Type 2 Diabetes Remission Research Articles

12524 Predictive Factors For Type 2 Diabetes Remission: Insights From A Digital Twin Intervention Program At 18 Months

Abstract Disclosure: P. Shamanna: None. M. Dharmalingam: None. A. Vadavi: None. A. Keshavamurthy: None. S. Bhonsley: None. M. Thajudeen: None. A. Balasubramanian: None. S.R. Joshi: None. Background and aims: Digital twin (DT) platform uses Artificial Intelligence (AI) and Internet of Things, to integrate multi-dimensional data for precision nutrition and health recommendations via the mobile app. Remission was defined as A1C levels less than 6.5% without medication for over 3 months. Evidence suggests that remission is more likely in individuals with early type 2 diabetes (T2D) who are not using insulin therapy and who can engage in significant weight loss. We evaluated the predictive value of baseline parameters on T2D remission, including duration of diabetes, HbA1c levels, diabetic medications as drug count, and CGM metrics, with the objective to improvise the patient selection strategies for remission Methods We analyzed T2D patients (n=209) who completed 18 months of digital twin intervention. Potential predictors were examined by logistic regression analyses, with model performance evaluated by accuracy, precision, recall, and Area under the Receiver Operating Characteristic Curve (AUC-ROC) metrics. Results The model achieved an accuracy of 78.57%, precision of 79.41%, recall of 93.10%, and AUC-ROC of 0.745. Significant inverse associations with remission were observed for the duration of diabetes (OR: 0.74), baseline HbA1c (OR: 0.76), and the number of anti-diabetic medications as oral drugs (OR: 0.77), indicating decreased odds of remission with increasing values. Conversely, positive associations were found for Time Below Range 2 at baseline (OR: 1.22) and HOMA2IR at baseline (OR: 1.24), suggesting increased odds of remission with higher values in these metrics. We describe the Receiver Operating Characteristic (ROC) curve for the diabetes remission prediction model, with the area under the curve (AUC) indicating the model's discriminatory ability. The duration of diabetes emerged as the most significant negative predictor, followed by baseline HbA1c and the number of diabetic drugs, while counterintuitive findings like the positive association of baseline HOMA2IR with remission suggest areas for further investigation. Conclusion We identified baseline parameters significantly influencing the likelihood of T2D remission in people undergoing digital twin intervention. The odds ratios indicate the effect sizes of these predictors, highlighting the importance of personalized, data-driven treatment approaches that potentially enhance remission outcomes. Further validation of these findings in larger external cohorts would be useful. Presentation: 6/1/2024

Comparison of clustering and phenotyping approaches for subclassification of type 2 diabetes and its association with remission in Indian population

Identification of novel subgroups of type 2 diabetes (T2D) has helped improve its management. Most classification techniques focus on clustering or subphenotyping but not on both. This study aimed to compare both these methods and examine the rate of T2D remission in these subgroups in the Indian population. K-means clustering (using age at onset, HbA1C, BMI, HOMA2 IR and HOMA2%B) and subphenotyping (using homeostatic model assessment (HOMA) estimates) analysis was done on the baseline data of 281 patients with recently diagnosed T2D who participated in a 1-year online diabetes management program. Cluster analysis revealed three distinct clusters: severe insulin-deficient diabetes (SIDD), severe insulin-resistant diabetes (SIRD), and mild obesity-related diabetes (MOD) while subphenotyping showed four distinct categories: hyperinsulinemic, insulinopenic, classical, and nascent T2D. Comparison of the two approaches revealed that the clusters aligned with phenotypes based on shared characteristics of insulin sensitivity (IS) and beta cell function (BCF). Clustering correctly identified individuals in nascent group (high IS and BCF) as having mild obesity related diabetes which subphenotyping did not. Post-one-year intervention, higher remission rates were observed in the MOD cluster (p = 0.383) and the nascent phenotype showing high IS and BCF (p = 0.061, Chi-Square test). In conclusion, clustering based on a comprehensive set of parameters appears to be a superior method for classifying T2D compared with pathophysiological subphenotyping. Personalized interventions may be highly effective for newly diagnosed individuals with high IS and BCF and may result in higher remission rates in these individuals. Further large-scale studies are required to validate these findings.

A service evaluation of weight management for glycaemic control and remission of type 2 diabetes using traditional food in Nepal (Ho-DIRECT NEPAL): a single-arm trial

Remission of early type 2 diabetes (T2D) is possible; however, diet programmes proven effective are unaffordable in many southeast Asian populations where T2D is more frequent and more aggressive at lower body weight and younger age. We evaluate an entirely food-based service. This study employed a single-arm intervention and follow-up design for intervention evaluation in existing hospital people with T2D of under 5 years known duration. Individuals attending a diabetes clinic in Kathmandu with early T2D (<5 years) aged 30-70 years, BMI ≥23kg/m2, were offered a low-cost nutritionally complete diet-programme, using traditional Nepali foods to provide 8-weeks ∼850kcal/day weight loss induction, and then weight maintenance. The participants received 4-weekly dietetic appointments (30-45min) and verbo-pictorial leaflets using household measures. Glucose-lowering medications (49/70at baseline) were stopped at baseline or soon after. The study was registered as ISRCTN10671396, testing a traditional food-based intervention for weight loss and T2D remission. For 70 individuals (45 female) invited between March 19, 2022 and September 19, 2023, baseline mean (SD) age was 48.6 (9.9) years, bodyweight 74.6 (9.5) kg, BMI 29.7 (3.6) kg/m2, known diabetes duration 2.5 (1.9) years, HbA1c on treatment 8.1 (1.6) %. At 12, 24 and 52 weeks respectively, evaluating n=44, 46, 45, bodyweight was 70.1 (8.5), 69.8 (8.9), 70.0 (8.8) kg, HbA1c 6.8 (0.9), 6.9 (1.5), 7.1 (1.3) %; HbA1c<6.5% was recorded for 46%, 48% and 36% and remission of T2D (HbA1c<6.5% off medication >3 months) in 43%, 39% and 29%. The main reported adherence barriers were fears of weakness, hunger, and inconvenience during travel. Incentives were ease of the diet, reduced doses and costs of medications, and improved appearance. Traditional food-based weight management can valuably improve control, reduce medication needs, and generate remissions of established T2D, but adherence barriers must be overcome to optimise outcomes. All Saints Educational Trust, England.

Very-low-calorie diet-based intensive lifestyle intervention for remission of type 2 diabetes: Real-world experience in a South Asian population.

Very low-calorie diet (VLCD) can induce weight loss and diabetes remission (DR) amongst people with obesity and recent-onset type 2 diabetes (T2D). We aimed to determine the effectiveness and acceptability of VLCD in achieving DR amongst Sri Lankan adults with T2D. A retrospective analysis was conducted in a diabetes practice where VLCD-based Diabetes Remission Programme (VDRP) was offered for adults (>18 years) with T2D for <3 years and body mass index over 25 kg/m2. VLCD (~800 kcal/day, provided with/without diet replacement formula) was offered for 8-12 weeks, followed by gradual food reintroduction and exercise. DR was defined as HbA1c <6.5% at least 3 months after stopping glucose-lowering medications. A total of 170 participants who enrolled in the VDRP (mean age 38.4 years [±11.1], men 68%, mean baseline HbA1c 86.9 [±18.1] mmol/mol (10.1 [±2.1]%), median duration of T2D 2 years [IQR 1-2]) and 87 (51%) of them followed the programme (attended at least one follow-up visit). Amongst the individuals who followed the VDRP, 40.2% achieved DR (35/87), compared with 2.4% (2/83) amongst those who did not follow the VDRP (aHR 9.3, 95% CI 2.2-16.4, p = 0.002). The proportion achieving normoglycaemia (HbA1c < 6.5%) but continued to take glucose-lowering medication was 20/87 among VDRP followers and 20/85 amongst VDRP non-followers. The commonest reasons for not following the VDRP were too restrictive dietary quantity (92%) and difficulties in finding recommended food items (67%). Majority (79%) would recommend VDRP to others. VDRP is effective in achieving T2D remission amongst Sri Lankan adults with recently diagnosed T2D and obesity. Over half of the participants followed the programme and over 75% would recommend it to others, indicating good acceptability.

Using Pre-operative Insulin Dose to Predict Diabetes Remission After Roux-En-Y Gastric Bypass and Sleeve Gastrectomy.

Obesity is intricately associated with type-2 diabetes (T2D) and other cardiovascular conditions, increasing morbidity, mortality, and health care costs. Metabolic and bariatric surgeries (MBS) have shown promising results in significant weight loss and T2D remission, but existing predictive scores for post-MBS diabetes remission do not consider insulin dosage, potentially overlooking a critical factor. A retrospective analysis of patients with T2D who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). The study focused on insulin dosage impact, divided into quartiles, on remission rates post-MBS. The effectiveness of RYGB vs SG was compared within insulin dose quartiles with up to 5 years of follow up. A total of 508 patients (64% female, 94.9% White, mean age 53.5 ± 10.5years, BMI (46.0 ± 8.3kg/m2) were included in the analysis. This study demonstrates a profound association between insulin dosage quartiles and T2D remission after MBS. Patients with lower insulin requirements showed superior remission rates; those in the lowest quartile had remission rates of 73%, 70%, and 62% at 1, 3, and 5 years, respectively, compared to 34%, 37%, and 36% in the highest quartile (P < 0.001 across all intervals). RYGB surgery showed a significantly better remission in the second and third insulin quartiles, suggesting its effectiveness over SG for patients with mid-range insulin requirements. This study underscores the importance of considering insulin dosage when predicting T2D remission post-MBS. The findings advocate for a more nuanced selection of MBS procedures based on individual insulin profiles, potentially enhancing diabetes remission outcomes.

Remission of type 2 diabetes: position statement of the Italian society of diabetes (SID)

AbstractThe primary cause of the pandemic scale of type 2 diabetes (T2D) is the excessive and/or abnormal accumulation of adiposity resulting from a chronic positive energy balance. Any form of weight loss dramatically affects the natural history of T2D, favoring prevention, treatment, and even remission in the case of significant weight loss. However, weight regain, which is often accompanied by the recurrence or worsening of obesity complications such as T2D, is an inevitable biological phenomenon that is an integral part of the pathophysiology of obesity. This can occur not only after weight loss, but also during obesity treatment if it is not effective enough to counteract the physiological responses aimed at restoring adiposity to its pre-weight-loss equilibrium state. Over the past few years, many controlled and randomized studies have suggested a superior efficacy of bariatric surgery compared to conventional therapy in terms of weight loss, glycemic control, and rates of T2D remission. Recently, the therapeutic armamentarium in the field of diabetology has been enriched with new antihyperglycemic drugs with considerable efficacy in reducing body weight, which could play a pathogenetic role in the remission of T2D, not through the classical incretin effect, but by improving adipose tissue functions. All these concepts are discussed in this position statement, which aims to deepen the pathogenetic links between obesity and T2D, shift the paradigm from a “simple” interaction between insulin resistance and insulin deficiency, and evaluate the efficacy of different therapeutic interventions to improve T2D management and induce diabetes remission whenever still possible.

Reconsidering the role of depression and common psychiatric disorders as partners in the type 2 diabetes epidemic

Common psychiatric disorders (CPDs) and depression contribute significantly to the global epidemic of type 2 diabetes (T2D). We postulated a possible pathophysiological mechanism that through Bridge-Symptoms present in depression and CPDs, promotes the establishment of emotional eating, activation of the reward system, onset of overweight and obesity and, ultimately the increased risk of developing T2D. The plausibility of the proposed pathophysiological mechanism is supported by the mechanism of action of drugs such as naltrexone-bupropion currently approved for the treatment of both obesity/overweight with T2D and as separate active pharmaceutical ingredients in drug addiction, but also from initial evidence that is emerging regarding glucagon-like peptide 1 receptor agonists that appear to be effective in the treatment of drug addiction. We hope that our hypothesis may be useful in interpreting the higher prevalence of CPDs and depression in patients with T2D compared with the general population and may help refine the integrated psychiatric-diabetic therapy approach to improve the treatment and or remission of T2D.

Data-Driven Patient clusters of Type 2 Diabetes May Help to Identify Patients at Risk and Predict Metabolic Surgery Outcomes on Diabetes Remission and NAFLD Pregression

Abstract Background Precision medicine and customized medicine have gained enormous attention in recent years, especially in the treatment of type 2 diabetes (T2D). Different subgroups of diabetes have been identified by research employing data-driven cluster analysis, each with a unique diabetes progression and complication risk (Ahlqvist et al., Lancet Diabetes Endocrinol. 2018). Aims We aimed to apply the proposed cluster analysis to a patent population post metabolic surgery and investigate the association with T2D remission and presence of NAFLD. Methods We retrospectively linked newly defined clusters to metabolic surgery outcomes in 53 T2D patients. Utilizing k-means and hierarchical clustering, three clusters emerged based on glutamate decarboxylase antibodies, age, BMI, HbA1c, and homoeostatic model assessment estimates of β-cell function (HOMA2-B%) and insulin resistance (HOMA2-IR). Intraoperative liver biopsies assessed nonalcoholic fatty liver disease (NAFLD) presence differentiating between simple steatosis (NAFL) and steatohepatitis (NASH). Clinical and biochemical data were collected over two years, focusing on T2D remission and NAFLD improvement. Results Cluster 1, characterized by the lowest BMI, highest NASH rate, impaired beta-cell function, and increased insulin resistance, displayed a favorable response to surgery, indicating robust regeneration of beta-cells. Despite increased insulin production, T2D remission was surprisingly low at 44.0% after one year, in contrast to 75.00% in Cluster 2 and 100.00% in Cluster 3. Metabolic surgery notably reduced insulin resistance and promoted NASH remission, evidenced by a significant reduction in a non-invasive NASH detection score and liver enzyme levels across all three clusters. Conclusion Our findings suggest that patients in Cluster 1 already show a lack of beta-cell compensation being associated with a higher prevalence of NAFLD and poorer diabetic control and therefore especially might benefit from an earlier intervention. Data-driven classification might help to customize treatment plans and identify patients at higher risk of problems at diagnosis.

Inhibition of de novo ceramide synthesis by sirtuin-1 improves beta-cell function and glucose metabolism in type 2 diabetes.

Obesity and type 2 diabetes (T2D) are major risk factors for cardiovascular (CV) diseases. Dysregulated pro-apoptotic ceramide synthesis reduces β-cell insulin secretion, thereby promoting hyperglycaemic states that may manifest as T2D. Pro-apoptotic ceramides modulate insulin sensitivity and glucose tolerance while being linked to poor CV outcomes. Sirtuin-1 (SIRT1) is a NAD + -dependent deacetylase that protects against pancreatic β-cell dysfunction; however, systemic levels are decreased in obese-T2D mice and may promote pro-apoptotic ceramide synthesis and hyperglycaemia. Herein, we aimed to assess the effects of restoring circulating SIRT1 levels to prevent metabolic imbalance in obese and diabetic mice. Circulating SIRT1 levels were reduced in obese-diabetic mice (db/db) as compared to age-matched non-diabetic db/+ controls. Restoration of SIRT1 plasma levels with recombinant murine SIRT1 for 4 weeks prevented body weight gain and improved glucose tolerance, insulin sensitivity, and vascular function in mice models of obesity and T2D. Untargeted lipidomics revealed that SIRT1 restored insulin secretory function of β-cells by reducing synthesis and accumulation of pro-apoptotic ceramides. Molecular mechanisms involved direct binding to and deacetylation of Toll-like receptor 4 (TLR4) by SIRT1 in β-cells, thereby decreasing the rate-limiting enzymes of sphingolipid synthesis SPTLC1/2 via AKT/NF-κB. Among patients with T2D, those with high baseline plasma levels of SIRT1 prior to metabolic surgery displayed restored β-cell function (HOMA2-β) and were more likely to have T2D remission during follow-up. Acetylation of TLR4 promotes β-cell dysfunction via ceramide synthesis in T2D, which is blunted by systemic SIRT1 replenishment. Hence, restoration of systemic SIRT1 may provide a novel therapeutic strategy to counteract toxic ceramide synthesis and mitigate CV complications of T2D.

Validation of the Individualized Metabolic Surgery score in predicting long-term remission of diabetes after duodenal switch-type procedures.

To validate the Individualized Metabolic Surgery (IMS) score and assess long-term remission of type 2 diabetes (T2D) after duodenal switch (DS)-type procedures in patients with obesity. In addition, to help guide metabolic procedure selection for those patients categorized as having severe T2D. This is a retrospective single cohort study of all patients with T2D and severe obesity, who underwent DS-type procedures at a single institution from December 2010 to December 2018. Study endpoints included validating the IMS score in our cohort and evaluating the impact of DS-type procedures on long-term (≥ 5 years) remission of T2D, especially in patients with severe disease. A receiver operator characteristic curve was used to assess the accuracy of the IMS score using the area under the curve (AUC). The study cohort included 30 patients with complete baseline and long-term glycaemic data after their index DS-type surgery. Twelve patients (40%) were classified with severe T2D, and the distribution of IMS-based severity groups was similar between our cohort and the original IMS study (P = .42). IMS scores predicted long-term T2D remission with AUC = 0.77. Patients with IMS-based severe diabetes achieved significantly higher long-term remission after DS-type procedures compared with gastric bypass and/or sleeve gastrectomy from the original IMS study (42% vs. 12%; P < .05). The IMS score properly classifies the severity of T2D in our study cohort and adequately predicts its long-term remission after DS-type procedures. While T2D remission decreases with more severe IMS scores, long-term remission remains high after DS-type procedures among patients with severe disease.

Remission of Type-2 Diabetes on Plant Based Diet

The incidence of diabetes has amplified worldwide, but health outcomes have not improved significantly. Anti-hyperglycemic medications are often accompanied by weight gain, hypoglycemia, and risk of cardiovascular events. Most diabetics are suggested a “low carb diet” as a nutritional strategy but the results short-termed and often unsustainable in most cases. Aim: This case report depicts the effectiveness of a personalized nutritional intervention program focused on Whole Food Plant Based Diet (WFPBD) and Intermittent Fasting (IF) in reducing blood glucose, body weight, waist circumference, without any pharmacological treatment. Methods: We present a case of a personalized nutritional intervention program of a 47-year-old diabetic female, weighing 86kg, measuring 168cm (BMI 30.5), with waist circumference of 43 inches. Her pre-intervention glycated hemoglobin (HbA1c) was 12.5%, post prandial glucose (PPG) was 342mg/dl, and fasting blood glucose (FBG) was 250mg/dl. Besides following a WFPBD, the patient was advised to do intermittent fasts of 14 hours, starting from about 6 pm in the evening and extending till about 8 am the next morning. The primary measures were changes in HbA1c, fasting and postprandial glucose levels, body weight, waist circumference, and BMI. Results: Nutritional intervention brought substantial improvements in several health parameters of the patient. Post-intervention, the patient was able to achieve an HbA1c of 6.40%, average FBG of 113mg/dl, average PPG of 127mg/dl, body weight of 74kg, BMI of 26.2, and waist circumference of 37 inches. Conclusions: The results suggest that a personalized dietary modification program combining WFPBD and IF can significantly improve metabolic health and potentially reverse T2D without the need for pharmacological treatment.

Weight loss outcomes with semaglutide based on diabetes severity using the individualized metabolic surgery score

Semaglutide demonstrated inferior weight loss responses in patients with type 2 diabetes (T2D) compared to patients with obesity without T2D. The individualized metabolic surgery (IMS) score was validated to predict T2D remission after bariatric surgery. The parameters of the IMS are HbA1c (<7%), insulin use, T2D medications and T2D duration. We aim to assess weight loss outcomes of semaglutide based on IMS score in patients with obesity and T2D. This is a retrospective multicentered cohort study of patients with T2D and BMI≥ 27kg/m2 taking ≥1mg of semaglutide recruited from January 2020 to December 2022. We excluded patients with a history of bariatric surgery or taking other anti-obesity medications. IMS was calculated at baseline and patients weight change was recorded at baseline, 3, 6, 9 and 12 months. IMS was classified as mild (0-24.9 points), moderate (25-94.9 points), and severe (95-180 points). Analysis was performed based on IMS score quartiles and combination of Mild-Moderate vs Severe categories. We performed mixed linear regression models including age, sex, and baseline weight to assess associations between IMS categories with total body weight loss percentage (TBWL%). We included 297 patients (42% female, mean age 62±12 years) in the analysis. At 12 months, there was a stepwise decrease in weight loss outcomes when comparing patients by IMS quartiles (LS mean TBWL%± SE): 8.8±0.8% vs 6.9±0.8% vs 5.7±0.9% vs 5.0±0.8%. In the mixed linear model, patients in the mild-moderate category achieved significantly superior weight loss outcomes (LS mean TBWL± SE:-8.3±0.7%) than patients in the severe category (-5.5±0.6%; difference:-2.9, 95% CI:-5.2 to-0.5, p=0.006) at 12 months. There was no significant difference in glycemic improvement regardless of IMS severity at baseline. In our cohort, lower IMS severity was associated with more weight loss in patients with obesity and T2D. Further studies are needed to understand T2D severity and its effect on semaglutide outcomes. Beyond payment to the research staff by Mayo Clinic, this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The impact of low-energy total diet replacement with behavioural support for remission of type 2 diabetes on disordered eating (ARIADNE): Protocol for a non-inferiority randomised controlled trial

IntroductionThe National Health Service (NHS) in England is currently piloting a weight loss programme for remission of newly diagnosed type 2 diabetes (T2D), where participants replace all food with low-energy nutritionally complete formula products for 12 weeks (total diet replacement, TDR) and receive behavioural support. In a clinical trial, this programme led to remission in nearly half the participants. However, this weight loss programme might also worsen disordered eating and prompt eating disorders in susceptible people. We aim to investigate if the TDR programme is non-inferior to standard care in terms of disordered eating in susceptible individuals. MethodsFifty six people with newly diagnosed T2D, BMI ≥ 27 kg/m2, and medium to high scores of disordered eating based on the Eating Disorders Examination questionnaire (EDE-Q) will be randomised 1:1 to TDR receiving remote weekly/bi-weekly dietetic support or standard care. Participants will be re-assessed remotely at 1, 3, 4, 6, and 12 months. The primary outcome will be the between-group difference in the score of the EDE-Q. If the sample size can be expanded to 150, we will reduce the non-inferiority boundary. Weight, glycated haemoglobin (HbA1c), impairment from disordered eating, and distress will be secondary outcomes. Using the recorded consultations, we will evaluate the process in observed changes in eating behaviour and disordered eating. ConclusionsIf TDR for T2D remission is deemed non-inferior to standard care, more people may enrol and benefit from T2D remission. If TDR exacerbates disordered eating, screening may reduce unintended harm.Trial Registration:NCT05744232 (ClinicalTrials.gov, prospectively registered).

The Diabetes Remission in India (DiRemI) study: Protocol for a prospective matched-control trial.

The global rise in diabetes, particularly in India, poses a significant public health challenge, with factors such as limited awareness, financial strain, and cultural considerations hindering its effective management. Although lifestyle changes have shown promising results, their consistent implementation and maintenance continue to pose challenges. Most studies have focused primarily on dietary modifications, overlooking other essential aspects of lifestyle intervention. The DiRemI study aims to address these gaps by evaluating the efficacy of a comprehensive one-year program that combines diet, exercise, psychological support, and medical management to achieve weight loss, diabetes remission, and improved glycemic control among patients with type 2 diabetes (T2D) in India, while also considering the unique needs of the Indian population. The DiRemI study is a prospective, open-label, matched-group trial aimed at assessing the impact of a one-year online integrated intensive lifestyle intervention (ILI) comprising dietary modifications, physical activity, psychological support, and medical management on weight loss and remission in adult T2D patients (aged 30-70 years), with a body mass index (BMI) between 25 and 35 kg/m2, and disease duration of <15 years. ILI will be compared with routine medical care (RMC). Participants will be recruited from three clinics: one providing ILI and two others providing RMC. The co-primary outcome will be weight loss and remission at 12 months, with a follow-up at 18 months. The proposed sample size is 360 participants (180 each in intervention and control group). The DiRemI study represents the first large-scale remission study in India to show the effectiveness of an integrated approach in the remission and management of T2D and its complications. The findings of this study hold the potential to report evidence-based strategies for managing T2D both in India and globally, thus alleviating the substantial burden of diabetes on public health systems. Clinical Trials Registry, India (Registered Number: CTRI/2023/06/053885).

Management of type 2 diabetes after metabolic bariatric surgery

Metabolic and bariatric surgery has been proven to be effective in the glycemic and metabolic control of type 2 diabetes (T2D) and obesity. While most patients experience remission of T2D after surgery, some individuals remain with suboptimal glycemic control. In addition, a significant subset of patients experience relapse of diabetes in the long term after attaining diabetes remission. As a heterogenous disease, the underlying etiology of T2D and response to treatment can be variable in different individuals. The mechanism of diabetes relapse is not completely understood as is the optimal medical management of T2D after metabolic and bariatric surgery. Nonetheless, person-centred collaborative and supportive care beyond the monitoring of parameters forms the cornerstone in formulating care for people with diabetes. This paper reviews the clinical management of T2D after bariatric surgery, including persistent T2D or diabetes relapse after initial remission.

Postprandial Triglyceride, Glucose and Insulin Levels 10 Years After Bariatric Surgery in Women With Severe Obesity - A Pilot Study: Part 2 - Biliopancreatic Diversion.

Obesity significantly increases the risk of developing metabolic and cardiovascular diseases. The most effective management tool for both obesity and type 2 diabetes (T2D) is bariatric/metabolic surgery. Delayed postprandial plasma triglyceride clearance contributes to the development of atherosclerosis in patients with T2D. Biliopancreatic diversion (BPD) was shown to be the most effective procedure in long-term T2D remission. However, the effect of BPD on postprandial metabolic profile has not been studied so far. In this pilot study, we therefore examined the changes in postprandial glucose, insulin, and triglyceride in women with severe obesity and T2D before surgery and then two and ten years after BPD. The studied cohort included 7 women (mean age at baseline=49.3±8.2 years) with severe obesity (mean BMI= 45.7±2.9 kg/m?) and T2D. A standardized liquid mixed-meal test was carried out in all subjects and the mean postprandial levels of plasma glucose, insulin, and triglyceride were analyzed by standard laboratory procedures. For statistical evaluation, ANOVA with Bonferroni multiple comparisons was used. Ten years after BPD not only a significant reduction of an average BMI (F=32.9, p<0.001) but also significant declines in mean postprandial plasma levels of glucose (F=155.3, p<0.001), insulin (F=69.8, p<0.001), and triglyceride (F=139.9, p<0.001) were demonstrated. The observed changes in postprandial metabolic profile may contribute to improved cardiometabolic health after bariatric surgery.

Preoperative predictors of type 2 diabetes remission after bilio-pancreatic diversion with duodenal switch

BackgroundMany patients achieve short-term type 2 diabetes (T2D) remission after bariatric surgery, but relapses are common. Diabetes outcomes after bariatric surgery vary across procedures and populations. T2D remission scores are simple clinical tools developed to predict remission after bariatric surgery. However, they have never been tested after Biliopancreatic diversion with duodenal switch (BPD-DS). ObjectivesThe aim of this study was to compare the predictive value of T2D remission scores and preoperative diabetes characteristics in predicting T2D remission after BPD-DS. SettingQuebec Heart and Lung Institute - Laval University. MethodsWe retrospectively identified 918 patients with preoperative T2D who had undergone BPD-DS. Retrospective chart review was performed and variables used to calculate predictive scores were captured. T2D status was assessed annually for up to 10 years postop. Predictive values for each score (DiarRem, Ad Diarem, and Diabetter) and single preoperative diabetes characteristics used to construct these algorithms were evaluated by area under receiver operating characteristic curves (AUC). ResultsDiabetter showed greater performance for prediction of durable diabetes remission than other algorithms with acceptable discriminative ability (AUC between .69 and .79), but was not superior to T2D duration as a single predictor (P = .24 and P = .18). At 10 years, T2D duration had a better discriminative ability for the prediction of T2D remission than all 3 predictive models (AUC = .85, P < .05). ConclusionsBetter chances for T2D remission following BPD-DS are associated with a shorter duration or T2D before surgery. Duration of T2D alone offers an excellent predictive ability and is a convenient alternative to diabetes remission scores to estimate chances of long-term diabetes remission after BPD-DS.

Remission of type 2 diabetes: a real perspective for clinical pratice

The Type 2 diabetes (T2D) is probably the biggest challenges of global public health. In United States, 4% of all Gross Domestic Product is spent with the diabetes complications. Despite the progress on studies to refrain the diabetes complications, the most effort is target for iniciatives like a search with new pharmacological oportunities and there is less interest in the cientific comunity and governments to study plausible and applicable strategies of lifestylechanges in diabetes. Even so, the publication of Diabetes Prevention Programstudy, that demonstrated the expressive reduction in the primary outcome, diagnosis of diabetes, was a Mark that starts a series of studies looking for the remission of T2D. The DiRECT study is the most strong evidence to demonstrate the remission of T2D in humans with lifestyle changes with results until 89% in patients that reduced their weight in 15% of initial. The objective of this review is present and discuss the Lifestyle Medicine as a real possibility for Diabetes Type 2 Remission.

Weight-loss Independent Clinical and Metabolic Biomarkers Associated with Type 2 Diabetes Remission Post-bariatric/metabolic Surgery

PurposeRemission of type 2 diabetes (T2D) can be achieved by many, but not all, people following bariatric/metabolic surgery. The mechanisms underlying T2D remission remain incompletely understood. This observational study aimed to identify novel weight-loss independent clinical, metabolic and genetic factors that associate with T2D remission using comprehensive phenotyping.Materials and MethodsTen patients without T2D remission (non-remitters) were matched to 10 patients with T2D remission (remitters) for age, sex, type of surgery, body weight, BMI, post-operative weight loss, duration from surgery and duration of T2D. Detailed body composition assessed using magnetic resonance imaging, gut hormones, serum metabolomics, insulin sensitivity, and genetic risk scores for T2D and anthropometric traits were assessed.ResultsRemitters had significantly greater β-cell function and circulating acyl ghrelin levels, but lower visceral adipose tissue (VAT): subcutaneous adipose tissue (SAT) ratio than non-remitters. Branched-chain amino acids (BCAAs) and VLDL particle size were the most discriminant metabolites between groups. A significant positive correlation between, VAT area, VAT:SAT ratio and circulating levels of BCAAs was observed, whereas a significant negative correlation between BCAAs and β-cell function was revealed.ConclusionWe highlight a potentially novel relationship between VAT and BCAAs, which may play a role in glucoregulatory control. Improvement in β-cell function, and the role ghrelin plays in its recovery, is likely another key factor influencing T2D remission post-surgery. These findings suggest that adjunctive approaches that target VAT loss and restoration of BCAA metabolism might achieve higher rates of long-term T2D remission post-surgery.Graphical

Comparison of various prediction models in the effect of Roux-en-Y gastric bypass on type 2 diabetes in the Chinese population 5 years after surgery.

Various prediction models of type 2 diabetes (T2D) remission have been externally verified internationally. However, long-term validated results after Roux-en-Y gastric bypass (RYGB) surgery are lacking. The best model for the Chinese population is also unknown. To evaluate the prediction effect of various prediction models on the long-term diabetes remission after RYGB in the Chinese population and to provide reference for clinical use. A retrospective clinical study at a university hospital. We retrospectively analyzed Chinese population data 5 years after RYGB and externally validated 11 predictive models to evaluate the predictive effect of each model on long-term T2D remission after RYGB. We enrolled 84 patients. The mean body mass index was 41 kg/m2, and the percentage of excess weight loss (%EWL) was 72.3%. The mean glycated hemoglobin level was 8.4% preoperatively and decreased to 5.9% after 5 years. The 5-year postoperative complete and partial remission rates of T2D were 31% and 70.2%, respectively. The ABCD scoring model (sensitivity, 84%; specificity, 76%; area under the curve [AUC], .866) and the Panuzi etal. [34] study (sensitivity, 84%; specificity, 81%; AUC, .842) showed excellent results. In the Hosmer-Lemeshow goodness-of-fit test, calibration values for ABCD and Panuzi etal. [34] were .14 and .21, respectively. The predicted-to-observed ratios of ABCD and Panuzi etal. [34] were .83 and .88, respectively. T2D was relieved to varying degrees 5 years after RYGB in patients with obesity. Theprediction models in ABCD and the Panuzi etal. [34] studies showed the best prediction effects. ABCD was recommended for clinical use because of excellent predictive performance, goodstatistical test results, and simple and practical design features.