Shift the paradigm to shift the weight: obesity care in the community

IntroductionObesity is a chronic relapsing condition characterised by abnormal or excessive accumulation of adipose tissue that presents a risk to health. It is associated with an increased risk of other chronic conditions including type 2 diabetes (T2DM), cardiovascular disease, renal and liver disease, musculoskeletal problems, and cancer. It can impact a person’s quality of life, wellbeing, and lifespan. Obesity is a complex condition, with a multitude of biological, social, environmental, and commercial factors, as well as food production and consumption processes, contributing to its development. One in four adults in the UK is living with obesity with comparable figures seen in children, and recent decades have seen an increase in prevalence

Effects of obesity surgery on food preferences, taste and reward in animals and humans

BACKGROUND: After Roux-en-Y gastric bypass bariatric surgery (RYGB) patients and animal models show a decreased preference for sweet/fatty foods. However, there are significant discrepancies in the findings of animal and human studies, and the mechanisms are not understood. AIMS: To investigate: 1. The effect of a high-fat (HFD) vs. low-fat (LFD) pre-operative maintenance diet on the ingestive behaviour of rats after RYGB 2. The effects of RYGB vs. gastric banding (BAND) surgery on food hedonics and brain reward systems in humans 3. The effects of RYGB on taste in humans METHODS: Study 1: Rats were fed either LFD or HFD before RYGB or sham surgery. Ingestive behaviour was assessed after surgery using food preference tests. Study 2: Brain reward responses to food were investigated using functional magnetic resonance imaging (fMRI), eating behaviour and metabolic phenotyping in body mass index (BMI) matched un-operated controls and patients after RYGB and BAND surgery. Study 3: The intensity and reward of sweet, fat and fat/sweet taste stimuli were assessed in patients undergoing RYGB using behavioural techniques. RESULTS: Study 1: Pre-operative maintenance diets with different fat contents, did not affect post-surgical weight loss or caloric intake. HFD-RYGB rats exhibited behaviour consistent with condition taste aversion to a familiar stimulus, compared to condition taste aversion to a novel stimulus in the LFD-RYGB rats. Study 2: Patients after RYGB had lower activation in brain reward systems to food and lower food hedonics than BAND patients and/or BMI-matched unoperated controls. Anorexigenic plasma gut hormones, plasma bile acids and dumping syndrome scores were higher in RYGB patients. Study 3: RYGB increased the intensity of fat/sweet taste solutions and reduced the reward value of fat/sweet stimuli. CONCLUSION: Pre-operative feeding may affect ingestive behaviour after RYGB. The mechanisms underlying the healthier food preferences after RYGB include the reduced reward value, and increased aversion to, high-calorie food and taste. Potential mediators are gut hormones, bile acids and altered gut nutrient sensing.Open Acces

Bariatric Surgery in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine condition in premenopausal women and is a common cause of anovulatory subfertility. Although obesity does not form part of the diagnostic criteria, it affects a significant proportion of women with PCOS and is strongly implicated in the pathophysiology of the disease. Both PCOS and obesity are known to impact fertility in women; obesity also reduces the success of assisted reproductive technology (ART). With or without pharmacotherapy, lifestyle intervention remains the first-line treatment in women with PCOS and obesity. Bariatric surgery is still an experimental treatment in women with PCOS and subfertility. This review will present an overview of the pathophysiology of PCOS and obesity and the role of bariatric surgery. Although data are sparse regarding the impact of bariatric surgery on subfertility in women with PCOS and obesity, existing studies point to a beneficial role in treating metabolic and reproductive dysfunction. [Abstract copyright: Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.

Length of biliopancreatic limb in Roux-en-Y gastric bypass and its impact on post-operative outcomes in metabolic and obesity surgery-systematic review and meta-analysis

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is a gold-standard procedure for treatment of obesity and associated comorbidities. No consensus on the optimal design of this operation has been achieved, with various lengths of bypassed small bowel limb lengths being used by bariatric surgeons. This aim of this systematic review and meta-analysis was to determine whether biliopancreatic limb (BPL) length in RYGB affects postoperative outcomes including superior reduction in weight, body mass index (BMI), and resolution of metabolic comorbidities associated with obesity. METHODS: A systematic search of the literature was conducted up until 1st June 2021. Meta-analysis of primary outcomes was performed utilising a random-effects model. Statistical significance was determined by p value  0.05). Even though results of four studies showed superior total body weight loss in the long BPL cohorts at 24 months post-operatively (pooled mean difference −6.92, 95% CI –12.37, −1.48, p = 0.01), this outcome was not observed at any other timepoint. CONCLUSION: Based on the outcomes of the present study, there is no definitive evidence to suggest that alteration of the BPL affects the quantity of weight loss or resolution of co-existent metabolic comorbidities associated with obesity

Impact of insulin sensitisation on metabolic and fertility outcomes in women with polycystic ovary syndrome and overweight or obesity - a systematic review, meta-analysis, and meta-regression

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-age women. This systematic review, meta-analysis and meta-regression aims to compare the effect of insulin sensitiser pharmacotherapy on metabolic and reproductive outcomes in women with PCOS and overweight or obesity. We searched online databases MEDLINE via OVID, EMBASE, Clinicaltrials.gov and EudraCT for trials published from inception to 13th November 2023. Inclusion criteria were double-blind, randomised controlled trials in women diagnosed with PCOS, body mass index (BMI) ≥ 25 kg/m2, which reported metabolic or reproductive outcomes. The intervention was insulin sensitisation pharmacotherapy versus placebo or other agents. The primary outcomes were the changes from baseline BMI, fasting blood glucose and menstrual frequency. Nineteen studies were included in this review. Metformin had the most significant effect on the fasting plasma glucose and body mass index. Insulin sensitiser pharmacotherapy significantly reduced fasting plasma glucose, body mass index, fasting serum insulin, HOMA-IR, sex hormone binding globulin and total testosterone, but the effect size was small. There was a lack of menstrual frequency and live birth data. The results indicate a role for insulin sensitisers in improving the metabolic and, to a lesser degree, reproductive profile in these women. Further research should examine insulin sensitisers' effects on objective measures of fecundity

Characteristics of Patients Lost to Follow-up after Bariatric Surgery

After bariatric surgery lifelong follow-up is recommended. Evidence of the consequences and reasons for being lost to follow-up (LTFU) is sparse. In this prospective study follow-up data of all patients who underwent bariatric surgery between 2008 and 2017 at a certified obesity centre were investigated. LTFU patients were evaluated through a structured telephone interview. Overall, 573 patients (female/male 70.9%/29.1%), aged 44.1 ± 11.2 years, preoperative BMI 52.1 ± 8.4 kg/m2 underwent bariatric surgery. Out of these, 33.2% had type 2 diabetes mellitus and 74.4% had arterial hypertension. A total of 290 patients were LTFU, of those 82.1% could be reached. Baseline characteristics of patients in follow-up (IFU) and LTFU were comparable, but men were more often LTFU (p = 0.01). Reported postoperative total weight loss (%TWL) and improvements of comorbidities were comparable, but %TWL was higher in patients remaining in follow-up for at least 2 years (p = 0.013). Travel issues were mentioned as the main reason for being LTFU. A percentage of 77.6% of patients reported to regularly supplement micronutrients, while 71.0% stated regular monitoring of their micronutrient status, mostly by primary care physicians. Despite comparable reported outcomes of LTFU to IFU patients, the duration of the in-centre follow-up period affected %TWL. There is a lack of sufficient supplementation and monitoring of micronutrients in a considerable number of LTFU patients

Medikamentöse Therapie der Adipositas – Konkurrenz zur bariatrischen Chirurgie oder sinnvolle Ergänzung?

Obesity is a complex chronic disease and requires a long-term multimodal approach. The current treatment algorithm for treatment of obesity mainly consists of a stepwise approach, which starts with a lifestyle intervention followed by or combined with medication treatment, whereas bariatric surgery is often reserved for the last option. This article provides an overview of the currently available conservative medicinal treatment regimens and the currently approved medications as well as medications currently undergoing approval studies with respect to the efficacy and possible side effects. Special attention is paid to the importance of combination treatment of pharmacotherapy and surgery in the sense of a multimodal treatment. The data so far show that using a multimodal approach an improvement in the long-term weight loss and metabolic benefits can be achieved for the patients. [Abstract copyright: © 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

Bariatric-metabolic surgery for NHS patients with type 2 diabetes in the United Kingdom National Bariatric Surgery Registry

Aim: Bariatric-metabolic surgery is approved by the National Institute of Health and Care Excellence (NICE) for people with severe obesity and type 2 diabetes (T2DM) (including class 1 obesity after 2014). This study analysed baseline characteristics, disease severity and operations undertaken in people with obesity and T2DM undergoing bariatric-metabolic surgery in the UK National Health Service (NHS) compared to those without T2DM. Methods: Baseline characteristics, trends over time and operations undertaken were analysed for people undergoing primary bariatric-metabolic surgery in the NHS using the National Bariatric Surgical Registry (NBSR) for 11 years from 2009 to 2019. Clinical practice before and after the publication of the NICE guidance (2014) was examined. Multivariate logistic regression was used to determine associations with T2DM status and the procedure undertaken. Results: 14,948/51,715 (28.9%) participants had T2DM, with 10,626 (71.1%) on oral hypoglycaemics, 4322 (28.9%) on insulin/other injectables, and with T2DM diagnosed 10+ years before surgery in 3876 (25.9%). Participants with T2DM, compared to those without T2DM, were associated with older age (p &lt; 0.001), male sex (p &lt; 0.001), poorer functional status (p &lt; 0.001), dyslipidaemia (OR: 3.58 (CI: 3.39–3.79); p &lt; 0.001), hypertension (OR: 2.32 (2.19–2.45); p &lt; 0.001) and liver disease (OR: 1.73 (1.58–1.90); p &lt; 0.001), but no difference in body mass index was noted. Fewer people receiving bariatric-metabolic surgery after 2015 had T2DM (p &lt; 0.001), although a very small percentage increase of those with class I obesity and T2DM was noted. Gastric bypass was the commonest operation overall. T2DM status was associated with selection for gastric bypass compared to sleeve gastrectomy (p &lt; 0.001). Conclusion: NHS bariatric-metabolic surgery is used for people with T2DM much later in the disease process when it is less effective. National guidance on bariatric-metabolic surgery and data from multiple RCTs have had little impact on clinical practice.</p