Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m2

doi:10.1016/j.soard.2009.08.009

Surgery for Obesity and Related Diseases

Volume 6, Issue 4, July–August 2010, Pages 332-338

https://doi.org/10.1016/j.soard.2009.08.009 Get rights and content

Abstract

Background

Roux-en-Y gastric bypass (RYGB) benefits patients with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) >35 kg/m²; however, its effectiveness in patients with T2DM and a BMI <35 kg/m² is unclear. Asian Indians have a high risk of T2DM and cardiovascular disease at relatively low BMI levels. We examined the safety and efficacy of RYGB in Asian Indian patients with T2DM and a BMI of 22–35 kg/m² in a tertiary care medical center.

Methods

A total of 15 consecutive patients with T2DM and a BMI of 22–35 kg/m² underwent RYGB. The data were prospectively collected before surgery and at 1, 3, 6, and 9 months postoperatively.

Results

Of the 15 patients, 8 were men and 7 were women (age 45.6 ± 12 years). Their preoperative characteristics were BMI 28.9 ± 4.0 kg/m², body weight 78.7 ± 12.5 kg, waist circumference 100.2 ± 6.8 cm, and duration of T2DM 8.7 ± 5.3 years. At baseline, 80% of subjects required insulin, and 20% controlled their T2DM with oral hypoglycemic medication. The BMI decreased postoperatively by 20%, from 28.9 ± 4.0 kg/m² to 23.0 ± 3.6 kg/m² (P <.001). All antidiabetic medications were discontinued by 1 month after surgery in 80% of the subjects. At 3 months and thereafter, 100% were euglycemic and no longer required diabetes medication. The fasting blood glucose level decreased from 233 ± 87 mg/dL to 89 ± 12 mg/dL (P <.001), and the hemoglobin A1c decreased from 10.1% ± 2.0% to 6.1% ± 0.6% (P <.001). Their waist circumference, presence of dyslipidemia, and hypertension improved significantly. The predicted 10-year cardiovascular disease risk (calculated using the United Kingdom Prospective Diabetes Study equations) decreased substantially for fatal and nonfatal coronary heart disease and stroke. No mortality, major surgical morbidity, or excessive weight loss occurred.

Conclusion

RYGB safely and effectively eliminated T2DM in Asian Indians with a BMI <35 kg/m². Larger, longer term studies are needed to confirm this benefit.

Section snippets

Methods

From December 2006 to December 2007, we studied 15 consecutive patients with T2DM who were scheduled to undergo RYGB and had a BMI of 22–35 kg/m². To ensure that we did not inadvertently study patients with type 1 diabetes mellitus, the study candidates were excluded if they had any of the following features: positive anti-glutamic acid decarboxylase or anti-islet cell antibodies, C-peptide <1 ng/mL, a family history of diabetes diagnosed before 30 years of age, or evidence of maturity-onset

Results

The study group consisted of 7 women and 8 men, with the following mean preoperative characteristics: age 45.6 ± 12 years, BMI 28.9 ± 4.0 kg/m², body weight 78.7 ± 12.5 kg, and waist circumference 100.2 ± 6.8 cm. The average duration of T2DM was 8.7 ± 5.3 years. The baseline glycemic indexes and other metabolic parameters are summarized in Table 1.

The average operative time was 1.5 hours. The patients were assisted to ambulate the evening of their operation and given water orally within 12

Discussion

Because RYGB typically promotes complete remission of T2DM in severely obese patients [12], [17], [18] and because mounting evidence has indicated that this results from hormonal and metabolic mechanisms beyond just those related to weight loss [19], the use of RYGB to treat T2DM in less obese patients has been increasingly considered [20], [21], [22]. This concept is particularly germane for populations with an enhanced risk of diabetes and CVD at lower BMI levels, such as Asian Indians [4],

Conclusion

Our study was impelled by 3 previous observations. First, RYGB is highly beneficial for patients with T2DM and a BMI >35 kg/m², causing T2DM remission in 84% of cases and reducing T2DM-related mortality by 92% [12], [15]. Second, the impressive antidiabetic effects of RYGB result from mechanisms beyond just weight loss [19]. Finally, Asian Indians carry significant risks of T2DM and CVD at lower BMI levels than do whites [4], [5], [6], [7], [8], [11], yet the latter population was primarily

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

References (31)

W.J. Lee et al.
Effect of laparoscopic mini-gastric bypass for type 2 diabetes mellitus: comparison of BMI > 35 and <35 kg/m2
J Gastrointest Surg
(2008)
R. Cohen et al.
Laparoscopic Roux-en-Y gastric bypass for BMI < 35 kg/m(2): a tailored approach
Surg Obes Relat Dis
(2006)
K.H. Schlendorf et al.
Limitations of the Framingham risk score are now much clearer
Prev Med
(2009)
J.A. Batsis et al.
Cardiovascular risk after bariatric surgery for obesity
Am J Cardiol
(2008)
H. Buchwald et al.
Trends in mortality in bariatric surgery: a systematic review and meta-analysis
Surgery
(2007)
W.P. James
WHO recognition of the global obesity epidemic
Int J Obes (Lond)
(2008)
K. Gu et al.
Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971–1993
Diabetes Care
(1998)
J.C. Chan et al.
Diabetes in Asia: epidemiology, risk factors, and pathophysiology
JAMA
(2009)
C.P. Wen et al.
Are Asians at greater mortality risks for being overweight than Caucasians?Redefining obesity for Asians
Public Health Nutr
(2009)
Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies
Lancet
(2004)

C.S. Yajnik et al.

Adiposity, inflammation and hyperglycaemia in rural and urban Indian men: Coronary Risk of Insulin Sensitivity in Indian Subjects (CRISIS) study

Diabetologia

(2008)

P. Deurenberg et al.

Asians are different from Caucasians and from each other in their body mass index/body fat percent relationship

Obes Rev

(2002)

M. Anjana et al.

Visceral and central abdominal fat and anthropometry in relation to diabetes in Asian Indians

Diabetes Care

(2004)

L. Lapidus et al.

Distribution of adipose tissue and risk of cardiovascular disease and death: a 12 year follow up of participants in the population study of women in Gothenburg, Sweden

BMJ

(1984)

B. Larsson et al.

Abdominal adipose tissue distribution, obesity, and risk of cardiovascular disease and death: 13 year follow up of participants in the study of men born in 1913

Br Med J (Clin Res Ed)

(1984)

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Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.
New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health-care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).
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Diabetic rats induced via a high-fat diet and low-dose streptozotocin administration were randomized to RYGB or sham surgery, and stool samples were collected at baseline and at postoperative week 8. The fecal microbiota was profiled using 16S ribosomal RNA gene sequencing. Additionally, we performed a case-control study of the gut microbial community profiles of T2D patients compared with those of healthy individuals via 16S ribosomal RNA gene sequencing of mucosal-luminal interface samples collected from the ascending colon during colonoscopy.
RYGB significantly reduced the weight and improved glucose tolerance and insulin sensitivity in diabetic rats. Principal coordinate analysis showed that RYGB caused marked alterations in the gut microbiota. The RYGB group was postoperatively enriched for Bacteroidetes, Proteobacteria, Fusobacteria, and Actinobacteria, whereas the sham surgery group was enriched for Firmicutes and Verrucomicrobia. Based on the gut microbial patterns in the T2D patients, we found that the family Coriobacteriaceae within Actinobacteria might contribute to the beneficial effects of RYGB on T2D.
RYGB significantly improves glucose metabolism and alters the gut microbiota. Moreover, the family Coriobacteriaceae may partly mediate the beneficial effects of RYGB on T2D and thus possibly contribute to the development of novel bacteria-based therapeutic approaches.
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: David Cummings is supported by NIH grants DK517498, DK68384, DK66568, and DK17047.

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Original articleDiabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m2

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Disclosures

J Gastrointest Surg

Surg Obes Relat Dis

Prev Med

Am J Cardiol

Surgery

WHO recognition of the global obesity epidemic

Int J Obes (Lond)

Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971–1993

Diabetes Care

Diabetes in Asia: epidemiology, risk factors, and pathophysiology

JAMA

Are Asians at greater mortality risks for being overweight than Caucasians?Redefining obesity for Asians

Public Health Nutr

Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies

Lancet

Adiposity, inflammation and hyperglycaemia in rural and urban Indian men: Coronary Risk of Insulin Sensitivity in Indian Subjects (CRISIS) study

Diabetologia

Asians are different from Caucasians and from each other in their body mass index/body fat percent relationship

Obes Rev

Visceral and central abdominal fat and anthropometry in relation to diabetes in Asian Indians

Diabetes Care

Distribution of adipose tissue and risk of cardiovascular disease and death: a 12 year follow up of participants in the population study of women in Gothenburg, Sweden

BMJ

Abdominal adipose tissue distribution, obesity, and risk of cardiovascular disease and death: 13 year follow up of participants in the study of men born in 1913

Br Med J (Clin Res Ed)

Original article
Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m²