Type 2 Diabetes Remission Research Articles

Long-term clinical and functional impact of biliopancreatic diversion on type 2 diabetes in morbidly and non–morbidly obese patients

SettingObesity surgery has been proposed as a treatment option for diabetic patients with body mass index (BMI)<35 kg/m2, but the efficacy of metabolic surgery has not been conclusively determined. ObjectivesTo evaluate the long-term metabolic outcome of non–morbidly obese (NMO) patients with type 2 diabetes (T2D) after biliopancreatic diversion (BPD). Material and methodsTwo groups of T2D patients with different degree of obesity (NMO, 17 cases, BMI 25–35 kg/m2; and morbidly obese [MO], 13 cases, BMI>35 kg/m2) were studied before and at 1 and 5 years after BPD in a university hospital setting. Insulin secretion was assessed by acute insulin response (AIR) to intravenous glucose and by insulinogenic index (IGI). ResultsIn all MO patients, T2D was remitted or controlled (1 case) at 1 year and results were maintained at 5 years; AIR (μU/mL) and IGI (μU/mg) improved (P<.001) at 1 year (from .1±3.1 to 18.52±21.9, and from 6.0±8.5 to 9.1±22.8, respectively) with a further increase (to 24.8±25.5 and to 14.3±13.8, respectively) at 5 years. Within the NMO group, T2D was remitted in 1/17 and controlled in 14/17 patients at 1 year, and in 2/17 and in 4/17 patients at 5 years, respectively; AIR (μU/mL) and IGI (μU/mg) remained unchanged throughout the postoperative period (from .31±9.26 to 1.5±2.8 at 1 yr and to .4±3.29 at 5 yr for AIR, and from 2.2±4.9 to 1.3±9.0 at 1 yr and to 2.3±3.3 at 5 yr for IGI). ConclusionsAfter BPD, restoration of β-cell secretion/production plays a pivotal role in determining postoperative T2D remission.

Remission of type 2 diabetes after omega loop gastric bypass for morbid obesity.

Roux-en-Y gastric bypass (RYGBP) is a validated technique for the treatment of morbid obesity and results in a significant rate of remission of type 2 diabetes (T2D). Omega gastric bypass (OGBP) is an effective and simpler alternative for weight loss, but its effect on T2D is unclear. Between December 2006 and September 2012, 804 laparoscopic OGBPs were carried out in our centre. Among these, 100 (12.4%) patients had T2D at the time of the intervention. Remission of T2D was defined by a glycated haemoglobin (HbA1c) level of <6% without concomitant treatment. Postoperative follow-up was completed by 81 patients (mean age: 49 ± 11 years; mean weight at surgery: 133 ± 29 kg; mean body mass index (BMI): 47 ± 9 kg/m(2)). Mean preoperative HbA1c was 8 ± 2 g/dL. Before OGBP, seven patients (9%) had received no oral hypoglycaemic treatment, 30 (37%) had received monotherapy, 26 (32%) bitherapy, six (7%) tritherapy and 12 (15%) patients had used insulin. Over a mean follow-up of 26 months (range 1-75), mean weight decreased to 94 ± 23 kg and mean BMI to 35 kg/m(2). Seventy-one (88%) patients had complete remission of T2D and the other 10 (12%) had reduced their treatment. Seven patients (58%) initially treated with insulin no longer required this treatment. Mean time to remission of T2D for patients receiving one or more oral therapies versus insulin was 6.9 versus 17.9 months. OMBP is effective treatment for obesity in terms of weight loss and remission of T2D.

Preoperative Use of Incretins Is Associated With Increased Diabetes Remission After RYGB Surgery Among Patients Taking Insulin

The main goal of this study was to determine the effects of incretins on type 2 diabetes (T2D) remission after Roux-en-Y gastric bypass (RYGB) surgery for patients taking insulin. Type 2 diabetes is a chronic disease with potentially debilitating consequences. RYGB surgery is one of the few interventions that can remit T2D. Preoperative use of insulin, however, predisposes to significantly lower T2D remission rates. A retrospective cohort of 690 T2D patients with at least 12 months follow-up and available electronic medical records was used to identify 37 T2D patients who were actively using a Glucagon-like peptide 1 (GLP-1) agonist in addition to another antidiabetic medication, during the preoperative period. Here, we report that use of insulin, along with other antidiabetic medications, significantly diminished overall T2D remission rates 14 months after RYGB surgery (9%) compared with patients not taking insulin (56%). Addition of the GLP-1 agonist, however, increased significantly T2D early remission rates (22%), compared with patients not taking the GLP-1 agonist (4%). Moreover, the 6-year remission rates were also significantly higher for the former group of patients. The GLP-1 agonist did not improve the remission rates of diabetic patients not taking insulin as part of their pharmacotherapy. Preoperative use of antidiabetic medication, coupled with an incretin agonist, could significantly improve the odds of T2D remission after RYGB surgery in patients also using insulin.

Should metabolic surgery be offered in morbidly obese patients with type I diabetes?

BackgroundBariatric surgery has recently been endorsed as an effective treatment of type 2 diabetes (T2D) in severely obese patients. Little is known about its metabolic effects in type 1 diabetes (T1D). The objectives were to assess bariatric surgery outcomes in T1D obese patients who underwent either a biliopancreatic diversion (BPD) or a sleeve gastrectomy (SG) and who were matched with T2D obese patients requiring insulin therapy. The study setting was at a university-affiliated tertiary care center. MethodsThrough retrospective analysis of prospectively collected data, ten patients with T1D (7 BPD, 3 SG) were matched with 20 patients with T2D (14 BPD, 6 SG) according to age, gender, type of surgery, initial Body Mass Index and insulin requirements (1:2 matching). Weight loss, diabetes control, and remission of co-morbidities were compared. ResultsMean follow-up was 55.1 months. Mean Excess BMI Loss% tended to be greater in T1D patients compared to T2D (77.1% versus 68.3%, P = .14). The remission and improvement rates of T2D were 55% and 45% versus 0% and 90% for T1D. The remission rate of T2D was significantly greater after BPD (71.43%) compared to SG (16.67%, P = .04). Insulin requirements were significantly reduced in both groups after surgery (T1D: .44±.24 versus 1.09±.7 units/kg/d, P = 0.03, T2D: .03±.12 versus .89±.77 units/kg/d, P = .0001). Remission rates of hypertension and dyslipidemia were similar for T1D and T2D (66.7% versus 62.5%, P = .63 and 88.9% versus 75%, P = .23). ConclusionsEven if metabolic surgery has limited effect on glycemic control in T1D, it improves insulin sensitivity and other co-morbidities. It should be considered as a therapeutic option in selected obese patients with metabolic syndrome and high cardio-vascular risk.

Effects of Roux-en-Y Gastric Bypass on β-Cell Function

Bariatric surgery, specifically Roux-en-Y gastric bypass (RYGB), has a rapid and drastic effect in obese patients with type 2 diabetes (T2D), many of whom show complete remission of the disease within days of the procedure. This has introduced the option of a surgical mode of diabetes therapy (1–3). The exact mechanisms by which RYGB drives clinical remission of T2D are not well understood. T2D develops when patients have a combination of two core defects—insulin resistance along with defects in insulin secretion (4). The significant weight loss induced by the procedure is obviously associated with increased insulin sensitivity. On the other hand, the rapid resolution of T2D prior to major weight loss may hint that the procedure directly affects β-cell function, independent of weight loss. RYGB consists of two major anatomical modifications: restriction of gastric volume by creation of a small pouch and division of the jejunum in a manner that reroutes nutrients from the pouch directly into the jejunum while bypassing the proximal small bowel. These modifications have led to the development of two hypotheses explaining the effects of the gut following RYGB on β-cell function (5). According to the “foregut hypothesis,” a yet-unidentified “anti-incretin” is secreted in patients with T2D upon exposure of the foregut to nutrients. Preventing contact of nutrients with the upper gut may lead to reduction of such a factor and thus relieve/unstress the β-cell. The “hindgut” hypothesis suggests that early exposure of the jejunum to nutrients results in a modification of gut-derived hormones, specifically incretins, leading to boosting of β-cell function (6). To elucidate the effects of the gut on β-cell function …

Modulation of Fibroblast Growth Factor 19 Expression by Bile Acids, Meal Replacement and Energy Drinks, Milk, and Coffee

BackgroundThe enterohepatic pathway involving the fibroblast growth factor 19 (FGF19) and bile acids (BA) has been linked with the etiology and remission of type 2 diabetes (T2D) following Roux-en-Y gastric bypass (RYGB) surgery. Specifically, diabetic patients had lower FGF19 circulating levels but postoperative FGF19 and BA levels were higher in diabetic patients that experience remission of T2D, as compared to non-diabetic patients and diabetic patients that do not experience remission. It has been proposed that this may be due to the direct flow of digestate-free bile acids into the ileum benefiting mostly T2D patients without severe diabetes.Methods/ResultsWe used a human colorectal cell line (LS174T) that endogenously expresses FGF19, real time PCR, and Elisas for precise quantitation of FGF19 mRNA and secreted protein levels. We report here that BA and fractions of BA stimulated FGF19 in vitro but this effect was partially blocked when BA were pre-incubated with a lipoprotein mix which emulates digested food. In addition, we show that FGF19 mRNA was stimulated by meal replacement drinks (Ensure, Glucerna, SlimFast), non-fat milk, and coffee which has been linked with reduced risk for developing diabetes. Pure caffeine and the 5-hour Energy drink, on the other hand, decreased FGF19 mRNA.ConclusionsIn summary, FGF19 expression in vitro is modifiable by popular drinks suggesting that such approaches could potentially be used for modulating FGF19 expression in humans.

GLP-1: The Oracle for Gastric Bypass?

Despite enormous efforts to find effective pharmacological targets, bariatric surgery is still the most effective treatment for morbid obesity. Beyond weight loss, this procedure often results in remarkable improvements in type 2 diabetes (T2D). However, several clinical trials have shown that between 22 and 28% of patients with T2D did not experience improvements in their diabetes after surgery (1). Personalized medicine seeks to identify the best possible therapeutic outcome with minimal adverse events. However, it requires an understanding of the molecular underpinnings of disease as well as signaling pathways triggered by both pharmacological and surgical treatments that predict an individual’s likelihood of responding favorably to treatment. Glucagon-like peptide 1 (GLP-1) is an incretin hormone that is released into the bloodstream postprandially from the ileum and colon. Among its multiple biological actions (2), GLP-1 stimulates insulin secretion in a glucose-dependent manner (3,4) and decreases appetite (5). GLP-1–based T2D therapies are now commonly used in combination with other drugs with the added weight-loss effect broadening its therapeutic application in human obesity (6,7). Since bariatric surgery causes weight loss and T2D remission with enhanced postprandial GLP-1 secretion, the role of GLP-1 as a mediator of surgery-associated benefits has been investigated (8,9). However, to date, this hypothesis remains inconclusive because mice lacking GLP-1 receptors (GLP-1Rs) responded similarly to controls after vertical sleeve gastrectomy (10). In this issue, Habegger et al. …

GLP-1—A Candidate Humoral Mediator for Glucose Control After Roux-en-Y Gastric Bypass

The worldwide increase in obesity is associated with a higher prevalence of type 2 diabetes (T2D), and severe obesity occurs with the greatest risk (1). Bariatric surgery is currently the most effective treatment not only for weight loss but also for prevention or treatment of T2D in such patients (2). It leads to remission or improvement of T2D in the majority of morbidly obese (3,4). Roux-en-Y gastric bypass (RYGB) is one of the most frequently performed procedures. With RYGB, the stomach is reduced to a small proximal pouch (30–50 mL) and anastomosed to the jejunum, thereby bypassing the majority of the stomach and duodenum. After RYGB, T2D improves rapidly often before significant weight loss occurs. The mechanisms behind this phenomenon are not clearly resolved. Caloric restriction contributes. Extreme caloric restriction to the limit just tolerated in patients after surgery improved insulin resistance in obese subjects similarly as found in after the first week after RYGB (5). Of interest, the malabsorptive component of the RYGB procedure approximately accounts only for up to 11% of the total reduction in combustible energy absorption (6). Changes of adipokine-induced inflammation and insulin resistance (7) and reduction of branched-chain amino acids correlating with insulin resistance (8) have been proposed as further mechanisms operating after bariatric surgery complementing the sole weight loss. A popular hypothesis points to an antidiabetic effect after RYGB of postprandially exaggeratedly released gut peptides, such as glucagon-like peptide 1 (GLP-1), already starting early after surgery. The release of GLP-1 depends on gastric emptying (GE) velocity (9). It lowers postprandial glycemia by stimulation of insulin, inhibition of glucagon secretion, and delay of GE. For example, …

The Role of Bariatric Surgery in the Treatment of Type 2 Diabetes: Current Evidence and Clinical Guidelines

The incidence of type 2 diabetes (T2D) continues to rise worldwide. The management of T2D is challenging and therefore amenable to multimodality treatment options. Many published observations of obese individuals with T2D that have undergone bariatric surgery consistently demonstrate remarkable improvement and short-term remission of T2D. Recently published randomized trials confirm these findings and demonstrate significantly improved glycemic control following bariatric procedures, especially Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy. However, the question of long-term remission remains uncertain. Clinicians may consider the use of bariatric surgery as a treatment option for certain obese patients with T2D who have failed intensive lifestyle intervention and conventional pharmacotherapy.

C-peptide levels predict type 2 diabetes remission after bariatric surgery.

C-peptide (Cp) serves as a surrogate of pancreatic beta-cell reserve. This study evaluates the clinical significance of basal Cp as a predictor of type 2 diabetes (T2D) remission after bariatric surgery (BS). Retrospective study of 22 patients with BMI > 35 kg/m² and T2D who underwent BS. Evaluation of anthropometric and glucose metabolism parameters before BS and at one-year follow-up. Analysis of patients with T2D remission (HbA1c < 6%, fasting glucose (FG) < 100 mg/dl, absence of pharmacologic treatment) and preoperative characteristics associated (logistic binary regression model). ROC curve to estimate an optimal Cp value to predict T2D remission. Preoperativeley (mean ± SD): age 53.3 ± 9.4 years, BMI 42.9 ± 6.8 kg/m², T2D duration 6.9 ± 5.2 years, FG 159.6 ± 56.6 mg/dL, HbA1c 7.5 ± 1.1%, Cp 4.0 ± 2.0 (median 3.8, range 0.1-8.9) ng/mL. At one year follow-up, remission of T2D in 12 cases (54.5%). Preoperative Cp correlated with 12-month HbA1c (r = -0.519, p = 0.013). Preoperative Cp was higher in those who achieved remission: 5.0 ± 1.7 vs 3.0 ± 1.7 ng/ml, p = 0,013. A Cp concentration > 3.75 ng/mL provided a clinically useful cut-off for prediction of T2D remission. T2D remission rates were different according to median preoperative Cp: 27.3% if Cp < 3.8 ng/mL and 81.7% if Cp > 3.8 ng/mL (p = 0.010). Patients with elevated preoperative Cp levels achieve higher rates of T2D remission one year after BS. A Cp concentration > 3.75 ng/mL seems clinically useful.

Gastric Bypass and Sleeve Gastrectomy for Type 2 Diabetes: A Systematic Review and Meta-analysis of Outcomes

Bariatric surgery is effective in the management of type 2 diabetes (T2D) and obesity; however, it is not clear whether Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG) is the most effective procedure. This review compared T2D remission and weight loss in patients with T2D after GBP or SG. All human SG or GBP studies published in English between 1 Jan 2007 and 30 April 2012 reporting on BMI and T2D outcomes were included. Analyses were performed separately for the most frequent distinct time points reported after surgery. A total of 21 prospective (three randomised control trials) and 12 retrospective studies, involving 1375 patients met eligibility criteria. T2D remission defined by hemoglobin A1c of <6.5 % for GBP and SG respectively was 67 and 56 % at 3 months, 76 and 68 % at 12 months, and 81 and 80 % at 36 months. Greater percent excess BMI loss occurred at 12 months (72.5 % after GBP and 66.7 % after SG) compared with 3 months (45.9 % after GBP and 25.9 % after SG). There was no significant difference in either T2D remission or weight loss with GBP compared with SG. Both GBP and SG result in similar early remission of T2D in 67 and 56 % of patients at 3 months respectively with modest additional T2D remission with time, although weight loss with both procedures increase substantially between 3 and 12 months post-operatively. Further randomised controlled trials comparing SG and GBP in patients with T2D using comparable definitions of diabetes remission with long-term follow-up are needed to evaluate relative benefits.

Remission of Type 2 Diabetes Mellitus Should Not Be the Foremost Goal after Bariatric Surgery

Remission of type 2 diabetes (T2D) is a desired outcome after bariatric surgery (BS). Even if this goal is not achieved, individuals who do not strictly fulfill remission criteria experience an overall improvement. The aim of this study was to evaluate the metabolic control status in patients considered as diabetes "non-remitters." A retrospective study of 125 patients (59.2 % women) with preoperative diagnosis of T2D who underwent BS in a single center (2006-2011) was conducted. We collected anthropometric and metabolic parameters before surgery and at 1-year follow-up. T2D remission was defined according to the 2009 consensus statement: glycosylated hemoglobin (HbA1c) <6 %, fasting glucose (FG) <100 mg/dLs, and absence of pharmacologic treatment. We evaluated metabolic status of non-remitters, according to the American Diabetes Association's (ADA) target recommendations: HbA1c <7 %, LDL-c <100 mg/dL, triglycerides <150 mg/dL, and HDL-c >40 (male) or >50 mg/dL (female). analysis of variance. Baseline characteristics (mean ± SD): age 53.5 ± 9.7 years, BMI 43.5 ± 5.6 kg/m(2), time since diagnosis of T2D 7.7 ± 7.9 years, FG 162.0 ± 56.3 mg/dL, HbA1c 7.7 ± 1.6 %. ADA's target recommendations were present in 12 patients (9.6 %) preoperatively, and in 45 (36.0 %) at 1-year follow-up (p <0.001). Sixty-two (49.6 %) patients did not achieve diabetes remission; 26 (41.9 %) had now diet treatment, 30 (48.4 %) oral medications, and 6 (9.7 %) required insulin. Of the non-remitters, 57 (91.9 %) had HbA1c <7 % and 18 (40.0 %) achieved ADA's target recommendations. There were no differences between remitters and non-remitters in the number of individuals reaching ADA's combined metabolic control. Although almost 50 % of the patients may not be classified as diabetes remitters, their significant improvement in metabolic control should be regarded as a success, according to most scientific societies' target recommendations.

Diagnosis of Diabetes Remission After Bariatic Surgery May be Jeopardized by Remission Criteria and Previous Hypoglycemic Treatment

Controversy exists regarding type 2 diabetes (T2D) remission rates after bariatric surgery (BS) due to heterogeneity in its definition and patients' baseline features. We evaluate T2D remission using recent criteria, according to preoperative characteristics and insulin therapy (IT). We performed a retrospective study from a cohort of 657 BS from a single center (2006-2011), of which 141 (57.4 % women) had T2D. We evaluated anthropometric and glucose metabolism parameters before surgery and at 1-year follow-up. T2D remission was defined according to 2009 consensus criteria: HbA1c <6%, fasting glucose (FG) <100 mg/dL, and absence of pharmacologic treatment. We analyzed diabetes remission according to previous treatment. Preoperative characteristic were (mean ± SD): age 53.9 ± 9.8 years, BMI 43.7 ± 5.6 kg/m2, T2D duration 7.4 ± 7.6 years, FG 160.0 ± 54.6 mg/dL, HbA1c 7.6 ± 1.6%. Fifty-six (39.7%) individuals had IT. At 1-year follow-up, 74 patients (52.5%) had diabetes remission. Percentage weight loss (%WL) and percentage excess weight loss (%EWL) were associated to remission (35.5 ± 8.1 vs. 30.2 ± 9.5 %, p = 0.001; 73.6 ± 18.4 vs. 66.3 ± 22.8%, p = 0.037, respectively). Duration of diabetes, age, and female sex were associated to nonremission: 10.3 ± 9.4 vs. 4.7 ± 3.8 years, p < 0.001; 55.1 ± 9.3 vs. 51.2 ± 9.9 years, p = 0.017; 58.9 vs. 33.3%, p = 0.004, respectively. Prior treatment revealed differences in remission rates: 67.1 % in case of oral therapy (OT) vs. 30.4% in IT, p < 0.001. OR for T2D remission in patients with previous IT, compared to those with only OT, were 0.157-0.327 (p < 0.05), adjusting by different models. Consensus criteria reveal lower T2D remission rates after BS than previously reported. Prior insulin use is a main setback for remission.

Predictive Factors of Type 2 Diabetes Remission 1 Year After Bariatric Surgery: Impact of Surgical Techniques

Type 2 diabetes (T2D) remission after bariatric procedures has been highlighted in many retrospective and some recent prospective studies. However, in the most recent prospective study, more than 50% of patients did not reach T2D remission at 1year. Our aim was to identify baseline positive predictors for T2D remission at 1year after bariatric surgery and to build a preoperative predictive score. We analysed the data concerning 161 obese operated on between June 2007 and December 2010. Among them, 46 were diabetic and were included in the study-11 laparoscopic adjustable gastric banding (LAGB), 26 Roux-en-Y gastric bypass (RYGB) and 9 sleeve gastrectomy (SG). We compared anthropometric and metabolic features during 1year of follow-up. A receiver operating characteristic analysis was performed to predict T2D remission. RYGB and SG were similarly efficient for body weight loss and more efficient than LAGB; 62.8% of patients presented with T2DM remission at 1year, with no significant difference according to the surgical procedure. A 1-year body mass index (BMI) <35kg m(-2) was predictive of T2DM remission whatever the procedure. The preoperative predictive factors of diabetes remission were baseline BMI ≤50kg m(-2), duration of type 2 diabetes ≤4years, glycated haemoglobin ≤7.1%, fasting glucose <1.14g/l and absence of insulin therapy. A short duration of diabetes and good preoperative glycaemic control increase the rate of T2DM remission 1year after surgery. Preoperative metabolic data could be of greater importance than the choice of bariatric procedure.

A Comment on the International Diabetic Federation Statement

To the Editors Dr. Walter Pories, a great pioneer in the development of bariatric into metabolic surgery [1], has provided major suggestions [2]) to the recent International Diabetes Federation (IDF) guidelines for metabolic surgery for type 2 diabetes (T2D) [3]. The remission of T2D after weight loss operations has long been recognized [4, 5], but the formal IDF position statement is a milestone. Importantly, Nicola Scopinaro, performing biliopancreatic diversion, has found an extremely high remission rate for T2D in diabetics with lower BMI [6]). There is one instance where the IDF guidelines require some caution. The position statement mentions in a table on management of diabetes near the end that there should be an audit of C-peptide and autoantibody status, e.g., antiGAD where available [3]). However, this assertion is not explained. A problem which can harm the use of metabolic surgery for meaningful remission of T2D is if the patient actually has a type 1 diabetes. Latent autoimmune diabetes in the adult (LADA) may have slow onset generally between ages 30 and 55, at any weight, and will ultimately progress to requiring insulin [7]. LADA is an explanation for some cases of diabetes at lower BMI. This type 1 diabetes should be diagnosed by very low fasting and/or meal-stimulated C-peptide (≤1 ng/ml), low plasma insulin, and presence of autoantibodies to glutamic acid decarboxylase (GAD), islet cells, insulin and/or insulin A2 [8]. These patients have relentless autoimmune destruction of the pancreas and may have other autoimmune disorders. Lee, Boza and Basso’s groups [9–11] exclude diabetic patients with low C-peptide (an indication of low beta-cell function) from bariatric metabolic surgery. Longstanding uncontrolled T2D with HbA1c of 10, despite initial insulin resistance/hyperinsulinemia, will eventually be unable to increase insulin response to signaling, as a result of betacell apoptosis [5]). This T2D will require insulin. However, Shashank Shah has noted that in those South Asian diabetics whose BMI is lower and have a lower body fat percentage (personal communication, Sept. 28, 2011), type 1 diabetes must be considered [12]. For metabolic operations to result in a significant and sustained remission of diabetes, especially in those presenting with lower BMI, adult-onset type 1 diabetes should first be ruled out.

Obesity and Diabetes: The Impact of Bariatric Surgery on Type‐2 Diabetes

Weight gain and obesity are driving the global epidemic of type-2 diabetes through metabolic and inflammatory pathways that cause insulin resistance and impair pancreatic beta-cell function, the two important factors that are directly responsible for the development of this disease in susceptible populations. Lifestyle methods and modest weight loss are powerful at preventing and managing type-2 diabetes, but sustaining substantial weight loss is problematic. Bariatric surgery provides exceptional sustained weight loss and remission of type-2 diabetes in 50-85% of subjects, especially if treated early before irreparable beta-cell damage has occurred. In addition, there is substantial evidence that bariatric surgery provides additional comorbidity and quality-of-life improvements and reduces mortality in patients with type-2 diabetes. There is an association between the extent of weight loss and remission of type-2 diabetes. Diversionary bariatric procedures such as gastric bypass and biliopancreatic diversion induce a rapid non-weight-loss-associated improvement in glycemic control. Several mechanisms have been proposed for this exciting and novel effect that may provide key insights into the pathogenesis of type-2 diabetes. A range of novel surgical, endoluminal procedures/devices, and pharmacologic therapies are likely to evolve when we better understand how bariatric surgery enables long-term changes in energy balance and non-weight-related metabolic improvements. Bariatric surgery should be considered for adults with BMI >or= 35 kg/m(2) and type-2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy. Although all bariatric procedures produce exceptional results in the management of type-2 diabetes, choice of procedure requires a careful risk-benefit analysis for the individual patient.

Bariatric Surgery, Safety and Type 2 Diabetes

Obesity and type 2 diabetes (T2D) represent major health concerns in the USA. Weight loss is the most important aspect in T2D management, as it reduces both morbidity and mortality. Available lifestyle, behavioral, and pharmacological strategies provide just mild to moderate weight loss. The greatest degree of T2D prevention or T2D amelioration in obese subjects has been reported in subjects who underwent bariatric surgery. In the current review, we will describe various types of bariatric surgery, related safety profiles, and their effect on T2D, as well as the potential mechanisms involved in the remission of T2D. Finally, we hereby examine whether bariatric surgery may be considered a treatment for T2D in pregnant women, children, adolescents and subjects at least 65 years old.