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Nunes VS, de Campos EVS, Baracat J, França V, Gomes ÉIL, Coelho RP, Nakandakare ER, Zago VHS, de Faria EC, Quintão ECR. Plasma Campesterol Is Positively Associated with Carotid Plaques in Asymptomatic Subjects. Int J Mol Sci 2022; 23:ijms231911997. [PMID: 36233298 PMCID: PMC9569444 DOI: 10.3390/ijms231911997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Increased cholesterol absorption and reduced synthesis are processes that have been associated with cardiovascular disease risk in a controversial way. However, most of the studies involving markers of cholesterol synthesis and absorption include conditions, such as obesity, diabetes, dyslipidemia, which can be confounding factors. The present study aimed at investigating the relationships of plasma cholesterol synthesis and absorption markers with cardiovascular disease (CVD) risk factors, cIMT (carotid intima-media thickness), and the presence of carotid plaques in asymptomatic subjects. METHODS A cross-sectional study was carried out in 270 asymptomatic individuals and anthropometrical parameters, fasting plasma lipids, glucometabolic profiles, high-sensitivity C-reactive protein (hs-CRP), markers of cholesterol synthesis (desmosterol and lathosterol), absorption (campesterol and sitosterol), cIMT, and the presence of atherosclerotic plaques were analyzed. RESULTS Among the selected subjects aged between 19 and 75 years, 51% were females. Age, body mass index, systolic and diastolic blood pressure, total cholesterol, non-HDL-C, triglycerides, glucose, and lathosterol/sitosterol ratios correlated positively with cIMT (p ≤ 0.05). Atherosclerotic plaques were present in 19% of the subjects. A direct association of carotid plaques with campesterol, OR = 1.71 (95% CI = 1.04-2.82, p ≤ 0.05) and inverse associations with both ratios lathosterol/campesterol, OR = 0.29 (CI = 0.11-0.80, p ≤ 0.05) and lathosterol/sitosterol, OR = 0.45 (CI = 0.22-0.95, p ≤ 0.05) were observed in univariate logistic regression analysis. CONCLUSIONS The findings suggested that campesterol may be associated with atherosclerotic plaques and the lathosterol/campesterol or sitosterol ratios suggested an inverse association. Furthermore, synthesis and absorption of cholesterol are inverse processes, and the absorption marker, campesterol, may reflect changes in body cholesterol homeostasis with atherogenic potential.
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Affiliation(s)
- Valéria Sutti Nunes
- Laboratorio de Lipides (LIM10), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 01246-900, SP, Brazil
| | - Edite Vieira Silva de Campos
- Lipid Laboratory and Center for Medicine and Experimental Surgery, Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, SP, Brazil
| | - Jamal Baracat
- Faculty of Medical Sciences, Department of Radiology, Hospital of Clinics, State University of Campinas (UNICAMP), Campinas 13083-888, SP, Brazil
| | - Victor França
- Lipid Laboratory and Center for Medicine and Experimental Surgery, Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, SP, Brazil
| | - Érica Ivana Lázaro Gomes
- Lipid Laboratory and Center for Medicine and Experimental Surgery, Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, SP, Brazil
| | - Raissa Peres Coelho
- Lipid Laboratory and Center for Medicine and Experimental Surgery, Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, SP, Brazil
| | - Edna Regina Nakandakare
- Laboratorio de Lipides (LIM10), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 01246-900, SP, Brazil
| | - Vanessa Helena Souza Zago
- Centro de Ciências da Vida, Pontifical Catholic University of Campinas, Campinas 13034-68, SP, Brazil
| | - Eliana Cotta de Faria
- Lipid Laboratory and Center for Medicine and Experimental Surgery, Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, SP, Brazil
| | - Eder Carlos Rocha Quintão
- Laboratorio de Lipides (LIM10), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 01246-900, SP, Brazil
- Correspondence: ; Tel.: +55-11-3061-7263
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Chen F, Liu B. Sleeve gastrectomy suppresses hepatic de novo cholesterogenesis and improves hepatic cholesterol accumulation in obese rats with type 2 diabetes mellitus. Nutrition 2022; 94:111531. [PMID: 34952362 DOI: 10.1016/j.nut.2021.111531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Cholesterol metabolic disturbance increases the risk of various acquired diseases and affects public health. An apparent correlation between hypercholesterolemia and type 2 diabetes mellitus (T2DM) was confirmed recently. Bariatric surgery can induce durable and sufficient loss of body weight and T2DM remission. A previous study illustrated a cholesterol-lowering effect of sleeve gastrectomy (SG), but the intrinsic mechanism is still elusive. The present study aimed to investigate the effects of SG on hypercholesterolemia and hepatic cholesterol accumulation in a T2DM rat model. METHODS Obese rats with T2DM were randomly subjected to sham operation, sham operation combined with food restriction, or SG. Body weight, food intake, blood glucose, body composition, and cholesterol level were measured at the indicated time points. Subsequently, hepatic cholesterol content and both protein and transcriptional levels of sterol regulatory element-binding protein 2, 3-hydroxy-3-methylglutaryl-coenzyme A reductase, and low-density lipoprotein receptor were measured at 2 and 4 wk postoperatively. RESULTS SG rapidly reduced blood glucose independent of loss of body weight and food restriction. Rats that underwent SG exhibited lower total cholesterol and free cholesterol in both serum and liver. The cholesterol-lowering effect was independent of loss of body weight and food restriction at just 2 wk postoperatively. Protein and mRNA expression of sterol regulatory element-binding protein 2, 3-hydroxy-3-methylglutaryl-coenzyme A reductase, and low-density lipoprotein receptor were inhibited at 2 wk postoperatively and recovered by 4 wk after SG. CONCLUSION SG alleviated hypercholesterolemia and hepatic cholesterol accumulation partially by inhibiting hepatic de novo cholesterogenesis.
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Affiliation(s)
- Fu Chen
- Department of General Surgery, Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Bingyang Liu
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, China.
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Iqbal Z, Adam S, Ho JH, Syed AA, Ammori BJ, Malik RA, Soran H. Metabolic and cardiovascular outcomes of bariatric surgery. Curr Opin Lipidol 2020; 31:246-256. [PMID: 32618731 DOI: 10.1097/mol.0000000000000696] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Bariatric surgery is an effective therapy for morbid obesity that also improves weight-related metabolic parameters and reduces morbidity and mortality. The purpose of this review is to consolidate our current understanding of metabolic, macrovascular and microvascular benefits of bariatric surgery and to provide an update. RECENT FINDINGS Early resolution of insulin resistance and type 2 diabetes mellitus (T2DM) varies by type of bariatric surgery and appears to be mediated by changes in secretion of gut hormones, metabolism of bile acids, expression of glucose transporters and the gut microbiome. Dyslipidaemia, atherosclerosis, microvascular complications of obesity and diabetes, systemic and tissue-level inflammation show evidence of regression and hypertension improves significantly after bariatric surgery. SUMMARY Bariatric surgery leads to improvements in obesity-related metabolic comorbidities such as dyslipidaemia, HDL functionality, hypertension, T2DM, insulin resistance and inflammation. It slows the atherosclerotic process and reduces cardiovascular and all-cause mortality. Recent data have demonstrated regression of the microvascular complications of obesity and diabetes including the regeneration of small nerve fibres. The magnitude of change in short-term metabolic effects depends on the surgical procedure whilst longer term effects are related to the amount of sustained excess weight loss.
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Affiliation(s)
- Zohaib Iqbal
- Faculty of Biology, Medicine and Health, University of Manchester
- Cardiovascular Trials Unit, Manchester University NHS Foundation Trust
| | - Safwaan Adam
- Faculty of Biology, Medicine and Health, University of Manchester
- The Christie Hospital NHS Foundation Trust, Manchester
| | - Jan H Ho
- Faculty of Biology, Medicine and Health, University of Manchester
- Cardiovascular Trials Unit, Manchester University NHS Foundation Trust
| | - Akheel A Syed
- Faculty of Biology, Medicine and Health, University of Manchester
- Department of Diabetes, Endocrinology and Obesity Medicine
| | - Basil J Ammori
- Faculty of Biology, Medicine and Health, University of Manchester
- Department of Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Rayaz A Malik
- Faculty of Biology, Medicine and Health, University of Manchester
- Weill-Cornell Medicine-Qatar, Doha, Qatar
| | - Handrean Soran
- Faculty of Biology, Medicine and Health, University of Manchester
- The Christie Hospital NHS Foundation Trust, Manchester
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Ministrini S, Fattori C, Ricci MA, Bianconi V, Paltriccia R, Boni M, Paganelli MT, Vaudo G, Lupattelli G, Pasqualini L. Microcirculatory Improvement Induced by Laparoscopic Sleeve Gastrectomy Is Related to Insulin Sensitivity Retrieval. Obes Surg 2019; 28:3151-3158. [PMID: 29752665 DOI: 10.1007/s11695-018-3290-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS Microvascular dysfunction is a potential factor explaining the association of obesity, insulin resistance, and vascular damage in morbidly obese subjects. The purpose of the study was to evaluate possible determinants of microcirculatory improvement 1 year after laparoscopic sleeve gastrectomy (LSG) intervention. METHODS Thirty-seven morbidly obese subjects eligible for bariatric surgery were included in the study. Post-occlusive reactive hyperemia (PORH) of the forearm skin was measured as area of hyperemia (AH) by laser-Doppler flowmetry before LSG and after a 1-year follow-up. RESULTS After intervention, we observed a significant reduction in BMI, HOMA index, HbA1c, and a significant increase of AH in all patients after surgery; this variation was significant only in those patients having insulin resistance or prediabetes/diabetes. Although significant correlation between the increase of AH and the reduction of both BMI, HOMA index, and HbA1c was observed, BMI was the only independent predictor of AH variation after LSG at the linear regression analysis. CONCLUSIONS Our study shows that LSG intervention is correlated with a significant improvement in the microvascular function of morbidly obese subjects; this improvement seems to be related to the baseline degree of insulin-resistance and to the retrieval of insulin-sensitivity post-intervention.
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Affiliation(s)
- Stefano Ministrini
- Department of Medicine, Università degli Studi di Perugia, Perugia, Italy.
| | - Chiara Fattori
- Department of Medicine, Università degli Studi di Perugia, Perugia, Italy
| | | | - Vanessa Bianconi
- Department of Medicine, Università degli Studi di Perugia, Perugia, Italy
| | - Rita Paltriccia
- Department of Medicine, Università degli Studi di Perugia, Perugia, Italy
| | - Marcello Boni
- General Surgery, ASL Umbria2, "S.Giovanni Battista" Hospital, Foligno, PG, Italy
| | | | - Gaetano Vaudo
- Department of Medicine, Università degli Studi di Perugia, Perugia, Italy
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Increased plasmatic NETs by-products in patients in severe obesity. Sci Rep 2019; 9:14678. [PMID: 31604985 PMCID: PMC6789039 DOI: 10.1038/s41598-019-51220-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022] Open
Abstract
Neutrophil extracellular traps (NETs) are DNAs products involved in immune process. Obesity through a low-grade chronic inflammation determines neutrophil activation, but it is still unclear its role in NETs formation. Here we analyzed the NETs levels in healthy and morbid obese, their association with anthropometric and glyco-metabolic parameters and their changes after bariatric surgery. For this study, we enrolled 73 patients with morbid obesity (BMI ≥40 kg/m2 or ≥35 kg/m2 + comorbidity) eligible to sleeve gastrectomy. In parallel, 55 healthy subjects and 21 patients with severe coronary artery disease were studied as controls. We evaluated anthropometric parameters, peripheral blood pressure, biochemical and serum analysis at the enrollment and at twelve months after surgery. Plasmatic levels of MPO-DNA complexes were assessed by ELISA. NETs levels were higher in obese than in control group (p < 0.001) and correlated with the main anthropometric variable (BMI, waist, hip), glyco-metabolic variables and systolic blood pressure. NETs trend after intervention was uneven. The reduction of NETs correlated with the entity of reduction of BMI (ρ = 0.416, p < 0.05), visceral fat area (ρ = 0.351, p < 0.05), and glycemia (ρ = 0.495, p < 0.001). In medical history of patients in whom NETs increased, we observed a higher number of thromboembolic events. Our observations indicate that severe obesity is associated with increased generation of NETs, which in turn could influence the patients' systemic inflammatory state. Weight loss and in particular, loss of adipose tissue after bariatric surgery does not in itself correct NET's dysregulated production. Finally, patients in whom NETs accumulation persists after surgery are probably those at the highest risk of cardiovascular events.
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Shamim AA, Gibbs KE, Afthinos JN. Comment on: Potential mechanisms of sleeve gastrectomy for reducing body weight and improving metabolism in patients with obesity. Surg Obes Relat Dis 2019; 15:1871-1872. [PMID: 31588006 DOI: 10.1016/j.soard.2019.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/24/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Adeel A Shamim
- Department of Surgery, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Karen E Gibbs
- Department of Surgery, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - John N Afthinos
- Department of Surgery, Long Island Jewish Forest Hills, Northwell Health, Forest Hills, New York
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Non-Cholesterol Sterol Concentrations as Biomarkers for Cholesterol Absorption and Synthesis in Different Metabolic Disorders: A Systematic Review. Nutrients 2019; 11:nu11010124. [PMID: 30634478 PMCID: PMC6356200 DOI: 10.3390/nu11010124] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/21/2018] [Accepted: 12/28/2018] [Indexed: 12/27/2022] Open
Abstract
Non-cholesterol sterols are validated biomarkers for intestinal cholesterol absorption and endogenous cholesterol synthesis. However, their use in metabolic disturbances has not been systematically explored. Therefore, we conducted a systematic review to provide an overview of non-cholesterol sterols as markers for cholesterol metabolism in different metabolic disorders. Potentially relevant studies were retrieved by a systematic search of three databases in July 2018 and ninety-four human studies were included. Cholesterol-standardized levels of campesterol, sitosterol and cholestanol were collected to reflect cholesterol absorption and those of lathosterol and desmosterol to reflect cholesterol synthesis. Their use as biomarkers was examined in the following metabolic disorders: overweight/obesity (n = 16), diabetes mellitus (n = 15), metabolic syndrome (n = 5), hyperlipidemia (n = 11), cardiovascular disease (n = 17), and diseases related to intestine (n = 16), liver (n = 22) or kidney (n = 2). In general, markers for cholesterol absorption and synthesis displayed reciprocal patterns, showing that cholesterol metabolism is tightly regulated by the interplay of intestinal absorption and endogenous synthesis. Distinctive patterns for cholesterol absorption or cholesterol synthesis could be identified, suggesting that metabolic disorders can be classified as 'cholesterol absorbers or cholesterol synthesizers'. Future studies should be performed to confirm or refute these findings and to examine whether this information can be used for targeted (dietary) interventions.
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Mika A, Kaczynski Z, Stepnowski P, Kaczor M, Proczko-Stepaniak M, Kaska L, Sledzinski T. Potential Application of 1H NMR for Routine Serum Lipidome Analysis -Evaluation of Effects of Bariatric Surgery. Sci Rep 2017; 7:15530. [PMID: 29138414 PMCID: PMC5686116 DOI: 10.1038/s41598-017-15346-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 10/25/2017] [Indexed: 12/23/2022] Open
Abstract
Routine laboratory lipid assays include simple measurements of total cholesterol, triacylglycerols and HDL. However, lipids are a large group of compounds involved in many metabolic pathways, and their alterations may have serious health consequences. In this study, we used 1H NMR to analyze lipids extracted from sera of 16 obese patients prior to and after bariatric surgeries. We observed a post-surgery decrease in serum concentrations of lipids from various groups. The hereby presented findings imply that 1H NMR is suitable for rapid, simple and non-invasive detection of lipids from 30 structural groups, among them triacylglycerols, phosphatidylcholine, phosphatidylethanolamine, sphingomyelin, total phospholipids, total, free and esterified cholesterol, total and unsaturated fatty acids. NMR-based analysis of serum lipids may contribute to a substantial increase in the number of routinely determined markers from this group; therefore, it may find application in clinical assessment of obese subjects prior to and after bariatric surgeries, as well as in the examination of patients with other metabolic diseases.
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Affiliation(s)
- Adriana Mika
- Department of Environmental Analysis, Faculty of Chemistry, University of Gdansk, Wita Stwosza 63, 80-308, Gdansk, Poland.
- Department of Pharmaceutical Biochemistry, Medical University of Gdansk, Debinki 1, 80-211, Gdansk, Poland.
| | - Zbigniew Kaczynski
- Faculty of Chemistry, University of Gdansk, Wita Stwosza 63, 80-308, Gdansk, Poland
| | - Piotr Stepnowski
- Department of Environmental Analysis, Faculty of Chemistry, University of Gdansk, Wita Stwosza 63, 80-308, Gdansk, Poland
| | - Maciej Kaczor
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Lukasz Kaska
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Tomasz Sledzinski
- Department of Pharmaceutical Biochemistry, Medical University of Gdansk, Debinki 1, 80-211, Gdansk, Poland
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Busetto L, Dicker D, Azran C, Batterham RL, Farpour-Lambert N, Fried M, Hjelmesæth J, Kinzl J, Leitner DR, Makaronidis JM, Schindler K, Toplak H, Yumuk V. Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management. Obes Facts 2017; 10:597-632. [PMID: 29207379 PMCID: PMC5836195 DOI: 10.1159/000481825] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/21/2017] [Indexed: 12/17/2022] Open
Abstract
Bariatric surgery is today the most effective long-term therapy for the management of patients with severe obesity, and its use is recommended by the relevant guidelines of the management of obesity in adults. Bariatric surgery is in general safe and effective, but it can cause new clinical problems and is associated with specific diagnostic, preventive and therapeutic needs. For clinicians, the acquisition of special knowledge and skills is required in order to deliver appropriate and effective care to the post-bariatric patient. In the present recommendations, the basic notions needed to provide first-level adequate medical care to post-bariatric patients are summarised. Basic information about nutrition, management of co-morbidities, pregnancy, psychological issues as well as weight regain prevention and management is derived from current evidences and existing guidelines. A short list of clinical practical recommendations is included for each item. It remains clear that referral to a bariatric multidisciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations.
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Affiliation(s)
- Luca Busetto
- Department of Internal Medicine, University of Padova, Padova, Italy
- *Prof. Dr. Luca Busetto, Clinica Medica 3, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy,
| | - Dror Dicker
- Department of Internal Medicine D and Obesity Clinic, Hasharon Hospital, Rabin Medical Center, Petah Tikva, Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Carmil Azran
- Clinical Pharmacy, Herzliya Medical Center, Herzliya, Israel
| | - Rachel L. Batterham
- Centre for Obesity Research, Rayne Institute, Department of Medicine, University College London, London, UK
- University College London Hospital Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital, London, UK
- National Institute of Health Research, University College London Hospital Biomedical Research Centre, London, UK
| | - Nathalie Farpour-Lambert
- Obesity Prevention and Care Program Contrepoids, Service of Therapeutic Education for Chronic Diseases, Department of Community Medicine, Primary Care and Emergency, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Martin Fried
- OB Klinika, Centre for Treatment of Obesity and Metabolic Disorders, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jøran Hjelmesæth
- Morbid Obesity Centre, Vestfold Hospital Trust and Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johann Kinzl
- Department of Psychiatry and Psychotherapy II, Medical University Innsbruck, Innsbruck, Austria
| | | | - Janine M. Makaronidis
- Centre for Obesity Research, Rayne Institute, Department of Medicine, University College London, London, UK
- National Institute of Health Research, University College London Hospital Biomedical Research Centre, London, UK
| | - Karin Schindler
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Hermann Toplak
- Department of Medicine, Medical University Graz, Graz, Austria
| | - Volkan Yumuk
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
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