Multicentre cohort study of antihypertensive and lipid-lowering therapy cessation after bariatric surgery.

BACKGROUND: Few studies have assessed changes in antihypertensive and lipid-lowering therapy after bariatric surgery. The aim of this study was to assess the 6-year rates of continuation, discontinuation or initiation of antihypertensive and lipid-lowering therapy after bariatric surgery compared with those in a matched control group of obese patients. METHODS: This nationwide observational population-based cohort study used data extracted from the French national health insurance database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009 were matched with control patients. Mixed-effect logistic regression models were used to analyse factors that influenced discontinuation or initiation of treatment over a 6-year interval. RESULTS: In 2009, 8199 patients underwent primary gastric bypass (55·2 per cent) or sleeve gastrectomy (44·8 per cent). After 6 years, the proportion of patients receiving antihypertensive and lipid-lowering therapy had decreased more in the bariatric group than in the control group (antihypertensives: -40·7 versus -11·7 per cent respectively; lipid-lowering therapy: -53·6 versus -20·2 per cent; both P < 0·001). Gastric bypass was the main predictive factor for discontinuation of therapy for hypertension (odds ratio (OR) 9·07, 95 per cent c.i. 7·72 to 10·65) and hyperlipidaemia (OR 11·91, 9·65 to 14·71). The proportion of patients not receiving treatment at baseline who were subsequently started on medication was lower after bariatric surgery than in controls for hypertension (5·6 versus 15·8 per cent respectively; P < 0·001) and hyperlipidaemia (2·2 versus 9·1 per cent; P < 0·001). Gastric bypass was the main protective factor for antihypertensives (OR 0·22, 0·18 to 0·26) and lipid-lowering medication (OR 0·12, 0·09 to 0·15). CONCLUSION: Bariatric surgery is associated with a good discontinuation of antihypertensive and lipid-lowering therapy, with gastric bypass being more effective than sleeve gastrectomy.

Long-term follow-up after bariatric surgery in a national cohort.

BACKGROUND: Lifelong medical follow-up is mandatory after bariatric surgery. The aim of this study was to assess the 5-year follow-up after bariatric surgery in a nationwide cohort of patients. METHODS: All adult obese patients who had undergone primary bariatric surgery in 2009 in France were included. Data were extracted from the French national health insurance database. Medical follow-up (medical visits, micronutrient supplementation and blood tests) during the first 5 years after bariatric surgery was assessed, and compared with national and international guidelines. RESULTS: Some 16 620 patients were included in the study. The percentage of patients with at least one reimbursement for micronutrient supplements decreased between the first and fifth years for iron (from 27.7 to 24.5 per cent; P < 0.001) and calcium (from 14·4 to 7·7 per cent; P < 0·001), but increased for vitamin D (from 33·1 to 34·7 per cent; P < 0·001). The percentage of patients with one or more visits to a surgeon decreased between the first and fifth years, from 87·1 to 29·6 per cent (P < 0·001); similar decreases were observed for visits to a nutritionist/endocrinologist (from 22·8 to 12·4 per cent; P < 0·001) or general practitioner (from 92·6 to 83·4 per cent; P < 0·001). The mean number of visits to a general practitioner was 7·0 and 6·1 in the first and the fifth years respectively. In multivariable analyses, male sex, younger age, absence of type 2 diabetes and poor 1-year follow-up were predictors of poor 5-year follow-up. CONCLUSION: Despite clear national and international guidelines, long-term follow-up after bariatric surgery is poor, especially for young men with poor early follow-up.

[Pregnancy and bariatric surgery: Critical points]. / Grossesse et chirurgie bariatrique: points critiques.

More than 200,000 people underwent obesity surgery in France. Most of them are women. Pregnancy after bariatric surgery is becoming a common situation. This surgery results in major nutritional and gastro-intestinal tract modifications that may influence or be influenced by pregnancy, and yields benefits as well as complications. A multidisciplinary management including a nutritionist, an obstetrician, an anesthesiologist, and a bariatric surgeon is required. The aim of this review is to analyze the impact of bariatric surgery on pregnancy and vice versa, and to identify the key points of this management.

Type 2 diabetes mellitus in France in 2012: results from the ObEpi survey.

AIM: This analysis estimates the prevalence of type 2 diabetes mellitus (T2DM) in French adults participating in the ObEpi (obesity epidemiology) 2012 survey and also proposes a description of that population, according to comorbidities, treatments and sociodemographic factors related to the disease. METHODS: A self-administered questionnaire was posted to 20,000 households from the Kantar Health panel. In total, 25,714 adults aged≥18 years and representative of the French population completed the survey between January and March 2012. RESULTS: The prevalence of T2DM was 5.5±0.3% (95% CI) in this representative sample of the adult French population. Average age of patients was 65.9 years; 55% were men. Mean body mass index was 29.9kg/m(2) (men: 29.4kg/m(2), women: 30.6 kg/m(2); P<0.01); the prevalence of obesity was 43.1% (men: 39.9%, women: 47.1%; P<0.01). Patient-reported treatments for comorbidities were frequent: high blood pressure, 59.1%; dyslipidaemia, 59.9%; myocardial infarction/angina pectoris, 9.7%; revascularization, 7.8%; heart failure, 7.4%; sleep apnoea, 8.3%; and osteoarthritis, 10.7%. With regards to known treatments, 81.4% of patients were taking oral antidiabetic drugs (OADs), and 15.3% were using insulin therapy. Also, 18.8% of diabetic respondents reported financial hardship. CONCLUSION: T2DM remains a disease of major concern: compared with the non-diabetic population, all parameters surveyed showed unfavourable ratings, particularly for women.

Quality of life after Roux-en-Y gastric bypass and changes in body mass index and obesity-related comorbidities.

AIM: Dynamics of improvement in health-related quality of life (QoL) after bariatric surgery have never been fully assessed, and neither has the potential influence of body mass index (BMI) and comorbidity modification. The objective of this study was to investigate early and medium-term changes in QoL following Roux-en-Y gastric bypass (RYGB), and their relationship to BMI and comorbidity variations. METHODS: A total of 71 obese subjects (80% women, mean age 42.1±11.2 years, mean baseline BMI 47.6±6.2kg/m(2)) undergoing RYGB filled in QoL questionnaires (SF-36) before and 3, 6 and 12 months after surgery. QoL was assessed using repeated-measures Anova, with associations between its changes and changes in BMI and comorbidities (diabetes, hypertension, dyslipidaemia, sleep apnoea, knee pain) assessed by mixed-effects models. RESULTS: Physical QoL scales (physical component summary, PCS) significantly increased over time (from 38.9±9.3 to 52.6±7.9; P<0.001) as did other physical SF-36 scales (all P<0.001), whereas mental QoL summary scale did not vary significantly (from 45.7±9.5 to 48.6±11.5; P=0.072). Major changes in QoL occurred at 3 months after surgical intervention to reach values comparable to those in the general population. PCS was mostly associated with changes in either BMI or comorbidity status except for diabetes, dyslipidaemia and sleep apnoea. CONCLUSION: Results show that improvements in physical QoL after RYGB are observed as early as 3 months after intervention, and are independently associated with weight loss and improvements in comorbidities.

Comparison of body composition, basal metabolic rate and metabolic outcomes of adults with Prader Willi syndrome or lesional hypothalamic disease, with primary obesity.

CONTEXT: The care of patients with hypothalamic obesity is challenging. OBJECTIVE: To compare body composition, basal metabolic rate (BMR) and metabolic outcomes of adults, with lesional or genetic hypothalamic obesity, with obese patients suffering from primary obesity, once matched for body mass index (BMI). DESIGN AND PATIENTS: Adults with hypothalamic obesity of genetic origin (Prader Willi syndrome (PWS)) or acquired hypothalamic damage (HD), such as craniopharygioma, were compared with obese control candidates awaiting bariatric surgery (C), with a BMI between 35 and 65 kg m(-)(2), and aged between 18 and 50 years. MAIN OUTCOME MEASURES: Body composition measured by whole-body dual-energy X-ray absorptiometry scanning, BMR using indirect calorimetry, hormonal and metabolic assessments. RESULTS: A total of 27 adults with a genetic diagnosis of PWS, 15 obese subjects with HD and 206 obese controls with similar BMI were studied. Compared with the control group, PWS patients had an increased percentage of fat mass (FM), and a decreased percentage of android FM. The BMR of PWS patients was significantly lower than controls and highly correlated with lean body mass in PWS and C patients. Body composition of HD was similar with those of obese patients. A trend toward an increased prevalence of diabetes in HD patients and of cytolysis in PWS was observed in comparison with primary obese patients. CONCLUSION: Genetic and lesional hypothalamic obesities have different consequences for phenotypic features such as body composition or BMR compared with primary obese patients. The mechanisms of adipose tissue development and metabolic complications may be different between genetic and lesional obesities.

Relationship between adiposity, emotional status and eating behaviour in obese women: role of inflammation.

BACKGROUND: Obesity is characterized by chronic low-grade inflammation that may lead to emotional distress and behavioural symptoms. This study assessed the relationship between adiposity, low-grade inflammation, eating behaviour and emotional status in obese women awaiting gastric surgery and investigated the effects of surgery-induced weight loss on this relationship. METHOD: A total of 101 women with severe or morbid obesity awaiting gastric surgery were recruited. Assessments were performed before and at 1 year post-surgery and included the measurement of neuroticism and extraversion using the revised Neuroticism-Extraversion-Openness personality inventory (NEO-PI-R) and eating behaviour using the Three-Factor Eating Questionnaire (TFEQ). Blood samples were collected for the measurement of serum inflammatory markers [interleukin-6 (IL-6), high-sensitive C-reactive protein (hsCRP)] and adipokines (leptin, adiponectin). RESULTS: At baseline, body mass index (BMI) was positively correlated with inflammatory markers and adipokines. Regression analyses adjusting for age and diabetes revealed that baseline concentrations of IL-6 and hsCRP were associated with the depression and anxiety facets of neuroticism, with higher inflammation predicting higher anxiety and depression. This association remained significant after adjusting for BMI. Gastric surgery induced significant weight loss, which correlated with reduced inflammation. After controlling for BMI variations, decreases in inflammatory markers, notably hsCRP, were associated with reduced anxiety and TFEQ-cognitive restraint scores. CONCLUSIONS: These findings indicate strong associations between adiposity, inflammation and affectivity in obese subjects and show that surgery-induced weight loss is associated concomitantly with reduced inflammation and adipokines and with significant improvement in emotional status and eating behaviour. Inflammatory status appears to represent an important mediator of emotional distress and psychological characteristics of obese individuals.

Bariatric surgery in young massively obese diabetic patients.

Obesity is the most important lifestyle-related risk factor for type 2 diabetes (T2DM). The prevalence of T2DM in adolescents is increasing in parallel with the increasing incidence of major obesity. In adult obese subjects, the greatest degree of T2DM prevention, improvement or recovery has been reported in patients who have undergone bariatric surgery. However, few studies are available on the benefits and risks of bariatric surgery in adolescents with T2DM. The indications for obesity surgery in this population are unusual, and should only be considered in academic settings after comprehensive interdisciplinary evaluation.

[Stress urinary incontinence and obesity]. / Incontinence urinaire d'effort et obésité.

In France, the prevalence of urinary incontinence is about 44%. Obesity, defined by a Body Mass Index (BMI) above 30kg/m(2), is well established as a risk factor of stress urinary incontinence. Odds ratio (OR) varies between 1.7 and 2.4. Urge or mixed incontinence also occurs in obesity. Urinary incontinence epidemiology is not well-known in obese women. Weight loss, obtained by a weight reduction diet program or bariatric surgery, improves urinary symptoms of stress, urge or mixed incontinence. Functional outcome of urge incontinence surgery is not influenced by obesity. Typically, functional outcome and morbidity of tension-free vaginal tape are not influenced by BMI variations.

Cathepsin S genotypes are associated with Apo-A1 and HDL-cholesterol in lean and obese French populations.

Cathepsin S (CTSS) is a cysteine protease that has a central role in remodeling the extracellular matrix and, as such, has been implicated in the etiology of cardiovascular disease. This study used five tag single nucleotide polymorphisms (tSNPs) to screen the CTSS gene in healthy lean (n = 1891) and obese French populations (n = 477) for their association with various phenotypes: body mass index, waist-to-hip ratio, glycemia, total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), apolipoprotein A1 (Apo-A1) and apolipoprotein B. Significant associations were identified between rs11576175 tSNP (A/G) and Apo-A1 and HDL-C plasma levels in a sex-specific manner. Lean female subjects homozygous for the minor A-allele had higher levels of circulating Apo-A1 (p = 0.0003), while lean male A/A carriers had higher levels of HDL-C (p = 0.007) compared with the other genotypes. In the obese cohort, associations were found between three tSNPs and Apo-A1 levels in adult female subjects: rs10888390 (G/A), p = 0.01; rs10888394 (T/C), p = 0.03; and rs1136774 (C/T), p = 0.02; however, only rs10888390 remained significant in a combined model (p = 0.03). These results provide the first evidence that CTSS sequence variations are associated with two human metabolic risk factors for cardiovascular diseases: plasma Apo-A1 and HDL-C concentrations.

Promoter adiponectin polymorphisms and waist/hip ratio variation in a prospective French adults study.

BACKGROUND: Adiponectin expression and plasma concentrations are decreased in human and animal models of obesity. Several single nucleotide polymorphisms (SNPs) in the adiponectin gene are known to influence the plasmatic concentration of the encoded protein. Some of these adiponectin polymorphisms have been associated with BMI in cross-sectional studies. OBJECTIVE: The aim of our study was to examine the longitudinal relationships between adiponectin gene polymorphisms and anthropometric indices. DESIGN: Two adiponectin gene (ADIPOQ) SNPs, -11391G>A and -11377C>G, were genotyped in 837 French Caucasian subjects from the SUpplémentation en VItamines et Minéraux Anti-oXydants (SU.VI.MAX) cohort. Anthropometric scores were measured at three clinical examinations over a 7-year period. RESULTS: For -11391G>A as well as for -11377C>G, we detected no association between the variant allele and anthropometric measurements at baseline. Considering longitudinal effects, we detected moderately higher waist-to-hip ratio (WHR) changes for the carriers of the -11391A (P=0.02) and -11377C (P=0.03) allele over the follow-up of the study. -11391G>A and -11377C>G define haplotypes associated also with WHR measurements and their changes over the follow-up of the study. Diploid configurations that combine -11391A and -11377C were associated with significantly higher WHR changes (DeltaCE: P=0.02) compared to other haplotypes. In addition, higher adiponectin levels were observed in AC/AC diplotypes compared to GG/GG carriers (P<0.0001). CONCLUSION: In the SU.VI.MAX study, genetic variations in the adiponectin gene affect abdominal fat gain over life span.

Inter-disciplinary European guidelines on surgery of severe obesity.

In 2005, for the first time in European history, an extraordinary Expert panel named 'The BSCG' (Bariatric Scientific Collaborative Group), was appointed through joint effort of the major European Scientific Societies which are active in the field of obesity management. Societies that constituted this panel were: IFSO - International Federation for the Surgery of Obesity, IFSO-EC - International Federation for the Surgery of Obesity - European Chapter, EASO - European Association for Study of Obesity, ECOG - European Childhood Obesity Group, together with the IOTF (International Obesity Task Force) which was represented during the completion process by its representative. The BSCG was composed not only of the top officers representing the respective Scientific Societies (four acting presidents, two past presidents, one honorary president, two executive directors), but was balanced with the presence of many other key opinion leaders in the field of obesity. The BSCG composition allowed the coverage of key disciplines in comprehensive obesity management, as well as reflecting European geographical and ethnic diversity. This joint BSCG expert panel convened several meetings which were entirely focused on guidelines creation, during the past two years. There was a specific effort to develop clinical guidelines, which will reflect current knowledge, expertise and evidence based data on morbid obesity treatment.

Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment.

In recent years, the recourse to obesity surgery to treat morbid obesities has grown. The number of "malabsorptive" interventions, such as the gastric bypass (RYGB: Roux-en-Y gastric bypass) increases each year. The RYGB, which combines two mechanisms promoting weight loss, restriction and malabsorption, has proven its effectiveness in term of weight loss and improvement of obesity-associated co-morbidities. However this intervention involves a profound change in digestive physiology and is the source of nutritional and metabolic complications. The deficits observed most frequently concern proteins, iron, calcium, vitamin B12 and vitamin D. The deficiencies in vitamin B1 are rare but potentially serious. Multidisciplinary follow-up is essential to ensure prevention, diagnosis and treatment of these complications. Based on an analysis of the literature, this article summarizes the various nutritional complications observed after RYGB and the means to diagnose it. It proposes practical recommendations for follow-up, preventive supplementation and treatment of these deficiencies, both generally and in the more specific case of a pregnancy after RYGB.

Leisure-time and occupational physical activity in relation to cardiovascular risk factors and eating habits in French adults.

OBJECTIVE: To investigate the relationships of two main physical activity domains (during leisure and at work) with cardiovascular risk factors and eating habits. DESIGN: Cross-sectional study. SETTING: Preventive medicine centre. SUBJECTS: In 5478 adults (32% women, aged 20-80 years) who consecutively underwent a standardised health examination, leisure-time physical activity (LTPA; i.e. non-sport leisure and sport activities), occupational physical activity (OPA) and eating habits were assessed by self-administered questionnaires. We analysed sex-specific relationships of LTPA and OPA (in quartiles) with (1) various cardiovascular risk factors and (2) eating habits using analysis of variance and logistic regression, respectively. RESULTS: In both genders, with and without adjustment for education in addition to age, LTPA was associated negatively with body mass index, body fat, waist circumference, resting heart rate, diastolic blood pressure and triglycerides, and positively associated with high-density lipoprotein cholesterol (all P < or = 0.005). OPA adjusted for age only was positively associated with most cardiovascular risk factors but these associations were not significant after further adjustment on education (except for waist circumference in women). Age- and education-adjusted LTPA was associated with increased frequency of consumption of fruits (odds ratio (OR) = 2.05, 95% confidence interval (CI) 1.68-2.52 in men; OR = 1.90, 95% CI 1.41-2.05 in women) and vegetables (OR = 1.81, 95% CI 1.48-2.21 in men; OR = 2.22, 95% CI 1.66-2.97 in women). CONCLUSIONS: The data emphasise the favourable associations of LTPA, a modifiable behaviour, with various cardiovascular risk factors and healthy eating habits. The results also suggest that the relationships of OPA with cardiovascular risk factors depend, at least in part, on socio-economic status as reflected by educational level.

Recommendations regarding obesity surgery.

In France, 1,000 obese persons per month undergo a bariatric operation. Obesity surgery requires coordination and monitoring of aftercare. The French public health-care insurer asked the medical associations involved in obesity management to provide guidelines for obesity surgery. The recommendations were developed by the national associations of Obesity, Nutrition and Diabetes: the Association Française d'Etudes et de Recherches sur l'Obésité (AFERO), member of the EASO and IASO; the Association de Langue Française pour l'Etude du Diabète et des Maladies Métaboliques (ALFEDIAM); the Société Française de Nutrition (SFN); and the Société Française de Chirurgie de l'Obésité (SOFCO). This article presents the short version of the guidelines.

Serum amyloid A: production by human white adipocyte and regulation by obesity and nutrition.

AIMS/HYPOTHESIS: The acute-phase proteins, serum amyloid As (SAA), are precursors of amyloid A, involved in the pathogenesis of AA amyloidosis. This work started with the characterisation of systemic AA amyloidosis concurrent with SAA overexpression in the subcutaneous white adipose tissue (sWAT) of an obese patient with a leptin receptor deficiency. In the present study a series of histopathological, cellular and gene expression studies was performed to assess the importance of SAA in common obesity and its possible production by mature adipocytes. MATERIALS AND METHODS: Gene expression profiling was performed in the sWAT of two extremely obese patients with a leptin receptor deficiency. Levels of the mRNAs of the different SAA isoforms were quantified in sWAT cellular fractions from lean subjects and from obese subjects before and after a very-low-calorie diet. These values were subsequently compared with serum levels of SAA in these individuals. In addition, histopathological analyses of sWAT were performed in lean and obese subjects. RESULTS: In sWAT, the expression of SAA is more than 20-fold higher in mature adipocytes than in the cells of the stroma vascular fraction (p<0.01). Levels of SAA mRNA expression and circulating levels of the protein are sixfold (p<0.001) and 3.5-fold (p<0.01) higher in obese subjects than in lean subjects, respectively. In lean subjects, 5% of adipocytes are immunoreactive for SAA, whereas the corresponding value is greater than 20% in obese subjects. Caloric restriction results in decreases of 45-75% in levels of the transcripts for the SAA isoforms and in circulating levels of the protein. CONCLUSIONS/INTERPRETATION: The results of the present study indicate that SAA is expressed by sWAT, and its production at this site is regulated by nutritional status. If amyloidosis is seen in the context of obesity, it is possible that production of SAA by adipocytes could be a contributory factor.

Single nucleotide polymorphisms of protein tyrosine phosphatase 1B gene are associated with obesity in morbidly obese French subjects.

AIMS/HYPOTHESIS: The development of insulin resistance may contribute to the occurrence and progression of the metabolic syndrome associated with obesity. Components contributing to the insulin pathway and its regulation are good candidates for the molecular study of metabolic syndrome pathogenesis. Protein tyrosine phosphatase 1B (PTP 1B) is an important negative regulator of insulin. We investigated whether PTP 1B SNPs are associated with obesity and obesity-related traits as well as global metabolic syndrome in morbidly obese subjects. METHODS: Untranslated and coding regions of the PTP 1B gene were screened in groups of non-diabetic and diabetic obese subjects and in non-obese subjects. Unrelated morbidly obese ( n=711) and non-obese ( n=427) French Caucasian subjects were genotyped for a case-control study. RESULTS: Six SNPs were identified: two rare variants were located in 5'UTR (-109 C>T and -69 C>T), two in the intronic regions (IVS3+38 G>T and IVS5+3666delT) and two have been described previously (P303P in exon 8 and P387L in exon 9). A case-control study showed an association between the frequent IVS5+3666delT SNP and obesity ( p=0.02). In the obese group, associations between PTP 1B SNPs and features of dyslipidaemia were found. P303P was associated with lower apolipoprotein A1 levels ( p=0.05) whereas P387L was associated with higher triglyceride ( p=0.0003), apolipoprotein B ( p=0.09) and lipoprotein a concentrations ( p=0.006). CONCLUSIONS/INTERPRETATION: Our results support the hypothesis that the PTP 1B gene contributes to the polygenic basis of obesity. PTP 1B SNPs may interact with environmental factors to induce more severe phenotypes, e.g. atherogenic dyslipidaemia, in morbidly obese subjects.