Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up

Weight loss benefits on HDL cholesterol persist even after weight regaining

BACKGROUND

Obesity-related comorbidities may relapse in patients with weight regain after bariatric surgery. However, HDL cholesterol (HDLc) levels increase after surgery and seem to remain stable despite a gradual increase in BMI. The aim of this study is to analyze the effects of weight regain after bariatric surgery on HDL cholesterol.

MATERIALS AND METHODS

This is a retrospective, observational, cohort study in patients who underwent bariatric surgery in the Hospital de la Santa Creu i Sant Pau (Barcelona) between 2007 and 2015. Patients without at least 5 years of follow-up after surgery, under fibrate treatment, and those who required revisional surgery were excluded from the analysis. Data were collected at baseline, 3 and 6 months after surgery, and then annually until 5 years post-surgery.

RESULTS

One hundred fifty patients were analyzed. 93.3% of patients reached > 20% of total weight loss after surgery. At 5th year, 37% of patients had regained > 15% of nadir weight, 60% had regained > 10%, and 22% had regained < 5% of nadir weight. No differences were found in HDLc levels between the different groups of weight regain, nor in the % of change in HDLc levels between nadir weight and 5 years, or in the proportion of patients with normal HDLc concentrations either.

CONCLUSION

HDLc remains stable regardless of weight regain after bariatric surgery.

Utilization of Anti-obesity Medications After Bariatric Surgery: Analysis of a Large National Database

PURPOSE

A significant proportion of patients experience insufficient weight loss or weight regain after bariatric surgery. There is a paucity of literature describing anti-obesity medication (AOM) use following bariatric surgery. We sought to identify prevalence and trends of AOM use following bariatric surgery.

MATERIALS AND METHODS

We utilized the IBM Explorys® database to identify all adults with prior bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy). Those prescribed AOMs (semaglutide, liraglutide, topiramate, phentermine/topiramate, naltrexone/bupropion, orlistat) within 5 years of surgery were further identified. Data was analyzed to characterize AOM utilization among different age, demographic, and comorbid populations.

RESULTS

A total of 59,160 adults with prior bariatric surgery were included. Among AOMs studies, prevalence of use was highest for topiramate (8%), followed by liraglutide (2.9%), phentermine/topiramate (1.03%), naltrexone/bupropion (0.95%) semaglutide (0.52%), and orlistat (0.17%). Age distribution varied, with the highest utilization among those age 35-39 years for topiramate, 40-44 years for phentermine/topiramate and naltrexone/bupropion, 45-49 years for semaglutide, and 65-69 years for liraglutide and orlistat. African American race was associated with higher utilization across all AOMs. Among comorbidities, hypertension, hyperlipidemia, and diabetes mellitus were most associated with AOM use.

CONCLUSION

Despite a relatively high incidence of weight regain, AOMs are underutilized following bariatric surgery. It is imperative that barriers to their use be addressed and that AOMs be considered earlier and more frequently in patients with insufficient weight loss or weight regain after bariatric surgery.

Efficacy of High-dose Liraglutide 3.0 mg in Patients with Poor Response to Bariatric Surgery: Real-world Experience and Updated Meta-analysis

PURPOSE

Poor response to bariatric surgery, characterized by insufficient weight loss (IWL) or weight regain (WR), poses a significant challenge in obesity treatment. This study aims to assess the effectiveness of liraglutide in addressing this issue.

MATERIALS AND METHODS

A retrospective, multicenter cohort study investigated the impact of liraglutide 3 mg on weight loss in adults with suboptimal responses or weight regain after bariatric surgery (BS). Additionally, a systematic review and meta-analysis were conducted for a comprehensive evaluation.

RESULTS

A total of 119 patients (mean age 41.03 ± 11.2 years, 71.4% female) who experienced IWL or WR after BS received pharmacologic therapy with liraglutide 3 mg. Mean percent weight loss in the entire cohort was 5.6 ± 2.6% at 12 weeks and 9.3 ± 3.6% at 24 weeks with a significant reduction in waist circumference (p < 0.0001). No serious side effects were reported. A meta-analysis, utilizing the fixed effect model with the metafor package in R, included 6 and 5 papers for the change in body weight and BMI after liraglutide treatment, respectively. The analysis demonstrated a considerable reduction in body weight (7.9; CI - 10.4; - 5.4, p < 0.0001) and BMI (3.09; CI 3.89; - 2.28, p < 0.0001).

CONCLUSION

Liraglutide 3 mg emerges as a viable option for significant weight loss in patients experiencing IWL or WR after BS. Its inclusion in a multimodal, sequential obesity treatment approach proves promising.

High-dose liraglutide improves metabolic syndrome in poor responders to bariatric surgery

Background

Bariatric surgery (BS) represents the most effective therapy for obesity class III, or class II with at least one weight-related comorbidity. However, some patients have insufficient weight loss or clinically relevant weight regain after a successful primary procedure. This study aimed to assess the efficacy of liraglutide treatment on weight loss, body composition and improvement of metabolic syndrome (MS) in patients defined as poor responders after BS.

Methods

The study involved 59 non-diabetic adults with obesity (M/F: 17/42, age: 38.6 ± 11.8 years, BMI 38.3 ± 5.5 kg/m2) who had been treated with BS and experienced a poor response, categorized as either IWL (insufficient weight loss) or WR (weight regain). All patients were prescribed pharmacological therapy with liraglutide and attended nutritional counseling. Anthropometric and clinical measurements, body composition and the presence of MS defined according to the ATP-III classification were evaluated before starting liraglutide and after 24 weeks of treatment.

Results

After 24 weeks of treatment with liraglutide, the mean weight loss was 8.4% ± 3.6% with no difference between gender, bariatric procedure, or type of poor response (IWL or WR). A significant decrease in fat mass, free-fat mass and total body water was documented. After 24 weeks, patients presented significantly lowered fasting glucose, total cholesterol, triglycerides, AST and ALT. The prevalence of MS was reduced from 35% at baseline to 1.6% after 24 weeks. No patients discontinued the treatment during the study.

Conclusion

In patients who experience poor response after BS, liraglutide is well tolerated and promotes significant weight loss, ameliorates cardiometabolic comorbidities, and reduces the prevalence of MS.

Weight Regain After Bariatric Surgery: Scope of the Problem, Causes, Prevention, and Treatment

PURPOSE OF REVIEW

Although bariatric surgery is the most effective treatment of severe obesity, a proportion of patients experience clinically significant weight regain (WR) with further out from surgery. The purpose of this review is to summarize the prevalence, predictors, and causes of weight regain.

RECENT FINDINGS

Estimating the prevalence of WR is limited by a lack of consensus on its definition. While anatomic failures such as dilated gastric fundus after sleeve gastrectomy and gastro-gastric fistula after Roux-en-Y gastric bypass can lead to WR, the most common causes appear to be dysregulated/maladaptive eating behaviors, lifestyle factors, and physiological compensatory mechanisms. To date, dietary, supportive, behavioral, and exercise interventions have not demonstrated a clinically meaningful impact on WR, and there is limited evidence for pharmacotherapy. Future studies should be aimed at better defining WR to begin to understand the etiologies. Additionally, there is a need for non-surgical interventions with demonstrated efficacy in rigorous randomized controlled trials for the prevention and reversal of WR after bariatric surgery.

Scores for Predicting Diabetes Remission in Bariatric Surgery: a Systematic Review and Meta-analysis

This systematic review aims to compare the accuracy of pre-existent scores predicting diabetes remission after bariatric and metabolic surgery. Among the scores, DiaBetter presented the largest area under the curve (AUC) (0.87; 95% CI, 0.84-0.9). Ad-DiaRem had the lowest AUC (0.79; 95% CI, 0.76-0.83). Ad-DiaRem showed the highest sensitivity (91%; 95% CI, 86-96%), with a specificity of 71.23% (95% CI 50.43 to 92.06%). IMS showed a sensitivity of 59% (95% CI, 20-90%), with the highest specificity (86%; 95% CI, 69-94%). Clinicians should associate the findings of the present review with patients' individual characteristics to help predict diabetes remission and evaluate the probability of the patient benefit from surgery.

Development and Validation of Dietary Behavior Inventory-Surgery (DBI-S) in the Scope of International Post-Bariatric Surgery Guidelines and Recommendations

(1) Dietary behavior is highly relevant for patients after bariatric surgery. No instrument exists assessing adherence to medical guidelines concerning the dietary behavior of patients after bariatric surgery. The aim of this study was to develop and validate such an instrument. (2) Data from patients after bariatric surgery (n = 543) were collected from March to May 2022. The development of the DBI-S was theory-based and interdisciplinary. Items’ and content validity of the DBI-S were examined. (3) The final version of the DBI-S consists of 13 items. Convergent validation was confirmed by significant correlations between DBI-S score and attitude towards healthy food (r = 0.26, p = <0.001) and impulsivity (r = −0.26, p = <0.001). Criterion validity was confirmed by significant correlations between DBI-S score and pre-/post-surgery BMI difference (r = −0.14, p = 0.002), pre-/post-surgery weight difference (r = 0.13, p = 0.003), and quality of life (r = 0.19, p = <0.001). Cluster analysis confirmed the ability to distinguish between two dietary behavior clusters (rather healthy and rather unhealthy). (4) The DBI-S is an economic and valid instrument to assess the adherence of post-bariatric surgery patients to the relevant dietary behavior recommendations and guidelines and can distinguish between rather unhealthy and healthy dietary behavior.

A systematic review of interventions to increase physical activity and reduce sedentary behaviour following bariatric surgery

Background

Objectives

Eligibility

Study appraisal and synthesis methods

Results

Limitations

Conclusion and implications of key findings

Systematic review registration number

PARIS: protocol for a prospective single arm, theory-based, group-based feasibility intervention study to increase Physical Activity and reduce sedentary behaviouR after barIatric Surgery

INTRODUCTION

Increased physical activity and reduced sedentary behaviour can encourage favourable outcomes after bariatric surgery. However, there is a lack of evidence as to how to support patients with behaviour change. The aim of this study is to assess the feasibility of a physiotherapist led, online group-based behaviour change intervention to increase physical activity and reduce sedentary behaviour following bariatric surgery.

METHODS AND ANALYSIS

Single arm feasibility study of a theory and evidence-based group behaviour change intervention based on the Behaviour Change Wheel and Theoretical Domains Framework using behaviour change techniques from the Behaviour Change Technique Taxonomy v1. The intervention has eight objectives and specifies behaviour change techniques that will be used to address each of these. Groups of up to eight participants who have had surgery within the previous 5 years will meet weekly over 6 weeks for up to 1½ hours. Groups will be held online led by a physiotherapist and supported by an intervention handbook. Feasibility study outcomes include: rate of recruitment, retention, intervention fidelity, participant engagement and acceptability. Secondary outcomes include: physical activity, sedentary behaviour, body composition, self-reported health status and will be analysed descriptively. Change in these outcomes will be used to calculate the sample size for a future evaluation study. Qualitative interviews will explore participants' views of the intervention including its acceptability. Data will be analysed according to the constant comparative approach of grounded theory.

ETHICS AND DISSEMINATION

This study has National Health Service Research Ethics Committee approval; Haydock 20/NW/0472. All participants will provide informed consent and can withdraw at any point. Findings will be disseminated through peer-reviewed journals, conference and clinical service presentations.

TRIAL REGISTRATION NUMBER

ISRCTN31524689.

Meta-analysis of Long-Term Relapse Rate of Type 2 Diabetes Following Initial Remission After Roux-en-Y Gastric Bypass

This study aims to determine the long-term relapse rate of type 2 diabetes (T2DM) following initial remission after Roux-en-Y gastric bypass (RYGB) surgery. We searched studies in PubMed, Embase, and the Cochrane Library. A total of 17 eligible studies were included for analysis. Meta-analysis suggested a pooled long-term relapse rate of 0.30 (95% confidence interval [CI], 0.26–0.34) and a remission rate of 0.63 (95% CI, 0.55–0.72) after RYGB and a hazard ratio of 0.73 (95% CI, 0.66–0.81) for comparison of RYGB and sleeve gastrectomy (SG). Subgroup analyses established pooled results. This study suggested RYGB may be a preferred regime for obese patients with T2DM because it is associated with lower long-term relapse and relatively higher initial remission and was also superior to SG due to lower risk of recurrence.

Type 2 diabetes and metabolic surgery guidelines and recommendations should urgently be unified

Metabolic surgery has been studied in the last decades as an effective and safe treatment for type 2 diabetes (T2D), and randomized controlled trials generally found surgery superior when compared with medical treatment. In 2016, the DSS-II Joint Statement recognized the importance of metabolic surgery in the treatment of T2D and urged clinicians to discuss, recommend, or at least consider this procedure for their patients. Diabetes societies also cogitate metabolic surgery as an option for T2D patients in their guidelines. However, there are some differences in recommendations that could lead a careful reader to some confusion. This was potentialized in a recent document published by the same DSS-II group concerning prioritization for surgery after the COVID-19 pandemic, in which the criteria suggested for an expedited recommendation that is not exactly evidence-based, and collided substantially with several clinical guidelines worldwide, especially with regard to secondary prevention of cardiovascular disease. A more harmonious discussion and unified guidelines between clinicians and surgeons are needed in order to provide the same message for those who read different articles.

Prevalence of insufficient weight loss 5 years after Roux-en-Y gastric bypass: metabolic consequences and prediction estimates: a prospective registry study

OBJECTIVE

The study aimed to investigate the heterogeneity of weight loss 5 years after Roux-en-Y gastric bypass (RYGB) and the association with cardiometabolic health as well as to model prediction estimates of surgical treatment failure.

DESIGN

Retrospective analysis of prospectively collected data from the Scandinavian Obesity Surgery Registry (SOReg).

SETTING

29 surgical units from the whole of Sweden contributed data. Inclusion was restricted to surgical units with a retention rate of >60% five years postsurgery.

PARTICIPANTS

10 633 patients were extracted from SOReg. In total 5936 participants were included in the final sample, 79.1% females. The mean age of participants before surgery was 39.4±9 years and mean body mass index (BMI) 42.9±5.1. 2322 were excluded (death before the 5-year follow-up (n=148), other types of surgery or reoperations (n=637), age at surgery <18 or >55 years (n=1329), presurgery BMI <35 kg/m² (n=208)). In total, 2375 (29%) of eligible individuals were lost to the 5-year follow-up.

MAIN OUTCOME

The occurrence of surgical treatment failure 5 years after surgery was based on the three previously published definitions: per cent excess BMI loss <50%, total weight loss <20% or BMI >35 where initial BMI was <50, or >40 where initial BMI was >50. In addition, we report the association between surgical treatment failure and biochemical markers of obesity-related comorbidity. We also developed predictive models to identify patients with a high risk of surgical treatment failure 5 years postsurgery.

RESULTS

In total, 23.1% met at least one definition of surgical treatment failure at year 5 which was associated with (adjusted OR) with 95% CI): type 2 diabetes (T2D, OR 2.1; 95% CI 1.6 to 2.7), dyslipidaemia (OR 1.8; 95% CI 1.6 to 2.1) and hypertension (OR 1.9; 95% CI 1.6 to 2.2). Surgical treatment failure at 5 years was predicted by combined demographic and anthropometric measures from baseline, 1 and 2 years postsurgery (area under the curve=0.874).

CONCLUSION

Laparoscopic RYGB leads to a marked and sustained weight loss with improvement of obesity-related comorbidity in most patients. However, 23% met at least one definition of surgical treatment failure, which was associated with a greater risk of relapse and a higher incidence of T2D, dyslipidaemia and hypertension 5 years after surgery. Poor initial weight loss and early weight regain are strong predictors of long-term treatment failure and may be used for early identification of patients who require additional weight loss support.

Long-term outcomes of metabolic surgery in overweight and obese patients with type 2 diabetes in Asia

AIM

To assess the outcomes of metabolic surgery in overweight and obese patients in Asia with type 2 diabetes (T2D).

MATERIALS AND METHODS

The treatment outcomes of 1999 patients from the Asian Diabetes Surgery Summit database were analysed. The changes in treatment effects across time were assessed with respect to the surgical procedures performed by using generalized estimating equations.

RESULTS

The most commonly performed procedure was the single-anastomosis gastric bypass (32.6%). Weight (from 106.2 ± 25.1 to 77.9 ± 18.8 kg), body mass index (BMI; from 38.7 ± 7.9 to 28.5 ± 5.9 kg/m² ), blood sugar (from 9.3 ± 4.1 to 5.7 ± 1.8 mmol/L) and HbA1c (from 8.4% ± 1.8% to 6.0% ± 1.1%) significantly improved from baseline to 1 year (P < .001) and remained stable at 5 years (weight, 86.3 ± 23.3 kg; BMI, 31.7 ± 7.9 kg/m² ; blood sugar, 5.8 ± 1.8 mmol/L, and HbA1c, 6.4% ± 1.2%; all P < .001 vs. baseline). Blood pressure and most lipid disorders also improved significantly. Of the treatment procedures, single-anastomosis gastric bypass had the most satisfactory outcomes with statistical significance for most disorders, whereas adjustable gastric banding displayed the least satisfactory outcomes.

CONCLUSIONS

Metabolic surgery remarkably improved body weight, T2D and other metabolic disorders in Asian patients. However, the efficacy of individual procedures varied substantially.

Psychopathology, disordered eating, and impulsivity in patients seeking bariatric surgery

BACKGROUND

Most patients who undergo bariatric surgery experience significant weight loss and improvements in obesity-related co-morbidities in the first 6-18 months after surgery. However, 20%-30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. Psychosocial functioning may contribute to suboptimal weight loss and/or postoperative psychosocial distress.

OBJECTIVE

Assess psychosocial functioning, eating behavior, and impulsivity in patients seeking bariatric surgery.

SETTING

Two university hospitals.

METHODS

Validated interviews and questionnaires. Impulsivity assessed via computer program.

RESULTS

The present study included a larger (n = 300) and more racially diverse (70% non-White) sample than previous studies of these relationships. Forty-eight percent of participants had a current psychiatric diagnosis and 78% had at least 1 lifetime diagnosis. Anxiety disorders were the most common current diagnosis (25%); major depressive disorder was the most common lifetime diagnosis (44%). Approximately 6% of participants had a current alcohol or substance use disorder; 7% had a positive drug screen before surgery. A current psychiatric diagnosis was associated with greater symptoms of food addiction and night eating. Current diagnosis of alcohol use disorder or a lifetime diagnosis of anxiety disorders was associated with higher delay discounting.

CONCLUSION

The study identified high rates of psychopathology and related symptoms among a large, diverse sample of bariatric surgery candidates. Psychopathology was associated with symptoms of disordered eating and higher rates of delay discounting, suggesting impulse control issues.

Factors Affecting Metabolic Outcomes Post Bariatric Surgery: Role of Adipose Tissue

Obesity is an ever-growing public health crisis, and bariatric surgery (BS) has become a valuable tool in ameliorating obesity, along with comorbid conditions such as diabetes, dyslipidemia and hypertension. BS techniques have come a long way, leading to impressive improvements in the health of the majority of patients. Unfortunately, not every patient responds optimally to BS and there is no method that is sufficient to pre-operatively predict who will receive maximum benefit from this surgical intervention. This review focuses on the adipose tissue characteristics and related parameters that may affect outcomes, as well as the potential influences of insulin resistance, BMI, age, psychologic and genetic factors. Understanding the role of these factors may help predict who will benefit the most from BS.

Telemedicine intervention on physical activity recovery after bariatric surgery: the MyGoodTrip randomized controlled trial (Preprint)

BACKGROUND

Despite bariatric surgery showing significant weight loss trajectories for many patients, a substantial proportion regain weight after the first year following surgery. The addition of telemedicine to standard care could support patients with engaging in a more active lifestyle and thus improve clinical outcomes.

OBJECTIVE

Our aim was to evaluate a telemedicine intervention program dedicated to the promotion of physical activity including digital devices, teleconsultation, and telemonitoring the first 6 months following bariatric surgery.

METHODS

This study employed a mixed methods design based on an open-label randomized controlled trial. Patients were included during the first week after bariatric surgery; then, they were randomized into 2 intervention groups: The TelePhys group received a monthly telemedicine consultation focusing on physical activity coaching, while the TeleDiet group received a monthly telemedicine consultation involving diet coaching. Data were collected using a watch pedometer and body weight scale, both of which were connected wirelessly. The primary outcome was the difference between the 2 groups in the mean numbers of steps at the first and sixth postoperative months. Weight change was also evaluated, and focus groups and interviews were conducted to enrich the results and capture perceptions of the telemedicine provided.

RESULTS

Among the 90 patients (mean age 40.6, SD 10.4 years; 73/90, 81% women; 62/90, 69% gastric bypass), 70 completed the study until the sixth month (n=38 TelePhys; n=32 TeleDiet), and 18 participants agreed to be interviewed (n=8 Telephys; n=10 TeleDiet). An increase in the mean number of steps between the first and sixth months was found in both groups, but this change was significant only in the TeleDiet group (P=.01). No difference was found when comparing both intervention groups. Interviewed participants reported having appreciated the teleconsultations, as the individualized tailored counseling helped them to make better choices about behaviors that could increase their likelihood of a daily life in better health. Weight loss followed by social factors (such as social support) were identified as the main facilitators to physical activity. Family responsibilities, professional constraints as well as poor urban policies promoting physical activity, and lack of accessibility to sport infrastructure were their major barriers to postoperative lifestyle adherence.

CONCLUSIONS

Our study did not show any difference in mobility recovery after bariatric surgery related to a telemedicine intervention dedicated to physical activity. The early postoperative timing for our intervention may explain the null findings. eHealth interventions aiming to change behaviors and carried out by clinicians require support from structured public health policies that tackle patients' obesogenic environment in order to be efficient in their struggle against sedentary lifestyle-related pathologies. Further research will need to focus on long-term interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02716480, https://clinicaltrials.gov/ct2/show/NCT02716480.

One Anastomosis Gastric Bypass for the Treatment of Type 2 Diabetes: Long-Term Results and Recurrence

BACKGROUND

Bariatric/metabolic surgery has been incorporated into the therapeutic treatment of type 2 diabetes mellitus (T2DM). Among many bariatric/metabolic procedures, one anastomosis gastric bypass (OAGB) is one of the most effective procedures but long-term data about T2DM recurrence after OAGB are lacking.

METHODS

Outcomes of 134 patients who had undergone OAGB for the treatment of T2DM with long-term (5 years) follow-up were assessed in a retrospective cohort study. The remission of T2DM after OAGB surgery was evaluated in different groups using a scoring system composed of the age, BMI, C-peptide level, duration of T2DM (ABCD score), and percent of total weight loss (%TWL).

RESULTS

The %TWL and percent of excess weight loss (%EWL) of the OAGB patients at 5 years after surgery were 29.2 (10.6) and 72.1(27.5), respectively. The mean BMI decreased from 39.5(7.9) to 27.6(5.3) kg/m² and mean glycated hemoglobin A1C (HbA1c) decreased from 8.9 to 5.9% in OAGB patients at 5 years after OAGB. The complete T2DM remission rate of OAGB was 76.1% at 1 year and 64.2% at 5 years after surgery. Forty-one (57.8%) out of 71 patients who completed a 10-year follow-up remained in complete T2DM remission. The T2DM recurrence rate of OAGB patients was 15.7% at 5 years after surgery.

CONCLUSIONS

OAGB is highly effective in inducing T2DM remission but a significant number of patients will still have T2DM recurrence. To select patient with an ABCD score > 5 and maintaining a weight loss greater than 30% is important for durable T2DM remission after OAGB.

Diabetes Remission and Relapse After Bariatric Surgery: a Nationwide Population-Based Study

PURPOSE

The long-term impact of bariatric surgery on the remission of type 2 diabetes (T2DM) remains to be clarified through large nationally representative cohorts. The objectives were to determine the incidence of T2DM remission and relapse after bariatric surgery, to determine the factors associated with remission and to establish a profile for patients at risk for relapse.

MATERIALS AND METHODS

We conducted a population-based cohort study using data from the French national health insurance database (Systeme national des données de santé [SNDS]). We had access to exhaustive regional data between 2013 and 2017 and to a national representative sample of the French population (EGB) from 2008 to 2018. Patients were included if they were adults and diabetics with incidental bariatric surgery.

RESULTS

This study shows that 50% of patients are in remission from diabetes after bariatric surgery within a median of 2 to 4 months. Diabetes relapse was observed in 13-20% within 10 years. The factors favouring remission already described were noted (non-insulin-dependent diabetes) and original factors were also identified, in particular the advantage of bypass surgery over sleeve gastrectomy, with more remissions and fewer relapses.

CONCLUSION

This study highlights a 50% prevalence of remission and a low prevalence of relapse. There are non-modifiable risk factors for remission and relapse (characteristics of diabetes, age, lipid-lowering therapy) and modifiable factors (type of surgery). Identifying these factors is essential for optimal management of patients. Additional data are essential to confirm the results of our analysis of the factors associated with relapse.

Preoperative and post-operative psychosocial interventions for bariatric surgery patients: A systematic review

Psychosocial interventions are increasingly being utilized to help patients prepare for, and adjust to changes following, bariatric surgery in order to optimize psychosocial adjustment and weight loss. The current systematic review examined the impact of preoperative and post-operative psychosocial interventions with a behavioural and/or cognitive focus on weight, dietary behaviours, eating pathology, lifestyle behaviours, and psychological functioning. A PsycINFO and Medline search of publications was conducted in March 2019. Two authors assessed retrieved titles and abstracts to determine topic relevance and rated the quality of included studies using a validated checklist. Forty-four articles (representing 36 studies) met the study inclusion criteria. The current evidence is strongest for the impact of psychosocial interventions, particularly cognitive behavioural therapy, on eating behaviours (eg, binge eating and emotional eating) and psychological functioning (eg, quality of life, depression, and anxiety). The evidence for the impact of psychosocial interventions on weight loss, dietary behaviours (eg, dietary intake), and lifestyle behaviours (eg, physical activity) is relatively weak and mixed. Psychosocial interventions can improve eating pathology and psychosocial functioning among bariatric patients, and the optimal time to initiate treatment appears to be early in the post-operative period before significant problematic eating behaviours and weight regain occur.

Preoperative predictors of early relapse/no-remission of type-2 diabetes after metabolic surgery in Chinese patients

Remission of type 2 diabetes mellitus (T2DM) after metabolic surgery in some patients is not sustained. There is limited data regarding the preoperative factors predicting early relapse of T2DM in Chinese patients. The objective of this study is to look for preoperative predictors of early T2DM relapse/no remission in patients with obesity and diabetes who underwent Roux-en-Y gastric bypass (RYGB) or loop duodeno-jejunal bypass with sleeve gastrectomy (LDJB-SG). This is a retrospective study of 113 patients who underwent RYGB or LDJB-SG for T2DM. All T2DM patients with BMI 27.5 to 37.5 kg/m² , having uncontrolled diabetes and T2DM patients with BMI > 37.5 were included in the study. A multivariate analysis with a logistic regression model was used for analysed factors. Nineteen patients (16.8%) had early relapse and 12 (10.6%) did not have remission. Mean age of patients was significantly more who relapsed/no-remission (44.9 vs 40.3 years). On univariate analysis, base line weight (86 vs 96.7 kg) was significantly lower in patients who relapsed/no-remission. Patients with sustained remission had statistically significant low glycosylated haemoglobin (P < .030), plasma glucose (120 minutes) (P < .002) on OGTT, area under curve glucose (P < .011) values and more C-peptide (P < .006) on univariate analysis. Only duration of diabetes (OR 2.78, 95% CI 1.56-4.97, P < .001) was found to be independent preoperative factor associated with early relapse/no-remission. Two years of diabetes duration was the cut-off point to predict relapse/no-remission (sensitivity 78.9, specificity 63.4, receiver operating characteristic curve 0.71). Duration of diabetes is the most probable, independent preoperative predictor of early T2DM relapse/no-remission in patient with obesity and diabetes undergoing metabolic surgery.

Late Relapse of Diabetes After Bariatric Surgery: Not Rare, but Not a Failure

OBJECTIVE

To characterize the status of cardiometabolic risk factors after late relapse of type 2 diabetes mellitus (T2DM) and to identify factors predicting relapse after initial diabetes remission following bariatric surgery to construct prediction models for clinical practice.

RESEARCH DESIGN AND METHODS

Outcomes of 736 patients with T2DM who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at an academic center (2004-2012) and had ≥5 years' glycemic follow-up were assessed. Of 736 patients, 425 (58%) experienced diabetes remission (HbA_1c <6.5% [48 mmol/mol] with patients off medications) in the 1st year after surgery. These 425 patients were followed for a median of 8 years (range 5-14) to characterize late relapse of diabetes.

RESULTS

In 136 (32%) patients who experienced late relapse, a statistically significant improvement in glycemic control, number of diabetes medications including insulin use, blood pressure, and lipid profile was still observed at long-term. Independent baseline predictors of late relapse were preoperative number of diabetes medications, duration of T2DM before surgery, and SG versus RYGB. Furthermore, patients who relapsed lost less weight during the 1st year after surgery and regained more weight afterward. Prediction models were constructed and externally validated.

CONCLUSIONS

While late relapse of T2DM is a real phenomenon (one-third of our cohort), it should not be considered a failure, as the trajectory of the disease and its related cardiometabolic risk factors is changed favorably after bariatric surgery. Earlier surgical intervention, RYGB (compared with SG) and more weight loss (less late weight regain) are associated with less diabetes relapse in the long-term.

Lack of Standard Definitions of Primary and Secondary (Non)responders After Primary Gastric Bypass and Gastric Sleeve: a Systematic Review

Lack of standard definitions of primary and secondary (non)responders after RYGB and SG makes it impossible to compare the literature. The aim was to analyze the different definitions used. MEDLINE® was searched for literature published between 01-07-2014 and 01-07-2017 concerning (1) patients who received a primary RYGB or SG and (2) the outcomes of primary and secondary (non)responders. One hundred twelve out of 650 papers were eligible. Forty out of 47 papers described a definition of weight loss success. Sixty-seven out of 112 papers mentioned weight loss failure of which 42 described a definition, in total 23 different definitions. Weight regain was mentioned in 77 papers; only 21 papers provided a definition. The recent literature regarding definitions of these outcomes is highly inconsistent. To compare the literature international consensus is required.

The Role of Bariatric Surgery on Diabetes and Diabetic Care Compliance

PURPOSE OF REVIEW

Bariatric surgery is a durable and long-term solution to treat both obesity and its associated comorbidities, specifically type 2 diabetes mellitus (T2DM). Many studies have demonstrated the benefits of bariatric surgery on T2DM, but weight recidivism along with recurrence of comorbidities can be seen following these procedures. Patient compliance post-bariatric surgery is linked to weight loss outcomes and comorbidity improvement/resolution. The role of compliance with respect to T2DM medication in bariatric patients specifically has not recently been examined. This article seeks to review the role of bariatric surgery on short- and long-term resolution of T2DM, recurrence, and compliance with T2DM medication following bariatric surgery.

RECENT FINDINGS

Seven randomized control trials have examined metabolic surgery versus medical therapy in glycemic control in patients meeting criteria for severe obesity. Six out of seven studies demonstrate a significant advantage in the surgical arms with regards to glycemic control, as well as secondary endpoints such as weight loss, serum lipid levels, blood pressure, renal function, and other parameters. While patient compliance with lifestyle modifications post-bariatric surgery is linked to weight loss outcomes, there are no studies to date that directly evaluate the role of lifestyle modifications and T2DM medication adherence in the management of T2DM post-bariatric surgery. Bariatric surgery is an effective treatment option to achieve long-term weight loss and resolution of obesity-related medical comorbidities, specifically T2DM. Patient compliance to lifestyle modifications post-bariatric surgery is linked to weight loss outcomes and comorbidity resolution. The role of diabetic care compliance in bariatric patient outcomes, however, is poorly understood. Further studies are needed to elucidate the predictors and associated risk factors for non-compliance in this patient population.

Impact of Weight Regain on the Evolution of Non-alcoholic Fatty Liver Disease After Roux-en-Y Gastric Bypass: a 3-Year Follow-up

BACKGROUND

The influence of post-surgical weight regain on the course of non-alcoholic fatty liver disease (NAFLD) is unclear.

OBJECTIVE

To evaluate the influence of weight regain on the NAFLD assessed by means of a non-invasive score after Roux-en-gastric bypass (RYGB) over a 3-year period.

METHODS

This is a prospective observational cohort study which evaluated individuals who underwent RYGB. Comparisons were made between the periods immediately before surgery and 12, 24, and 36 months following surgery. Liver disease was estimated by means of the NAFLD fibrosis score. Individuals were classified into three categories according to weight regain status: (1) no weight regain, (2) expected weight regain (regain less or equal than 20% of the maximal weight lost), (3) obesity recidivism (regain above 20% of the maximal weight lost).

RESULTS

Of 90 patients analyzed after 3 years of surgery, 35.6% presented obesity recidivism and 28.8% of the expected regain; 35.6% presented no regain. There was no difference in baseline fibrosis score between groups; at 3 years, the score observed in the relapse group was significantly higher than that observed in the other two groups (p = 0.015). The percent variation of the fibrosis score was significantly higher in the recidivism group (+ 11.8 ± 77.2%) than in the expected regain (- 45.6 ± 64.5%) and no regain (- 37.8 ± 63.2%) groups (p = 0.013).

CONCLUSION

Long-term significant post-RYGB weight regain is associated with a significantly attenuated improvement of NAFLD evaluated by means of liver fibrosis score.

Mid-term 4-Year Outcomes with Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy Surgery at a Single US Center

BACKGROUND

Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of Roux-en-Y duodenal switch (RYDS). Long-term data on this operation is lacking in the literature. We reviewed our mid-term data of this RYDS modification.

PURPOSE

To analyze the outcomes with SADI-S at 4 years.

METHODS

Data from patients who underwent a primary SADI-S procedure performed by three surgeons at a single institution from June 2013 through February 2018 were retrospectively reviewed. All revision bariatric surgeries were excluded. Regression analyses were performed for all follow-up weight loss data.

RESULTS

There were 437 patients in our database. The pre-operative mean body mass index (BMI) was 49.8 ± 8.8 kg/m². The 30-day complication rate was 7.7%. The 30-day readmission, reoperation, and mortality rates were 1.8, 1.3, and 0.2%, respectively. The long-term complication rate was 10.9%. Seventy-nine patients were 4 years post SADI-S surgery and follow-up was possible for 44 patients (55.7%). At 4 years, patients had an average change in BMI of 18.1 ± 6 units with an excess weight loss (EWL) of 85.7 ± 27.3%. At 4 years, 97.6% patients were able to maintain HbA1c < 6% with or without the use of diabetic medication. There was a statistically significant difference between most of the pre-operative and post-operative nutritional data.

CONCLUSIONS

SADI-S is a safe and effective procedure in both short- and mid-term data points. Diabetes resolution and weight loss appear similar to traditional RYDS and better than RYGB.

Sustained Improvements in Glucose Metabolism Late After Roux-En-Y Gastric Bypass Surgery in Patients with and Without Preoperative Diabetes

To describe glucose metabolism in the late, weight stable phase after Roux-en-Y Gastric Bypass (RYGB) in patients with and without preoperative type 2 diabetes we invited 55 RYGB-operated persons from two existing cohorts to participate in a late follow-up study. 44 (24 with normal glucose tolerance (NGT)/20 with type 2 diabetes (T2D) before surgery) accepted the invitation (median follow-up 2.7 [Range 2.2–5.0 years]). Subjects were examined during an oral glucose stimulus and results compared to preoperative and 1-year (1 y) post RYGB results. Glucose tolerance, insulin resistance, beta-cell function and incretin hormone secretion were evaluated. 1 y weight loss was maintained late after surgery. Glycemic control, insulin resistance, beta-cell function and GLP-1 remained improved late after surgery in both groups. In NGT subjects, nadir glucose decreased 1 y after RYGB, but did not change further. In T2D patients, relative change in weight from 1 y to late after RYGB correlated with relative change in fasting glucose and HbA1c, whereas relative changes in glucose-stimulated insulin release correlated inversely with relative changes in postprandial glucose excursions. In NGT subjects, relative changes in postprandial nadir glucose correlated with changes in beta-cell glucose sensitivity. Thus, effects of RYGB on weight and glucose metabolism are maintained late after surgery in patients with and without preoperative T2D. Weight loss and improved beta-cell function both contribute to maintenance of long-term glycemic control in patients with type 2 diabetes, and increased glucose stimulated insulin secretion may contribute to postprandial hypoglycemia in NGT subjects.

Influence of post-Roux-en-Y gastric bypass weight recidivism on insulin resistance: a 3-year follow-up

BACKGROUND

Although some early metabolic benefits provided by bariatric surgery are known to occur regardless of weight loss, the impact of mid- to long-term weight recidivism after Roux-en-Y gastric bypass (RYGB) on metabolic outcomes is not profoundly understood.

OBJECTIVE

To investigate the effect of weight recidivism on insulin resistance among nondiabetic individuals with morbid obesity after RYGB during a 3-year follow-up.

SETTING

Public tertiary university hospital.

METHODS

This is a cohort study based on a prospectively collected database of a public tertiary university hospital, which enrolled individuals with morbid obesity who underwent RYGB and were followed-up for 3 years. Weight loss was classified into the following 3 categories: (1) no weight regain; (2) expected regain (regain ≤20% of the maximum weight loss); and (3) obesity recidivism (regain >20% of the maximum weight loss). Homeostasis model assessment (HOMA) values were compared over time.

RESULTS

Of 100 patients, 20% presented obesity recidivism and 52% an expected regain after 3 years of surgery; 28% showed no regain. The recidivism group presented a significant increase in HOMA 3 years after surgery (P = .02). The recidivism group presented a significantly higher HOMA 3 years after surgery than the observed in the other groups (P < .001), as well as a significantly higher percentage of HOMA variation throughout the follow-up (P = .02).

CONCLUSION

Weight recidivism after RYGB was significantly associated with a worsening of insulin resistance among nondiabetic individuals with morbid obesity. Thus, weight loss seems to play a significant role in the maintenance of the early metabolic improvement achieved after RYGB.

Psychosocial Predictors of Response to Telephone-Based Cognitive Behavioural Therapy in Bariatric Surgery Patients

OBJECTIVE

Bariatric surgery is an empirically supported treatment for severe obesity; however, it does not directly target underlying behavioural and psychological factors that potentially contribute to obesity. Mounting evidence supports the efficacy of cognitive behavioural therapy (CBT) for improving eating psychopathology and psychological distress among bariatric patients, and telephone-based CBT (Tele-CBT) is a novel delivery method that increases treatment accessibility.

METHODS

This study aimed to identify demographic and clinical predictors of response to Tele-CBT among 79 patients who received Tele-CBT in 3 previous studies. Listwise deletion was applied, after which 58 patients were included in a multivariate linear regression adjusted for age, sex and education status, to evaluate patient rurality index (urban or nonurban), and baseline binge eating, emotional eating and depression symptoms, as predictors of tele-CBT response.

RESULTS

The predictors explained 31% of the observed variance [R²=0.312, F(4,57)=3.238, p<0.01]. Patient rurality index (beta=0.341, p<0.01) was the only statistically significant predictor of Tele-CBT response.

CONCLUSIONS

Given the limited psychosocial resources available in many bariatric surgery programs, the findings suggest that Tele-CBT may be particularly beneficial for patients residing in nonurban communities with limited access to other health-care services.

Genetic Testing to Predict Weight Loss and Diabetes Remission and Long-Term Sustainability after Bariatric Surgery: A Pilot Study

Introduction: The aim of this pilot study was to assess genetic predisposition risk scores (GPS) in type 2 diabetic and non-diabetic patients in order to predict the better response to bariatric surgery (BS) in terms of either weight loss or diabetes remission. Research Design and Methods: A case-control study in which 96 females (47 with type 2 diabetes) underwent Roux-en-Y gastric by-pass were included. The DNA was extracted from saliva samples and SNPs were examined and grouped into 3 GPS. ROC curves were used to calculate sensitivity and specificity. Results: A highly sensitive and specific predictive model of response to BS was obtained by combining the GPS in non-diabetic subjects. This combination was different in diabetic subjects and highly predictive of diabetes remission. Additionally, the model was able to predict the weight regain and type 2 diabetes relapse after 5 years’ follow-up. Conclusions: Genetic testing is a simple, reliable and useful tool for implementing personalized medicine in type 2 diabetic patients requiring BS.

Obesity and cardiovascular risk: a call for action from the European Society of Hypertension Working Group of Obesity, Diabetes and the High-risk Patient and European Association for the Study of Obesity: part A: mechanisms of obesity induced hypertension, diabetes and dyslipidemia and practice guidelines for treatment

: Obesity is a key factor for cardiovascular diseases and complications. Obesity is associated with hypertension, dyslipidemia and type II diabetes, which are the major predictors of cardiovascular disease in the future. It predisposes for atrial fibrillation, heart failure, sudden cardiac death, renal disease and ischemic stroke that are the main causes of cardiovascular hospitalization and mortality. As obesity and the cardiovascular effects on the vessels and the heart start early in life, even from childhood, it is important for health policies to prevent obesity very early before the disease manifestation emerge. Key roles in the prevention are strategies to increase physical exercise, reduce body weight and to prevent or treat hypertension, lipids disorders and diabetes earlier and efficiently to prevent cardiovascular complications.Epidemiology and mechanisms of obesity-induced hypertension, diabetes and dyslipidemia will be reviewed and the role of lifestyle modification and treatment strategies in obesity will be updated and analyzed. The best treatment options for people with obesity, hypertension, diabetes and dyslipidemia will discussed.

Metabolic surgery for the treatment of type 2 diabetes in patients with BMI lower than 35 kg/m2 : Why caution is still needed

Bariatric surgery has shifted from being a risky procedure to an evidence-based one, with proven benefits on all-cause mortality, cardiovascular disease, cancer, and diabetes control. The procedure has an overall positive result on type 2 diabetes mellitus (T2DM), with a substantial number of patients achieving disease remission. This has resulted in several studies assessing possible weight-independent effects of bariatric surgery on glycemic improvement, in addition to recommendation of the procedure to patients with class 1 obesity and T2DM, for whom the procedure was classically not indicated, and adoption of a new term, "metabolic surgery," to highlight the overall metabolic benefit of the procedure beyond weight loss. Recently, the Diabetes Surgery Summit (DSS) has included metabolic surgery in its T2DM treatment algorithm. Although the discussion brought by this consensus is highly relevant, the recommendation of metabolic surgery for patients with uncontrolled T2DM and a body mass index of 30 to 35 kg/m² still lacks enough evidence. This article provides an overall view of the metabolic benefits of bariatric/metabolic surgery in patients with class 1 obesity, compares the procedure against clinical treatment, and presents our rationale for defending caution on recommending the procedure to less obese individuals.

IMPACT OF WEIGHT LOSS TRAJECTORY FOLLOWING RANDOMIZATION TO BARIATRIC SURGERY ON LONG-TERM DIABETES GLYCEMIC AND CARDIOMETABOLIC PARAMETERS

Objective: It is unclear whether acute weight loss or the chronic trajectory of weight loss after bariatric surgery is associated with long-term type 2 diabetes mellitus (T2DM) glycemic improvement. This ancillary study of the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial aimed to answer this question. Methods: In STAMPEDE, 150 patients with T2DM were randomized to bariatric surgery, and 96 had 5-year follow-up. Data post-Roux-en-Y gastric bypass (RYGB, n = 49) and sleeve gastrectomy (SG, n = 47) were analyzed. We defined percent weight loss in the first year as negative percent decrease from baseline weight to lowest weight in the first year. Percent weight regain was positive percent change from lowest weight in the first year to fifth year. Weight change was then correlated with cardiometabolic (CM) and glycemic outcomes at 5 years using Spearman rank correlations and multivariate analysis. Results: In both RYGB and SG, less weight loss in the first year positively correlated with higher 5-year glycated hemoglobin (HbA1c) (RYGB, β = +0.13; P<.001 and SG, β = 0.14; P<.001). In SG, greater weight regain from nadir positively correlated with higher HbA1c (β = 0.06; P = .02), but not in RYGB. Reduced first-year weight loss was also correlated with increased 5-year triglycerides (β = 1.81; P = .01), but not systolic blood pressure. Weight regain did not correlate with CM outcomes. Conclusion: Acute weight loss may be more important for T2DM glycemic control following both RYGB and SG as compared with weight regain. Clinicians should aim to assist patients with achieving maximal weight loss in the first year post-op to maximize long-term health of patients. Abbreviations: BMI = body mass index; HbA1c = glycated hemoglobin; RYGB = Roux-en-Y gastric bypass; SBP = systolic blood pressure; SG = sleeve gastrectomy; STAMPEDE = Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently; T2DM = type 2 diabetes mellitus; TG = triglyceride.

Long-term diabetes outcomes after bariatric surgery-managing medication withdrawl

BACKGROUND/OBJECTIVES

Bariatric surgery leads to type 2 diabetes mellitus (T2DM) remission, but recurrence can ensue afterwards. However, literature provides heterogenous remission/recurrence criteria and there is no consensus on long-term T2DM management after surgery. We aim to assess T2DM remission/recurrence rates using standardized criteria and to identify relapse predictors. We also intend to analyze the management of residual T2DM and the impact of maintaining/withdrawing metformin in avoiding future relapse.

SUBJECTS/METHODS

We investigated a cohort of 110 obese patients with T2DM who underwent bariatric surgery and were followed for 5 years (Y0-Y5). Patients who ever attained remission were accounted for cumulate remission, while prevalent remission was considered for individuals who were on remission in a specific visit.

RESULTS

A complete prevalent remission of 47.3% was reached at Y1 and it remained stable till Y5 (46.4-48.2%). Complete cumulative rate was of 57.3% at Y5. Five-year T2DM recurrence rate was 15.9% and it was associated with higher pre-operative HbA1c levels (β = 1.06; p < 0.05) and a milder excess body weight loss (EBWL) (β = 0.49; p < 0.05). Glucose-lowering agents were fully stopped in 51.4% of the patients till Y1 and in 16.2% of them afterwards. Medication withdrawal was mainly attempted in patients with a lower baseline HbA1c (β = 0.54; p < 0.01) and higher first-year EBWL (β = 1.04; p < 0.01). Patients that kept metformin after reaching a HbA1c in the complete remission range (<6.0%) did not have greater odds of avoiding relapse in the next visit (OR = 0.33; p = 0.08).

CONCLUSIONS

Baseline HbA1c and EBWL were the main variables driving both T2DM relapse after bariatric surgery and the attempt to withdrawal anti-diabetic medication. In our population keeping metformin once an HbA1c < 6.0% is achieved did not seem to diminish relapse but further studies on this matter are needed.

Metabolic and Endocrine Consequences of Bariatric Surgery

Obesity is one of the most serious worldwide epidemics of the twenty-first century according to the World Health Organization. Frequently associated with a number of comorbidities, obesity threatens and compromises individual health and quality of life. Bariatric surgery (BS) has been demonstrated to be an effective treatment to achieve not only sustained weight loss but also significant metabolic improvement that goes beyond mere weight loss. The beneficial effects of BS on metabolic traits are so widely recognized that some authors have proposed BS as metabolic surgery that could be prescribed even for moderate obesity. However, most of the BS procedures imply malabsorption and/or gastric acid reduction which lead to nutrient deficiency and, consequently, further complications could be developed in the long term. In fact, BS not only affects metabolic homeostasis but also has pronounced effects on endocrine systems other than those exclusively involved in metabolic function. The somatotropic, corticotropic, and gonadal axes as well as bone health have also been shown to be affected by the various BS procedures. Accordingly, further consequences and complications of BS in the long term in systems other than metabolic system need to be addressed in large cohorts, taking into account each bariatric procedure before making generalized recommendations for BS. In this review, current data regarding these issues are summarized, paying special attention to the somatotropic, corticotropic, gonadal axes, and bone post-operative health.

The Effects of Duodenojejunal Omega Switch in Combination with High-Fat Diet and Control Diet on Incretins, Body Weight, and Glucose Tolerance in Sprague-Dawley Rats

Background

Despite excellent results of bariatric surgery in the treatment of type 2 diabetes and weight loss in human subjects, some patients do not obtain desired results. One of the reasons for this is that not all patients follow caloric intake recommendations.

Aim

The aim of this study was to investigate the effect of duodenojejunal omega switch (DJOS) surgery on body weight, glucose tolerance, and incretins in rats.

Methods

DJOS and SHAM surgery were performed on rats maintained for 8 weeks on high-fat diet (HF) and control diet (CD), respectively. After surgery, four groups were kept on the same diet as before the surgery, and four groups had a changed diet (CD vs. HF and HF vs. CD) for the next 8 weeks. Glucose tolerance, insulin tolerance, glucose-stimulated insulin, glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide/glucose-dependent insulinotropic polypeptide (GIP) secretion, food intake, and body weight were measured.

Results

A change of diet after surgery resulted in reduced glucose tolerance. Plasma insulin levels were lowered between DJOS and SHAM surgeries for the HF/HF and CD/HF groups. DJOS surgery did not reduce body weight in the studied groups, irrespective of diet. In the HF/HF group, ΔGLP-1 was lower for DJOS surgery in comparison with other groups. Differences of weight changes were observed for groups HF/HF and HF/CD. After DJOS surgery, ΔGIP was lower in the CD/HF group compared with HF/HF.

Conclusions

Our results show that applications of different types of diets, before and after surgery, is a sensitive method for studies of mechanism of glucose intolerance after DJOS surgery.

Diabetes Outcomes More than a Decade Following Sustained Weight Loss After Laparoscopic Adjustable Gastric Band Surgery

BACKGROUND

Long-term outcome data are needed to define the role of bariatric surgery in type 2 diabetes (T2D). To address this, we collated diabetes outcomes more than a decade after laparoscopic adjustable gastric band (LAGB) surgery.

METHOD

Clinical and biochemical measures from 113 obese T2D patients who underwent LAGB surgery in 2003 and 2004 were analyzed. Diabetes remission was defined as HbA1c < 6.2% (44 mmol/mol) and fasting glucose < 7.0 mmol/L.

RESULTS

Seventy-nine patients had weight data at 10 years and attained a median [Q1, Q3] weight loss of 16 [10, 21] percent. Sixty patients attended a follow-up assessment. Their baseline HbA1c of 7.8 [7.1, 9.3] percentage units (62 [54, 78] mmol/mol) had decreased to 6.6 [6.1, 8.4] (49 [43, 68] mmol/mol) despite no significant change in glucose-lowering therapy. Eleven patients (18%) were in diabetes remission and another 18 had HbA1c ≤ 6.5%. Significant improvements in physical measures of quality of life, blood pressure, and lipid profile were also observed but there was no change in the proportion of patients with albuminuria and a significant decline in estimated glomerular filtration rate. Twelve patients in the follow-up cohort (20%) required anti-reflux medication after surgery and 26 (43%) underwent gastric band revision surgery.

CONCLUSION

Weight loss for over 10 years after LAGB surgery delivers clinically meaningful improvements in HbA1c, blood pressure, lipids, and quality of life at the cost of a high rate of revision surgery and increased use of anti-reflux medication. These findings support the use of bariatric surgery as a long-term treatment for weight loss and wellbeing in patients with T2D.

STUDY REGISTRATION

Registered with the Australian Clinical trials registry as ACTRN12615000089538.

Predictors of glycemic control after sleeve gastrectomy versus Roux-en-Y gastric bypass: A meta-analysis, meta-regression, and systematic review

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most commonly performed bariatric procedures globally. However, it remains controversial which procedure provides better glycemic control. To identify predictors of glycemic control after SG versus RYGB, a systematic search of PubMed, EMBASE, and the Cochrane Library was conducted up to January 2017 for comparative studies with both SG and RYGB arms for the treatment of type 2 diabetes (T2D). A meta-analysis and systematic review was performed to evaluate glycemic control after SG versus RYGB with both short- and long-term follow-up. A meta-regression was performed to evaluate impacts of clinical indicators on glycemic control after SG versus RYGB. A total of 17 comparative studies involving 1160 patients were included. SG and RYGB achieved similar diabetic remission rates with both short- and long-term follow-up. However, SG provided lower endpoint glycosylated hemoglobin (A1C) after 1-year follow-up (mean deviation = .17, 95% confidence interval .03-.31, P = .02). When adjusted by baseline A1C, SG and RYGB provided similar percent delta A1C with 1-, 2-, 3-, and 5-year follow-up. The baseline body mass index, duration of T2D, preoperative fasting plasma glucose, and preoperative A1C had predictive value for glycemic control after SG, but only duration of T2D and preoperative A1C were correlated with that after RYGB. These findings showed that the choice of procedure between SG and RYGB predicts no better glycemic control. However, more factors should be considered when SG is recommended to a given patient with diabetes.

Weight Loss Medications in Young Adults after Bariatric Surgery for Weight Regain or Inadequate Weight Loss: A Multi-Center Study

This paper presents a retrospective cohort study of weight loss medications in young adults aged 21 to 30 following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between November 2000 and June 2014. Data were collected from patients who used topiramate, phentermine, and/or metformin postoperatively. Percentage of patients achieving ≥5%, ≥10%, or ≥15% weight loss on medications was determined and percent weight change on each medication was compared to percent weight change of the rest of the cohort. Our results showed that 54.1% of study patients lost ≥5% of their postsurgical weight; 34.3% and 22.9% lost ≥10% and ≥15%, respectively. RYGB had higher median percent weight loss (−8.1%) than SG (−3.3%) (p = 0.0515). No difference was found in median percent weight loss with medications started at weight plateau (−6.0%) versus after weight regain (−5.4%) (p = 0.5304). Patients taking medications at weight loss plateau lost 41.2% of total body weight from before surgery versus 27.1% after weight regain (p = 0.076). Median percent weight change on metformin was −2.9% compared to the rest of the cohort at −7.7% (p = 0.0241). No difference from the rest of the cohort was found for phentermine (p = 0.2018) or topiramate (p = 0.3187). Topiramate, phentermine, and metformin are promising weight loss medications for 21 to 30 year olds. RYGB patients achieve more weight loss on medications but both RYGB and SG benefit. Median total body weight loss from pre-surgical weight may be higher in patients that start medication at postsurgical nadir weight. Participants on metformin lost significantly smaller percentages of weight on medications, which could be the result of underlying medical conditions.

Therapeutic potential of deep brain stimulation of the nucleus accumbens in morbid obesity

OBJECTIVE

Morbid obesity is a growing problem worldwide. The current treatment options have limitations regarding effectiveness and complication rates. New treatment modalities are therefore warranted. One of the options is deep brain stimulation (DBS) of the nucleus accumbens (NAC). This review aims to summarize the current knowledge on NAC-DBS for the treatment of morbid obesity.

METHODS

Studies were obtained from multiple electronic bibliographic databases, supplemented with searches of reference lists. All animal and human studies reporting on the effects of NAC-DBS on body weight in morbidly obese patients were included. Articles found during the search were screened by 2 reviewers, and when deemed applicable, the relevant data were extracted.

RESULTS

Five relevant animal experimental papers were identified, pointing toward a beneficial effect of high-frequency stimulation of the lateral shell of the NAC. Three human case reports show a beneficial effect of NAC-DBS on body weight in morbidly obese patients.

CONCLUSIONS

The available literature supports NAC-DBS to treat morbid obesity. The number of well-conducted animal studies, however, is very limited. Also, the optimal anatomical position of the DBS electrode within the NAC, as well as the optimal stimulation parameters, has not yet been established. These matters need to be addressed before this strategy can be considered for human clinical trials.

Ileal transposition rapidly improves glucose tolerance and gradually improves insulin resistance in non-obese type 2 diabetic rats

Background

Many studies have confirmed that ileal transposition can improve type 2 diabetes mellitus (T2DM), accompanied by increased glucagon-like peptide-1 (GLP-1). We performed the experiment on diabetic rats to evaluate the effects and mechanisms of ileal transposition on the glycemic metabolism.

Methods

Twenty Goto-Kakizaki (GK) rats were randomly divided into the ileal transposition group (IT group) and the sham operation group (Sham group). Weight, food intake, fasting plasma glucose (FPG), fasting insulin (F-ins), oral glucose tolerance test (OGTT) and GLP-1 were determined at baseline and 1, 4, 8, 16 and 24 weeks post-operatively. The homeostasis model assessment-insulin resistance (HOMA-IR) index and the area under the curve (AUC) during OGTT were measured. Histological determination of the GLP-1 receptor (GLP-1R) was performed on the pancreas and ileum 24 weeks post-operatively.

Results

In comparison with the Sham group, the IT group showed a higher GLP-1 level and lower AUC at 4, 8, 16 and 24 weeks post-operatively (all P < 0.05) and a lower FPG, F-ins levels and HOMA-IR at 8, 16 and 24 weeks post-operatively (all P < 0.05). Compared with baseline levels, the plasma GLP-1, AUC and FPG levels decreased significantly at each post-operative time point in the IT group (all P < 0.05), but not in the Sham group (all P > 0.05); F-ins and HOMA-IR significantly decreased at 8, 16 and 24 weeks post-operatively in the IT group (all P < 0.05). GLP-1R expression in the IT group was significantly higher than that of the Sham group in both the pancreas and the ileum at 24 weeks post-operatively (P < 0.05).

Conclusions

Ileal transposition ameliorated glucose metabolism without reduction in weight or food intake in GK rats, which may be induced by the increased GLP-1 expression. However, the delayed improvement of insulin resistance, accompanied by decreased plasma insulin levels, might not directly result from the increased GLP-1.

Possibilities of metabolic surgery for the treatment of type 2 diabetes mellitus in patients with grade 1 alimentary obesity

Many studies have demonstrated the high effectiveness of bariatric surgery in patients with grade 23 obesity and type 2 diabetes mellitus. Currently, surgery is one of the most effective ways to decrease body mass, to maintain long-term weight loss and to manage type 2 diabetes mellitus. Particular interest has been generated by the strong influence of bariatric surgical interventions on the disruption of carbohydrate metabolism in patients who undergo surgery. This change leads to an improvement in the course of type 2 diabetes mellitus as well as its full remission. This review presents information on the mechanisms that are needed to improve glycaemic control in patients with obesity even after bariatric surgery. This review also contains a comparative analysis of how various surgical interventions influence the course of diabetes, the reasons for postbariatric glycaemia and predictors of the effectiveness of bariatric surgeries in terms of metabolic control in patients with type 2 diabetes mellitus. Until recently, the primary focus of the studies by bariatric surgeons was on patients with grade 23 obesity and type 2 diabetes mellitus. However, in this review, special attention is given to the patients with a body mass index that ranges from 30 to 35 kg/m. Gained experience of the bariatric surgeons leads to high effectiveness with respect to the influence on the course of diabetes in patients with grade 1 obesity, which allows us to significantly expand the range of patients who should be recommended for this surgery. In addition, some information concerning surgical and metabolic complications of bariatric surgical intervention is provided, which allows us to seriously consider this treatment.