The long-term effectiveness of a lifestyle intervention in severely obese individuals. Microvascular Outcomes in Patients With Diabetes After Bariatric Surgery Versus Usual Care Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35 kg/m2 Predictive Factors of Type 2 Diabetes Remission 1 Year After Bariatric Surgery: Impact of Surgical Techniques Outcomes of bariatric surgery in patients with body mass index <35 kg/m2. The Sleeve Bypass Trial: a multicentre randomized controlled trial comparing the long term outcome of laparoscopic sleeve gastrectomy and gastric bypass for morbid obesity in terms of excess BMI loss percentage and quality of life Bariatric Surgery versus Lifestyle Interventions for Morbid Obesity—Changes in Body Weight, Risk Factors and Comorbidities at 1 Year Bariatric surgery versus conventional medical therapy for type 2 diabetes. Effect of Laparoscopic Mini-Gastric Bypass for Type 2 Diabetes Mellitus: Comparison of BMI >35 and <35 kg/m2 Randomized Pilot Trial of Bariatric Surgery Versus Intensive Medical Weight Management on Diabetes Remission in Type 2 Diabetic Patients Who Do NOT Meet NIH Criteria for Surgery and the Role of Soluble RAGE as a Novel Biomarker of Success Laparoscopic adjustable gastric banding for patients with body mass index of <or=35 kg/m2. Evaluation of the biochemical, inflammatory and oxidative profile of obese patients given clinical treatment and bariatric surgery. Impact of Laparoscopic Sleeve Gastrectomy and Laparoscopic Gastric Bypass on HbA1c Blood Level and Pharmacological Treatment of Type 2 Diabetes Mellitus in Severe or Morbidly Obese Patients. Results of a Multicenter Prospective Study at 1 Year Comparison of a low-glycemic index vs standard diabetic diet. Cognitive function predicts weight loss after bariatric surgery. Prevalence of Sleep Apnea in Morbidly Obese Patients who Presented for Weight Loss Surgery Evaluation: More Evidence for Routine Screening for Obstructive Sleep Apnea before Weight Loss Surgery Body weight, insulin resistance, and serum adipokine levels 2 years after 2 types of bariatric surgery. Weight Loss in Severely Obese Subjects Prevents the Progression of Impaired Glucose Tolerance to Type II Diabetes: A longitudinal interventional study Inhibition of C-Reactive Protein in Morbidly Obese Patients After Laparoscopic Sleeve Gastrectomy
OBJECTIVE Severe obesity ( body mass index [ BMI ] ≥40 kg/m(2 ) ) is a serious public health concern . Although bariatric surgery is an efficacious treatment approach , it is limited in reach ; thus , nonsurgical treatment alternatives are needed . We examined the 4-year effects of an intensive lifestyle intervention  on body weight and cardiovascular disease risk factors among severely obese , compared with overweight ( 25 ≤ BMI < 30 ) , class I ( 30 ≤ BMI < 35 ) , and class II obese ( 35 ≤ BMI < 40 ) participants . METHODS There were 5145 individuals with type 2 diabetes ( 45 - 76 years , BMI ≥25 kg/m(2 ) ) r and omized to an intensive lifestyle intervention or diabetes support and education .  The lifestyle intervention group received a behavioral weight loss program that included group and individual meetings , a ≥10 % weight loss goal , calorie restriction , and increased physical activity . Diabetes support and education received a less intense educational intervention . Four-year changes in body weight and cardiovascular disease risk factors were assessed . RESULTS Across BMI categories , 4-year changes in body weight were significantly greater in lifestyle participants compared with diabetes support and education ( Ps < .05 ) . At year 4 , severely obese lifestyle participants lost 4.9%±8.5 % , which was similar to class I ( 4.8%±7.2 % ) and class II obese participants ( 4.4%±7.6 % ) , and significantly greater than overweight participants ( 3.4%±7.0 % ; P < .05 ) . Four-year changes in low-density-lipoprotein cholesterol , triglycerides , diastolic blood pressure , HbA(1c ) , and blood glucose were similar across BMI categories in lifestyle participants ; however , the severely obese had less favorable improvements in high-density-lipoprotein cholesterol ( 3.1±0.4 mg/dL ) and systolic blood pressure ( -1.4±0.7 mm Hg ) compared with the less obese ( Ps < .05 ) . CONCLUSION Lifestyle interventions can result in important long-term weight losses and improvements in cardiovascular disease risk factors among a significant proportion of severely obese individuals The profound effects of bariatric surgery on glycemic control are well established in many studies , including several r and omized trials that compared surgery versus intensive medical and lifestyle treatment of type 2 diabetes mellitus ( T2DM ) ( 17 ) . Remission of T2DM is common after bariatric surgery , and Roux-en-Y gastric bypass ( RYGB ) outperforms sleeve gastrectomy ( SG ) in most reports ( 4 , 8 , 9 ) . More important than improvements in glycemic control is whether these glycemic changes reduce the incidence of major complications , such as microvascular events . In the United States , T2DM is the primary cause of nephropathy , end-stage renal disease , adult blindness , and neuropathy , which together lead to significant downstream costs and decreased quality of life ( 1012 ) . Thus , a major goal of diabetes treatment is to mitigate the risk for these long-term sequelae ( 13 ) . We have previously shown that in patients with T2DM who have bariatric surgery  , risk for incident microvascular disease is reduced for every year of remission from T2DMeven if patients eventually relapse back to T2DM ( indicating a legacy effect ) ( 14 ) . However , a detailed 2016 review of long-term microvascular outcomes of diabetes concluded that data were inadequate to support a superior effect of bariatric surgery compared with medical therapy ( 15 ) . Two recently published studies help inform this question ( 4 , 16 ) . The STAMPEDE ( Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently ) trial ( 4 ) r and omly assigned 150 patients with obesity and T2DM to have RYGB , SG , or an intensive medical and lifestyle intervention . After 5 years , urinary albumincreatinine ratios had decreased in the SG group only . Retinopathy did not change in any group , and neuropathy was not examined . STAMPEDE was limited by a relatively small sample size , which made it underpowered for rare outcomes . The prospect i ve SOS ( Swedish Obesity Subjects ) matched cohort study ( 16 ) followed 2010 patients who had bariatric surgery ( 13 % RYGB , 19 % gastric b and ing , and 68 % vertical-b and ed gastroplasty ) and 2037 matched patients who received usual care .  The incidence of microvascular disease after 15 years of follow-up was significantly lower in the surgery group than the control group ( hazard ratio [ HR ] , 0.56 [ 95 % CI , 0.48 to 0.66 ] ) , including among subgroups with prediabetes ( HR , 0.18 [ CI , 0.11 to 0.30 ] ) , established diabetes ( HR , 0.54 [ CI , 0.40 to 0.72 ] ) , and normoglycemia ( HR , 0.63 [ CI , 0.48 to 0.81 ] ) at baseline . The SOS study was limited by the small number of RYGB procedures and lack of SG procedures , which are now the 2 most common bariatric procedures worldwide ( 17 ) . To address these gaps in the literature , we did a matched cohort study to determine whether bariatric surgery was associated with lower incidence of microvascular disease than usual care for severe obesity and T2DM . We hypothesized that patients having  bariatric surgery would have lower risk for any incident microvascular disease ( composite of the first occurrence of retinopathy , neuropathy , or nephropathy ) . We further hypothesized that patients having bariatric surgery would have lower risk for incident retinopathy , nephropathy , and neuropathy than nonsurgical patients . Methods Setting s We did a retrospective observational cohort study of adults with T2DM who had bariatric surgery between 2005 and 2011 while enrolled in 1 of 4 integrated health care systems from the Health Care Systems Research Network : Kaiser Permanente ( KP ) Washington in Washington state , HealthPartners in Minnesota , KP Northern California , and KP Southern California . All study procedures were review ed and approved by the institutional review board at each site , and we were permitted to do the research without explicit consent from participants . Data Sources At each study site , staff used st and ardized electronic medical records , insurance cl aims , and other data systems ( 18 ) to extract enrollee data , including enrollment and insurance coverage ; demographics ; blood pressure ; height ; weight ; laboratory values ; medications dispensed ; deaths ; outpatient , inpatient , and emergency department use ; and inpatient and outpatient diagnosis and procedure codes . Surgical Participants The bariatric population included adults ( aged 19 to 79 years ) with severe obesity ( body mass index [ BMI ] 35 kg/m2 ) and T2DM who had a primary ( first observed ) bariatric surgical procedure between 1 January 2005 and 31 December 2011 . Following an approach adopted in prior studies ( 14 , 19 , 20 ) , we used a combination of bariatric registries ; review of medical records ; codes from the International Classification of Diseases , Ninth Revision ( ICD-9 ) ( 43.89 , 44.31 , 44.38 , 44.39 , 44.68 , 44.69 , and 44.95 ) ; and Current Procedural Terminology codes ( 43633 , 43644 , 43645 , 43659 , 43770 , 43775 , 43842 , 43843 , 43844 , 43845 , 43846 , and 43847 ) to identify bariatric procedures .  Patients were classified as having T2DM if they had a hemoglobin A1c ( HbA1c ) level of at least 6.5 % or fasting plasma glucose level of at least 6.99 mmol/L ( 126 mg/dL ) at the most recent measurement within 2 years before surgery , or a current prescription for any diabetes medication . After selecting the population , we applied the following exclusion criteria based on information in the 2 years before surgery : less than 1 full year of continuous enrollment ; history of gastrointestinal surgery for cancer ; pregnancy in the year before surgery ; gestational diabetes as the sole diabetes diagnosis ; metformin as the sole indicator of possible T2DM ( that is , no other T2DM medications , laboratory values , or diagnoses ) ; preexisting neuropathy , retinopathy , or nephropathy ( defined in Outcome and Censoring Definitions ) ; and maximum preoperative BMI less than 35 kg/m2 . This left 4972 patients . We further excluded 850 patients who were missing values for BMI , HbA1c level , or serum creatinine concentration in the 2 years before surgery . Surgical patients who were missing these values differed from those who had complete data ( Appendix Table 1 ) . Specifically , they were more likely to be non-Hispanic white , to be from the HealthPartners site , to have had their procedure in the first year of our study ( 2005 ) , and to have had a shorter observed duration of T2DM at the time of surgery . Of the remaining 4122 patients , 4024 could be matched to at least 1 nonsurgical patient ( Figure 1 ) . Figure 1 . Flow diagram for identification of eligible patients with T2DM and no history of microvascular disease who had bariatric surgery .  BMI = body mass index ; EHR= electronic health record ; HbA1c= hemoglobin A1c ; T2DM= type 2 diabetes mellitus . * Adults aged 2079 y who had a primary ( first observed ) bariatric surgical procedure between 1 January 2005 and 31 December 2011 .  Bariatric procedures were identified using a combination of bariatric registries ; review of medical records ; International Classification of Diseases , Ninth Revision , codes ( 43.89 , 44.31 , 44.38 , 44.39 , 44.68 , 44.69 , and 44.95 ) ; and Current Procedural Terminology codes ( 43633 , 43644 , 43645 , 43659 , 43770 , 43775 , 43842 , 43843 , 43844 , 43845 , 43846 , and 43847 ) . We excluded patients with any of the following : < 1 y of continuous enrollment ; history of gastrointestinal surgery for cancer ; pregnancy in the year before surgery ; gestational diabetes as the sole diabetes diagnosis ; preexisting neuropathy , nephropathy , or retinopathy ; metformin as the sole indicator of possible T2DM ( no other T2DM medications , laboratory values , or diagnoses ) ; or maximum BMI < 35 kg/m2 . Patients may have > 1 type of missing data ( BMI , creatinine concentration , or HbA1c level ) or have no follow-up time after surgery . 98 surgical patients could not be matched to a nonsurgical patient on site , age , BMI , insulin use , HbA1c level , and sex . Appendix Table 1 . Comparison of Characteristics of Surgical Patients Who Were Missing Values for BMI , HbA1c , or Serum Creatinine at Baseline Versus Those Who Had Complete Information on These Values at Baseline Matched Nonsurgical Participants For each surgical patient , we identified up to 3 matched nonsurgical control participants via a 2-step process . First , among all patients with diabetes and at least 1 BMI measurement of 35 kg/m2 or greater who did not have bariatric surgery during the study ( n= 320345 ) , we identified a pool of potential control participants who were enrolled at the time of the surgery ; satisfied the study inclusion criteria ; and matched the surgical patient on the basis of study site , sex , age ( 10 years ) , BMI ( 5 kg/m2 ) , HbA1c level ( 1.5 percentage points ) , and insulin use . Second , for each control participant in the pool , we calculated Mahalanobis distance from the surgical patient on the basis of age , BMI , HbA1c level , diabetes duration , and total days of health care use in the 7 to 24 months before the date of surgery ( 21 ) . Finally , up to 3 control participants were selected on the basis of the shortest Mahalanobis distance . Throughout , nonsurgical patients could be used as a control for only 1 surgical patient ( matching without replacement ) . The Appendix gives additional details on the process we used to establish the matched cohort . Outcome and Censoring Definitions The primary outcome measure was time to incident microvascular disease ( composite of the first occurrence of retinopathy , neuropathy , or nephropathy ) . Retinopathy was defined by the first appearance of either ICD-9 code 362.0x ( diabetic retinopathy ) or both a retinal surgical procedure code or other retinopathic code ( Appendix Table 2 ) and ICD-9 code 250.5x ( diabetes with ophthalmic manifestations ) . Neuropathy was identified on the basis of the first occurrence of ICD-9 code 250.6 ( diabetes with neurologic manifestations ) or 357.2 ( polyneuropathy in diabetes ) . Finally , nephropathy was defined by at least 2 measures of estimated glomerular filtration rate less than 60 mL/min/1.73 m2 separated by at least 90 days without any intervening values of 60 mL/min/1.73 m2 or greater . We approximated BACKGROUND Weight loss protects against type 2 diabetes but is hard to maintain with behavioral modification alone . In an analysis of data from a nonr and omized , prospect i ve , controlled study , we examined the effects of bariatric surgery on the prevention of type 2 diabetes . METHODS In this analysis , we included 1658 patients who underwent bariatric surgery and 1771 obese matched controls ( with matching performed on a group , rather than individual , level ) . None of the participants had diabetes at baseline . Patients in the bariatric-surgery cohort underwent b and ing  ( 19 % ) , vertical b and ed gastroplasty ( 69 % ) , or gastric bypass ( 12 % ) ; nonr and omized , matched , prospect i ve controls received usual care . Participants were 37 to 60 years of age , and the body-mass index ( BMI ; the weight in kilograms divided by the square of the height in meters ) was 34 or more in men and 38 or more in women . This analysis focused on the rate of incident type 2 diabetes , which was a prespecified secondary end point in the main study . At the time of this analysis ( January 1 , 2012 ) , participants had been followed for up to 15 years . Despite matching , some baseline characteristics differed significantly between the groups ; the baseline body weight was higher and risk factors were more pronounced in the bariatric-surgery group than in the control group . At 15 years , 36.2 % of the original participants had dropped out of the study , and 30.9 % had not yet reached the time for their 15-year follow-up examination . RESULTS During the follow-up period , type 2 diabetes developed in 392 participants in the control group and in 110 in the bariatric-surgery group , corresponding to incidence rates of 28.4 cases per 1000 person-years and 6.8 cases per 1000 person-years , respectively ( adjusted hazard ratio with bariatric surgery , 0.17 ; 95 % confidence interval , 0.13 to 0.21 ; P<0.001 ) . The effect of bariatric surgery was influenced by the presence or absence of impaired fasting glucose ( P=0.002 for the interaction ) but not by BMI ( P=0.54 ) . Sensitivity analyses , including end-point imputations , did not change the overall conclusions . The postoperative mortality was 0.2 % , and 2.8 % of patients who underwent bariatric surgery required reoperation within 90 days owing to complications . CONCLUSIONS Bariatric surgery appears to be markedly more efficient than usual care in the prevention of  type 2 diabetes in obese persons . ( Funded by the Swedish Research Council and others ; Clinical Trials.gov number , NCT01479452 . ) Background Many mildly to moderately obese individuals with a body mass index ( BMI ) lower than 35 kg/m2 have serious diseases related to their obesity . Nonsurgical therapy is ineffective in the long term , yet surgery has never been made widely available to this population . Methods Between 2002 and 2007 , 53 patients with a BMI lower than 35 kg/m2 underwent laparoscopic adjustable gastric b and ing at our institution . Data on all these patients were collected prospect ively and entered into an institutional review board – approved electronic registry . The study parameters included preoperative age , gender , BMI , presence of comorbidities , percentage of excess weight loss ( % EWL ) , and resolution of comorbidities . Results The mean preoperative age of the patients was 46.9 years ( range , 16–68 years ) , and the mean preoperative BMI was 33.1 kg/m2 ( range , 28.2–35.0 kg/m2 ) . Of the 53 patients , 49 ( 92 % ) had at least one obesity-related comorbidity . The mean BMI decreased to 28.1 ± 2.4 kg/m2 , 25.8 ± 2.9 kg/m2 , and 25.8 ± 3.1 kg/m2 and mean % EWL was 48.3 ± 17.6 , 69.9 ± 28.0 , and 69.7 ± 31.7 at 0.5 , 1 , and 2 years , respectively . Substantial improvement occurred for the following comorbidities evaluated : hypertension , depression , diabetes , asthma , hypertriglyceridemia , obstructive sleep apnea , hypercholesterolemia , and osteoarthritis . There was one slip , two cases of b and obstruction ( from food ) , two cases of esophagitis , and two port leaks , but no mortality . Conclusion The authors are very encouraged by this series of low- BMI patients who underwent laparoscopic adjustable gastric b and ing .  Their weight loss has been excellent , and their complications have been acceptable . Their comorbidities have partially or wholly resolved . With further study , it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m2 Type 2 diabetes ( T2D ) remission after bariatric procedures has been highlighted in many retrospective and some recent prospect i ve studies . However , in the most recent prospect i ve study , more than 50 % of patients did not reach T2D remission at 1 year . Our aim was to identify baseline positive predictors for T2D remission at 1 year 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 b and ing ( LAGB ) , 26 Roux-en-Y gastric bypass ( RYGB ) and 9 sleeve gastrectomy ( SG ) .  We compared anthropometric and metabolic features during 1 year 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 1 year , with no significant difference according to the surgical procedure . A 1-year body mass index ( BMI ) < 35 kg m−2 was predictive of T2DM remission whatever the procedure . The preoperative predictive factors of diabetes remission were baseline BMI ≤50 kg m−2 , duration of type 2 diabetes ≤4 years , glycated haemoglobin ≤7.1 % , fasting glucose < 1.14 g/l and absence of insulin therapy . A short duration of diabetes and good preoperative glycaemic control increase the rate of T2DM remission 1 year after surgery . Preoperative metabolic data could be of greater importance than the choice of bariatric procedure BACKGROUND Patients who are categorized with class I obesity have a body mass index ( BMI ) of 30 - 34.99 kg/m(2 ) . This population of patients has a predisposition to diabetes , hypertension , and dyslipidemia . The aim of the present study was to investigate the improvements of these co-morbidities in a class I obese population that had undergone a bariatric procedure . METHODS After internal review board approval and with adherence to the Health Insurance Portability and Accountability Act guidelines , a retrospective review was performed of a prospect ively maintained data base of 42 class I obese patients who underwent a bariatric procedure at our institution during a 10-year period , from February 2000 to May 2010 . The fasting glucose level , glycosylated hemoglobin level , lipid profile , initial weight , and BMI were measured in the preoperative and postoperative periods . RESULTS Our patient population consisted of 30 women and 12 men , with a preoperative mean BMI of 33.9 kg/m(2 ) .  Laparoscopic sleeve gastrectomy was performed in 24 patients ( 57 % ) , laparoscopic Roux-en-Y gastric bypass in 8 ( 19 % ) , and laparoscopic adjustable gastric b and ing in 10 ( 24 % ) . Of these 42 patients , 25 ( 60 % ) had type 2 diabetes , 1 patient was glucose intolerant , 27 ( 64 % ) had arterial hypertension , 25 ( 60 % ) had dyslipidemia , 17 ( 40 % ) had sleep apnea , and 8 ( 19 % ) had osteoarthritis . The postoperative findings included a mean BMI of 26.5 kg/m(2 ) and a mean weight loss of 41.4 lb . Of the 25 diabetic patients , 5 ( 20 % ) gained remission and 12 ( 48 % ) improvement of their diabetic status . The single patient with glucose intolerance showed improvement . Of the 27 patients with arterial hypertension , 9 ( 33 % ) showed remission and 13 ( 52 % ) improvement . Dyslipidemia resolved in 5 patients ( 20 % ) and improved in 13 ( 52 % ) . Obstructive sleep apnea resolved in 10 ( 59 % ) and improvement was seen in 1 patient ( 6 % ) . Finally , osteoarthritis resolved in 1 patient ( 12 % ) and improved in 5 ( 63 % ) . CONCLUSION Bariatric surgery can significantly improve or resolve co-morbid metabolic conditions in patients with class I obesity Background Obesity is an increasing disease worldwide . Bariatric surgery is the only effective therapy to induce sufficient long-term weight loss for morbidly obese patients .  Laparoscopic Roux-en-Y Gastric Bypass ( LRYGB ) is the gold st and ard surgical technique . Laparoscopic Sleeve Gastrectomy ( LSG ) is a new promising bariatric procedure which has the advantage of maintaining an intact gastrointestinal tract . The aim of this study is to evaluate the efficiency of both techniques . Our hypothesis is that LSG has a similar percentage excess BMI loss ( % E BMI L ) after 5 years compared to LRYGB . Methods / Design The Sleeve Bypass Trial is a r and omized multicentre clinical trial : patients eligible for bariatric surgery are r and omized to either LSG or LRYGB . Patients with a body mass index ( BMI ) ≥ 40 kg/m2 or BMI 35 kg/m2 with obesity related comorbidity ( T2 DM , sleep apnoea , hypertension ) are eligible for r and omization . At r and omization patients are stratified for centre , sex , T2 DM and BMI ≥ 50 kg/m2 . A total number of 620 patients will be enrolled and equally ( 1:1 ) r and omized to both treatment arms . Only surgeons experienced in both operation techniques will participate in the Sleeve Bypass trial . The primary endpoint is the 5-year weight loss ( % E BMI L ) of LSG and LRYGB . Secondary endpoints are resolution of obesity related comorbidity , complications , revision bariatric surgery and quality of life ( QOL ) defined in various question naires . Discussion Long-term % E BMI L between the two treatment strategies used to be in favour of LRYGB , but more recent results throughout the world show similar % E BMI L in both techniques . If weight loss is comparable , obesity-related comorbidity and QOL after bariatric procedures should be taken into account when deciding on which surgical technique is to be preferred for certain subgroups in the future . Trial registration Dutch Trial Register : NTR 4741 Background Few studies have looked at non-surgical alternatives for morbid obese patients . This study aims to compare 1-year weight loss and changes in risk factors and comorbidities after bariatric surgery and three conservative treatments . Methods Patients with morbid obesity ( BMI > 40 or BMI > 35 kg/m2 plus comorbidities ) on waiting list for bariatric surgery  , were non-r and omly allocated to ( A ) bariatric surgery or to one of three conservative treatments ; ( B ) residential intermittent program ; ( C ) commercial weight loss camp and ( D ) hospital outpatient program . Body weight , risk factors and comorbidities were assessed at baseline and 1 year . Results Of 206 participants , 179 completed the study . All treatments result ed in significant weight loss , but bariatric surgery ( 40 ± 14 kg , 31 ± 9 % ) led to the largest weight loss ( P < 0.0001 ) . There were no differences in weight loss between B and C ( 22 ± 13 kg , 15 ± 8 % vs. 18 ± 12 kg , 13 ± 8 % ) , but these result ed in larger weight loss compared with D ( 7 ± 10 kg , 5 ± 8 % ) . There were no differences in changes in total or LDL cholesterol , triacylglycerols or glucose between groups ; however , the increase in HDL cholesterol was significantly larger in groups A and C. There were no differences in comorbidities resolution between groups A and B , C and D combined ( except hypertension , which was better in group A ) . Conclusion In conclusion , although bariatric surgery leads to a greater weight loss at 1 year compared with conservative treatment , in patients with morbid obesity , clinical significant weight loss and similar improvements in risk factors and comorbidities resolution can also be achieved with lifestyle interventions BACKGROUND Roux-en-Y gastric bypass and biliopancreatic diversion can markedly ameliorate diabetes in morbidly obese patients , often result ing in disease remission . Prospect i ve , r and omized trials comparing these procedures with medical therapy for the treatment of diabetes are needed . METHODS In this single-center , nonblinded , r and omized , controlled trial , 60 patients between the ages of 30 and 60 years with a body-mass index ( BMI , the weight in kilograms divided by the square of the height in meters ) of 35 or more , a history of at least 5 years of diabetes , and a glycated hemoglobin level of 7.0 % or more were r and omly assigned to receive conventional medical therapy or undergo either gastric bypass or biliopancreatic diversion . The primary end point was the rate of diabetes remission at 2 years ( defined as a fasting glucose level of < 100 mg per deciliter [ 5.6 mmol per liter ] and a glycated hemoglobin level of < 6.5 % in the absence of pharmacologic therapy ) . RESULTS At 2 years , diabetes remission had occurred in no patients in the medical-therapy group versus 75 % in the gastric-bypass group and 95 % in the biliopancreatic-diversion group ( P<0.001 for both comparisons ) . Age , sex , baseline BMI , duration of diabetes , and weight changes were not significant predictors of diabetes remission at 2 years or of improvement in glycemia at 1 and 3 months . At 2 years , the average baseline glycated hemoglobin level ( 8.65±1.45 % ) had decreased in all groups , but patients in the two surgical groups had the greatest degree of improvement ( average glycated hemoglobin levels , 7.69±0.57 % in the medical-therapy group , 6.35±1.42 % in the gastric-bypass group , and 4.95±0.49 % in the biliopancreatic-diversion group ) . CONCLUSIONS In severely obese patients with type 2 diabetes , bariatric surgery result ed in better glucose control  than did medical therapy . Preoperative BMI and weight loss did not predict the improvement in hyperglycemia after these procedures . ( Funded by Catholic University of Rome ; Clinical Trials.gov number , NCT00888836 . ) Background Laparoscopic gastric bypass result ed in significant weight loss and resolution of type 2 diabetes mellitus ( T2DM ) .  The current indication for bariatric surgery is mainly applied for patients with body mass index ( BMI ) > 35 kg/m2 with comorbidity status . However , little is known concerning T2DM patients with BMI < 35 kg/m2 . Recent studies have suggested that T2DM patients with BMI < 35 kg/m2 might benefit from gastric bypass surgery . Methods From Jan 2002 to Dec 2006 , 820 patients who underwent laparoscopic mini-gastric bypass were enrolled in a surgically supervised weight loss program .  We identified 201 ( 24.5 % ) patients who had impaired fasting glucose or T2DM . All the clinical data were prospect ively collected and stored . Patients with BMI < 35 kg/m2 were compared with those of BMI > 35 kg/m2 . Successful treatment of T2DM was defined by HbA1C < 7.0 % , LDL < 100 mg/dl , and triglyceride < 150 mg/dl . Results Among the 201 patients , 44 ( 21.9 % ) had BMI < 35 kg/m2 , and 114 ( 56.7 % ) had BMI between 35 and 45 , 43 ( 21.4 % ) had BMI > 45 kg/m2 . Patients with BMI < 35 kg/m2 are significantly older , female predominant , had lower liver enzyme and C-peptide levels than those with BMI > 35 kg/m2 . The mean total weight loss for the population was 32.1 , 33.4 , 31.9 , and 32.8 % ( at 1 , 2 , 3 , 5 years after surgery ) , and percentage to change in BMI was 31.9 , 34.2 , 32.2 , and 29.5 % at 1 , 2 , 3 , and 5 years . One year after surgery , fasting plasma glucose returned to normal in 89.5 % of BMI < 35 kg/m2 T2DM and 98.5 % of BMI > 35 kg/m2 patients ( p = 0.087 ) . The treatment goal of T2DM ( HbA1C < 7.0 % , LDL < 150 mg/dl and triglyceride < 150 mg/dl ) was met in 76.5 % of BMI < 35 kg/m2 and 92.4 % of BMI > 350 kg/m2 ( p = 0.059 ) . Conclusion Laparoscopic gastric bypass result ed in significant and sustained weight loss with successful treatment of T2DM up to 87.1 % . Despite a slightly lower response rate of T2DM treatment , patients with BMI < 35 still had an acceptable DM resolution , and this treatment option can be offered to this group of patients Objective : To compare bariatric surgery versus intensive medical weight management ( MWM ) in patients with type 2 diabetes mellitus ( T2DM ) who do not meet current National Institutes of Health criteria for bariatric surgery and to assess whether the soluble form of receptor for advanced glycation end products ( sRAGE ) is a biomarker to identify patients most likely to benefit from surgery . Background : There are few studies comparing surgery to MWM for patients with T2DM and BMI less than 35 . Methods : Fifty-seven patients with T2DM and BMI 30 to 35 , who otherwise met the criteria for bariatric surgery were r and omized to MWM versus surgery ( bypass , sleeve or b and , based on patient preference ) . The primary outcomes assessed at 6 months were change in homeostatic model of insulin resistance ( HOMA-IR ) and diabetes remission . Secondary outcomes included changes in HbA1c , weight , and sRAGE . Results : The surgery group had improved HOMA-IR ( −4.6 vs + 1.6 ; P = 0.0004 ) and higher diabetes remission ( 65 % vs 0 % , P < 0.0001 ) than the MWM group at 6 months . Compared to MWM , the surgery group had lower HbA1c ( 6.2 vs 7.8 , P = 0.002 ) , lower fasting glucose ( 99.5 vs 157 ; P = 0.0068 ) , and fewer T2DM medication requirements ( 20 % vs 88 % ; P < 0.0001 ) at 6 months . The surgery group lost more weight ( 7 . vs 1.0 BMI decrease , P < 0.0001 ) . Higher baseline sRAGE was associated with better weight loss outcomes ( r = −0.641 ; P = 0.046 ) . There were no mortalities . Conclusions : Surgery was very effective short-term in patients with T2DM and BMI 30 to 35 . Baseline sRAGE may predict patients most likely to benefit from surgery . These findings need to be confirmed with larger studies . Clinical Trials.gov ID : BACKGROUND Many mild-to-moderately obese individuals ( body mass index [ BMI ] 30 - 35 kg/m(2 ) ) have serious diseases related to their obesity . Nonoperative therapy is ineffective in the long term , yet surgery has never been made widely available to this population . METHODS Between 1996 and 2004 , 93 patients with a BMI of 30 - 35 kg/m(2 ) underwent laparoscopic adjustable gastric b and ing with the LAP-B AND . All patients were referred by their primary physician , entered into a comprehensive bariatric surgery program at one Australian center , and operated on by one surgeon . Data on all patients were collected prospect ively and entered into an electronic registry . The study parameters included preoperative age , gender , BMI , presence of co-morbidities , percentage of excess weight loss , and resolution of co-morbidities . RESULTS The mean age was 44.6 years ( range 16 - 76 ) , mean weight was 98 kg , and the mean BMI was 32.7 kg/m(2 ) ( range 30 - 34 ) . Of the 93 patients , 42 ( 45 % ) had co-morbidities , including asthma , diabetes , hypertension , and sleep apnea .  The proportion of patients in follow-up was 79 % , 85 % , and 89 % at 1 , 2 , and 3 years , respectively . The mean weight was reduced to 71 kg at 1 year , 72 kg at 2 years , and 72 kg at 3 years . The mean BMI was reduced to 27.2 + /- 2.2 , 27.3 + /- 3.1 , and 27.6 + /- 3.7 kg/m(2 ) , respectively , and the mean percentage of excess weight loss was 57.9 % + /- 24.5 % , 57.6 + /- 29.3 % , and 53.8 % + /- 32.8 % at 1 , 2 , and 3 years , respectively . At 3 years , the BMI was 18 - 24 kg/m(2 ) in 34 % , 25 - 29 kg/m(2 ) in 51 % , and 30 - 35 kg/m(2 ) in 10 % . At 3 years , the percentage of excess weight loss was < 25 % in 10 % , 25 - 50 % in 24 % , 50 - 75 % in 51 % , and > 75 % in 10 % . The co-morbidities improved or completely resolved in most patients . No mortality occurred . CONCLUSION We are very encouraged by this series of low BMI patients treated with the LAP-B AND . Their weight loss has been good , the complications have been minimal , and the co-morbidities have partially or wholly resolved . With additional study , it is reasonable to expect the weight guidelines for bariatric surgery to be altered to include patients with a BMI of 30 - 35 kg/m(2 ) BACKGROUND We investigated the biochemical and inflammatory parameters as well as biomarkers of oxidative stress in morbidly obese patients before and after bariatric surgery and clinical treatment .  METHODS This study was conducted using 60 individuals ( 10 men and 50 women ) distributed into 3 groups :  the control group , 20 non-diabetic obese patients given clinical treatment , the bariatric group , 20 non-diabetic obese patients given a Roux-en-Y bypass gastroplasty , and the bariatric diabetic group , 20 diabetic obese patients given a Roux-en-Y bypass gastroplasty .  Measurements were made before and 1 , 3 , 6 , and 12months after surgery and clinical treatment . RESULTS We showed a significant decrease in body weight , body mass index ( BMI ) and waist circumference , accompanied by a decrease in the lipid profile and glucose and glycated hemoglobin concentrations in the groups that received bariatric surgery . The concentrations of lipid peroxidation , carbonyl protein and NPSH , as well as superoxide dismutase ( SOD ) and catalase ( CAT ) activity , significantly decreased in both groups after surgery . The concentrations of inteleukin-6 , inteleukin-1 , TNF-α and resistin were also significantly lower , while adiponectin concentrations significantly increased 12months after bariatric surgery . No significant alterations were observed in the biochemical , inflammatory or oxidative parameters of the control group . CONCLUSIONS Our findings demonstrate a decrease in body mass and a subsequent improvement in biochemical , metabolic and anthropometric parameters in patients given bariatric surgery .  This may contribute to the reduction of oxidative damage in these patients and consequently a reduction in the risk of the development and progression of multiple co-morbidities associated with obesity Gastric bypass ( GBP ) has proved its efficacy 30 years ago in the management of  diabetes mellitus ( T2DM ) for severe obese patients . More recently , interesting results have been published after sleeve gastrectomy ( SG ) in the same indication . Between 2005 and 2008 , three bariatric centers have prospect ively collected the data of T2DM patients treated by laparoscopic gastric bypass ( LGBP ) or laparoscopic sleeve gastrectomy ( LSG ) .  Effects on hemoglobin A1c ( HbA1c ) , pharmacological treatment and excess weight loss after 1 year of surgery have been analyzed . All patients ( 35 LGBP and 33 LSG ) were treated with oral anti-diabetics ( OAD ) or insulin before surgery ( 32 OAD and three insulin in LGBP group and 27 OAD and six insulin in LSG group ) . The average body mass index ( BMI ) in the LGBP group was 47.9 and 50.6 kg/m² in the LSG group . At 1 year after surgery , the average HbA1c lost was 2,537 in the GBP group and 2,175 in the SG group . T2DM had resolved ( withdrawal of pharmacological treatment ) in 60 % of the LGBP group and 75.8 % of the LSG group . Reduced use of pharmacological therapy was noted in 31.42 % of the LGBP group and 15.15 % of the LSG group . Percentage excess weight loss and BMI lost were 56.35 % and 29.75 % in the LGBP group and 60.11 % and 29.80 % in the LSG group , respectively . During short-term follow-up , the impact on regulation of HbA1c blood level of LGBP or LSG is important . At 1 year after surgery , LSG seems to be as effective as LGBP for the management of T2DM in severely obese patients AIM There is insufficient evidence for the efficacy of a low-glycemic index ( GI ) diet in the management of diabetes . The goal of this study was to measure the effect of a low GI versus a st and ard diabetic diet in adults with diabetes type 2 . METHODS This was an open label , r and omized , crossover study . Twenty persons with type 2 diabetes were r and omized to two groups . Each group followed a st and ard diabetic diet or a low glycemic index diet for 3 months . The effectiveness of the two diets was evaluated using a hyperinsulinemic euglycemic clamp with endogenous glucose production measurement , indirect calorimetry and bioimpedance analysis . Outcome measures were body mass , BMI , body fat , glycosylated hemoglobin , fasting glucose , lipid profile , insulin sensitivity and hepatic glucose production . RESULTS Body mass after 3 months following the diabetic diet was 93 kg ( 83 - 104 ) vs. low glycemic index diet 92 kg ( 85 - 104 ) P<0.05 , BMI 31.3 kg/m(2 ) ( 27.5 - 35.9 ) vs. 30.7 kg/m(2 ) ( 27 - 35.3 ) P<0.05 , body fat 28 % ( 25.5 - 43 ) vs. 27 % ( 23 - 43 ) P<0.05 ( median and interquartile range ) . There was no statistically significant difference between diets for glycosylated hemoglobin , fasting glucose , lipid profile , insulin sensitivity or hepatic glucose production . CONCLUSIONS The results are comparable with other studies showing a modest effect of a low GI diet in the management of diabetes . We found a modestly greater weight loss , body fat and BMI reduction on the low GI diet BACKGROUND Clinical ly significant cognitive impairment is found in a subset of patients undergoing bariatric surgery .  These difficulties could contribute to a reduced adherence to postoperative lifestyle changes and decreased weight loss . The present study is the first to prospect ively examine the independent contribution of cognitive function to weight loss after  bariatric surgery .  Executive function/attention and verbal memory at baseline were expected to negatively predict the percentage of excess weight loss ( % EWL ) and body mass index ( BMI ) at follow-up . Three sites of the Longitudinal Assessment of Bariatric Surgery parent project were used : Columbia ( New York , NY ) , Cornell ( Princeton , NJ ) , and the Neuropsychiatric Research Institute ( Fargo , ND ) . METHODS A total of 84 individuals enrolled in the Longitudinal Assessment of Bariatric Surgery project undergoing bariatric surgery  completed a  cognitive evaluation at baseline . The BMI and % EWL were calculated at the 12-week and 12-month postoperative follow-up visits . RESULTS Clinical impairment in task performance was most prominent in tasks associated with verbal recall and recognition ( 14.3 - 15.5 % of the sample ) and perseverative errors ( 15.5 % ) . After accounting for demographic and medical variables , the baseline test results of attention/executive function and memory predicted the BMI and % EWL at 12 months but not at 12 weeks . CONCLUSIONS These results have demonstrated that baseline cognition predicts for greater % EWL and lower BMI 12 months after bariatric surgery . Additional work is needed to clarify the degree to which cognition contributes to adherence and the potential mediation of cognition on the relationship between adherence and weight loss in this group The incidence of obstructive sleep apnea has been underestimated in morbidly obese patients who present for evaluation for weight loss surgery . This retrospective study shows that the incidence of obstructive sleep apnea in this patient population is greater than 70 per cent and increases in incidence as the body mass index increases . Obstructive sleep apnea ( OSA ) is a common comorbidity in obese patients who present for evaluation for gastric bypass surgery . The incidence of sleep apnea in obese patients has been reported to be as high as 40 per cent . A retrospective review of our prospect ively collected data base was performed . All patients being evaluated for weight loss surgery for obesity were screened preoperatively for OSA using a sleep study . The  overall incidence of sleep apnea in our patients was 78 per cent ( 227 of 290 ) . All 227 were diagnosed by formal sleep study . There were 63 ( 22 % ) males and 227 ( 78 % ) females . The mean age was 43 years ( range , 17–75 years ) . The mean body mass index ( BMI ) was 52 kg/m2 ( range , 31–94 kg/m2 ) . The prevalence of OSA in the severely obese group ( BMI 35–39.9 kg/m2 ) was 71 per cent . For the morbidly obese group ( BMI 40–40.9 kg/m2 ) , the prevalence was 74 per cent and for the superobese group ( BMI 50–59.9 kg/m2 ) 77 per cent . Those with a BMI 60 kg/m2 or greater , the prevalence of OSA rose to 95 per cent . The incidence of sleep apnea in patients presenting for weight loss surgery was greater than 70 per cent in our study . Patients presenting for weight loss surgery should undergo a formal sleep study to diagnose OSA before bariatric surgery OBJECTIVE Bariatric surgery reverses obesity-related comorbidities , including type 2 diabetes mellitus . Several studies have already described differences in anthropometrics and body composition in patients undergoing Roux-en-Y gastric bypass compared with laparoscopic adjustable gastric b and ing  , but the role of adipokines in the outcomes after the different types of surgery is not known . Differences in weight loss and reversal of insulin resistance exist between the 2 groups and correlate with changes in adipokines . METHODS Fifteen severely obese women ( mean body mass index [ BMI ] : 46.7 kg/m(2 ) ) underwent 2 types of laparoscopic weight loss surgery ( Roux-en-Y gastric bypass=10 , adjustable gastric b and ing=5 ) .  Weight , waist and hip circumference , body composition , plasma metabolic markers , and lipids were measured at set intervals during a 24-month period after surgery . RESULTS At 24 months , patients who underwent Roux-en-Y were overweight ( BMI 29.7 kg/m(2 ) ) , whereas patients who underwent gastric b and ing remained obese ( BMI 36.3 kg/m(2 ) ) . Patients who underwent Roux-en-Y lost significantly more fat mass than patients who underwent gastric b and ing ( mean difference 16.8 kg , P<.05 ) . Likewise , leptin levels were lower in the patients who underwent Roux-en-Y ( P=.003 ) , and levels correlated with weight loss , loss of fat mass , insulin levels , and Homeostasis Model of Assessment 2 . Adiponectin correlated with insulin levels and Homeostasis Model of Assessment 2 ( r=-0.653 , P=.04 and r=-0.674 , P=.032 , respectively ) in the patients who underwent Roux-en-Y at 24 months . CONCLUSION After 2 years , weight loss and normalization of metabolic parameters were less pronounced in patients who underwent gastric b and ing  compared with patients who underwent Roux-en-Y gastric bypass . Our findings require confirmation in a prospect i ve r and omized trial OBJECTIVE To determine if weight loss may prevent conversion of impaired glucose tolerance ( IGT ) to diabetes , because weight loss reduces insulin resistance . The prevalence of IGT in the U. S. population is estimated at 11.2 % , more than twice that of diabetes . Furthermore , because an oral glucose tolerance test is needed for its detection , most of these patients are undiagnosed . Screening for IGT would be meaningful if progression to diabetes could be delayed or prevented . RESEARCH DESIGN AND METHODS For an average of 5.8 years ( range 2–10 years ) , 136 individuals with IGT and clinical ly severe obesity ( > 45 kg excess body weight ) were followed . The experimental group included 109 patients with IGT who underwent bariatric surgery for weight loss . The control group was made up of 27 subjects with IGT who did not have bariatric surgery . The criteria of the World Health Organization was used to detect IGT and diabetes in this population . The main outcome measure of this nonr and omized control trial is the incidence density , or number of events ( development of diabetes ) divided by the time of exposure to risk . RESULTS Of the 27 subjects in the control group , 6 developed diabetes during an average of 4.8 ± 2.5 years of postdiagnosis follow-up , yielding a rate of conversion to diabetes of 4.72 cases per 100 person-years . The 109 individuals of the experimental group were followed for an average of 6.2 ± 2.5 years postbariatric surgery . Based on the 95 % confidence interval of the comparison group , we would expect to find that between 22 and 36 subjects in the experimental group developed diabetes over the follow-up period . Only 1 of the 109 experimental-group patients developed diabetes , result ing in a conversion rate of the experimental group of only 0.15 cases per 100 person-years , which is significantly lower ( P < 0.0001 ) than the control group . CONCLUSIONS Weight loss in patients with clinical ly severe obesity prevents the progression of IGT to diabetes by > 30-fold Background Obesity is considered a low- grade chronic inflammatory condition as reflected by increased C-reactive protein ( CRP ) levels . Inflammation is emerging as a predictor of cardiovascular disease and it may be a precursor of the metabolic syndrome . Bariatric surgery is commonly performed as a treatment for morbid obesity offering significant reductions in premature myocardial infa rct ion . Laparoscopic sleeve gastrectomy ( LSG ) is a relatively new bariatric procedure that is currently used as a definitive procedure for weight loss . The aim of this study is to assess the impact of sleeve gastrectomy on CRP levels . Methods This study is part of an ongoing , prospect i ve , cohort study to evaluate LSG impact on iron indices . CRP levels were compared preoperatively and 6 months after surgery . Similarly , demographics including body mass index and excess weight were also compared at these same study points . Data were analyzed using Student paired t test and Pearson product moment correlation analysis . Results Twenty-nine morbidly obese patients were included . There was significant decrease in body mass index ( BMI ) between the preoperative and 6-month period ( 50.9 ± 13.2 and 35.1 ± 6.85 , respectively ; P < 0.001 ) . Also CRP levels were statistically significantly lower at 6 months after surgery ( preoperative 12.3 ± 7.53 mg/L and postoperative 5.6 ± 4.2 mg/L. P < 0.0001 ) . The significant weight loss as reflected by change in BMI was correlated with the difference between preoperative and postoperative CRP levels . Conclusions Massive weight loss in morbidly obese patients induced by LSG causes a significant decrease in CRP levels , which could reduce the risk of cardiovascular diseases in these patients
In contrast , some RCT data of nonsurgical therapies show benefits at 10 years of follow-up or more .
AND RELEVANCE Current evidence suggests that , when compared with nonsurgical treatments , bariatric surgical procedures in patients with a BMI of 30 to 35 and diabetes are associated with greater short-term weight loss and better intermediate glucose outcomes .
IMPORTANCE Bariatric surgery is beneficial in persons with a body mass index ( BMI ) of 35 or greater with obesity-related comorbidities .
There is interest in using these procedures in persons with lower BMI and diabetes .
OBJECTIVE To assess the association between bariatric surgery vs nonsurgical treatments and weight loss and glycemic control among patients with diabetes or impaired glucose tolerance and BMI of 30 to 35 .