[Serum ghrelin changes after bariatric surgery]

OBJECTIVE

To study the effect of bariatric surgery on serum ghrelin in patients with morbid obesity.

MATERIAL AND METHODS

We experimentally analyzed serum ghrelin in 96 rats. Of these, 84 rats underwent sleeve gastrectomy, and 12 rats comprised the control group (no surgery). We measured body weight and serum ghrelin using ELISA method after 1, 3, 7, 14, 21 and 30 days after surgery. Serum ghrelin was studied before and after bariatric surgery in 23 patients with morbid obesity.

RESULTS

Baseline serum ghrelin was lower in larger rats and obese patients compared to normal body weight. We found no decrease in serum ghrelin after resection of fundal ghrelin-releasing part of the stomach.

CONCLUSION

Stomach volume changes after restrictive bariatric surgery (sleeve resection or gastroplication) are accompanied by mild increase in serum ghrelin. This increment is greater after more significant body weight loss after surgery. Similar researches will help to find new treatment strategies for pathological obesity.

[Short-term outcomes of mechanical and hand-sewn laparoscopic one-anastomosis mini-gastric bypass]

OBJECTIVE

To evaluate the short-term outcomes of mechanical and hand-sewn laparoscopic one-anastomosis mini-gastric bypass.

MATERIAL AND METHODS

There were 233 patients who underwent laparoscopic one-anastomosis mini-gastric bypass. Short-term results were analyzed in groups of mechanical (the first group, n=108) and hand-sewn (the second group, n=125) gastrojejunostomy. No significant between-group differences in baseline data were detected (demographic characteristics, body mass index, comorbidity and previous abdominal surgeries).

RESULTS

Surgery time and blood loss were similar in both groups. Intraoperative morbidity was 7.2-10.2% (p=0.485). All complications required no surgical conversion (Satava-Kazaryan grade I). Overall postoperative morbidity was 16.0-21.3% (p=0.314). Most events corresponded to Accordion grade I and had no significant effect on hospital-stay.

CONCLUSION

This study revealed no significant differences in short-term outcomes after laparoscopic one-anastomosis gastric bypass with mechanical and hand-sewn gastrojejunostomy. Further study of long-term clinical outcomes is necessary.

Results of sleeve gastrectomy in obese patients with type 2 diabetes mellitus and impaired glucose tolerance: Retrospective cohort registry-based study

Background. In the available literature, the data on the positive effects of sleeve gastrectomy in treatment of type 2 diabetes mellitus (T2DM) and impaired glucose tolerance (IGT) become more common, however, they are heterogeneous and not always unambiguous.

The aim. To analyze our own results of treatment of patients with type 2 diabetes mellitus and impaired glucose tolerance, who underwent sleeve gastrectomy.

Materials and methods. Retrospective cohort registry-based study was carried out. From 2016 to April 2021, 29 (19 %) and 7 (4.6 %) patients with diagnosed T2DM and IGT respectively underwent surgery. Of these, sleeve gastrectomy was performed in 13  (44.8  %)  patients with type  2 diabetes mellitus and in 5  (71.4  %)  patients with IGT. The mean duration of follow-up for T2DM and IGT patients was 14.2 ± 12.3 and 11.2 ± 9.0 months respectively.

Results. The mean %EWL (% excess weight loss) in patients with T2DM and IGT was 44.1 ± 17.3 and 51.5 ± 16.9 respectively, and the mean %TWL (% total weight loss) was 25.0 ± 8.0 and 27.8 ± 6.0 respectively. At the moment of observation, all patients had normal level of fasting blood glucose. The level of HbA1c in patients with type 2 diabetes before the surgery was 8.2 ± 1.6, after surgery, at the time of observation – 5.8 ± 0.5 (U = 4; p ≤ 0.01). Targeted HbA1c values was recorded in all 13 patients with type 2 diabetes.

Conclusion. Our study shows the efficiency of sleeve gastrectomy both in terms of weight loss and of the remission for patients with T2DM and IGT. 

[The first experience of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity]

OBJECTIVE

To study the results of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity.

MATERIAL AND METHODS

A prospective cohort study included 74 patients who underwent bariatric surgery (Senhance digital laparoscopy system) between January 2022 and May 2023. Of these, 12 patients underwent robot-assisted longitudinal gastrectomy, 20 patients - robot-assisted Roux-en-Y gastric bypass, 36 patients - robot-assisted gastric bypass with one anastomosis/mini-gastric bypass, 6 patients - surgical exploration. We assessed duration of surgery, docking, placement of trocars and robotic manipulators, the need for their intraoperative displacement, incidence of intraoperative complications and conversions to laparoscopic surgery, intraoperative blood loss and early postoperative complications, severity of pain syndrome on the 1st day after surgery.

RESULTS

Mean surgery time was 87 [67, 120], 116 [78, 139], 96 [79, 125] and 141 [112, 184] min, respectively. Intraoperative blood loss was less than 50 ml. There were no complications requiring surgical treatment, cardiovascular, respiratory and other complications within 1 month.

CONCLUSION

Robot-assisted bariatric surgery using the Senhance system is feasible and safe for patients. Immediate results of robotic surgery are comparable to those after laparoscopy. However, large experience and cost-effectiveness analysis are required to assess the feasibility of robotic systems in bariatric surgery.

[Endoscopic intragastric injection of botulinum toxin in the treatment of patients with morbid obesity: opportunities and prospects]

The authors consider modern epidemiological and demographic data on morbid obesity. Literature review is devoted to non-surgical treatment of patients with morbid obesity. The authors analyze the results of experimental and clinical studies on endoscopic intragastric injection of botulinum toxin and bariatric efficacy of this approach. The indications for endoscopic intragastric injection of botulinum toxin and advantages of this technique are clearly formulated. The authors identified the most significant criteria for objective assessment of clinical effectiveness of endoscopic intragastral injection of botulinum toxin, as well as scientific and methodological principles necessary for this technique. Clinical efficacy of intragastric injection of botulinum toxin including overweight loss, anorexigenic and gastroparetic effects indicates inconsistent results and certain unresolved problems. Thus, large-scale multiple-center randomized controlled trials and multivariate analysis are required to determine the role of endoscopic intragastric injection of botulinum toxin in complex treatment of patients with morbid obesity.

Successful pregnancy with primary infertility as a result of simultaneous bariatric intervention and laparoscopic oophorectomy in women with large cystic ovarian teratoma and morbid obesity

The article presents a clinical observation of a patient with primary infertility on the background of morbid obesity (BMI – 64.6 kg/sq.m.) and large cystic teratoma of the right ovary, who underwent bariatric surgery – laparoscopic minigastric bypass and simultaneous laparoscopic right-sided oophorectomy. Along with the true gynecological causes of female infertility, which include, among others, benign formations of the uterine appendages, obesity is a proven significant factor in its development. The use of various infertility treatment options in obese women is ineffective, and pregnancy outcomes are often disappointing. The only proven effective treatment for morbid obesity is bariatric surgery. The implementation of bariatric intervention, and, as a result, a significant decrease in body weight, directly positively affects fertility rates. However, the polyetiological nature of primary infertility in women dictates the need for an integrated approach to treatment. A feature of the presented case is the simultaneous elimination of both etiological factors of infertility – gynecological and endocrine after one surgical intervention. The goal was achieved – after 10 months, the patient was diagnosed with a progressive uterine pregnancy for a period of 11 weeks, with a decrease in body weight by 49.9% of overweight. The course of pregnancy was uneventful. Childbirth independent, newborn full-term boy without deviations. After the birth of the child, the patient continued to reduce body weight and, 29 months after surgery, she achieved a loss of 67% of her excess weight. The presented case clearly demonstrates the advantages of simultaneous elimination of the most likely causes of primary infertility. However, the implementation of such interventions by laparoscopic access requires extensive surgical experience, technical equipment and comprehensive readiness of the medical institution.

The problem of obesity «through the eyes» of patients (results of the survey of patients of the outpatient registry)

Aim. To assess, based on the results of the questionnaire, patients' awareness of the presence, possible causes and health effects of overweight /obesity; to determine patients' self-assessment of their own weight, information about the methods used to treat the disease, adherence to therapy.Material and methods. The survey of patients of the outpatient registry was carried out as part of a face-to-face visit of inclusion in the observational study of EVA using a specially designed questionnaire. Out of 582 patients of the PROFILE registry who came for a visit in the period from 08.04.2019 to 24.03.2020, 295 people with a body mass index (BMI) were included in the study>25 kg/m2.Results. According to the BMI values, the patients of the study cohort were divided into 4 groups: 108 (36.6%) with pre-obesity, 124 (42.1%) with class I obesity, 42 (14.2%) with class II obesity, 21 (7.1%) with class III obesity. With an increase in the class of obesity, the number of patients who admit the presence of this pathology in self-assessment increases (p<0.0001): 26.6% of patients with grade I obesity, 47.6% with grade II obesity and 81% of patients with grade III obesity gave correct answers. Among the possible causes of overweight/obesity, every third patient of the study indicated physical inactivity (31.3%) and every fifth specified excessive nutrition (20.8%). The majority of patients, 244 (82.7%), believe that being overweight worsens their health, the same number of patients, 255 (86.4%), are sure that they need to lose weight. The most common (70% of responses) for weight loss patients used various dietary restrictions, fasting, only 17% of patients increased the level of physical activity. Frequent violation of the principles of rational nutrition was revealed (insufficient amount of fruits and vegetables in the diet, salting food, eating a large amount of easily digestible carbohydrates. One hundred and thirty nine (47.1%) patients noted that it was difficult for them to observe any restrictions in food, to adhere to a diethalf of all patients and 70% of patients with class III obesity experience a constant feeling of hunger. Of the 25 patients to whom pharmacotherapy was recommended, 21 (84%) people were adherent.Conclusion. Overweight and obese patients are not always critical of self-assessment of their body weight, and the main reasons for being overweight or obese considered to be inactivity and various violations of the principles of rational nutrition. The patients of the study cohort were characterized by eating disorders and half of the patients showed signs of food addiction. Recommendations for the pharmacotherapy of obesity were received by less than 10% of patients in the study cohort, while the patients' adherence to drug therapy was high.

[Heart failure and obesity]

Obesity is an independent predictor of cardiovascular diseases (CVD), including heart failure (HF). Nevertheless, numerous studies have shown that patients with CVD who are overweight and slightly obese have a better short-term and moderate prognosis than thinner patients with CVD. This phenomenon has been called the obesity paradox. Understanding the obesity paradox is important in patients with HF, given the high prevalence of obesity in patients with HF. The article presents an overview of clinical studies devoted to the study of obesity as a risk factor for HF, the pathogenesis of HF in obesity, and highlights the issues of the obesity paradox and the treatment of obesity in this category of patients.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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Association between Adiponectin and Leptin Receptor Genetic Polymorphisms and Clinical Manifestations of Metabolic Syndrome

Abdominal obesity coupled with polygenic hereditary defects is considered the initial event in the development of metabolic syndrome (MS). The purpose of this study was to analyse the frequency with which polymorphic loci of adiponectin (ADIPOQ) and leptin (LEP) genes occur in patients with MS and the association between the symptoms of MS and these polymorphisms. DNA was isolated from the whole blood of 207 patients with MS and 100 healthy individuals (control group) using the phenol-chloroform method. Gene polymorphisms were determined using real-time polymerase chain reaction (PCR). The most common variant of the ADIPOQ (rs2241766) gene among MS patients was the GT genotype. The A allele of the LEP (rs7799039) gene was found to be the most frequent in MS patients. The highest systolic blood pressure was found in carriers of the GG genotype of the LEP (rs7799039) gene. The carriers of the ADIPOQ (rs2241766) GT genotype were associated with the highest systolic blood pressure and body mass index (BMI); carriers of the ADIPOQ (rs2241766) GG genotype were associated with the highest diastolic blood pressure, hyperglycaemia, and elevated glycated haemoglobin (HbA1c). The results of this study allowed us to establish the unique gene variants associated with the risk of developing MS in the Crimean population.

[Adipocytokines: modern definition, classification and physiological role]

Adipose tissue is an endocrine organ which produces a large number of secretory bioactive substances also known as adipocytokines affecting directly insulin resistance (IR), glucose and lipid metabolism, angiogenesis and inflammation. The studies show a close connection between the imbalance of adipocytokines formed as a result of excessive deposit of adipose tissue in the course of the development of type 2 diabetes mellitus and cardiovascular diseases. In the present review, we summarize current data on the effect of the adipocytokines on the liver, skeletal muscles, adipose tissue, endothelial cells and inflammatory processes, as well as attempt to define the term «adipocytokines» and classify adipocytokines according to their influence on metabolic processes and pro-inflammatory status. Some of adipocytokines (adiponectin, omentin, leptin, resistin, tumor necrosis factor-α and interleukin-6) are divided into two groups: adipocytokines reducing IR, and adipocytokines increasing IR.

Obesity as a risk factor for diseases of the digestive system

Currently, the global prevalence of obesity among the worlds adult population is about 650 million people, which makes it possible to consider this chronic metabolic disease as a non-infectious pandemic of the 21st century. It has been proven that obesity is associated with several gastroenterological diseases, while the mechanisms of these associations are extremely heterogeneous and multifactorial. Hypertrophy and hyperplasia of adipocytes in obesity lead to a change in the profile of adipokine production (a decrease in adiponectin, an increase in leptin), an increase in the production of pro-inflammatory cytokines (interleukin-1, 6, 8, tumor necrosis factor ), C-reactive protein, free fatty acids, as well as active forms of oxygen (superoxide radicals, H2O2). All the above induces the development of chronic slowly progressive inflammation, oxidative stress, and insulin resistance. In addition, peptides secreted by adipocytes (adiponectin, leptin, nesfatin-1 and apelin) can modulate gastrointestinal motility, acting both centrally and peripherally. The qualitative and quantitative changes in the intestinal microbiota observed in obese patients (increased Firmicutes and decreased Bacteroidetes) lead to a decrease in the production of short-chain fatty acids and an increase in the intestinal permeability due to disruption of intercellular tight junctions, which leads to increased translocation of bacteria and endotoxins into the systemic circulation. Numerous studies have demonstrated the association of obesity with diseases of the esophagus (gastroesophageal reflux disease, Barretts esophagus, esophageal adenocarcinoma, esophageal motility disorders), stomach (functional dyspepsia, stomach cancer), gallbladder (cholelithiasis, gallbladder cancer), pancreas (acute pancreatitis, pancreatic cancer), liver (non-alcoholic fatty liver disease, hepatocellular carcinoma), intestine (diverticular disease, irritable bowel syndrome, colorectal cancer).

Sympathetic hyperactivity in patients with hypertension: pathogenesis and treatment. Part I

The article is devoted to the influence of sympathetic  nervous system (SNS) on the cardiovascular  system.  Influence of SNS activity on the blood pressure  level and the pathogenesis of hypertension  development, as well as the effect of SNS on many biochemical and metabolic parameters playing a key role in the development  of metabolic syndrome and hypertension  are considered. Possible mechanisms  of action of various methods that reduce  the SNS activity, restore  the function of autonomic nervous system  and normalize the cardiovascular system and blood pressure  are considered.

[Effectiveness of laparoscopic bariatric surgery: gastric plication vs sleeve gastrectomy]

OBJECTIVE

To evaluate an effectiveness of laparoscopic bariatric surgery - sleeve gastrectomy and gastric plication.

MATERIAL AND METHODS

In 2017, laparoscopic gastric plication in 47 obese patients and sleeve gastrectomy in 108 patients were performed at the Askerkhanov Medical Center and Loginov Moscow Clinical Scientific Center. Patients with morbid obesity (BMI ≥40 kg/m²) and obesity grade II (BMI ≥35.0 kg/m²) with one of such comorbidities as hypertension, diabetes mellitus type II, sleep apnea, degenerative joint disease, cholelithiasis underwent surgical treatment. The first group consisted of 35 patients who underwent laparoscopic gastric plication, the second group - 87 patients after laparoscopic sleeve gastrectomy. Overweight loss, quality of life, and course of comorbidities were evaluated before surgery, in 12 and 24 months after surgery. MOS SF-36 questionnaire was used to assess the quality of life.

RESULTS

Overweight loss after 24 months was 52.4±6.1% and 67.9±8.4% in the first and second groups, respectively (p=0.001). Quality of life after gastric plication is lower compared to sleeve gastrectomy. The greatest difference in favor of sleeve gastrectomy was obtained after 24 months regarding physical functioning (64.3±14.9 vs. 79.2±17.7; p=0.010) and emotional functioning (60.7±28.8 vs. 78.0±25.2; p=0.009). Regression of comorbidities after sleeve gastrectomy is more significant than after gastric plication.

CONCLUSION

Gastric plication is less effective than sleeve gastrectomy. However, postoperative morbidity requiring redo surgery is lower after gastric plication.

[Gut microbiota is a factor of risk for obesity and type 2 diabetes]

Gut microbiota (GM) is a set of bacteria which colonize the gastrointestinal tract. GM and its active metabolites take part in intestinal and hepatic gluconeogenesis, in the synthesis of incretin hormones, and affect the regulation of appetite. Thus, GM and its metabolites participate in the homeostasis of carbohydrates and fats. An imbalance in the set of the intestinal flora and a disturbance of the production of active metabolites sharply increases the risk of developing obesity and type 2 diabetes. There are conflicting data in the literature on the role of specific microorganisms in the development of metabolic disorders. Research is needed to identify specific types of bacteria and their active metabolites which affect the development of obesity and type 2 diabetes.

[Changes in metabolic parameters and glomerular filtration rate in patients with morbid obesity after bariatric surgery]

AIM

To study the effect of weight loss in the short term after bariatric surgery (BO) on metabolic parameters and glomerular filtration rate (GFR) in patients with morbid obesity.

MATERIALS AND METHODS

We studied 40 adult (over 18 years) patients with morbid obesity who underwent bariatric surgery. Metabolic indices and calculated GFR according to the CKD-EPI formula in patients before and after bariatric surgery were compared.

RESULTS

In the whole group of operated patients, the average body mass index (BMI) after surgery decreased from 45.8 to 30.5 kg/m2. In 11 (92%) patients with impaired carbohydrate metabolism, remission of diabetes mellitus was achieved and sugar-lowering drugs were canceled. In patients with baseline GFR90 ml/min/1.73 m2 after surgery, there is a tendency towards a decrease in GFR, probably due to a decrease in hyperfiltration. In patients with baseline GFR90 ml/min/1.73 m2 after surgery, a statistically significant increase in the level of GFR was noted. The greater metabolic efficacy of combined operations (mini-gastric bypass, biliopancreatic diversion) in relation to the correction of carbohydrate and fat metabolism was revealed.

CONCLUSION

Obesity is a modifiable risk factor for decreased kidney function and the progression of chronic kidney disease. Bariatric surgery is an effective treatment for morbid obesity. The study proved the positive effect of weight loss after BO on renal function, including by improving the course of diseases associated with obesity.

Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V., Mayorov A.Yu. 9th edition

Dear Colleagues! We are glad to present the 9th Edition (revised) of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2018, 2019), American Association of Clinical Endocrinologists (AACE, 2019), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014, 2018) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EXAMINE, ELIXA, SUSTAIN, DEVOTE, EMPA-REG OUTCOME, CANVAS, DECLARE, CARMELINA, REWIND, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 463 million patients by the end of 2019. According to the current estimation by the International Diabetes Federation, 578 million patients will be suffering from diabetes mellitus by by 2030 and 700 million by 2045. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4 584 575 patients with DM in this country by the end of 2018 (3,1% of population) with 92% (4 238 503) Type 2 DM, 6% (256 202) Type 1 DM and 2% (89 870) other types of DM, including 8 006 women with gestational DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) con- firmed that only 54% of Type 2 DM are diagnosed. So real number of patients with DM in Russia is 9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications. Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. In сurrent edition of the Standards: New goals of glycemic control for the elderly, based on the presence of functional dependence, as well as for pregnant women, children and adolescents, are given. Added a snippet that describes the continuous glucose monitoring. Only low-density lipoprotein cholesterol level is used as a target for lipid metabolism. Proposes more stringent target levels of blood pressure. It also features updated guidelines on stratification of treatment in newly diagnosed Type 2 diabetes: the excess of the initial level of HbA1c over the target level was used as a criterion. In the recommendations for the personalization of the choice of antidiabetic agents, it is taken into account that in certain clinical situations (the presence of atherosclerotic cardiovascular diseases and their risk factors, chronic heart failure, chronic kidney disease, obesity, the risk of hypoglycemia) certain classes of hypoglycemic agents (or individual drugs) have proven advantages. Recommendations for psychosocial support are added. The position of metabolic surgery as a method of treatment of DM with morbid obesity is updated. Recommendations for diagnostic and treatment of hypogonadism syndrome in men with DM are added. For the first time, evidence levels of confidence and credibility levels of recommendations for diagnostic, therapeutic, rehabilitative and preventive interventions based on a systematic review of the literature are given in accordance with the recommendations of the Center for Healthcare Quality Assessment and Control of the Ministry of Health of the Russian Federation. This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discus- sions held at national meetings and forums. These guidelines are intended for endocrinologists, primary care physicians and other medical professionals involved in the treatment of DM. On behalf of the Working Group

Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V., Mayorov A.Yu. 9th edition

Dear Colleagues! We are glad to present the 9th Edition (revised) of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2018, 2019), American Association of Clinical Endocrinologists (AACE, 2019), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014, 2018) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EXAMINE, ELIXA, SUSTAIN, DEVOTE, EMPA-REG OUTCOME, CANVAS, DECLARE, CARMELINA, REWIND, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 463 million patients by the end of 2019. According to the current estimation by the International Diabetes Federation, 578 million patients will be suffering from diabetes mellitus by by 2030 and 700 million by 2045. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4 584 575 patients with DM in this country by the end of 2018 (3,1% of population) with 92% (4 238 503) Type 2 DM, 6% (256 202) Type 1 DM and 2% (89 870) other types of DM, including 8 006 women with gestational DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) con- firmed that only 54% of Type 2 DM are diagnosed. So real number of patients with DM in Russia is 9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications. Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. In сurrent edition of the Standards: New goals of glycemic control for the elderly, based on the presence of functional dependence, as well as for pregnant women, children and adolescents, are given. Added a snippet that describes the continuous glucose monitoring. Only low-density lipoprotein cholesterol level is used as a target for lipid metabolism. Proposes more stringent target levels of blood pressure. It also features updated guidelines on stratification of treatment in newly diagnosed Type 2 diabetes: the excess of the initial level of HbA1c over the target level was used as a criterion. In the recommendations for the personalization of the choice of antidiabetic agents, it is taken into account that in certain clinical situations (the presence of atherosclerotic cardiovascular diseases and their risk factors, chronic heart failure, chronic kidney disease, obesity, the risk of hypoglycemia) certain classes of hypoglycemic agents (or individual drugs) have proven advantages. Recommendations for psychosocial support are added. The position of metabolic surgery as a method of treatment of DM with morbid obesity is updated. Recommendations for diagnostic and treatment of hypogonadism syndrome in men with DM are added. For the first time, evidence levels of confidence and credibility levels of recommendations for diagnostic, therapeutic, rehabilitative and preventive interventions based on a systematic review of the literature are given in accordance with the recommendations of the Center for Healthcare Quality Assessment and Control of the Ministry of Health of the Russian Federation. This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discus- sions held at national meetings and forums. These guidelines are intended for endocrinologists, primary care physicians and other medical professionals involved in the treatment of DM. On behalf of the Working Group

Cardiovascular risk in type 2 diabetes patients

Cardiovascular diseases remain leading cause of high mortality in diabetes patients. The article is focused on the influence of diabetes on cardiovascular risks. The prevalence presented, as the significance of the main and additional risk factors of cardiovascular diseases in the development of macrovascular complications in diabetes. In the context of influence on cardiovascular risks, modern glucose lowering drugs are considered, the safety and efficacy properties. Advantages of dapagliflozin underscored, the novel oral drug of new generation, with safe and prominent antidiabetic effect and ability to correct the main factors of cardiovascular risk (obesity, hypertension).