Fasting Plasma Glucose in the Screening for Type 2 Diabetes in Morbidly Obese Subjects

Background  

Higher mortality rates among morbidly obese (BMI of ≥40 or ≥35 kg/m² with weight-related comorbidities) subjects are mainly explained by comorbidities such as type 2 diabetes. As bariatric surgery ameliorates diabetes, obese diabetic subjects will receive great benefits from bariatric surgery. Screening for diabetes prior to surgical referral is therefore crucial.     

Short-term Effects of Sleeve Gastrectomy on Type 2 Diabetes Mellitus in Severely Obese Subjects

Background Data on the effectiveness of sleeve gastrectomy (SG) in improving or resolving type 2 diabetes mellitus (T2DM) are scarce. Methods A 4-month prospective study was conducted on the changes in glucose homeostasis in 35 severely obese T2DM subjects undergoing laparoscopic SG (LSG) and 50 subjects undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP), matched for DM duration, type of DM treatment, and glycemic control. Results At 4-months after surgery, LSG and LRYGBP operated subjects lost a similar amount of weight (respectively, 20.6 ± 0.7% and 21.0 ± 0.6%). T2DM had resolved respectively in 51.4% and 62.0% of the LSG and LRYGBP operated subjects (P = 0.332). A shorter preoperative DM duration (P < 0.05), a preoperative DM treatment not including pharmacological agents, and a better pre-surgical fasting plasma glucose (P < 0.01) or HbA1c (P < 0.01), were significantly associated with a better type 2 DM outcome in both surgical groups. Conclusions Our data show that LSG and LRYGBP result in a similar rate of type 2 DM resolution at 4-months after surgery. Moreover, our data suggest that mechanisms beyond weight loss may be implicated in DM resolution following LSG and LRYGBP.     

Type 2 Diabetes Mellitus and the Metabolic Syndrome Following Sleeve Gastrectomy in Severely Obese Subjects

BACKGROUND: Data on the effectiveness of sleeve gastrectomy in improving or resolving type 2 diabetes mellitus (T2DM) and the metabolic syndrome (MS) are scarce. METHODS: A twelve-month prospective study on the changes in glucose homeostasis and the MS in 91 severely obese T2DM subjects undergoing laparoscopic SG (SG; n = 39) or laparoscopic Roux-en-Y gastric bypass (GBP; n = 52), matched for DM duration, type of DM treatment, and glycemic control was conducted. RESULTS: At 12 months after surgery, subjects undergoing SG and GBP lost a similar amount of weight (%EBL: SG: 63.00 +/- 2.89%, BPG: 66.06 +/- 2.34%; p = 0.413). On that evaluation, T2DM had resolved, respectively, in 33 out of 39 (84.6%) and 44 out of 52 (84.6%) subjects after SG and GBP (p = 0.618). The rate of resolution of the MS (SG: 62.2%, BPG: 67.3%; p = 0.392) was also comparable. A shorter DM duration (p < 0.05), a DM treatment not including pharmacological agents (p < 0.05), and a better glycemic control (p < 0.05), were significantly associated with T2DM resolution in both surgical groups. Weight loss was not associated with T2DM resolution after SG or GBP, but was associated with resolution of the MS following the two surgical procedures (p < 0.05). CONCLUSIONS: Our data show that at 12 months after surgery, SG is as effective as GBP in inducing remission of T2DM and the MS. Furthermore, our data suggest that SG and GBP represent a successful an integrated strategy for the management of the different cardiovascular risk components of the MS in subjects with T2DM.     

Glycemic Control after Sleeve Gastrectomy and Roux-En-Y Gastric Bypass in Obese Subjects with Type 2 Diabetes Mellitus

Background

Roux-en-Y gastric bypass (LRYGB) has weight-independent effects on glycemia in obese type 2 diabetic patients, whereas sleeve gastrectomy (LSG) is less well characterized. This study aims to compare early weight-independent and later weight-dependent glycemic effects of LRYGB and LSG.

Methods

Eighteen LRYGB and 15 LSG patients were included in the study. Glucose, insulin, GLP-1, and GIP levels were monitored during a modified 30 g oral glucose tolerance test before surgery and 2 days, 3 weeks, and 12 months after surgery. Patients self-monitored glucose levels 2 weeks before and after surgery.

Results

Postoperative fasting blood glucose decreased similarly in both groups (LRYGB vs. SG; baseline—8.1?±?0.6 vs. 8.2?±?0.4 mmol/l, 2 days—7.8?±?0.5 vs. 7.4?±?0.3 mmol/l, 3 weeks—6.6?±?0.4 vs. 6.6?±?0.3 mmol/l, respectively, P <?0.01 vs. baseline for both groups; 12 months—6.6?±?0.4 vs. 5.9?±?0.4, respectively, P <?0.05 for LRYGB and P <?0.001 for LSG vs. baseline, P =?ns between the groups at all times). LSG, but not LRYGB, showed increased peak insulin levels 2 days postoperatively (mean?±?SEM; LSG +?58?±?14%, P <?0.01; LRYGB ??8?±?17%, P =?ns). GLP-1 levels increased similarly at 2 days, but were higher in LRYGB at 3 weeks (AUC; 7525?±?1258 vs. 4779?±?712 pmol?×?min, respectively, P <?0.05). GIP levels did not differ. Body mass index (BMI) decreased more after LRYGB than LSG (??10.1?±?0.9 vs. ??7.9?±?0.5 kg/m², respectively, P <?0.05).

Conclusion

LRYGB and LSG show very similar effects on glycemic control, despite lower GLP-1 levels and inferior BMI decrease after LSG.

     

Improvement in Glycemic Control in Morbidly Obese Type 2 Diabetic Subjects by Gastric Stimulation

Background  Gastric electrical stimulation synchronized to the refractory period of gastric electrical activity and applied during meals was evaluated for safety and for improvement of body weight and glycemic control in obese type 2 diabetes. Methods  The study involved obese diabetic type 2 (ODM) patients in a multicenter open-label European feasibility trial. A total of 24 ODM (nine males, 15 females) treated with insulin and/or oral hyperglycemic agents and body mass index between 33.3 to 49.7 kg/m² were implanted laparoscopically with a TANTALUS system. Results  There were 18 adverse events related to the implant procedure or the device reported in 12 subjects. All were short lived and resolved with no sequelae. In the 21 subjects that reached the 1-year visit weight was reduced by 4.5 ± 2.7 kg (p < 0.05) and HbA1c by 0.5 ± 0.3% (p < 0.05). In a subgroup (n = 11) on stable or reduced oral medication, weight was reduced by 6.3 ± 3.4 kg (p < 0.05) and HbA1c by 0.9 ± 0.4% (p < 0.05). The group on insulin (n = 6) had no significant changes in weight and HbA1c. Conclusions  The TANTALUS system is well tolerated in obese type 2 diabetic subjects. Gastric electrical stimulation can potentially improve glucose metabolism and induce weight loss in obese diabetic patients, who are not well controlled on oral antidiabetic therapy. Further evaluation is required to determine whether this effect is due to induced weight loss and/or to direct signal dependent mechanisms.     

Plasma Ceramides Are Elevated in Obese Subjects With Type 2 Diabetes and Correlate With the Severity of Insulin Resistance

OBJECTIVE—To quantitate plasma ceramide subspecies concentrations in obese subjects with type 2 diabetes and relate these plasma levels to the severity of insulin resistance. Ceramides are a putative mediator of insulin resistance and lipotoxicity, and accumulation of ceramides within tissues in obese and diabetic subjects has been well described.RESEARCH DESIGN AND METHODS—We analyzed fasting plasma ceramide subspecies by quantitative tandem mass spectrometry in 13 obese type 2 diabetic patients and 14 lean healthy control subjects. Results were related to insulin sensitivity measured with the hyperinsulinemic-euglycemic clamp technique and with plasma tumor necrosis factor-α (TNF-α) levels, a marker of inflammation. Ceramide species (C18:1, 18:0, 20:0, 24:1, and 24:0) were quantified using electrospray ionization tandem mass spectrometry after separation with high-performance liquid chromatography.RESULTS—Insulin sensitivity (mg · kg⁻¹ · min⁻¹) was lower in type 2 diabetic patients (4.90 ± 0.3) versus control subjects (9.6 ± 0.4) (P < 0.0001). Type 2 diabetic subjects had higher (P < 0.05) concentrations of C18:0, C20:0, C24:1, and total ceramide. Insulin sensitivity was inversely correlated with C18:0, C20:0, C24:1, C24:0, and total ceramide (all P < 0.01). Plasma TNF-α concentration was increased (P < 0.05) in type 2 diabetic subjects and correlated with increased C18:1 and C18:0 ceramide subspecies.CONCLUSIONS—Plasma ceramide levels are elevated in type 2 diabetic subjects and may contribute to insulin resistance through activation of inflammatory mediators, such as TNF-α.Type 2 diabetes is an insulin-resistant state characterized by impaired glucose tolerance (1) and inflammation (2). Much evidence has demonstrated the role of increased circulating free fatty acids and tissue fat accumulation in the development of muscle and liver insulin resistance (1,3,4). The disturbances in plasma and tissue lipid metabolism result from an oversupply of lipid substrates, both exogenously and endogenously (increased lipolysis secondary to adipocyte insulin resistance), and perturbations in fat oxidation and utilization by muscle and liver, resulting in the accumulation of ectopic fat (4). Ectopic fat is “lipotoxic” and has been linked to the severity of insulin resistance and pancreatic β-cell dysfunction, i.e., the core defects in type 2 diabetes (1,4). Ectopic fat comprises various lipid species, including long-chain fatty acyl CoAs, diacylglycerol, and ceramide. It is well documented that ceramide accumulates within insulin-resistant tissues of animals (5–7) and humans (8–10) and inhibits insulin action and subsequent glucose uptake through inactivation of Akt. Ceramide also induces inflammation through activation of the nuclear factor-κB–tumor necrosis factor-α (TNF-α) axis (5–7).TNF-α is released from adipocytes and circulating mononuclear cells (MNCs) in response to stimuli, such as lipid infusion, lipopolysaccharide, reactive oxygen species, and hyperglycemia, and elevated TNF-α concentrations have been shown to induce insulin resistance (11–14). TNF-α also activates the plasma membrane enzyme sphingomyelinase (SMase) that hydrolyzes sphingomyelin to ceramide, allowing ceramides to accumulate within the cell (5,6,15–17). This accumulation of ceramide within tissues is thought to initiate a positive feedback mechanism, leading to enhanced production of proinflammatory cytokines (5), resulting in further inhibition of insulin-stimulated glucose uptake. Both plasma TNF-α concentrations and intracellular lipid intermediates, such as ceramides, are elevated in subjects with type 2 diabetes (8,18). Thus, ceramide is a bioactive lipid and putative mediator of insulin resistance that could link nutrient (fat) oversupply and cytokine-induced inflammation in tissues (5–7).Plasma ceramide levels also have been shown to correlate with coronary artery disease, independent of the plasma cholesterol concentration (19,20). However, the role of circulating ceramides has received little attention with respect to the development of insulin resistance and type 2 diabetes. Conflicting reports exist as to whether total circulating ceramides are elevated in obese (21) and type 2 diabetic subjects (22). Subspecies of plasma ceramides have been demonstrated to be increased in patients with sepsis and atherosclerosis (23–25), but the relationship between plasma ceramide subspecies levels and insulin resistance has not been investigated in patients with type 2 diabetes.Given their central role in the induction of insulin resistance and inflammation, elevated plasma ceramide levels may serve as a biomarker or direct perpetuator of insulin resistance and lipid-induced inflammation. Elevated plasma ceramide concentrations also may serve to identify individuals who are at risk to develop type 2 diabetes. The objective of this study was to quantify the concentration of individual ceramide subspecies in the circulation of patients with type 2 diabetes and healthy control subjects and to examine the correlation between plasma levels of ceramide subspecies and insulin sensitivity, measured with the euglycemic-hyperinsulinemic clamp, and plasma TNF-α concentration, a marker of inflammation.     

Long-Term Results of Gastric Bypass Surgery in Morbidly Obese Type 1 Diabetes Patients

Background  

Long-term effects of bariatric surgery in morbidly obese type 1 patients are unknown. Five to eight-year experience in the case series of type 1 diabetes subjects is presented.     

Prevalence of Undiagnosed and Inadequately Treated Type 2 Diabetes Mellitus,Hypertension, and Dyslipidemia in Morbidly Obese Patients Who Present for Bariatric Surgery

Background

Pharmacotherapy is considered the primary treatment modality for diabetes mellitus (DM), hypertension (HTN), and dyslipidemia (DYS). We sought to investigate the status of DM, HTN, and DYS in patients who seek bariatric surgery.

Methods

Demographic and comorbidity history were prospectively collected on 1,508 patients referred for bariatric consultation at a single institution from February 2008 to March 2012. We utilized published consensus guidelines (GL) to benchmark the efficacy of standard pharmacotherapy for these metabolic diseases, and 881 patients met the study design criteria.

Results

Most patients exhibited at least one form of metabolic dysregulation (pre-DM or DM, 75.8 %; pre-HTN or HTN, 91.1 %; pre-DYS or DYS, 84.0 %; metabolic syndrome, 76.0 %). The majority of patients either did not meet GL treatment goals (DM, 45.7 %; HTN, 39.5 %; DYS, 22.3 %) or were previously undiagnosed (DM, 15.8 %; HTN, 13.7 %; DYS, 41.7 %). Non-GL pharmacotherapy was significantly less effective than GL pharmacotherapy at achieving treatment goals for DM (31.8 vs 53.2 %, p?<?0.001) and HTN (43.6 vs 63.2 %, p?=?0.007). Patients with concurrent DM, HTN, and DYS (35.5 %) were less likely than patients with only one or two of these metabolic diseases to achieve GL treatment goals for HTN (38.1 vs 72.6 %, p?<?0.001) and DYS (55.7 vs 73.8 %, p?=?0.002). Only 8.0 % of these patients achieved treatment goals for all three metabolic comorbidities.

Conclusions

In this patient group, DM, HTN, and DYS were poorly compensated, even when pharmacotherapy was consistent with published GL. This may be due to disease burden in bariatric surgery candidates or to inadequate medical management prior to presentation.     

Metabolic Effects of Bariatric Surgery in Insulin-Sensitive Morbidly Obese Subjects

Background

The effects of bariatric surgery (BS) in metabolically healthy morbidly obese (MO) subjects are not well established. Against this background, we characterized the metabolic and inflammatory profiles of MO subjects with insulin sensitivity (IS) in the normal range, and evaluated the changes on these parameters following BS in this population.

Methods

We conducted a retrospective analysis of prospectively collected data in MO women undergoing BS between 2006 and 2010. Anthropometric, metabolic comorbidities, and inflammatory markers were compared at baseline and 12 months after BS, between 52 women (10.4 %) presenting with a HOMA-IR <2.94 (80th percentile reference population) (IS-MO group) and an age- and BMI-matched group of women (n?=?52) with HOMA-IR >2.94.

Results

The IS-MO women presented a more favorable metabolic and inflammatory profile as compared to the IR-MO group. However, an enlarged waist circumference (WC), a high-sensitivity C-reactive protein (hs-CRP) >3 mg/dL, and metabolic syndrome (MS) were present in 100 %, 90 %, and 51.9 % of the IS-MO group at baseline. At 12 months after surgery, all the MS components and hs-CRP improved in IS-MO subjects (p?<?0.01). The prevalence of the MS in the IS-MO group significantly decreased (11 %, p?<?0.05) despite WC and hs-CRP being abnormal respectively in 53.3 % and 20.0 % of women in this group.

Conclusions

In MO women, an IS in the normal range is associated with a limited protection from metabolic co-morbidities. Nonetheless, BS results in the amelioration of the altered metabolic and inflammatory profiles also in this group of subjects.     

Behavior of Type 2 Diabetes Mellitus in Morbid Obese Patients Submitted to Gastric Bypass

Introduction Surgical treatment of obesity has not only resulted in weight loss, but also the control of associated diseases in the postoperative period. The aim of this study was to determine the post-op response of type 2 diabetes mellitus (DM2) to gastric bypass. Methods A historical cohort study was performed involving all the diabetic, morbid obese patients who underwent gastric bypass during the period of May 2000 to October 2006 at the Centro da Obesidade Mórbida. Patient records were reviewed with regard to sex, age, anthropometric measurements, glycemia, glycosylated hemoglobin, pre-op insulin, and DM2 outcome. Results A total of 125 diabetic, morbid obese patients were operated; they had a mean age of 42.6 ± 9.7 years and body mass index of 49 ± 8.3 kg/m². Of these patients, 63 (50.4%) required medication for control of DM2, and the rest managed only with diet. Of these 63 patients, 43 (68.2%) achieved control of DM2 and were discharged without the need for antidiabetic medication, and 20 (31.7%) were discharged still on medication. One month after surgery, seven more patients discontinued medication for DM2, and 18 months after surgery, 97.6% of the patients showed control of DM2. Conclusion Gastric bypass is effective in controlling DM2 in morbid obese patients.     

Preoperative Gender Differences in Pulmonary Gas Exchange in Morbidly Obese Subjects

Background  Morbidly obese men may have poorer pulmonary gas exchange compared to morbidly obese women (see Zavorsky et al., Chest 131:362–367, 2007). The purpose was to compare pulmonary gas exchange in morbidly obese men and women at rest and throughout exercise. Methods  Twenty-five women (age = 38 ± 10 years, 164 ± 7 cm, body mass index or BMI = 51 ± 7 kg/m², peak oxygen consumption or O_2peak = 2.0 ± 0.4 l/min) and 17 men (age = 43 ± 9 years, 178 ± 7 cm, BMI = 50 ± 10 kg/m², O_2peak = 2.6 ± 0.8 l/min) were recruited to perform a graded exercise test on a cycle ergometer with temperature-corrected arterial blood-gas samples taken at rest and every minute of exercise, including peak exercise. Results  At rest, women were 98% predicted for pulmonary diffusion compared to 88% predicted in men. At rest, women had better pulmonary gas exchange compared to the men which was related to women having a lower waist-to-hip ratio (WHR; p < 0.01). Only 20% of the subjects had an excessive alveolar-to-arterial oxygen partial pressure difference (≥25 mmHg) at peak exercise, but 75% of the subjects showed inadequate compensatory hyperventilation at peak exercise (arterial carbon dioxide pressure >35 mmHg), and both were not different between genders. Conclusion  At rest, morbidly obese men have poorer pulmonary gas exchange and pulmonary diffusion compared to morbidly obese women. The better gas exchange in women is related to the lower WHR in the women. During exercise, few subjects showed disturbances in pulmonary gas exchange despite demonstrating poor compensatory hyperventilation at peak exercise. G.S. Zavorsky was the recipient of the 2005 Baxter Corporation Award in Anesthesia from the Canadian Anesthesiologist’s Society. G.S. Zavorsky was also a Research Scholar—Junior 1 from the Quebec Health Research Foundation (Fonds de la Recherche en Santé du Québec, FRSQ). N.V. Christou is a consultant for Ethicon Endo-Surgery Inc. and has stock ownership in Weight Loss Surgery.     

Increased Incidence of Vertebral Fracture in Older Female Hemodialyzed Patients with Type 2 Diabetes Mellitus

Bone disease in hemodialysis (HD) patients with type 2 diabetes mellitus (DM) is characterized by low bone turnover (Inaba M, et al. Am J Kidney Dis 2002; 39:1261-1269), although their bone quality is yet to be determined. The present study was designed to examine whether the prevalence of vertebral fracture in female HD patients with type 2 DM, age 65 years and older, might be increased, and the relation of this fracture to bone mineral density (BMD) determined by dual X-ray absorptiometry (DXA), since few data are available on the effect of DM on bone strength at lumbar spine. The prevalence of vertebral fracture in type 2 DM HD patients was 32.3%, which was greater than that of non-DM HD patients (13.3%) when adjusted for age and HD duration. Logistic regression analysis elucidated the presence of DM and age as independent risk factors for an increased prevalence of vertebral fracture in HD patients. In non-DM HD patients, those with vertebral fracture showed age significantly higher and BMD in either lumbar spine or distal one third of radius significantly lower than the respective value in those without fracture. However, in DM HD patients, neither BMD in lumbar spine nor distal one third of radius was significantly lower in those with vertebral fracture than in those without. Furthermore, age did not differ significantly between DM HD patients with and without fracture. In conclusion, female type 2 DM HD patients, age 65 years and older, showed significantly higher incidence of vertebral fracture than non-DM HD patients. Although age and low BMD emerged as independent risk factors for vertebral fracture in non-DM HD patients, those factors failed to be a risk factor in DM HD patients, suggesting that BMD determined by DXA might not be reliable in assessing bone strength in DM HD patients.     

Efficacy of Laparoscopic Sleeve Gastrectomy and Intensive Medical Management in Obese Patients with Type 2 Diabetes Mellitus

Background

There are a dearth of studies comparing laparoscopic sleeve gastrectomy (LSG) and intensive medical treatment (IMT) in obese type 2 diabetes mellitus (T2DM) patients. This study compares these modalities in terms of weight loss, metabolic parameters and quality of life (QOL) score.

Methods

We evaluated the efficacy of LSG (n?=?14) vs. IMT (n?=?17) comprising of low calorie diet, exenatide, metformin and if required insulin detemir in 31 obese T2DM patients with BMI of 37.9?±?5.3kg/m² and target HbA1c?<?7 %. The mean (±SD) age of the patients was 49.6?±?11.9 years and 74 % were women. The mean duration of diabetes was 8.5?±?6.1 years and mean HbA1c was 8.6?±?1.3 %. Primary end point was excess body weight loss (EBWL) at the final follow-up.

Results

The mean duration of follow-up was 12.5?±?5.0 (median 12) months. EBWL was 61.2?±?17.6 % and 27.4?±?23.6 % in LSG and IMT group respectively (p?<?0.001). Glycemic outcomes improved in both with mean HbA1c of 6.6?±?1.5 % in LSG and 7.1?±?1.2 % in IMT group. In LSG group, there was resolution of diabetes and hypertension in 36 and 29 % of patients respectively while none in the IMT group. HOMA-IR, hsCRP, ghrelin and leptin decreased while adiponectin increased significantly in LSG compared to IMT group. QOL score improved in LSG as compared to IMT.

Conclusions

In obese T2DM patients, LSG is superior to IMT in terms of weight loss, resolution of comorbidities and QOL score.     

Prevalence of Non-alcoholic Steatohepatitis in Morbidly Obese Subjects Undergoing Gastric Bypass

Background: Obesity is the most common cause of non-alcoholic steatohepatitis (NASH). This is a prospective study to determine the incidence and severity of NASH in patients undergoing Roux-en-Y gastric bypass (RYGBP) for morbid obesity. We also examined the relationship between NASH and potential risk factors. Methods: In 48 consecutive patients at RYGBP, a core liver biopsy was obtained from the left lateral segment. A single liver pathologist reviewed the histology for steatosis, ballooning/disarray, necroinflammation, and fibrosis. Results: 84% of patients were female, and average BMI was 51. 18% had WHR >1. The following risk factors were present: DM 16%; hyperlipidemia 61%; HTN 47%; and abnormal LFTs 18%. 90% had abnormal liver histology, and 56% qualified for the diagnosis of NASH. Only DM and abnormal LFTs were found to be significantly related to NASH. Conclusions: NASH is a common co-morbidity of obesity and requires systemized grading and staging to develop accurate knowledge of the incidence, severity, natural history and impact of weight loss.     

Resolution of Diabetes Following Vertical Gastroplasty in Morbidly Obese Patients

Case reports are presented on three patients treated for morbid obesity by vertical gastroplasty. Prior to surgery the patients had diabetes which required insulin, up to 200 units per day, or oral hypoglycaemics for its control. Six months after surgery the diabetes had been resolved in all three patients, and they were no longer dependent on medication. Subjective reports from the patients suggests that their quality of life improved significantly.     

Long-Term Effects of Laparoscopic Roux-en-Y Gastric Bypass on Diabetes Mellitus,Hypertension and Dyslipidaemia in Morbidly Obese Patients

Background

Severely obese patients have an increased risk for developing metabolic complications such as type 2 diabetes mellitus (T2DM), dyslipidaemia (DL) and hypertension (HT). The aim of the present study is to research the effect of a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) on T2DM, HT and DL in the long-term.

Methods

Fifty-two out of 89 (58 %) adult severely obese patients with T2DM who had received a LRYGB between January 2000 and December 2008 were evaluated. Primary outcome of evaluation was remission of T2DM according to the definition of 2009 consensus statement. Complete remission was defined as achievement fasting plasma glucose (FPG) of <5.6 mmol/l (<100.8 mg/dL) and HbA1c <42 mmol/mol (<6.0 %)) without glucose-lowering medication for at least 1 year. Partial remission was defined as a FPG of 5.6–6.9 mmol/l (100.8–124.2 mg/dL) and HbA1c 42–48 mmol/mol (6.0–6.5 %), without glucose-lowering medication for at least 1 year. Remission of T2DM was considered if the patient met the criteria for complete or partial remission. Secondary outcomes were remission of HT, DL and changes in medication use.

Results

Patients had a mean age of 47.5?±?9.6 years, body mass index of 46.6?±?6.4 kg/m² and a mean duration of T2DM of 6.1?±?5.4 years at the time of surgery. The mean post-operative follow-up period was 6.9?±?2.3 years. At the end of the follow-up, mean weight loss was 60?±?24 % excess weight loss (EWL) and 26?±?10 % total body weight loss (TBWL). Mean HbA1c level had significantly decreased from 64.8?±?19.7 mmol/mol to 46.4?±?12.9 mmol/l (p?p?p?p?=?0.020) and duration of T2DM (odds ratio 0.637, p?=?0.010) were independent risk factors for failed remission of T2DM. The number of patients with HT was significantly reduced from 73 % to 54 % (p?=?0.042), and number of patients with DL was non-significantly decreased from 71 % to 54 % (p?=?0.068).

Conclusions

The laparoscopic RYGB operation results in a sustained EWL of 60 % (26 % TBWL) with 52 % long-term remission of T2DM. However, 19 % of the patients had a relapse of their T2DM. Furthermore, HT and DL improved markedly.     

Treating Diabetes in the Morbidly Obese by Laparoscopic Gastric Banding

Background: Remission of diabetes following Roux-en-Y gastric bypass has been postulated to occur partly by bypass of the foregut. Laparoscopic adjustable gastric banding (LAGB) also reduces food intake but does not bypass the foregut, and its effects on diabetes have yet to be elucidated. Methods: Patients with diabetes or a history of diabetes and >6 months follow-up after LAGB were studied. Follow-up was conducted separately by a surgeon with regard to weight loss and potential morbidity and by a physician with regard to diabetic control. Results: 14 patients had had gestational diabetes, and diabetes was controlled by diet in 25, oral hypoglycemics in 38 and insulin in 11 patients. Reduction in body mass index (BMI) and percentage of excess weight loss (%EWL) were similar in these 4 subgroups, with a median reduction in BMI of 11.7 kg/m² and %EWL of 51.1% at 24 months. 26 of 38 patients controlled with oral hypoglycemic medication and 6 of 11 insulin-dependent diabetics had all medication stopped at a median of 6.5 months following LAGB. Univariate and multivariate analyses identified %EWL ≥ 30.6% at 6 months as the only significant predictor of remission of diabetes. Conclusion:Two-thirds of the diabetic patients have had remission of diabetes following LAGB. LAGB is an effective treatment for diabetes in obese patients.     

Systemic Inflammation in Morbidly Obese Subjects: Response to Oral Supplementation with Alpha-Linolenic Acid

Background Morbidly obese patients frequently display asymptomatic chronic activation of acute phase response, with potentially adverse metabolic and cardiovascular consequences. Nutritional preparations to improve this phenomenon have rarely been administered. Aiming to investigate the supplementation of flaxseed flour, a source of omega-3 fatty acids, a prospective randomized double-blind cross-over study was designed. Methods Outpatient obese subjects (n = 41) were clinically and biochemically screened, and results for 24 randomized subjects are shown. Age was 40.8 ± 11.6 years (83.3% females) and body mass index (BMI) was 47.1 ± 7.2 kg/m². Flaxseed flour (Farinha de Linhaca Dourada LinoLive, Cisbra, Brazil) in the amount of 30 g/day (5 g of alpha-linolenic acid – omega-3) and an equal mass of placebo (manioc flour) were administered for 2 weeks each. Variables included general biochemical investigation, white blood cell count (WBC), C-reactive protein (CRP), serum amyloid A (SAA) and fibronectin. Results No intolerance was registered. Body weight and general biochemical indices remained stable. Initial CRP and SAA were elevated (13.7 ± 9.9 and 17.4 ± 8.0). WBC (8100 ± 2100/mm³) and fibronectin (463.2 ± 61.3 mg/dL) were acceptable but in the upper normal range. Corresponding findings after supplementation of flaxseed were 10.6 ± 6.2 mg/L, 14.3 ± 9.2 mg/L, 7300 ± 1800/mm³ and 412.8 ± 38.6 respectively (P < 0.05 ). No change during the control period regarding baseline occurred when placebo was randomized to be given first; however, when it followed omega-3 supplementation, CRP and SAA recovered, whereas WBC and fibronection remained depressed during those 2 weeks (7500 ± 2100/mm³ and 393.2 ± 75.8 mg/dL, P < 0.05). Conclusions 1) Various inflammatory markers were elevated in the studied population, although not necessarily exceeding the normal range; 2) Significant reduction could be demonstrated; 3) Some persistent effects of flaxseed supplement 2 weeks after discontinuation were observed.