Metabolic effects of bariatric surgery in type 2 diabetic patients with body mass index < 35 kg/m2

Aim: The aim of this meta‐analysis is to assess the metabolic effects of bariatric surgery in type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) < 35 kg/m². Methods: We performed an electronic literature search of published articles to identify relevant evidence since inception to June 2011. Primary outcome measures were metabolic improvement and resolution diabetes after bariatric surgery. The weighted mean difference (WMD) and its 95% confidence interval (CI) were calculated from the raw data extracted from the original literature. The software Review Manager (version 4.3.1) was applied for meta‐analysis. Results: Thirteen trials involving 357 patients were included in the meta‐analysis. The follow‐up interval ranged from 6 months to 18 years. According to WMD calculation, bariatric surgery led to 5.18 kg/m² of BMI lowering (95% CI, 3.79–6.57, p < 0.00001), 4.8 mmol/l of fasting plasma glucose (FPG) decrement (95% CI, 3.88–5.71 mmol/l, p < 0.00001), 2.59% of HbA1c decreasing (95% CI, 2.12–3.07%, p < 0.00001), 56.67 mg/dl of triglyceride decrement (95% CI 11.53–101.82, p = 0.01) and 48.38 mg/dl of total cholesterol reduction (95% CI 21.08–75.68, p = 0.0005). Moreover, the procedures produced an increased high‐density lipoprotein cholesterol by 5.37 mg/dl (95% CI ?11.37–0.63, p = 0.08). However, this effect was not statistically significant. Overall, 80.0% of the patients achieved adequate glycaemic control (HbA1c < 7%) without antidiabetic medication. The surgeries produced a low incidence of major complications (3.2%) with no mortality. Conclusions: Bariatric surgery is effectual and safe in the treatment of non‐severely obese (BMI < 35 kg/m²) T2DM patients. Moreover, the metabolic benefits acquired from the procedures can be long sustained after the surgery.     

Tissue Doppler imaging of the right and left ventricle in severe obesity (body mass index >35 kg/m2)

We investigated right and left heart function in 51 patients with a body mass index of >35 kg/m(2) who underwent evaluation for gastric bypass surgery using standard Doppler echocardiography and color tissue Doppler imaging. Left atrial diameter (3.7 +/- 0.5 vs 3.3 +/- 0.4 cm, p <0.001), left ventricular end-diastolic diameter (5.0 +/- 0.6 vs 4.5 +/- 0.4 cm, p <0.001), and left ventricular mass index (119 +/- 49 vs 76 +/- 26 g/m, p <0.001) were increased in patients with severe obesity. Early diastolic mitral annular velocity (7.5 +/- 2.1 vs 9.6 +/- 3.0 cm/s, p <0.001), early diastolic/late diastolic mitral annular velocity ratio (1.38 +/- 0.6 vs 1.94 +/- 1.3, p = 0.007), early diastolic tricuspid annular velocity (7.8 +/- 2.6 vs 9.5 +/- 2.4 cm/s, p = 0.002), early diastolic/late diastolic tricuspid annular velocity ratio (0.9 +/- 0.36 vs 1.1 +/- 0.4, p = 0.048), and mitral annular systolic velocity (5.7 +/- 1.3 vs 6.5 +/- 1.5 cm/s, p = 0.012) were significantly lower in obese patients. Early diastolic mitral inflow/mitral annular velocity ratio was increased in the obese (13.5 +/- 4.7 vs 9.1 +/- 3.6, p <0.001). Tricuspid annular systolic velocities did not differ.     

氯吡格雷抵抗与老年代谢综合征患者体质指数及胰岛素抵抗的临床研究

目的本研究探讨“氯吡格雷抵抗”现象与老年代谢综合征患者体质指数（BMI）与胰岛素抵抗的临床意义。方法选取90例诊断为代谢综合征的老年住院患者,根据BMI的不同分为肥胖组（BMI〉28）、超重组（BMI24—28）、标准组（BMI〈24）,每组30例,3组均给予氯吡格雷75mg／d治疗,以5μmol二磷酸腺苷（ADP）作为血小板聚集的激动剂,测定每组的HOMA指数及治疗前后血小板聚集率％的绝对差值（A聚集率）,以△聚集率〈10％作为氯吡格雷抵抗阳性标准。结果90例患者中,发现△聚集率〈10％者13例（14．4％）,肥胖组△聚集率较标准组降低。肥胖组氯吡格雷抵抗发生率为30％,超重组为10％、标准组为3．3％,三组间差异有统计学意义（P〈0．05）;且在肥胖组,HOMA-指数较标准组明硅增加（P〈0．05）,结论老年代谢综合征患者中存在氯毗格雷抵抗现象,且与体质指数与胰岛素抵抗相关。     

Asian women have greater abdominal and visceral adiposity than Caucasian women with similar body mass index

Background:

In the Multiethnic Cohort Study, Japanese Americans (JA) have lower mean body mass index (BMI) compared with Caucasians, but show a higher waist-to-hip ratio at similar BMI values and a greater risk of diabetes and obesity-associated cancers.

Objective:

We investigated the abdominal, visceral and hepatic fat distribution in these Asian and Caucasian Americans.

Design:

A cross-sectional sample of 60 female cohort participants (30 JA and 30 Caucasians), of ages 60–65 years and BMIs 18.5–40 kg m⁻², underwent anthropometric measurements and a whole-body dual energy X-ray absorptiometry (DXA) scan: a subset of 48 women also had abdominal magnetic resonance imaging (MRI).

Results:

By design, JA women had similar BMIs (mean 26.5 kg m⁻²) to Caucasian women (27.1 kg m⁻²). JA women were found to have a significantly smaller hip circumference (96.9 vs 103.6 cm; P=0.007) but not a significantly lower DXA total fat mass (25.5 vs 28.8 kg; P=0.16). After adjusting for age and DXA total fat mass, JA women had a greater waist-to-hip ratio (0.97 vs 0.89; P<0.0001), DXA trunk fat (15.4 vs 13.9 kg; P=0.0004) and MRI % abdominal visceral fat (23.9 vs 18.5% P=0.01) and a lower DXA leg fat mass (8.2 vs 10.0 kg; P=<.0001). Their MRI % subcutaneous fat (33.4 vs 30.2% P=0.21) and % liver fat (5.8 vs 3.8% P=0.06) did not significantly differ from that of Caucasian women.

Conclusions:

Our findings build on limited past evidence, suggesting that Asian women carry greater abdominal and visceral fat when compared with Caucasian women with similar overall adiposity. This may contribute to their elevated metabolic risk for obesity-related diseases.     

Effect of weight loss due to lifestyle intervention on subclinical cardiovascular dysfunction in obesity (body mass index >30 kg/m2)

Subclinical myocardial and vascular dysfunctions occur in subjects with obesity. We investigated whether these changes were reversible with weight loss due to lifestyle intervention. Quantitative assessment of myocardial and vascular functions was performed at baseline and after a minimum of 8 weeks of a lifestyle intervention program in 106 subjects with significant risk factors but no history of cardiovascular disease and normal ejection fractions. Myocardial function was assessed using strain rate, strain, regional myocardial systolic velocity, and diastolic velocity (e(m)). Myocardial reflectivity was assessed by calibrated integrated backscatter. Vascular function was assessed using brachial arterial reactivity and arterial compliance. Exercise capacity was measured by peak oxygen consumption per unit time (VO(2)). Weight loss (-4.5 +/- 2.0%) was achieved by 48 subjects, and 58 maintained or increased weight (+1 +/- 1.5%, p <0.001). Compared with the stable weight group, the weight loss group showed significant improvement in brachial arterial reactivity (8.6 +/- 4.9% vs 6.7 +/- 4.9%, p <0.05), e(m) (6.4 +/- 1.9 vs 5.5 +/- 1.9 cm/s, p <0.01), and reflectivity (calibrated integrated backscatter, 18.3 +/- 4.9 vs 16.2 +/- 5.2 dB, p <0.01). The magnitude of weight change correlated with changes in e(m) (r = 0.36) and calibrated integrated backscatter (r = 0.33). The change in e(m) correlated with peak VO(2) (r = 0.38, p <0.001) and was an independent predictor for peak VO(2) even after adjustment for age and body mass index in a multivariate model (R(2) = 0.45, p <0.001). Weight loss was not associated with a significant change in systolic parameters (regional myocardial systolic velocity, global strain, and strain rate) or arterial compliance.     

不同体质指数的2型糖尿病患者血管性血友病因子水平和胰岛素抵抗的临床研究

目的了解不同体质指数（BMI）的2型糖尿病（T2DM）患者的血管性血友病闪子（vWF）水平以及胰岛素抵抗（IR）程度。方法依据BMI将134例T2DM患者分为正常体重组（50例）、超重组（50例）与肥胖组（34例）,分别测定血浆vWF水平,并评估、比较各组IR程度。结果肥胖组的vWF水平、HOMAIR高于正常体重组（P〈0．05）;各组间胰岛素作用指数（IAI）及定量胰岛素敏感性指数（QUICKI）有统计学差异（P〈0．05）;HOMAIR、IAI及QUICKI各指标间呈正相关。结论肥胖的T2DM患者血浆vWF水平升高、IR程度明最加重。     

血清游离脂肪酸水平在不同体重指数及糖耐量个体中与胰岛素敏感性及相关指标的关系

目的　运用Bergman的最小模型技术研究不同体重指数 (BMI)及糖耐量个体血清空腹游离脂肪酸水平与胰岛素敏感性之间的关系。方法　用放射免疫分析法检测 2 6例正常人 (正常BMI及糖耐量 )、39例糖耐量正常单纯性肥胖者、新近诊断的 2 5例糖耐量异常 (IGT)患者及 2 1例 2型糖尿病患者的血清空腹游离脂肪酸 (FFA)水平 ,测定空腹血清甘油三酯 (TG)、血清总胆固醇 (TC)水平 ,并利用Bergman最小模型技术计算胰岛素敏感性指数 (ISI)。结果　 (1)正常对照组血清FFA值显著低于单纯肥胖组、IGT组及 2型糖尿病组 ,但FFA值在后 3组之间差异无显著性。 (2 )正常对照组ISI值显著高于单纯肥胖组、IGT组及 2型糖尿病组 ,但ISI值在后 3组之间差异无显著性。 (3)在校正了BMI因素影响后 ,正常对照组血清FFA值仍显著低于其他各组。 (4 )相关性研究显示 ,血清FFA值与ISI值呈明显负相关 ,与简易胰岛素敏感性指数HOMAIR以及BMI、腰臀围比 (WHR)、TG值呈明显正相关 (r值分别为 - 0 4 5 4、0 2 13、0 2 4 1、0 336、0 4 14 ,P值分别 <0 0 1、<0 0 5、<0 0 5、<0 0 1、<0 0 1) ,而与年龄、性别及TC值无相关性 ;(5 )以FFA为应变量 ,ISI、HOMAIR、BMI、WHR、TG为自变量进行多元逐步回归分析显示 ,ISI、BMI、TG为影响空腹血     

体重、体重指数与绝经后妇女骨丢失率的相关性研究

目的 评价体重、体重指数对绝经后妇女骨转换率的影响。方法 对1042名门诊体检的健康绝经后妇女测定身高、体重,计算体重指数（BMI）,DXA骨密度仪测定腰椎和股骨部位骨密度（BMD）,同时留取血液和尿液测定骨转换指标,如血清骨钙素（SM-BGP）、血清骨特异性碱性磷酸酶（S-BALP）、血Ⅰ型前胶原C端肽（S-PICP）,和骨吸收指标,如尿吡啶啉（U-PYD）、尿脱氧吡啶啉（U-DPD）、尿I型胶原羧基端肽（U-CTX）、尿Ⅰ型胶原氨基端肽（U-NTX）、尿钙（U-Ca）、尿肌酐（U-Cr）以及可以反映骨代谢的血完整甲状旁腺素（S-PTH）。结果 U-CTX/Cr（r=-0.233,P=0.000）、U-NTX/Cr（r=-0.110,P=0.016）和SM-BGP（r=-0.193,P=0.027）与BMI呈负相关。根据体重指数将受试对象分为三组：BMI≤24kg/m^2（正常组）,24kg/m^2〈BMI〈27kg／m^2（超重组）．27kg／m^2≤BMI（肥胖组）．U—CTX／Cr在三组的水平分别为：287．73±98．47;239．37±85．26;204．14±79．91,各组间差异均有统计学意义;U-NTX／Cr在三组的水平分别为：61．77±29．83;54．45±20．37;49．53±19．81,只在组1和组3间差异有统计学意义;SM—BGP在三组的水平分别为：26．16±12．75;24．57±10．98;20．82±7．99,组3与组1、组2间差异有统计学意义。多元逐步网归分析,BMI、腰椎BMD和年龄是影响绝经后妇女U—CTX／Cr、U—NTX／Cr、SM～BGP的主要因素。结论 BMI与骨转换率旱负相关,对于绝经后妇女,随着BMI的升高其骨形成（SM—BGP）或骨吸收（U—CTX、U—NTX）均有降低的趋势。     

Dehydroepiandrosterone sulfate levels in women. Relationships with age, body mass index and insulin levels

Sex and age are the major determinants of serum levels of dehydroepiandrosterone sulfate (DHEA-S): they are about twice in men than in women and show a progressive reduction from the end of the puberty to aging in both sexes. It has been reported that DHEA-S levels are also negatively influenced by insulin. Moreover, DHEA-S levels reduction has been associated to increased risk for cardiovascular disease, which connotes hyperinsulinemic states, such as obesity. We have evaluated serum levels of DHEA-S and insulin as function of age and body mass index (BMI) in 376 adult women (age 18.1-89.6 yrs, median 42.2; BMI 15.7-57.8 kg/m2, median 32.7) by multiple regression and piecewise regression analysis. Insulin levels positively associated to BMI (p=0.000002) and DHEA-S levels negatively associated with age (p=0.000001). Considering the whole population, DHEA-S levels were related positively with BMI (p=0.0013) independently of age. DHEA-S were also directly related to insulin levels independently of age (p=0.042), but this association disappeared after correction for BMI. Piecewise regression analysis did not reveal a threshold level for the increase of BMI (p=0.0004). Interestingly, DHEA-S levels and BMI were positively associated before but not after menopause. Taking into account only obese population, (no.=143, age 18.7-67.3 yrs, mean 39.0, median 39.4) DHEA-S levels were again related negatively with age and positively with BMI, while were unrelated with waist to hip ratio (p=0.391). Our data show that increasing body mass and insulin secretion is not associated to DHEA-S reduction in women. This evidence suggests that DHEA-S is unlikely implicated in the pathogenesis of cardiovascular disease in obese women.     

PCOS患者血清脂联素水平与体质量指数、胰岛素抵抗的相关性探讨

目的 探讨多囊卵巢综合征(PCOS)患者血清脂联素水平与体质量指数(BMI)、胰岛素抵抗(IR)的关系.方法 选择206例PCOS患者(PCOS组)和同期收治的74例非PCOS患者(对照组),测定其BMI、血清脂联素水平;PCOS组同时测定血糖、胰岛素,计算胰岛素指数(HOMA-IR,≥1.66为IR).结果 随BMI增加,两组血清脂联素水平呈递减趋势(正常体质量>超重>肥胖);PCOS组合并糖耐量异常(IGT)者和IR者脂联素分别为(3.97±1.27)和(4.90±2.62)mg/L,明显低于无IGT者和无IR者的(6.50±3.11)和(6.82±4.40)mg/L,P<0.01.结论 PCOS患者血清脂联素水平与BMI及IR密切相关,此为更深入了解脂联素在代谢中的作用及影响因素提供了理论依据.     

Role of bariatric-metabolic surgery in the treatment of obese type 2 diabetes with body mass index <35 kg/m2: a literature review

Bariatric surgery has been used to treat type 2 diabetes mellitus (T2DM); however, its efficacy is still debatable. This literature review analyzed articles that evaluated the effects of bariatric surgery in treatment of T2DM in obese patients with a body mass index (BMI) of <35?kg/m(2). A paired t test was applied for the analysis of pre- and postintervention mean BMI, fasting plasma glucose (FPG), and glycosylated hemoglobin (A1c) values. A significant (P<0.001) reduction in BMI (from 29.95±0.51?kg/m(2) to 24.83±0.44?kg/m(2)), FPG (from 207.86±8.51?mg/dL to 113.54±4.93?mg/dL), and A1c (from 8.89±0.15% to 6.35±0.18%) was observed in 29 articles (n=675). T2DM resolution (A1c <7% without antidiabetes medication) was achieved in 84.0% (n=567) of the subjects. T2DM remission, control, and improvement were observed in 55.41%, 28.59%, and 14.37%, respectively. Only 1.63% (n=11) of the subjects presented similar or worse glycemic control after the surgery. T2DM remission (A1c <6% without antidiabetes medication) was higher after mini-gastric bypass (72.22%) and laparoscopic/Roux-en-Y gastric bypass (70.43%). According to the Foregut and Hindgut Hypotheses, T2DM results from the imbalance between the incretins and diabetogenic signals. The procedures that remove the proximal intestine and do ileal transposition contribute to the increase of glucagon-like peptide-1 levels and improvement of insulin sensitivity. These findings provide preliminary evidence of the benefits of bariatric-metabolic surgery on glycemic control of T2DM obese subjects with a BMI of <35?kg/m(2). However, more clinical trials are needed to investigate the metabolic effects of bariatric surgery in T2DM remission on pre-obese and obese class I patients.     

体质指数与血清尿酸水平的相关性研究

目的探讨体检者的体质指数(BMI)与血清尿酸水平的相关性。方法选取2018年首都医科大学附属北京朝阳医院年龄大于18岁的行健康体检者1 514名作为研究对象,按照BMI分为正常组、超重组和肥胖组,检测代谢指标并行组间比较,分析血清尿酸水平与BMI、三酰甘油等的相关性,利用logistic回归分析高尿酸血症(HUA)的危险因素。结果体检者的血清尿酸水平随BMI增加而升高,在不同BMI分组中的差异有统计学意义。血清尿酸水平与BMI、三酰甘油、空腹胰岛素、稳态模型评估的胰岛素抵抗指数(HOMA-IR)均呈显著正相关(均为P<0.05)。男性(OR=3.02)、超重和肥胖(OR=1.51和2.59)、三酰甘油升高(OR=1.62)、低密度脂蛋白胆固醇升高(OR=2.23)是HUA的危险因素(均为P<0.05)。结论血清尿酸水平与BMI、三酰甘油、空腹胰岛素、HOMA-IR呈正相关,而男性、超重和肥胖、三酰甘油升高、低密度脂蛋白胆固醇升高是HUA的危险因素。     

Relationship between body mass index and high cystatin levels among US adults

High cystatin C levels among patients without clinically recognized chronic kidney disease (CKD) may identify patients who are at preclinical stages of CKD. Higher body mass index (BMI) has been found to be associated with increased risk of CKD. However, the association between BMI and high cystatin C levels is not clear. The authors examined participants older than 20 years from the National Health and Nutrition Examination Survey 1999 to 2002 (N=2583, 50.2% women). BMI was categorized as <25 kg/m(2), 25-29.9 kg/m(2), and ≥30 kg/m(2) . Main outcome was high cystatin C (>1 mg/dL) among patients without clinically recognized CKD (estimated glomerular filtration rate <60 mL/min/1.73 m(2) or microalbuminuria). Higher BMI was positively associated with high cystatin C, independent of age, sex, race-ethnicity, education, smoking, alcohol intake, cholesterol, and C-reactive protein levels. Compared with patients with BMI <25 kg/m(2) (referent), the multivariable odds ratio (95% confidence interval) of high cystatin C was 2.53 (1.79-3.58) (P trend <.0001 among patients with BMI ≥30 kg/m(2)). The association between BMI and high cystatin C persisted in subgroup analyses by sex, race-ethnicity, and among those without diabetes or hypertension. Among US adults without clinically recognized CKD, higher BMI levels were independently associated with high cystatin C levels.     

Rate of change and instability in body mass index, insulin resistance, and lipid metabolism as predictors of atherosclerotic vascular disease

CONTEXT: By definition, levels of metabolic risk factors predict atherosclerotic vascular disease, but the effects of long-term adverse change and instability remain underresearched. OBJECTIVE: Our objective was to quantify long-term rates of change and instability in risk factors and relate these measures to clinical atherosclerotic vascular disease outcomes. DESIGN AND SETTING: We conducted a prospective cohort study with unmatched and age- and follow-up-matched control analyses at a teaching hospital day ward. PARTICIPANTS: Participants included 465 predominantly healthy white males in an occupational cohort who had undergone repeated metabolic risk factor measurements (mean observation period 11.6 yr, range 2-28 yr), 62 of whom developed clinical atherosclerotic vascular disease. MAIN OUTCOME MEASURES: Rate of change and instability in metabolic risk factor levels were quantified in each individual by linear regression with time and evaluated as predictors of atherosclerotic vascular disease and coronary and cerebrovascular disease separately. RESULTS: As expected, baseline and/or mean follow-up measures of established risk factors relating to blood pressure, lipid metabolism, and subclinical inflammation were significant predictors. Predictors independent of baseline and mean follow-up levels, confirmed in matched and unmatched analyses, were 1) for atherosclerotic vascular disease, instability in weight (cases vs. controls: 2.9 vs. +2.5%); 2) for coronary heart disease, instability in body mass index (3.0 vs. +2.3%), a decline (-0.041 vs. -0.011 per decade) and instability (19.1 vs. 14.6%) in the high-density lipoprotein/non-high-density lipoprotein cholesterol ratio, declining erythrocyte sedimentation rate, and increasing uric acid; and 3) for cerebrovascular disease, a decline in insulin sensitivity (-0.394 vs. 0.324 per decade). CONCLUSIONS: Within an individual, long-term change in metabolic risk factors, as well as their absolute levels, can be important in atherosclerotic vascular disease.     

脂联素/瘦素与胰岛素抵抗指数的相关性

目的研究健康人群、肥胖和2型糖尿病(T2DM)患者的血清脂联素/瘦素(APN/LEP)与胰岛素抵抗指数的关系。方法采用病例对照研究,2型糖尿病伴有肥胖组(DO)42例,T2DM不伴肥胖组(NDO)42例,单纯性肥胖组(OB)37例,正常对照组(NC)28名。检洲了4组研究对象血脂、血糖(FBG)、空腹胰岛素(Fins)、APN、LEP水平,用HOMA模型公式计算胰岛素抵抗指数(HOMA-IR)。结果正常对照组(NC)的脂联素/瘦素明显大于其它三组,统计学检验差异有显著性意义(P0.05),而其它三组间的脂联素/瘦素差异无显著性意义。糖尿病肥胖组(DO)的HOMA-IP明显高于其它三组,统计学检验差异有显著性意义(P0.05)。随着脂联素/瘦素的降低,胰岛素抵抗指数呈上升趋势。结论胰岛素抵抗指数与脂联素/瘦素间呈显著负相关,脂联素/瘦素有望成为反映胰岛素抵抗的新指标。     

Relationship between adiponectin levels, acylated ghrelin levels, and short-term body mass index changes in children with diabetes mellitus type 1 at diagnosis and after insulin therapy

OBJECTIVE: To determine the effect of the initial metabolic imbalance and its restoration after insulin therapy on adiponectin and acylated ghrelin levels in children with type 1 diabetes mellitus (T1DM). Study design: Twenty prepubertal children with newly diagnosed T1DM were prospectively studied at diagnosis and after 1 and 4 months of therapy. Body mass index (BMI) and serum levels of adiponectin, resistin, total and acylated ghrelin, leptin, tumor necrosis factor alpha (TNF-alpha), and interleukin-6 (IL-6) were determined. The control group comprised 40 healthy prepubertal children. RESULTS: BMI was decreased at diagnosis, normalized at 1 month, and remained so thereafter. Adiponectin levels at diagnosis were similar to controls, increasing significantly after 1 month and normalizing at 4 months. Acylated ghrelin levels were lower at diagnosis, with a significant increase at 1 month and normalizing at 4 months. Resistin levels were normal at all time points. Leptin levels were decreased, while TNF-alpha and IL-6 were increased at diagnosis and normalized at 1 month. CONCLUSIONS: These findings suggest that BMI is not the main predictor of acylated ghrelin or adiponectin levels in newly diagnosed T1DM subjects and that these peptides may play an important role in the metabolic adaptation in this disease.