Type 2 Diabetes Mellitus Resolution Research Articles

Bariatric Surgery in the United Kingdom: A Cohort Study of Weight Loss and Clinical Outcomes in Routine Clinical Care.

BackgroundBariatric surgery is becoming a more widespread treatment for obesity. Comprehensive evidence of the long-term effects of contemporary surgery on a broad range of clinical outcomes in large populations treated in routine clinical practice is lacking. The objective of this study was to measure the association between bariatric surgery, weight, body mass index, and obesity-related co-morbidities.Methods and FindingsThis was an observational retrospective cohort study using data from the United Kingdom Clinical Practice Research Datalink. All 3,882 patients registered in the database and with bariatric surgery on or before 31 December 2014 were included and matched by propensity score to 3,882 obese patients without surgery. The main outcome measures were change in weight and body mass index over 4 y; incident diagnoses of type 2 diabetes mellitus (T2DM), hypertension, angina, myocardial infarction (MI), stroke, fractures, obstructive sleep apnoea, and cancer; mortality; and resolution of hypertension and T2DM. Weight measures were available for 3,847 patients between 1 and 4 mo, 2,884 patients between 5 and 12 mo, and 2,258 patients between 13 and 48 mo post-procedure. Bariatric surgery patients exhibited rapid weight loss for the first four postoperative months, at a rate of 4.98 kg/mo (95% CI 4.88–5.08). Slower weight loss was sustained to the end of 4 y. Gastric bypass (6.56 kg/mo) and sleeve gastrectomy (6.29 kg/mo) were associated with greater initial weight reduction than gastric banding (2.77 kg/mo). Protective hazard ratios (HRs) were detected for bariatric surgery for incident T2DM, 0.68 (95% CI 0.55–0.83); hypertension, 0.35 (95% CI 0.27–0.45); angina, 0.59 (95% CI 0.40–0.87);MI, 0.28 (95% CI 0.10–0.74); and obstructive sleep apnoea, 0.55 (95% CI 0.40–0.87). Strong associations were found between bariatric surgery and the resolution of T2DM, with a HR of 9.29 (95% CI 6.84–12.62), and between bariatric surgery and the resolution of hypertension, with a HR of 5.64 (95% CI 2.65–11.99). No association was detected between bariatric surgery and fractures, cancer, or stroke. Effect estimates for mortality found no protective association with bariatric surgery overall, with a HR of 0.97 (95% CI 0.66–1.43). The data used were recorded for the management of patients in primary care and may be subject to inaccuracy, which would tend to lead to underestimates of true relative effect sizes.ConclusionsBariatric surgery as delivered in the UK healthcare system is associated with dramatic weight loss, sustained at least 4 y after surgery. This weight loss is accompanied by substantial improvements in pre-existing T2DM and hypertension, as well as a reduced risk of incident T2DM, hypertension, angina, MI, and obstructive sleep apnoea. Widening the availability of bariatric surgery could lead to substantial health benefits for many people who are morbidly obese.

Association between the preoperative fasting and postprandial C-peptide AUC with resolution of type 2 diabetes 6 months following bariatric surgery

Background and AimsBariatric surgery results in the remission of type 2 diabetes mellitus (T2DM) in morbidly obese subjects. The aim of the study was to investigate the predictive value of both static and dynamic measures of C-peptide in relation to T2DM resolution 6months after bariatric surgery regardless of the operation type. Methods and ResultsA non-randomized prospective study of 24 participants with T2DM undergoing bariatric surgery. Measurements of fasting and 2-hour plasma glucose, insulin, C-peptide and measures of insulin sensitivity were recorded temporally during an oral glucose tolerance test pre-operatively and 6months post-operatively. A responder was defined with a fasting glucose <5.6mmol/L and HbA1c <6.0% postoperatively. Within the sample there were 11 responders and 13 non-responders at 6months. There was a significant difference in the duration of diabetes between the groups. Fasting C-peptide (P≤0.05) and 2-hour C-peptide (P≤0.05) were higher in responders compared to non-responders. Significantly higher C-peptide levels were observed preoperatively at all time points for responders, with significantly higher area under the curve (AUC0–60 and AUC0–120). Using the lower quartiles for C-peptide levels, both fasting C-peptide (>2.5ng/mL [0.83nmol/L]) and 2-hour C-peptide (>5.2ng/mL [1.73nmol/L]) had a sensitivity and negative predictive value of 100% to predict T2DM remission. Logistic regression showed that C-peptide, duration of diabetes and BMI were associated with response. The area under the ROC curve was 0.94 and a regression model predicted diabetes remission with a sensitivity of 85.7% and a specificity of 88.9%. ConclusionsThis study demonstrated that static (fasting) and dynamic (AUC, 2-hour) C-peptide measurements predict T2DM resolution 6months following bariatric surgery. This work provides insight into C-peptide dynamics as a predictor of response to bariatric surgery.

Metabolic Surgery Is No Longer Just Bariatric Surgery

Metabolic Surgery Is No Longer Just Bariatric Surgery

Dynamics of type 2 diabetes mellitus laboratory remission after Roux-en-Y gastric bypass in patients with body mass index lower than 35 kg/m(2) and higher than 35 kg/m(2) in a 3-year observation period.

IntroductionBariatric surgery as treatment of type 2 diabetes mellitus (T2DM) in morbidly obese patients is becoming common. Although a large number of studies demonstrating high efficacy of bariatric methods in diabetics with body mass index (BMI) < 35 kg/m2 have been published, this promising solution is still not accepted enough even in the era of a diabetes offensive.AimTo analyze the dynamics of T2DM remission in patients with BMI < 35 kg/m2 and > 35 kg/m2 after Roux-en-Y gastric bypass (RYGB).Material and methodsData of 30 patients with BMI < 35 kg/m2 and 82 with BMI > 35 kg/m2 who underwent RYGB between 2007 and 2010 were collected from a prospectively designed database. The laboratory resolution of T2DM was determined by fasting plasma glucose (FPG ≤ 100 mg/dl) and glycosylated hemoglobin (HbA1c ≤ 6%).ResultsThe T2DM regression was observed in 80% of the patients with BMI < 35 kg/m2 and 83% in a group with BMI > 35 kg/m2 1 year after RYGB and about 80% 2 and 3 years after the operation in both groups. Normalization of average HbA1c and FPG was observed in the BMI > 35 kg/m2 group after 3 months, while in the BMI < 35 kg/m2 group it was reached 6 months postoperatively. Changes in main markers of T2DM were parallel with the BMI decrease 3–12 months after RYGB, but early resolution in some patients was observed independently of weight loss.ConclusionsThe mid-term observation of patients after RYGB revealed the laboratory remission of T2DM. Ultimate evaluation of T2DM markers 3 years after surgery demonstrates high effectiveness of RYGB in managing T2DM in both groups.

GLP-1 Action and Glucose Tolerance in Subjects With Remission of Type 2 Diabetes After Gastric Bypass Surgery

OBJECTIVEGlucagon like peptide-1 (GLP-1) has been suggested as a major factor for the improved glucose tolerance ensuing after Roux-en-Y gastric bypass (RYGBP) surgery. We examined the effect of blocking endogenous GLP-1 action on glucose tolerance in subjects with sustained remission of type 2 diabetes mellitus (T2DM) present before RYGBP.RESEARCH DESIGN AND METHODSBlood glucose, insulin, C-peptide, glucagon, GLP-1, and glucose-dependent insulinotropic peptide levels were measured after a meal challenge with either exendin-(9–39) (a GLP-1r antagonist) or saline infusion in eight subjects with sustained remission of T2DM after RYGBP and seven healthy controls.RESULTSInfusion of exendin-(9–39) resulted in marginal deterioration of the 2-h plasma glucose after meal intake in RYGBP subjects [saline 78.4 ± 15.1 mg/dL compared with exendin-(9–39) 116.5 ± 22.3 mg/dL; P < 0.001]. Furthermore, glucose response to meal intake was similarly enlarged in the two study groups [percent change in the area under the curve of glucose exendin-(9–39) infusion versus saline infusion: controls 10.84 ± 8.8% versus RYGBP 9.94 ± 8.4%; P = 0.884]. In the RYGBP group, the blockade of the enlarged GLP-1 response to meal intake resulted in reduced insulin (P = 0.001) and C-peptide (P < 0.001), but no change in glucagon (P = 0.258) responses.CONCLUSIONSThe limited deterioration of glucose tolerance on blockade of GLP-1 action in our study suggests the resolution of T2DM after RYGBP may be explained by mechanisms beyond enhancement of GLP-1 action.

From gut changes to type 2 diabetes remission after gastric bypass surgeries

Increasing evidence suggests that the gut may influence the host's metabolism and ultimately change the outcomes of type 2 diabetes mellitus (T2DM). We review the evidence on the relationship between the gut and T2DM remission after gastric bypass surgery, and discuss the potential mechanisms underlying the above relationship: gut anatomical rearrangement, microbial composition changes, altered gut cells, and gut hormone modulation. However, the exact changes and their relative importance in the metabolic improvements after gastric bypass surgery remain to be further clarified. Elucidating the precise metabolic mechanisms of T2DM resolution after bypass surgery will help to reveal the molecular mechanisms of pathogenesis, and facilitate the development of novel diagnoses and preventative interventions for this common disease.

Preoperative Fasting Plasma C-Peptide Level May Help to Predict Diabetes Outcome After Gastric Bypass Surgery

To evaluate whether preoperative measurement of fasting plasma C-peptide levels is useful to predict diabetes outcome after Roux-en-Y gastric bypass (RYGB) surgery. Diabetes outcome after RYGB was evaluated in 126 obese patients: 41 non-diabetic controls (NDC), 29 with impaired glucose tolerance (IGT) and 56 had type 2 diabetes mellitus (T2DM). Body weight, fasting plasma glucose, fasting C-peptide levels, and HbA1c were measured at baseline and 3.6 ± 0.16 years after GBS. Complete resolution of diabetes was defined as: fasting glucose <7.0 mmol/l, HbA1c <6.5 %, achieved without anti-diabetic medication. Patients with complete resolution of diabetes had a more recent diagnosis of T2DM, lower preoperative HbA1c levels and lower daily doses of metformin and insulin use. These parameters were related to postoperative HbA1c levels but they failed to mark the specific patients who had not reached complete resolution of T2DM. Fasting preoperative C-peptide levels had better predictive power: 90 % of T2DM patients with preoperative fasting C-peptide levels >1.0 nmol/l achieved a postoperative HbA1c <6.5 %, and 74 % achieved complete resolution of their diabetes. In contrast, none of the T2DM patients with a preoperative fasting C-peptide <1.0 nmol/l attained these goals. A preoperative fasting plasma C-peptide level <1.0 nmol/l in severely obese T2DM patients indicates partial β-cell failure, and is associated with a markedly reduced chance of complete resolution of T2DM after RYGB. We therefore advocate measuring C-peptide levels in all diabetic patients up for bariatric surgery to improve the prediction of outcome.

Bariatric surgery as a treatment option in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is a leading cause of blindness, non-traumatic amputation and end-stage renal disease as well as a major cardiovascular risk factor. Tight glycemic control reduces the incidence of microvascular complications of T2DM whereas its effects on macrovascular complication are more controversial. However, glycemic targets are achieved by a minority of diabetic patients despite the availability of several antidiabetic agents. In the present commentary, we discuss the findings of two recent randomized studies that compared bariatric surgery with medical treatment in patients with uncontrolled T2DM. Both studies showed that bariatric surgery results in remission of T2DM in the majority of patients. However, both studies were limited to relatively young patients without comorbidities, had relatively short follow-up and did not assess the effects of surgery on T2DM complications. Moreover, the perioperative complications of bariatric surgery and its limited availability in some areas are additional barriers to the wider implementation of this therapeutic approach. On the other hand, the elucidation of the mechanisms underpinning the resolution of T2DM following bariatric surgery might result in the development of novel, more effective pharmacotherapies for this common disease.

Update on the Mechanisms Facilitating Weight Loss and Resolution of Type 2 Diabetes Following Bariatric Surgery

AbstractThe prevalence of type 2 diabetes mellitus (T2DM) and obesity is steadily increasingworldwide. To fight the twin pandemics of obesity and T2DM, clinicians need everytool they can get. Major, durable weight loss is uncommon with medical andbehavioral approaches; many diabetes drugs promote weight gain, while using themto obtain better blood glucose profiles increases the risk of hypoglycemia. Bariatricsurgery seems to be the most effective method for promoting major and durableweight loss in obese subjects, leading also to ameliorations of obesity-associated comorbidities,especially T2DM. Currently, indications for bariatric surgery includemorbidly obese patients or patients with a body mass index (BMI) &gt;35 withsignificant co-morbidities. Currently, bariatric surgery (also referred to as“metabolic surgery”) is advocated for the treatment of T2DM even in overweightsubjects who do not meet the current BMI criteria. This review examines the currentevidence regarding the mechanisms of T2DM resolution following bariatric surgery.

Perioperative Morbidity, Mortality and Early Outcome of the First 360 Gastric Bypass Operations Performed in a District Hospital

We report the results for the first consecutive 360 Roux-en-Y gastric by-pass (RYGB) operations performed in a district hospital in Finland. Demographic data, perioperative characteristics, and follow-up data were entered prospectively in the hospital's database for bariatric patients. We performed 325 primary laparoscopic Roux-en-Y gastric bypass (LRYGB) operations, one open RYGB, and 34 revisions. Mean BMI before the operations was 47.5 ± 7.8 kg/m2 (31.5-91.0 kg/m2). The percentage of patients with type 2 diabetes mellitus (T2DM) was high; 52.3% (170 patients). The mean operative time decreased from 110 minutes during the first 108 operations to 82 minutes for the second 108 operations, and to 74 minutes for the last 109 operations (P < 0.001). Postoperative hospital stay was significantly reduced (P < 0.001) for the last 109 patients compared to the first and second group of patients. Overall morbidity averaged 19.1% (62/325). Severe complications were detected in 15 patients (4.6%). There was a tendency to more serious complications in the first group of patients. There was one death (mortality 0.3%). With a follow-up rate of 97% at 3 months T2DM had resolved in 48.2%, and had resolved or improved in a minimum of 92.9% of the diabetic patients. Weight loss (WL) and excess weight loss (EWL) averaged 20% and 46% respectively. Operative time and postoperative hospital stay decrease significantly with increasing experience. The first one hundred patients may be at higher risk for complications. LRYGB operations may have an important impact on the resolution of T2DM in the operated population.

Cirugía bariátrica y diabetes mellitus tipo 2. ¿Son todas las técnicas quirúrgicas iguales?

Both obesity and type2 diabetes mellitus (T2DM) are two major health problems out of control and with a significant health cost. The main risk factor for the development of T2DM is suffering from obesity, and nearly 90% of patients with T2DM are overweight or obese. Bariatric Surgery can lead to a long-term resolution T2DM in more than half of people with obesity and diabetes who undergo this surgery. Bariatric surgery highlights the current limitations of medical treatment of obesity, and brings up important issues, such as: should we offer surgical treatment to patients with diabetes and obesity when medical therapy fails?, where in the T2DM therapy algorithm, should bariatric surgery be placed?, what surgical technique would be more indicated, and at what body mass index should it be recommended? A better understanding of the pathophysiological mechanisms responsible for the resolution of T2DM after the bariatric surgery will help to properly answer the questions above raised above, and potentially contribute to the development of effective medical treatments, alternatives to bariatric surgery.

Impact of Roux-en-Y gastric bypass on regulation of diabetes type 2 in morbidly obese patients

BackgroundThe idea of surgery as treatment for type 2 diabetes mellitus (T2DM) was established in the US and was based on observation of patients after bariatric surgery. Resolution of T2DM is observed within a few weeks after surgery, in some cases even during hospitalization. The aim of this study was to evaluate the impact of Roux-en-Y gastric bypass (RYGB) on diabetes in morbidly obese patients.MethodsWe present 73 patients with T2DM who underwent laparoscopic RYGB (LRYGB) to treat morbid obesity. In the group of 73 obese patients (mean BMI = 42.3), there were 41 females and 32 males.ResultsRegression of T2DM was observed in 51 patients (69.8%) while hospitalized. In addition, 14 patients’ (19.1%) glycemia and HBA1c stabilized within 12 weeks after surgery (total regression rate of 88.9%).ConclusionThe ultimate evaluation of this method of treating T2DM is still lacking and requires several years of meticulous clinical studies. Despite that, considering the high cost of life-long conservative therapy of T2DM and its complications and the severe impact T2DM has on quality of life, surgical metabolic intervention may become the most reasonable solution in many cases.

Glycemic control after stomach-sparing duodenal-jejunal bypass surgery in diabetic patients with low body mass index

Bariatric surgery frequently results in the resolution of type 2 diabetes mellitus (T2DM). One of the many factors that could explain such findings is the duodenal exclusion of the alimentary tract. To test this hypothesis, a surgical model that induces glycemic control without significant weight loss would be ideal. In the present study, we evaluated the early metabolic changes that occur in overweight diabetic patients after laparoscopic duodenal-jejunal bypass (DJB) and determined the factors associated with success in T2DM resolution. The setting was a private practice. A total of 35 patients (20 men and 15 women) were included in the present study. The mean preoperative body mass index was 28.4 ± 2.9 kg/m(2). DJB was performed in all patients, and the anthropometric data and blood samples were collected at baseline (preoperatively) and 3, 6, 9, and 12 months after surgery. Success was defined when patients reached a glycated hemoglobin level of <7% without diabetic medication. T2DM remission was observed in 14 (40%) of 35 patients. No differences in the homeostasis model assessment insulin resistance index levels and patient weight were observed before and 12 months after DJB surgery. Gender, duration of T2DM, previous use of insulin, preoperative homeostasis model assessment insulin resistance index, and C-peptide levels were not significant predictive factors of success or nonsuccess. The only factor that significantly predicted postoperative positive outcomes was a waist circumference reduction of ≥ 7% compared with baseline within the first 6 months after surgery. DJB improves glycemic control; however, it does not increase insulin sensitivity in overweight diabetic patients. These changes were observed without significant weight loss.

Comparable early changes in gastrointestinal hormones after sleeve gastrectomy and Roux-En-Y gastric bypass surgery for morbidly obese type 2 diabetic subjects

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) are associated with similar type 2 diabetes mellitus (T2DM) resolution rates for morbidly obese subjects. However, the mechanisms underlying the resolution of T2DM after SG have not been clarified to date. This study aimed to compare the early changes in gastrointestinal hormones involved in insulin and glucagon secretion in morbidly obese T2DM subjects undergoing SG or RYGBP. This prospective study investigated 12 subjects with T2DM who had undergone SG (n = 6) or RYGBP (n = 6). Five body mass index (BMI)-matched obese non-diabetic subjects and five BMI-matched obese diabetic subjects served as control subjects. Glucose, insulin, glucagon, glucagon-like peptide 1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and GLP-2 were determined after a standardized mixed liquid meal before surgery and 6 weeks afterward. After 6 weeks, five of the six subjects in each surgical group presented with T2DM remission, although the area under the curve (AUC)0–120 of glucose was greater than that of the non-diabetic control subjects (P < 0.01). Postsurgically, the indices of insulin and glucagon secretion were comparable between the two surgical groups. The AUC0–120 of GLP-1 (P < 0.05) and GLP-2 (P < 0.05) was significantly and comparably enlarged after SG and RYGB. The postsurgical GIP response was significantly associated with the glucagon response throughout the meal test (ρ = 0.747; P < 0.01). The data show that in a cohort of morbidly obese T2DM subjects, SG and RYGBP are associated with an early improvement in glucose tolerance, similar changes in insulin and glucagon secretion, and a similar GLP-1, GIP, and GLP-2 response to a standardized mixed liquid meal.

Case-Matched Outcomes in Bariatric Surgery for Treatment of Type 2 Diabetes in the Morbidly Obese Patient

To compare the relative efficacy of medical management, the duodenal switch (DS), and the laparoscopic adjustable gastric band (LAGB) to the Roux-en-Y gastric bypass (RYGB) for treatment of type 2 diabetes mellitus (T2DM). The RYGB resolves T2DM in a high proportion of patients and is considered the standard operation for T2DM resolution in morbidly obese patients. However, no data exist comparing the efficacy of medical management and other bariatric operations to the RYGB for treatment of T2DM in comparable patient populations. We performed a retrospective case-matched study of morbidly obese patients with T2DM who had undergone medical management (nonsurgical controls [NSC]; N = 29), LAGB (N = 30), or DS (N = 27) and were compared with matched T2DM patients who had undergone RYGB. Matching was performed with respect to age, sex, body mass index, and hemoglobin A1C (HbA1C). Outcomes assessed were changes in body mass index, HbA1C, and diabetes medication scores at 1 year. The Roux-en-Y gastric bypass produced greater weight loss, HbA1C normalization, and medication score reduction compared to both NSC and LAGB-matched cohorts. Duodenal switch produced greater reductions in HbA1C and medication score than RYGB, despite no greater weight loss at 1 year. Surgical complications were rarely life threatening. This study provides an important perspective about the comparative efficacy of LAGB, DS, and NSC to the RYGB for treatment of T2DM among obese patients. After 1 year of follow-up, RYGB is superior to NSC and LAGB with respect to weight loss and improvement in diabetes whereas DS is superior to RYGB in reducing HbA1C and medication score.

Glucocentricity or adipocentricity: A critical view of consensus and clinical guidelines for the treatment of type 2 diabetes mellitus

Eighty percent of patients with type 2 diabetes mellitus (T2DM) are overweight or obese, which in turn is associated with other cardiovascular risk factors and an increased risk of cancer. Large intervention studies that focused on intensive glycemic control have failed to show a reduction of cardiovascular events in T2DM patients. The two major concerns in these studies were weight gain and severe hypoglycemia in the arms of intensive intervention, which could have mitigated the potential beneficial effect of glycemic control. On the contrary, weight loss in diabetic patients through changes in lifestyle, drugs and/or surgery simultaneously improves all cardiovascular risk factors including hyperglycemia. Bariatric surgery has shown an early resolution of T2DM in a large percentage of patients and a decrease of diabetes-specific mortality. Despite this, all consensus and recommendations for the treatment of T2DM focus their decisions on the glycated hemoglobin value. This article aims to open a debate on the need to replace the glucose-centered therapeutic strategy for a weight-centered strategy.

Reduction in endotoxemia, oxidative and inflammatory stress, and insulin resistance after Roux-en-Y gastric bypass surgery in patients with morbid obesity and type 2 diabetes mellitus

Roux-en-Y gastric bypass (RYGB) results in profound weight loss and resolution of type 2 diabetes mellitus (T2DM). The mechanism of this remarkable transition remains poorly defined. It has been proposed that endotoxin (lipopolysaccharide [LPS]) sets inflammatory tone, triggers weight gain, and initiates T2DM. Because RYGB may diminish LPS from endogenous and exogenous sources, we hypothesized that LPS and the associated cascade of oxidative and inflammatory stress would diminish after RYGB. Fifteen adults with morbid obesity and T2DM undergoing RYGB were studied. After an overnight fast, a baseline blood sample was collected the morning of surgery and at 180 days to assess changes in glycemia, insulin resistance, LPS, mononuclear cell nuclear factor (NF)-κB binding and mRNA expression of CD14, TLR-2, TLR-4, and markers of inflammatory stress. At 180 days after RYGB, subjects had a significant decrease in body mass index (52.1 ± 13.0 to 40.4 ± 11.1), plasma glucose (148 ± 8 to 101 ± 4 mg/dL), insulin (18.5 ± 2.2 mμU/mL to 8.6 ± 1.0 mμU/mL) and HOMA-IR (7.1 ± 1.1 to 2.1 ± 0.3). Plasma LPS significantly reduced by 20 ± 5% (0.567 ± 0.033 U/mL to 0.443 ± 0.022 E U/mL). NF-κB DNA binding decreased significantly by 21 ± 8%, whereas TLR-4, TLR-2, and CD-14 expression decreased significantly by 25 ± 9%, 42 ± 8%, and 27 ± 10%, respectively. Inflammatory mediators CRP, MMP-9, and MCP-1 decreased significantly by 47 ± 7% (10.7 ± 1.6 mg/L to 5.8 ± 1.0 mg/L), 15 ± 6% (492 ± 42 ng/mL to 356 ± 26 ng/mL) and 11 ± 4% (522 ± 35 ng/mL to 466 ± 35 ng/mL), respectively. LPS, NF-κB DNA binding, TLR-4, TLR-2, and CD14 expression, CRP, MMP-9, and MCP-1 decreased significantly after RYGB. The mechanism underlying resolution of insulin resistance and T2DM after RYGB may be attributable, at least in part, to the reduction of endotoxemia and associated proinflammatory mediators.

Glucocentrismo o adipocentrismo: una visión crítica de los consensos y guías clínicas para el tratamiento de la diabetes mellitus tipo 2

Eighty percent of patients with type 2 diabetes mellitus (T2DM) are overweight or obese, which in turn is associated with other cardiovascular risk factors and an increased risk of cancer. Large intervention studies focused on intensive glycemic control have failed to show a reduction of cardiovascular events in T2DM patients. The two major concerns in these studies were weight gain and severe hypoglycemia in the arms of intensive intervention, which could have mitigated the potential beneficial effect of glycemic control. On the contrary, weight loss in diabetic patients through changes in lifestyle, drugs and/or surgery simultaneously improves all cardiovascular risk factors including hyperglycemia. Bariatric surgery has shown an early resolution of T2DM in a large percentage of patients and a decrease of diabetes-specific mortality. Despite this, all consensus and recommendations for the treatment of T2DM focus their decisions on the glycated hemoglobin value. This article aims to open a debate on the need to replace the glucose-centered therapeutic strategy for a weight-centered strategy.

Relationship of bypassed limb length and remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is widely accepted as a valid surgery in the treatment of morbid obesity [1] and is known to cause remission of type 2 diabetes mellitus (T2DM), although the exact mechanism of T2DM remission remains unclear. Different lengths of the bypassed limbs in LRYGB have been proposed by surgeons [2], but no study has reported on the relationship of the length of the bypassed limbs and T2DM resolution. We describe an interesting case of T2DM remission after LRYGB, T2DM recurrence, and, finally, T2DM remission again after surgical adjustment of the length of the bypassed limbs.

Bariatric surgeries: beyond restriction and malabsorption

Behavioral and pharmaceutical intervention to treat obesity and its comorbidities typically results in only a 5-10% weight loss. Thus, bariatric surgery is the most effective obesity treatment with some surgeries resulting in 30% sustained weight loss. Although this degree of weight loss has profound metabolic impact, these surgeries seem to have metabolic effects that are independent of weight loss. In support of this is the clinical literature showing rapid resolution of Type 2 diabetes mellitus (T2DM) that occurs before significant weight loss. To gain a complete understanding of the weight loss-independent effects of bariatric surgery, animal models have been developed. These are becoming more widely implemented and allow the use of pair-fed or weight-matched sham-operated controls in order to gain mechanistic insights into the mode of action of bariatric surgery. Increases in anorectic gut hormones, such as glucagon-like peptide-1 and peptide YY, or decreases in the orexigenic hormone ghrelin have been seen and are implicated as mediators of weight loss-independent actions of bariatric surgery. Changes in nutrient processing and sensing may also have a mechanistic role that is independent of, or that regulates, gut hormone responses to these surgeries. Ultimately, the hope is that understanding the mechanisms of bariatric surgeries will aid in the development of less invasive surgeries or pharmacological therapies that are more specifically, and perhaps individually, targeted at weight loss and/or resolution of T2DM.