consensus among 42 experts. Results: The panelists agreed on the need for educational and organizational changes in the current medical practices for diagnosing and treating B12 deficiency. Recognition of clinical symptoms should receive the highest priority in establishing the diagnosis. There is agreement that the serum B12 concentration is useful as a screening marker and methylmalonic acid or homocysteine can support the diagnosis. Patient lifestyle, disease history, and medications can provide clues to the cause of B12 deficiency. Regardless of the cause of the deficiency, initial treatment with parenteral B12 was regarded as the first choice for patients with acute and severe manifestations of B12 deficiency. The use of high-dose oral B12 at different frequencies may be considered for long-term treatment. Prophylactic B12 supplementation should be considered for specific high-risk groups. Conclusions: There is a consensus that clinical symptoms need to receive more attention in establishing the diagnosis of B12 deficiency. B12 laboratory markers can support the diagnosis. The severity of clinical symptoms, the causes of B12 deficiency, and the treatment goals govern decisions regarding the route and dose of B12 therapy.

Long-Term Protective Effects and Mechanisms of Gastric Bypass Surgery on the Kidneys in Hypertensive Obese Rat

OBJECTIVE

Investigate the long-term protective effects of gastric bypass surgery on the kidneys of hypertensive obese rats to better understand the role of gastric bypass surgery in preventing renal injury in humans with hypertension and obesity.

METHODS

Compare 6-week-old spontaneously hypertensive rats, including 30 Roux-en-Y gastric bypass (RYGB) and 30 sham operations. Body weight and blood pressure were monitored before and up to 12 months after the operation. Blood lipids, blood creatinine, and blood urea nitrogen were measured. Kidney pathology was assessed using HE staining, while renal fibrosis was observed via Masson staining. Inflammatory indicators were examined by ELISA. The expression of the NLRP3 gene in the kidney was measured using immunofluorescence and western blot, and the changes in key pathways including ASC/IL-1β protein were verified.

RESULTS

RYGB reduced the body weight of hypertensive obese rats and had a protective effect on blood pressure. Additionally, the bypass effectively mitigated renal inflammation and fibrosis. Moreover, RYGB modulated the expression of NLRP3 and prevented kidney damage via the ASC/IL-1 pathway.

CONCLUSION

This study validates that RYGB effectively attains sustained blood pressure control in hypertensive obese rats and has a potential kidney-protective mechanism via the NLRP3-ASC/IL-1β pathway.

Remission of Nonalcoholic Fatty Liver Disease After Radical Surgery in Patients with Colorectal Cancer: A Single-Center Retrospective Study

Purpose: The purpose of this study was to investigate the relationship between remission of nonalcoholic fatty liver disease (NAFLD) and radical surgery for colorectal cancer (CRC) patients. Methods: From January 2014 to December 2021, data of patients with concurrent CRC and NAFLD who underwent radical surgery in a single-center hospital were retrospectively collected. NAFLD was defined as a mean computed tomography (CT) liver attenuation value of <40 Hounsfield units (HUs). Comparison of preoperative and 1-year postoperative CT images was performed to evaluate the change of NAFLD. Multivariate logistic regression analysis was performed to identify independent predictive factors for NAFLD remission. The Kaplan-Meier method was used to estimate overall survival (OS) and disease-free survival (DFS) between the remission group and no remission group. Results: In this study, a total of 55 eligible patients were included. The remission group had 33 (60.0%) patients and the no remission group had 22 (40.0%) patients. The mean preoperative weight was 66.1 ± 9.9 kg. The mean preoperative body mass index (BMI) was 25.4 ± 2.5 kg/m2. We found that the average weight was significantly decreased (P < 0.01), average BMI was significantly decreased (P < 0.01), and HU score was significantly increased (P < 0.01). By comparing baseline characteristics between the remission group and no remission group, we found that the remission group exhibited larger tumor sizes (P = 0.036) than the no remission group. In the multivariate logistic regression analysis, we found that weight change was a predictor for NAFLD (odds ratio = 0.764, 95% confidence interval = 0.618-0.944, P = 0.013). We did not find any statistically significant differences in OS (P = 0.182) or DFS (P = 0.248) between the remission group and no remission group. Conclusions: The NAFLD remission rate reached 60.0% for CRC patients 1 year after radical surgery. In addition, we found that weight change was a predictor of NAFLD remission.

Discontinuation of blood pressure-lowering, glucose-lowering, and lipid-lowering medications after bariatric surgery in patients with morbid obesity: a nationwide cohort study in South Korea

BACKGROUND

Limited evidence exists on the patterns of medication use for hypertension, diabetes mellitus (DM), and dyslipidemia after bariatric surgery among Asian patients.

OBJECTIVES

To investigate the patterns in the use of blood pressure-lowering, glucose-lowering, and lipid-lowering medications following BS in Korean patients with morbid obesity.

SETTING

This study is a retrospective cohort study using the Health Insurance Review and Assignment claims database of South Korea (from 2019 to 2021).

METHODS

We included patients who underwent BS between 2019 and 2020 in South Korea. We evaluated the treatment patterns of blood pressure-lowering, glucose-lowering, and lipid-lowering medications at 3-month intervals for 1-year following BS, including medication use, individual medication classes, and the number of medications prescribed. Furthermore, we estimated remission rates for each disorder based on patient characteristics by defining patients who discontinued their medications for at least 2 consecutive quarters as remission.

RESULTS

A total of 3810 patients were included in this study. For 1-year following BS, a marked decrease in the number of patients using blood pressure-lowering, glucose-lowering, and lipid-lowering medications was observed. The most remarkable decrease occurred in glucose-lowering medications, which decreased by approximately -75.1% compared with that at baseline. This tendency was consistently observed when analyzing both the number of medications prescribed and the specific medication classes. Regarding remission rates, patients who were female, younger, and received the biliopancreatic diversion-duodenal switch as their BS showed a relatively higher incidence of remission than other groups.

CONCLUSIONS

BS was associated with a decrease in the use of medications for hypertension, diabetes mellitus (DM), and dyslipidemia.

Impact of RYGB surgery on plasma immunoglobulins: association between blood pressure and glucose levels six months after surgery

We aimed to study levels of natural antibodies in plasma, and their associations to clinical and fecal biomarkers, before and 6 months after Roux-en-Y gastric bypass (RYGB) surgery. Thirty individuals with obesity [16 type 2 diabetic, 14 non-diabetic (ND)] had RYGB surgery. Total plasma IgA, IgG and IgM antibody levels and specific antibodies to oxidized low-density lipoprotein (oxLDL), malondialdehyde-acetaldehyde adducts, Porphyromonas gingivalis gingipain A hemagglutinin domain (Rgp44), and phosphocholine were measured using chemiluminescence immunoassay. Associations between plasma and fecal antibodies as well as clinical markers were analyzed. RYGB surgery reduced blood pressure, and the glycemic state was improved. A higher level of diastolic blood pressure was associated with lower plasma antibodies to oxLDL after surgery. Also, lower level of glucose markers associated with lower level of plasma antibodies to bacterial virulence factors. Antibodies to oxLDL decreased after surgery, and positive association between active serum lipopolysaccharide and specific oxLDL antibodies was detected. Total IgG levels decreased after surgery, but only in ND individuals. Reduced level of total plasma IgG, improved state of hypertension and hyperglycemia and their associations with decreased levels of specific antibodies in plasma, suggest an improved state of systemic inflammation after RYGB surgery.

Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years

BACKGROUND

Obesity represents a major obstacle for controlling hypertension, the leading risk factor for cardiovascular mortality.

OBJECTIVES

The purpose of this study was to determine the long-term effects of bariatric surgery on hypertension control and remission.

METHODS

We conducted a randomized clinical trial with subjects with obesity grade 1 or 2 plus hypertension using at least 2 medications. We excluded subjects with previous cardiovascular events and poorly controlled type 2 diabetes. Subjects were assigned to Roux-en-Y gastric bypass (RYGB) combined with medical therapy (MT) or MT alone. We reassessed the original primary outcome (reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg) at 5 years. The main analysis followed the intention-to-treat principle.

RESULTS

A total of 100 subjects were included (76% women, age 43.8 ± 9.2 years, body mass index: 36.9 ± 2.7 kg/m2). At 5 years, body mass index was 36.40 kg/m2 (95% CI: 35.28-37.52 kg/m2) for MT and 28.01 kg/m2 (95% CI: 26.95-29.08 kg/m2) for RYGB (P < 0.001). Compared with MT, RYGB promoted a significantly higher rate of number of medications reduction (80.7% vs 13.7%; relative risk: 5.91; 95% CI: 2.58-13.52; P < 0.001) and the mean number of antihypertensive medications was 2.97 (95% CI: 2.33-3.60) for MT and 0.80 (95% CI: 0.51-1.09) for RYGB (P < 0.001). The rates of hypertension remission were 2.4% vs 46.9% (relative risk: 19.66; 95% CI: 2.74-141.09; P < 0.001). Sensitivity analysis considering only completed cases revealed consistent results. Interestingly, the rate of apparent resistant hypertension was lower after RYGB (0% vs 15.2%).

CONCLUSIONS

Bariatric surgery represents an effective and durable strategy to control hypertension and related polypharmacy in subjects with obesity. (GAstric bypass to Treat obEse Patients With steAdy hYpertension [GATEWAY]; NCT01784848).

Risk Stratification and Treatment of Obesity for Primary and Secondary Prevention of Cardiovascular Disease

PURPOSE OF REVIEW

In this review, we discuss contemporary and emerging approaches for risk stratification and management of excess adiposity for the primary and secondary prevention of cardiovascular disease.

RECENT FINDINGS

Obesity is simultaneously a pandemic-scale disease and major risk factor for the incidence and progression of a wide range of cardiometabolic conditions, but risk stratification and treatment remain clinically challenging. However, sex-, race-, and ethnicity-sensitive anthropometric measures, body composition-focused imaging, and health burden-centric staging systems have emerged as important facilitators of holistic risk prediction. Further, expanding therapeutic approaches, including comprehensive lifestyle programs, anti-obesity pharmacotherapies, device/endoscopy-based interventions, metabolic surgery, and novel healthcare delivery resources offer new empowerment for cardiovascular risk reduction in individuals with obesity. Personalized risk stratification and weight management are central to reducing the lifetime prevalence and impact of cardiovascular disease. Further evidence informing long-term safety, efficacy, and cost-effectiveness of novel approaches targeting obesity are critically needed.

An examination of relationships between vitamin B12 status and functional measures of peripheral neuropathy in young adult vegetarians

Introduction

Prevalence rates for vitamin B12 deficiency in U.S. adult vegetarians may exceed 30%, which is concerning given the role for this vitamin in numerous nervous system functions, including the synthesis of myelin sheaths. Defective myelin synthesis and repair are directly linked to peripheral neuropathy; yet, few investigations have examined how physical indicators of peripheral neuropathy (e.g., hand dexterity, vibration sensitivity and balance) are impacted in individuals adhering to vegetarian diets. This feasibility research explored the relationships between peripheral neuropathy and vitamin B12 status using a cross-sectional study design. In addition, a small pilot trial was conducted for limited-efficacy testing of vitamin B12 supplementation for reducing peripheral neuropathy.

Methods

Healthy, able-bodied adults (n = 38; 19-40 years of age) reported exclusive adherence to a vegetarian or vegan diet for 3 years. Peripheral neuropathy was measured using a force plate for assessing balance, and a vibration sensitivity tester and pegboard tests to assess hand dexterity. Serum vitamin B12 and folate were measured using standard radioimmunoassay techniques.

Results

Twenty-six percent of the sample displayed deficient or marginal vitamin B12 status (serum vitamin B12 <221 pmol/L). Participants with adequate vitamin B12 status scored 10% higher on the Purdue pegboard assembly test and 20% higher on the left hand adjusted functional dexterity test in comparison to participants with marginal-to-deficient vitamin B12 status (p < 0.05).

Discussion

These data provide preliminary evidence that peripheral neuropathy can be detected in individuals with marginal-to-deficient vitamin B12 status.

Shorter History of Hypertension as a Predictor of Hypertension Remission after 3-years of Bariatric Surgery: Data from the GATEWAY Trial

BACKGROUND

Previous evidence explored predictors of hypertension (HTN) remission after bariatric but data are limited to observational studies and lack of ambulatory blood pressure monitoring (ABPM). This study was aimed to evaluate the rate of HTN remission after bariatric surgery using ABPM and to define predictors of mid-term HTN remission.

METHODS

We included patients enrolled in the surgical arm of the GATEWAY randomized trial. HTN remission was defined as controlled blood pressure (< 130 × 80 mmHg) evaluated by 24-h ABPM while no need of anti-hypertensive medications after 36 months. A multivariable logistic regression model was used to assess the predictors of HTN remission after 36 months.

RESULTS

46 patients submitted Roux-en-Y gastric bypass (RYGB). HTN remission occurred in 39% (n = 14 out of 36 patients with complete data at 36 months). Patients with HTN remission had shorter HTN history than no remission group (5.9 ± 5.5 vs. 12.5 ± 8.1 years; p = 0.01). The baseline insulin levels were lower in patients who presented HTN remission, although not statistically significant (OR: 0.90; CI 95%: 0.80-0.99; p = 0.07). In the multivariate analysis, the HTN history (years) was the only independent predictor of HTN remission (OR: 0.85; 95% CI: 0.70-0.97; p = 0.04). Therefore, for each additional year of HTN history, the chance of HTN remission decreases by approximately 15% after RYGB.

CONCLUSION

After 3 years of RYGB, HTN remission defined by ABPM was common and independently associated with a shorter HTN history. These data underscore the need of early effective approach of obesity aiming greater impact in its comorbidities.

Cardiovascular Effects of Weight Loss in Obese Patients with Diabetes: Is Bariatric Surgery the Additional Arrow in the Quiver?

Obesity is an increasingly widespread disease worldwide because of lifestyle changes. It is associated with an increased risk of cardiovascular disease, primarily type 2 diabetes mellitus, with an increase in major cardiovascular adverse events. Bariatric surgery has been shown to be able to reduce the incidence of obesity-related cardiovascular disease and thus overall mortality. This result has been shown to be the result of hormonal and metabolic effects induced by post-surgical anatomical changes, with important effects on multiple hormonal and molecular axes that make this treatment more effective than conservative therapy in determining a marked improvement in the patient's cardiovascular risk profile. This review, therefore, aimed to examine the surgical techniques currently available and how these might be responsible not only for weight loss but also for metabolic improvement and cardiovascular benefits in patients undergoing such procedures.

Obesity-related hypertension: Implications for advanced nursing practice

ABSTRACT

Obesity increases the risk of hypertension and other cardiometabolic comorbidities. Lifestyle modifications are usually recommended, though lasting effects on weight and BP reduction are limited. Weight-loss medications, especially incretin mimetics, are effective for short- and long-term treatment. Metabolic surgery provides cure of obesity-related hypertension in some patients. NPs are well positioned to manage obesity-related hypertension to improve clinical outcomes of affected individuals.

Hypertension and hypercholesterolemia are predictive factors associated with type 2 diabetes persistence after metabolic surgery: A prospective study

BACKGROUND

Metabolic surgery is the most effective therapeutic strategy for the management of type 2 diabetes (T2DM). Several preoperative clinical factors have been associated with T2DM remission after metabolic surgery. However, other potential predictors remain unexplored.

AIM

To assess the role of basal (pre-surgery) clinical and biochemical parameters in T2DM remission after metabolic surgery.

METHODS

A prospective study including 98 patients with T2DM undergoing metabolic surgery was performed. Clinical, anthropometric, and biochemical data were collected at baseline and 1 year following metabolic surgery.

RESULTS

Patients without T2DM remission 1 year after metabolic surgery presented a longer duration of diabetes and higher glycated hemoglobin (HbA1c) levels; a higher percentage of these subjects were using insulin therapy, antihypertensive drugs, and lipid-lowering therapies before metabolic surgery, compared to those patients with T2DM remission. A lower percentage of T2DM remission after metabolic surgery was observed among patients with hypertension/hypercholesterolemia before surgery, compared to those patients without hypertension/hypercholesterolemia (51.7 % vs 86.8 %, p < 0.001, and 38.5 % vs 75 %, p < 0.001, respectively), and among patients with longer duration of diabetes (≥5 years vs <5 years; 44.4 % vs 83 %, respectively; p < 0.001). In the logistic regression model, diabetes duration, basal HbA1c, and the presence of hypertension and hypercholesterolemia before surgery were inversely related to T2DM remission following metabolic surgery, after adjusting for sex, age, waist circumference, and type of surgery.

CONCLUSIONS

In a cohort of patients with obesity and T2DM, preoperative hypertension and hypercholesterolemia, together with a longer diabetes duration and higher HbA1c concentrations, were independent predictors of T2DM persistence after metabolic surgery.

Association Between Obesity and Chronic Kidney Disease: Multivariable Mendelian Randomization Analysis and Observational Data From a Bariatric Surgery Cohort

Obesity is postulated to independently increase chronic kidney disease (CKD), even after adjusting for type 2 diabetes (T2D) and hypertension. Dysglycemia below T2D thresholds, frequently seen with obesity, also increases CKD risk. Whether obesity increases CKD independent of dysglycemia and hypertension is unknown and likely influences the optimal weight loss (WL) needed to reduce CKD. T2D remission rates plateau with 20-25% WL after bariatric surgery (BS), but further WL increases normoglycemia and normotension. We undertook bidirectional inverse variance weighted Mendelian randomization (IVWMR) to investigate potential independent causal associations between increased BMI and estimated glomerular filtration rate (eGFR) in CKD (CKDeGFR) (<60 mL/min/1.73 m2) and microalbuminuria (MA). In 5,337 BS patients, we assessed whether WL influences >50% decline in eGFR (primary outcome) or CKD hospitalization (secondary outcome), using <20% WL as a comparator. IVWMR results suggest that increased BMI increases CKDeGFR (b = 0.13, P = 1.64 × 10-4; odds ratio [OR] 1.14 [95% CI 1.07, 1.23]) and MA (b = 0.25; P = 2.14 × 10-4; OR 1.29 [1.13, 1.48]). After adjusting for hypertension and fasting glucose, increased BMI did not significantly increase CKDeGFR (b = -0.02; P = 0.72; OR 0.98 [0.87, 1.1]) or MA (b = 0.19; P = 0.08; OR 1.21 [0.98, 1.51]). Post-BS WL significantly reduced the primary outcome with 30 to <40% WL (hazard ratio [HR] 0.53 [95% CI 0.32, 0.87]) but not 20 to <30% WL (HR 0.72 [0.44, 1.2]) and ≥40% WL (HR 0.73 [0.41, 1.30]). For CKD hospitalization, progressive reduction was seen with increased WL, which was significant for 30 to <40% WL (HR 0.37 [0.17, 0.82]) and ≥40% WL (HR 0.24 [0.07, 0.89]) but not 20 to <30% WL (HR 0.60 [0.29, 1.23]). The data suggest that obesity is likely not an independent cause of CKD. WL thresholds previously associated with normotension and normoglycemia, likely causal mediators, may reduce CKD after BS.

Contemporary medical, device, and surgical therapies for obesity in adults

The goal of obesity management is to improve health. Sustained weight loss of more than 10% overall bodyweight improves many of the complications associated with obesity (eg, prevention and control of type 2 diabetes, hypertension, fatty liver disease, and obstructive sleep apnoea), as well as quality of life. Maintenance of weight loss is the major challenge of obesity management. Like all chronic diseases, managing obesity requires a long-term, multimodal approach, taking into account each individual's treatment goals, and the benefit and risk of different therapies. In conjunction with lifestyle interventions, anti-obesity medications and bariatric surgery improve the maintenance of weight loss and associated health gains. Most available anti-obesity medications act on central appetite pathways to reduce hunger and food reward. In the past 5 years, therapeutic advances have seen the development of targeted treatments for monogenic obesities and a new generation of anti-obesity medications. These highly effective anti-obesity medications are associated with weight losses of more than 10% of overall bodyweight in more than two-thirds of clinical trial participants. Long-term data on safety, efficacy, and cardiovascular outcomes are awaited. Long-term studies have shown that bariatric surgical procedures typically lead to a durable weight loss of 25% and rapid, sustained improvements in complications of obesity, although they have not yet been compared with new-generation highly effective anti-obesity medications. Further work is required to determine optimal patient-specific treatment strategies, including combinations of lifestyle interventions, anti-obesity medications, endoscopic and bariatric surgical procedures, and to ensure equitable access to effective treatments.

Management of hypertension in obstructive sleep apnea

Obstructive sleep apnea (OSA) plays an important role in the development of hypertension. Thus, this review summarizes pharmacological and non-pharmacological approaches to blood pressure (BP) control in patients with OSA. Current treatments for OSA, such as continuous positive airway pressure, are effective at lowering BP. However, they only provide a modest BP reduction, and pharmacological treatment remains important for achieving optimal BP control. Furthermore, current guidelines for the treatment of hypertension do not make specific recommendations on pharmacological treatment protocols for controlling BP in patients with OSA. Moreover, the BP-lowering effects of various classes of antihypertensives may be different in hypertensive patients with OSA than in those without OSA due to the underlying mechanisms that promote hypertension in OSA. The acute and chronic increase in sympathetic nerve activity in patients with OSA explain the effectiveness of beta blockers in controlling BP in these patients. As activation of the renin-angiotensin-aldosterone system may also promote hypertension in OSA, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers have generally been found effective for lowering BP in hypertensive patients with OSA. The aldosterone antagonist spironolactone also produces a good antihypertensive response in patients with OSA and resistant hypertension. However, there are limited data available that compare the effects of various classes of antihypertensive medication on BP control in those with OSA, and most data have been obtained from small-scale studies. This demonstrates the need for large-scale randomized controlled trials to evaluate a range of BP-lowering regimens in patients with OSA and hypertension.

Impact of Roux-en-Y Gastric Bypass and Vertical Gastrectomy on weight loss: a retrospective and longitudinal study in the State of Paraná, Brazil

AIM

to compare the impact of Roux's Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) techniques on body weight reduction over 1 and 5 years after bariatric surgery in obese patients in the state of Paraná.

METHODS

longitudinal and retrospective study, conducted between January 2010 and December 2013, with 737 patients of both sexes submitted to RYGB or SG and evaluated in the preoperative, 1 and 5 years after bariatric surgery (BS). Age, height, body weight, Body Mass Index (BMI), biochemical and pressure parameters were recorded.

RESULTS

of the total of patients, men represented lower frequency, were slightly older, with higher body weight, BMI and worse metabolic and pressure conditions than women in pre-BS (p<0.05). Regardless of sex, RYGB and SG were effective in promoting body weight reduction and BMI in 1 and 5 years after BS; the RYGB technique had greater impact on these variables in both sexes (p<0.05). The highest percentage of lost weight was observed in women who underwent the RYGB technique in the first year after BS. Five years after BS, the RYGB technique promoted a higher rate of body weight reduction in men and women compared to the SG technique (p<0.05).

CONCLUSION

regardless of sex, the RYGB technique promotes a higher degree of body weight reduction and BMI over time compared to the SG; having its biggest impacts in the 1 year after BS, especially in women.

Multimorbidity and loneliness. Longitudinal analysis based on the GSOEP

BACKGROUND

Our aim was to examine the longitudinal association between multimorbidity and loneliness in the general adult population (and in different age groups) in Germany.

METHODS

Longitudinal data were used from the German Socio-Economic Panel (n= 44,385 observations in the years 2013 and 2017) - a nationally representative sample including adults aged 18 years and above. Respondents are re-surveyed annually. Loneliness was quantified using the established UCLA-3. Multimorbidity was defined as the coexistence of two or more conditions and was indicated by a list containing 13 somatic and mental diseases. Asymmetric linear fixed effects regressions (also stratified by three age groups: 18 to 44 years; 45 to 64 years, 65 years and older) were used to examine the association between the onset and end of multimorbidity as well as loneliness.

RESULTS

After adjusting for possible confounders, regression analysis revealed that the onset of multimorbidity is associated with an increase in loneliness in the total sample (β = 0.07, p < 0.001) and among individuals aged 65 years and older (β = 0.13, p < 0.001), whereas no significant association was found in the other age groups. The end of multimorbidity was not associated with loneliness neither in the total group nor in the individual age groups.

CONCLUSION

This study revealed an association between the onset of multimorbidity and higher loneliness particularly among individuals in late life. Thus, preventing or delaying multimorbidity may be beneficial to avoid loneliness among older adults.

Comparison of hypertension remission and relapse after sleeve gastrectomy and one-anastomosis gastric bypass: a prospective cohort study

This study aimed to assess the remission and relapse of hypertension (HTN) in hypertensive individuals who underwent sleeve gastrectomy (SG) and one-anastomosis gastric bypass (OAGB) and identify the predictors of HTN remission and relapse following bariatric surgery. A prospective cohort study with a follow-up of 3 years was conducted on severely obese patients between 2013 and 2018. Hypertension remission was defined as the normalization of blood pressure (BP) with the discontinuation of medical treatment, and HTN relapse was defined as the need for the onset of antihypertensive drugs or the occurrence of BP impairment. A total of 787 hypertensive patients were included in this study. The cumulative incidence of HTN remission and relapse were 83.9% (95% CI: 81.6-86.5) and 31.4% (95% CI: 25.6-38.2), respectively. Remission and relapse were not significantly different among the patients undergoing either surgery (SG or OAGB). A higher remission rate was linked to a younger age and the use of fewer antihypertensive medications pre-operation. However, failure to successfully lose weight during the first year postoperative and weight regain predicted a higher risk of HTN relapse after 3 years. Following bariatric surgery, BP drops initially but then gradually rises. These alterations are responsible for about 31% relapse after 3 years in those who initially achieve remission. Patients who are younger and use less antihypertensive medications before surgery may benefit the most from bariatric surgery in terms of HTN. First-year successful weight loss and control of weight regain may prevent HTN relapse in the following years.

O impacto do Bypass Gástrico em Y de Roux e da Gastrectomia Vertical na perda de peso: um estudo retrospectivo e longitudinal no Estado do Paraná, Brasil

RESUMO Objetivo: comparar o impacto das técnicas Bypass Gástrico em Y de Roux (BGYR) e Gastrectomia Vertical (GV) na redução do peso corporal ao longo de 1 e 5 anos após a cirurgia bariátrica em pacientes obesos no Estado do Paraná. Métodos: estudo longitudinal e retrospectivo, realizado entre janeiro de 2010 a dezembro de 2013, com 737 pacientes de ambos os sexos submetidos a BGYR ou GV e avaliados no pré-cirúrgico, 1 e 5 anos após Cirurgia Bariátrica (CB). Foram registrados idade, estatura, peso corporal, Índice de Massa Corpórea (IMC), parâmetros bioquímicos e pressóricos. Resultados: do total de pacientes, homens representavam menor frequência, eram ligeiramente mais velhos, com maior peso corporal, IMC e pior condição metabólica e pressórica que mulheres no pré-CB (p<0,05). Independente do sexo, BGYR e GV foram efetivas em promover redução do peso corporal e IMC em 1 e 5 anos pós-CB; tendo a técnica de BGYR maior impacto nestas variáveis em ambos os sexos (p<0,05). A maior porcentagem de peso perdido foi observada em mulheres submetidas a técnica da BGYR no primeiro ano após a CB. Cinco anos após a CB, a técnica de BGYR promoveu maior taxa de redução de peso corporal em homens e mulheres comparado a técnica da GV (p<0,05). Conclusão: independente do sexo a técnica de BGYR promove maior grau de redução do peso corporal e IMC ao longo do tempo em comparação com a GV; tendo seus maiores impactos no 1 ano pós-CB sobretudo em mulheres.

[Indications in Obesity Therapy - Surgeons First?]

Obesity is a growing problem worldwide. For the first time since 2010, more people have been overweight than underweight. In particular, obesity-associated diseases, above all type 2 diabetes mellitus, pose enormous challenges to the healthcare system. On July 3, 2020, the German Bundestag recognised obesity as a disease and initiated the development of a diseases management program (DMP), which is currently being drawn up. So far, the indication for treatment of obesity in Germany has been based on the S3 guideline "Surgery of obesity and metabolic diseases" of the DGAV from 2018 and the S3 guideline "Prevention and therapy of obesity" of the German Obesity Society e. V. from 2014. This article gives an overview of the currently available conservative, medical, endoscopic and surgical treatment methods for overweight and obesity in Germany and explains the indications. Against the background of the reorientation of obesity treatment as a part of the DMP and the forthcoming revisions of the guidelines, the previous indication should be discussed critically. The scientific findings of the last few years show that surgical treatment of obesity not only achieves the greatest weight loss in the long term, but also that obesity-associated diseases are then treated more effectively and overall mortality is reduced significantly more effectively than with conservative treatment.

Hypertension management in patients with cardiovascular comorbidities

Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.

Trends in bariatric surgeries in the Brazilian Federative Units, 2009-2019: a descriptive study

OBJECTIVE

our objective is to describe the epidemiological distribution of hospitalizations and postoperative deaths, as well as the trends of bariatric surgeries performed by SUS in all Brazilian federative units (FUs) from an analysis of the period from 2009 to 2019.

METHODS

This is an observational, descriptive ecological time-series study with quantitative and descriptive analysis, based on secondary data. The period analyzed was from 2009 to 2019. We collected, from DATASUS, data from obese men and women who were hospitalized after undergoing bariatric surgery. Prais-Winsten regression was performed to identify the trends.

RESULTS

In the period, 83,829 bariatric surgeries were performed, of which 161 resulted in death, representing 0.19% of the procedures. We found an increasing trend in the number of surgeries for Brazil (β=0.04; p<0.001), but 11 FUs showed a stationary trend and three, decreasing ones (six UFs did not have enough data to enter the analysis). In the North and Northeast regions, stationary trends prevailed, while in the Center-West, the decreasing trends, and in the South and Southeast, the increasing ones.

CONCLUSIONS

we found an evident disparity between regions, suggesting deficiencies in access to health. By demonstrating which FUs and demographic characteristics have the lowest rates of surgeries, our study is able to direct public policies towards a more egalitarian Brazilian public health.

Integrated Care Model of Adiposity-Related Chronic Diseases

PURPOSE OF REVIEW

Although obesity is a disease, most patients with obesity do not undergo effective treatment nor adhere to long-term care. We examine the barriers that patients with obesity confront when searching for effective treatment and propose an integrated care model of adiposity-related chronic diseases in a cardio-renal metabolic unit.

RECENT FINDINGS

The current care of obesity is fragmented between primary care providers, medical specialists and metabolic bariatric surgeons with little or no coordination of care between these providers. The current care of obesity heavily focuses on weight loss as the primary aim of treatment thereby reenforcing the weight stigma and turning patients away from effective therapy like metabolic bariatric surgery. An interdisciplinary cardio-renal metabolic unit that, besides weight loss, emphasizes prevention/remission of adiposity-related chronic diseases may deliver thorough and rewarding care to most patients with obesity.

Surgery for the treatment of obesity in children and adolescents

BACKGROUND

Child and adolescent overweight and obesity have increased globally and are associated with significant short- and long-term health consequences.

OBJECTIVES

To assess the effects of surgery for treating obesity in childhood and adolescence.

SEARCH METHODS

For this update, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Latin American and Caribbean Health Science Information database (LILACS), World Health Organization International Clinical Trials Registry Platform (ICTRP)and ClinicalTrials.gov on 20 August 2021 (date of the last search for all databases). We did not apply language restrictions. We checked references of identified studies and systematic reviews.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of surgical interventions for treating obesity in children and adolescents (age < 18 years) with a minimum of six months of follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or which included participants with a secondary or syndromic cause of obesity, or who were pregnant.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias using the Cochrane Risk of Bias 2.0 tool. Where necessary, we contacted authors for additional information.

MAIN RESULTS

With this update, we did not find any new RCTs. Therefore, this updated review still includes a single RCT (a total of 50 participants, 25 in both the intervention and comparator groups). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi-component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle groups, respectively. The trial was conducted in a private hospital, receiving funding from the gastric banding manufacturer. For most of the outcomes, we identified a high risk of bias, mainly due to bias due to missing outcome data. Laparoscopic gastric banding surgery may reduce BMI by a mean difference (MD) of -11.40 kg/m2 (95% CI -13.22 to -9.58) and weight by -31.60 kg (95% CI -36.66 to -26.54) compared to a multi-component lifestyle programme at two years follow-up. The evidence is very uncertain due to serious imprecision and a high risk of bias. Adverse events were reported in 12/25 (48%) participants in the intervention group compared to 11/25 (44%) in the control group. A total of 28% of the adolescents undergoing gastric banding required revisional surgery. The evidence is very uncertain due to serious imprecision and a high risk of bias. At two years of follow-up, laparoscopic gastric banding surgery may increase health-related quality of life in the physical functioning scores by an MD of 16.30 (95% CI 4.90 to 27.70) and change in health scores by an MD of 0.82 (95% CI 0.18 to 1.46) compared to the lifestyle group. The evidence is very uncertain due to serious imprecision and a high risk of bias. No data were reported for all-cause mortality, behaviour change, participants' views of the intervention and socioeconomic effects. Finally, we have identified three ongoing RCTs that are evaluating the efficacy and safety of metabolic and bariatric surgery in children and adolescents.

AUTHORS' CONCLUSIONS

Laparoscopic gastric banding led to greater body weight loss compared to a multi-component lifestyle program in one small study with 50 participants. These results have very limited application, primarily due to more recent recommendations derived from observation studies to avoid the use of banding in youth due to long-term reoperation rates. This systematic review update still highlights the lack of RCTs in this field. The authors are concerned that there may be ethical barriers to RTCs in this field, despite the lack of other effective therapies for severe obesity in children and adolescents and the significant morbidity and premature mortality caused by childhood obesity. Nevertheless, future studies, whether pre-registered and planned non-randomised or pragmatic randomised trials, should assess the impact of the surgical procedure and post-operative care to minimise adverse events, including the need for post-operative adjustments and revisional surgery. Long-term follow-up is also critical to comprehensively assess the impact of surgery as participants enter adulthood.

Comparison of Sleeve Gastrectomy vs Intensive Lifestyle Modification in Patients With a BMI of 30 to Less Than 35

IMPORTANCE

There is a lack of studies evaluating sleeve gastrectomy compared with intensive lifestyle treatment in patients with class 1 obesity (body mass index [BMI] 30 to <35 [calculated as weight in kilograms divided by height in meters squared]).

OBJECTIVE

To compare outcomes and safety of sleeve gastrectomy compared with intensive nonoperative obesity treatment in patients with class 1 obesity.

DESIGN, SETTING, AND PARTICIPANTS

This matched, nationwide cohort study included patients with class 1 obesity who underwent a sleeve gastrectomy or intensive lifestyle treatment between January 1, 2012, and December 31, 2017, and who were registered in the Scandinavian Obesity Surgery Registry or the Itrim health database. Participants with class 1 obesity were matched 1:2 using a propensity score including age, sex, BMI, treatment year, education level, income, cardiovascular disease, and use of antibiotic drugs, antidepressants, and anxiolytics.

INTERVENTIONS

Sleeve gastrectomy or intensive lifestyle treatment.

MAIN OUTCOMES AND MEASURES

Outcomes included weight loss after intervention, changes in metabolic comorbidities, substance use disorders, self-harm, and major cardiovascular events retrieved from the National Patient Register, Prescribed Drug Register, and Cause of Death Register as well as the Scandinavian Obesity Surgery Registry and the Itrim health database. Data were analyzed from December 1, 2021 until May 31, 2022.

RESULTS

The study included 1216 surgery patients and 2432 lifestyle participants with similar mean (SD) BMI (32.8 [1.4] vs 32.9 [1.4]), mean (SD) age (42.4 [9.7] vs 42.6 [12.7] years), and sex (1091 [89.7%] vs 2191 [90.1%] women). Surgery patients had greater 1-year weight loss compared with controls (22.9 kg vs 11.9 kg; mean difference, 10.7 kg; 95% CI, 10.0-11.5 kg; P < .001). Over a median follow-up of 5.1 years (IQR, 3.9-6.2 years), surgery patients had a lower risk of incident use of diabetes drugs (59.7 vs 100.4 events per 10 000 person-years; hazard ratio [HR], 0.60; 95% CI, 0.39-0.92; P = .02) and greater 2-year diabetes drug remission (48.4% vs 22.0%; risk difference 26.4%; 95% CI, 11.7%-41.0%; P < .001), but higher risk for substance use disorder (94 vs 50 events per 10 000 person-years; HR, 1.86; 95% CI, 1.30-2.67; P < .001) and self-harm (45 vs 25 events per 10 000 person-years; HR, 1.81; 95% CI, 1.09-3.01; P = .02). No between-group difference in occurrence of major cardiovascular events was observed (23.4 vs 24.8 events per 10 000 person-years; HR, 0.96; 95% CI, 0.49-1.91; P = .92).

CONCLUSIONS AND RELEVANCE

In this cohort study, compared with intensive nonoperative obesity treatment, sleeve gastrectomy in patients with class 1 obesity was associated with greater weight loss, diabetes prevention, and diabetes remission but a higher incidence of substance use disorder and self-harm.

Remission and Relapse of Hypertension After Bariatric Surgery: A Retrospective Study on Long-Term Outcomes

To compare hypertension remission and relapse after bariatric surgery compared with usual care.

Background

The effect of Roux-en-Y gastric bypass and sleeve gastrectomy on hypertension remission and relapse has not been studied in large, multicenter studies over long periods and using clinical blood pressure (BP) measurements.

Methods

This retrospective cohort study was set in Kaiser Permanente Washington, Northern California, and Southern California. Participants included 9432 patients with hypertension 21-65 years old who underwent bariatric surgery during 2005-2015 and 66,651 nonsurgical controls matched on an index date on study site, age, sex, race/ethnicity, body mass index, comorbidity burden, diabetes status, diastolic and systolic BP, and number of antihypertensive medications.

Results

At 5 years, the unadjusted cumulative incidence of hypertension remission was 60% (95% confidence interval [CI], 58-61%) among surgery patients and 14% (95% CI, 13-14%) among controls. At 1 year, the adjusted hazard ratio for the association of bariatric surgery with hypertension remission was 10.24 (95% CI, 9.61-10.90). At 5 years, the adjusted hazard ratio was 2.10 (95% CI, 1.57-2.80). Among those who remitted, the unadjusted cumulative incidence of relapse at 5 years after remission was 54% (95% CI, 51-56%) among surgery patients and 78% (95% CI 76-79%) among controls, although the adjusted hazard ratio was not significant (hazard ratio, 0.71; 95% CI, 0.46-1.08).

Conclusions

Bariatric surgery was associated with greater hypertension remission than usual care suggesting that bariatric surgery should be discussed with patients with severe obesity and hypertension. Surgical patients who experience remission should be monitored carefully for hypertension relapse.

Medication Use for Obesity-Related Comorbidities After Sleeve Gastrectomy or Gastric Bypass

IMPORTANCE

Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear.

OBJECTIVE

To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021.

EXPOSURES

Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

MAIN OUTCOMES AND MEASURES

The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation.

RESULTS

Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]).

CONCLUSIONS AND RELEVANCE

Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.

Cardio-psycho-metabolic outcomes of bariatric surgery: design and baseline of the WAS trial

Obesity is a rapidly emerging health problem and an established risk factor for cardiovascular diseases. Bariatric surgery profoundly reduces body weight and mitigates sequelae of obesity. The open, randomized controlled Würzburg Adipositas Studie (WAS) trial compares the effects of Roux-en-Y gastric bypass (RYGB) vs psychotherapy-supported lifestyle modification in morbidly obese patients. The co-primary endpoint addresses 1-year changes in cardiovascular function (peak VO2 during cardiopulmonary exercise testing) and the quality of life (QoL) (Short-Form-36 physical functioning scale). Prior to randomization, all included patients underwent a multimodal anti-obesity treatment for 6-12 months. Thereafter, the patients were randomized and followed through month 12 to collect the primary endpoints. Afterwards, patients in the lifestyle group could opt for surgery, and final visit was scheduled for all patients 24 months after randomization. Sample size calculation suggested to enroll 90 patients in order to arrive at minimally 22 patients per group evaluable for the primary endpoint. Secondary objectives were to quantify changes in body weight, left ventricular hypertrophy, systolic and diastolic function (by echocardiography and cardiac MRI), functional brain MRI, psychometric scales, and endothelial and metabolic function. WAS enrolled 93 patients (72 women, median age 38 years, BMI 47.5 kg/m2) exhibiting a relevantly compromised exercise capacity (median peakVO2 18.3 mL/min/kg) and the QoL (median physical functioning scale 50). WAS is the first randomized controlled trial focusing on the effects of RYGB on cardiovascular function beyond hypertension. In addition, it will provide a wealth of high-quality data on the cerebral, psychiatric, hepatic, and metabolic function in obese patients after RYGB.

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.

Hypertension Remission after Colorectal Cancer Surgery: A Single-Center Retrospective Study

The purpose of this study was to evaluate the effect of colorectal cancer surgery on hypertension. Patients who underwent colorectal cancer surgery were retrospectively enrolled. Hypertension before and 1 year after colorectal cancer surgery was recorded. As a result, eighty patients had remission of hypertension, 307 patients had no remission 1 year after colorectal cancer surgery, and the remission rate was 20.7%. In conclusion, patients with concurrent colorectal cancer and hypertension had a 20.7% remission rate 1 year after colorectal cancer surgery. Age, but not the type of surgery, was a predictive factor for the remission of hypertension.

Tendências das cirurgias bariátricas nas Unidades Federativas brasileiras, 2009-2019: um estudo descritivo

RESUMO Objetivo: nosso objetivo é descrever a distribuição epidemiológica das internações e óbitos pós-operatórios, bem como as tendências das cirurgias bariátricas realizadas pelo SUS em todas as unidades federativas (UFs) brasileiras a partir de uma análise do período de 2009 a 2019. Métodos: trata-se de um estudo observacional descritivo ecológico de série temporal com análise quantitativa e descritiva, com base em dados secundários. O período analisado foi de 2009 a 2019. Coletamos, no DATASUS, dados de homens e mulheres que possuem obesidade e foram internados após terem sido submetidos à cirurgia bariátrica. A regressão de Prais-Winsten foi utilizada para identificar as tendências. Resultados: no período, 83.829 cirurgias bariátricas foram realizadas, tendo 161 evoluído para óbitos, o que representa 0,19% dos procedimentos. Encontramos uma tendência crescente no número de cirurgias para o Brasil (β=0,04; p<0,001), mas 11 UFs apresentaram tendência estacionária e três, decrescente (seis UFs não tinham dados suficientes para entrar na análise). Nas regiões Norte e Nordeste prevaleceram tendências estacionárias, enquanto no Centro-Oeste, as decrescentes, e no Sul e Sudeste, as crescentes. Conclusões: encontramos uma evidente disparidade entre as regiões, sugerindo deficiências de acesso à saúde. Ao demonstrar quais UFs e características demográficas apresentam menores índices de cirurgias, nosso estudo é capaz de direcionar políticas públicas para uma saúde pública brasileira mais igualitária.

Bariatric/Metabolic Surgery

Bariatric surgery is a gastro-intestinal surgery aimed at obtaining weight loss in obesity. The rapid metabolic effects of this type of operations provided a rational to change its name to metabolic surgery, in fact often the improvement of metabolic diseases is observed before a meaningful weight reduction.In this review, we examine the effects of laparoscopic metabolic surgery on life expectancy, type 2 diabetes, hypertension, cardiovascular disease and cancer.Furthermore, we review the surgical endoscopy approaches to obesity including primary obesity procedures and revision procedures that address weight regain after bariatric surgery.Finally, as a bridge to the specific chapter, we summarize the effects on weight reduction of new anti-obesity medications.

Is Hypertension Despite Use of Two or More Anti-hypertensive Medications for Patients with a BMI < 40 kg/m2 Justified for Eligibility for Bariatric Surgery?

PURPOSE

Several insurance policies require the presence of hypertension, defined as blood pressure > 140 mmHg systolic (SBP), or 90 mmHg diastolic (DBP), despite concurrent use of >1 anti-hypertensive agents for patients with a BMI <40 kg/m² to qualify for bariatric surgery (BS). The scientific validity of this requirement is assessed.

MATERIAL AND METHODS

A total of 461 patients who underwent BS in a community hospital were included. Systolic (SBP) and diastolic (DBP) blood pressure BP (in mmHg) was assessed by an automated manometer at each office visit until 3 years postoperatively and recorded in a prospectively maintained database.

RESULTS

Thirty-six (7.8%) patients with BMI <40 Kg/m², treated by 1, 2, or three anti-hypertensive medications and BP below 140/90, would have been denied BS under such policies. Number of anti-hypertensive medications had no impact on SBP/DBP control preoperatively. Patients being treated preoperatively with < 3 anti-hypertensive medications had a significantly higher percentage of hypertension resolution at 1 (one-med: 66.2%, two-med: 50.9% vs. three-med: 12.5%, p<.0001), 2 (one-med: 63.9%, two-med: 52.8% vs. three-med: 15.4%, p=.0068), and 3 (one-med: 76.9%, two-med: 52.9% vs. three-med: 20%, p=.005) years postoperatively. Multivariate regression demonstrated a significant correlation between the number of preoperative anti-hypertensive medications, preoperative SBP or DBP, and %TBWL.

CONCLUSION

Patients treated with fewer than 3 anti-hypertensive medications did not have a better BP control preoperatively but were more likely to resolve their hypertension postoperatively. Restricting access to BS of patients with hypertension treated by fewer than 3 anti-hypertensive medications is not supported by this study.

Remission, relapse, and risk of major cardiovascular events after metabolic surgery in persons with hypertension: A Swedish nationwide registry-based cohort study

BACKGROUND

Several studies have shown that metabolic surgery is associated with remission of diabetes and hypertension. In terms of diabetes, factors such as duration, insulin use, weight loss, and age have been shown to contribute to the likelihood of remission. Such factors have not been determined for hypertension. The aim of this study was to evaluate factors associated with the remission and relapse of hypertension after metabolic surgery, as well as the risk for major adverse cardiovascular event (MACE) and mortality in patients with and without remission.

METHODS AND FINDINGS

All adults who underwent metabolic surgery between January 2007 and June 2016 were identified in the nationwide Scandinavian Obesity Surgery Registry (SOReg). Through cross-linkage with the Swedish Prescribed Drug Register, Patient Register, and Statistics Sweden, individual data on prescriptions, inpatient and outpatient diagnoses, and mortality were retrieved. Of the 15,984 patients with pharmacologically treated hypertension, 6,286 (39.3%) were in remission at 2 years. High weight loss and male sex were associated with higher chance of remission, while duration, number of antihypertensive drugs, age, body mass index (BMI), cardiovascular disease, and dyslipidemia were associated with lower chance. After adjustment for age, sex, BMI, comorbidities, and education, the cumulative probabilities of MACEs (2.8% versus 5.7%, adjusted odds ratio (OR) 0.60, 95% confidence interval (CI) 0.47 to 0.77, p < 0.001) and all-cause mortality (4.0% versus 8.0%, adjusted OR 0.71, 95% CI 0.57 to 0.88, p = 0.002) were lower for patients being in remission at 2 years compared with patients not in remission, despite relapse of hypertension in 2,089 patients (cumulative probability 56.3%) during 10-year follow-up. The main limitations of the study were missing information on nonpharmacological treatment for hypertension and the observational study design.

CONCLUSIONS

In this study, we observed an association between high postoperative weight loss and male sex with better chance of remission, while we observed a lower chance of remission depending on disease severity and presence of other metabolic comorbidities. Patients who achieved remission had a halved risk of MACE and death compared with those who did not. The results suggest that in patients with severe obesity and hypertension, metabolic surgery should not be delayed.

Weight-Loss Strategies for Prevention and Treatment of Hypertension: A Scientific Statement From the American Heart Association

Hypertension is a major risk factor for cardiovascular and renal diseases in the United States and worldwide. Obesity accounts for much of the risk for primary hypertension through several mechanisms, including neurohormonal activation, inflammation, and kidney dysfunction. As the prevalence of obesity continues to increase, hypertension and associated cardiorenal diseases will also increase unless more effective strategies to prevent and treat obesity are developed. Lifestyle modification, including diet, reduced sedentariness, and increased physical activity, is usually recommended for patients with obesity; however, the long-term success of these strategies for reducing adiposity, maintaining weight loss, and reducing blood pressure has been limited. Effective pharmacotherapeutic and procedural strategies, including metabolic surgeries, are additional options to treat obesity and prevent or attenuate obesity hypertension, target organ damage, and subsequent disease. Medications can be useful for short- and long-term obesity treatment; however, prescription of these drugs is limited. Metabolic surgery is effective for producing sustained weight loss and for treating hypertension and metabolic disorders in many patients with severe obesity. Unanswered questions remain related to the mechanisms of obesity-related diseases, long-term efficacy of different treatment and prevention strategies, and timing of these interventions to prevent obesity and hypertension-mediated target organ damage. Further investigation, including randomized controlled trials, is essential to addressing these questions, and emphasis should be placed on the prevention of obesity to reduce the burden of hypertensive cardiovascular and kidney diseases and subsequent mortality.

The Impact of Bariatric Surgery Versus Non-Surgical Treatment on Blood Pressure: Systematic Review and Meta-Analysis

The purpose of this study was to compare bariatric surgery versus non-surgical treatment on blood pressure for patients with obesity. Nineteen RCTs (1353 total patients) were included. In the pooled analyses, bariatric surgery reduces more systolic blood pressure (WMD: - 3.937 mmHg, CI95%: - 6.000 to - 1.875, p < 0.001, I² = 0%), diastolic blood pressure (WMD: - 2.690 mmHg, CI95%: - 3.994 to - 1.385, P < 0.001, I² = 0%) and more antihypertensives. In subgroup analyses, patients after Roux-en-Y gastric bypass, with poor control of hypertension (BP > 130/80 mmHg) and diabetes mellitus (HbA1C > 7.0%, FPG > 7.0 mmol/L), elder patients (> 45 years), non-severe obesity (BMI < 40 kg/cm², body weight < 120 kg), less waist circumference (< 115 cm) tend to decrease more blood pressure. Besides, patients after surgery also lost more weight (p < 0.001), decreased more waist circumference (p < 0.001), fasting plasma glucose (p < 0.001), glycosylated hemoglobin (p < 0.001), triglycerides (p < 0.001), hsCRP (p = 0.001), increased more high-density lipoprotein cholesterol (p < 0.001), and had better remission of metabolic syndrome (p < 0.001). Changes in total cholesterol, low-density lipoprotein cholesterol, renal function, resting heart rate, and 6-min walking test were not significantly different. Therefore, bariatric surgery is more effective than non-surgical treatment in controlling patients' blood pressure.

Comparative Effectiveness of Gastric Bypass and Vertical Sleeve Gastrectomy for Hypertension Remission and Relapse: The ENGAGE CVD Study

Weight loss is an effective strategy for the management of hypertension, and bariatric surgery is the most effective weight loss and maintenance strategy for obesity. The importance of bariatric surgery in the long-term management of hypertension and which operation is most effective is less clear. We compared the effectiveness of vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) for remission and relapse of hypertension after surgery in the ENGAGE CVD cohort study (Effectiveness of Gastric Bypass Versus Gastric Sleeve for Cardiovascular Disease). Operations were done by 23 surgeons across 9 surgical practices. Hypertension remission and relapse were assessed in each year of follow-up beginning 30 days and up to 5 years postsurgery. We used a local instrumental variable approach to account for selection bias in the choice of VSG or RYGB. The study population included 4964 patients with hypertension at the time of surgery (n=3186 VSG and n=1778 RYGB). At 1 year, 27% of patients with RYGB and 28% of patients with VSG achieved remission. After 5 years, without accounting for relapse, 42% of RYGB and 43% of VSG patients had experienced hypertension remission. After accounting for relapse, only 17% of RYGB and 18% of VSG patients remained in remission 5 years after surgery. There were no statistically significant differences between VSG and RYGB for hypertension remission, relapse, or mean systolic and diastolic blood pressure at any time during follow-up.

Comparative Effectiveness of Roux-en-Y Gastric Bypass vs. One Anastomosis Gastric Bypass on Kidney Function

PURPOSE

Obesity and its associated medical problems increase risk of kidney function decline while prior studies suggest that bariatric surgery may improve kidney outcomes. However, little is known about the comparative effectiveness of different types of bariatric surgery on kidney function. In this study, we compare the effects of laparoscopic one anastomosis gastric bypass (LOAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) on kidney function one year after surgery.

MATERIALS AND METHODS

The patients' demographic, medical, and surgical data were prospectively collected and retrospectively reviewed. Type 2 diabetes mellitus, hypertension, and dyslipidemia, body mass index (BMI), and kidney function tests were obtained before and one year after surgery. Kidney function was evaluated by estimated glomerular filtration rate (eGFR) and spot urine albumin to creatinine ratio (ACR). Changes in eGFR and ACR were compared between LRYGB vs. LOAGB after adjustment for confounders (age, sex, remission of associated medical problems, preoperative BMI, and percentage of excess BMI loss) using ANCOVA model.

RESULTS

Both surgical techniques significantly decreased the post-surgery presence of diabetes, hypertension, and dyslipidemia (p < 0.001 for all paired comparisons). The eGFR level significantly increased and the ACR level significantly decreased in both groups (p < 0.001 for all paired comparisons before and after adjustment). However, eGFR and ACR mean differences between LRYGB and LOAGB were not significantly different after adjustment for confounding variables (p = 0.9 and 0.4, respectively).

CONCLUSION

Both LOAGB and LRYGB improved 1-year eGFR and ACR equally independently from weight loss and other confounders.

Three-year effects of bariatric surgery on obstructive sleep apnea in patients with obesity grade 1 and 2: a sub-analysis of the GATEWAY trial

BACKGROUND

Most of the evidence on bariatric surgery on obstructive sleep apnea (OSA) is based on observational studies and/or short-term follow-up in patients with obesity grade 3.

SUBJECTS/METHODS

This randomized study compared the effects of roux-en-Y gastric bypass (RYGB) or usual care (UC) on OSA severity in patients with obesity grade 1-2. Mild, moderate, and severe OSA was defined by the apnea-hypopnoea index (AHI): 5-14.9; 15-29.9, and ≥30 events/h, respectively. OSA remission was defined by converting any form of OSA into normal AHI (<5 events/h).

RESULTS

After 3-year of follow-up, the body-mass index increased in the UC while decreased in the RYGB group: +1.7 (-1.9; 2.7) versus -10.6 (-12.7; -9.2) kg/m², respectively. The AHI increased by 5 (-4.2; 12.7) in the UC group while reduced in the RYGB group to -13.2 (-22.7; -7) events/h. UC significantly increase the frequency of moderate OSA (from 15.4 to 46.2%). In contrast, RYGB had a huge impact on reaching no OSA status (from 4.2 to 70.8%) in parallel to a decrease of moderate (from 41.7 to 8.3%) and severe OSA (from 20.8 to 0%).

CONCLUSIONS

RYGB is an attractive strategy for mid-term OSA remission or decrease moderate-to-severe forms of OSA in patients with obesity grade 1-2.