Ghrelin, glucagon-like peptide-1, and peptide YY secretion in patients with and without weight regain during long-term follow-up after bariatric surgery: a cross-sectional study.

Introduction: Weight loss after bariatric surgery is attributed, at least in part, to the altered gastrointestinal (GI) hormone secretion, which is thought to be responsible for a number of beneficial metabolic effects. Material and methods: We conducted a cross-sectional study. Twelve patients who underwent laparoscopic sleeve gastrectomy (SG) and 20 patients who underwent a variant of biliopancreatic diversion with Roux-en-Y gastric bypass and long limbs (BPD/RYGB-LL) were evaluated ≥ 7 years postoperatively. Ghrelin, glucagon-like peptide-1 (GLP-1), and peptide YY (PYY) secretion were compared between patients with successful weight loss maintenance (WM group) and patients with weight regain (WR group). Results: In both types of surgery, standard liquid mixed meal (SLMM) ingestion did not result in significant changes in fasting GI hormone levels. Fasting ghrelin levels did not differ between the WM group and the WR group in both types of surgery. In SG patients, SLMM ingestion elicited greater suppression of ghrelin levels in the WM group (p = 0.032). No difference in GLP-1 secretion was observed between the 2 groups of patients in both types of surgery. When patients were examined, regardless of the type of bariatric surgery they had undergone, postprandial PYY levels were lower in the WM group (p < 0.05), while fasting and postprandial PYY levels were correlated positively with an increase in body mass index (BMI) in the evaluation (Spearman's rho ≥ 0.395, p < 0.03). Conclusions: Our data do not support the hypothesis that long-term weight regain after bariatric surgery is associated with an unfavourable GI hormone secretion pattern.

Are the Changes in Gastrointestinal Hormone Secretion Necessary for the Success of Bariatric Surgery? A Critical Review of the Literature.

Ghrelin, glucagon-like peptide-1 (GLP-1), and peptide YY (PYY) are involved in energy balance regulation and glucose homeostasis. Obesity is characterized by lower fasting levels and blunted postprandial responses of ghrelin, GLP-1, and possibly PYY. Both Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) have been shown to increase postprandial GLP-1 and PYY levels. Human studies have shown that enhanced postprandial GLP-1 and PYY release are associated with favorable weight loss outcomes after RYGB. However, studies in knockout mice have shown that GI hormones are not required for the primary metabolic effects of bariatric surgery. Here, we summarize the complex interaction between obesity, bariatric surgery, and GI hormones in order to determine the exact role of GI hormones in the success of bariatric surgery.

A year in type 2 diabetes mellitus: 2018 review based on the Endorama lecture.

The aim of this article is to review and present the most important studies published in the field of type 2 diabetes mellitus (T2DM) during 2018. These studies were presented in a lecture given on this topic at the Endorama Meeting in Patras, Greece, in January 2019. In order to identify the most important and relevant articles, a search in the English language was conducted in PubMed for publications up to the end of December 2018, with special attention paid to publications in high impact factor journals. The highlights of the main Diabetes Meetings [ADA (American Diabetes Association) and EASD (European Association of Diabetes)], as well as Medscape, were also reviewed. Last but not least, press releases regarding advances in the diagnosis and treatment of T2DM were considered. We finally selected and discussed important studies concerning diagnosis, pathophysiology, and management of this very common clinical entity (19 studies). The majority of studies were clinical trials dealing with new therapeutic tools for treatment of the disease, with the greatest focus being on GLP-1RA. We also presented in brief the main points of new guidelines published for T2DM by various scientific societies (3 sets of guidelines). During 2018, not only leading diabetes associations published guidelines on the disease, but also societies belonging to other primary scientific fields. This is indicative of the awareness of physicians and scientists that T2DM constitutes today a major health problem and of the need for public health strategies for its treatment and prevention.

Influence of Supervised Disease Understanding and Diabetes Self-Management on Adherence to Oral Glucose-Lowering Treatment in Patients with Type 2 Diabetes.

INTRODUCTION: Systematic patient education has been reported to improve adherence to treatment, leading to better clinical outcomes. This cluster randomized real-world study investigated the effect of a systematic education program and telephone support on self-reported adherence to oral glucose-lowering treatment in patients with type 2 diabetes mellitus (T2DM). METHODS: Centers were randomized (1:1) to provide either standard-of-care (control group) or standard-of-care along with the education program and telephone support (empowerment group). Adherence to treatment and satisfaction with treatment were assessed using the four-item Morisky Medication Adherence Scale (MMAS-4) and the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The study population included 457 patients (258/199 male/female) with T2DM and non-optimal glycemic control, on oral antidiabetic treatment (age 62.7 [11.4]; disease duration 8.5 [6.5] years). RESULTS: MMAS-4 high adherence rates for the control and empowerment groups were increased by 3.8% and 16.8% at 4 months (Breslow-Day test p = 0.04) and by 8.5% and 18.8% at 8 months of follow-up, respectively (Breslow-Day test p = 0.09), compared to baseline. Intense physical activity was increased in both control and empowerment groups by 2.3% and 13.9% at 4 months (Breslow-Day test p = 0.082) and by 4.0% and 22.5% at 8 months of follow-up (Breslow-Day test p < 0.001). Baseline mean (SD) HbA1c was significantly lower in the control group compared with the empowerment group [7.7% versus 8.0%, p = 0.001] and decreased in both groups at 4 months by 0.7% and 0.9%, respectively. The change from baseline in the mean DTSQ status score at 4 months was greater in the empowerment group, and the effect was sustained at 8 months (control group: 29.1, 30.5, and 30.9; empowerment group: 25.0, 28.7, and 29.4 at baseline, 4 and 8 months, respectively, p < 0.001). CONCLUSION: Systematic education combined with telephone support delivered by physicians might be associated with improvement in treatment adherence and treatment satisfaction in patients with T2DM. FUNDING: MSD, Greece.

The Real-Life Effectiveness and Care Patterns of Type 2 Diabetes Management in Greece.

AIM: To investigate the prevalence of hypoglycaemia during sulfonylurea (SU) treatment of type 2 diabetes mellitus (T2DM) in Greece and its influence on glycaemic control, treatment adherence and quality of life (QoL). PATIENTS AND METHODS: This was a retrospective cross-sectional study. We included 383 T2DM patients ≥30 years old on treatment with SU in monotherapy or in combination with metformin for at least 6 months. Patients were requested to fill in retrospective questionnaires on hypoglycaemia experience, adherence, weight gain and lifestyle/behavioural factors along with QoL (EQ-5D-3L), treatment satisfaction (TSQM), and fear of hypoglycaemia (HFS-II Worry scale). RESULTS: HbA1c<7% was found in 161 (42.0%) patients. In total, 165 (43.1%) patients reported hypoglycaemic symptoms during the previous 6 months: 41.6% (67/161) of those with HbA1c <7% and 44.1% (98/222) of those with HbA1c ≥7%. Glycaemic control was achieved by 43.1% (94/218) of patients without hypoglycaemia and 50.0% (41/82), 36.8% (25/68) and 6.7% (1/15) of patients with mild, moderate or severe hypoglycaemia, respectively (p=0.013). In multivariate analysis, both occurrence (none vs. mild/moderate/severe) and severity (none vs. mild vs. moderate vs. severe) of hypoglycaemia were significantly associated with impaired global treatment satisfaction (p=0.002 and p<0.0001 respectively) and HFS-II Worry scale scores (both p<0.0001), while lower QoL (EQ-5D (UK) Index) was related to hypoglycaemia severity (p=0.024) only. Finally, treatment adherence was associated with increased (none/mild vs. moderate/severe) hypoglycaemia severity in univariate analysis (p=0.019). CONCLUSION: A high prevalence of patient treated with SU reported hypoglycaemia in Greek healthcare settings with negative effects on treatment satisfaction, patient worry and adherence. Severity of hypoglycaemic symptoms was associated with reduced glycaemic control.

Expert consensus on the rational clinical use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.

Two proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, evolocumab and alirocumab, have recently been approved by both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of hypercholesterolemia. These fully human monoclonal antibodies selectively block PCSK9, thus permitting the low-density lipoprotein (LDL) receptor to effectively recycle to the surface of liver cells. The administration of these antibodies leads to robust LDL cholesterol (LDL-C) lowering by 50-60% on top of maximum hypolipidemic treatment. At least 4 randomized, placebo-controlled studies are under way and will address the question of whether the administration of these PCSK9 inhibitors is associated with a significant reduction of cardiovascular events. Because of the high cost associated with the use of these medications it is very important to consider which patients may gain the most benefit, at least until the results of outcome studies are available. In this Consensus paper, 34 clinicians/scientists define 3 groups of patients that should be currently considered as candidates for the use of these novel drugs. These include: 1a. Adults with established cardiovascular disease and LDL-C≥100 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe, 1b. Adults with diabetes and established cardiovascular disease or chronic kidney disease or target organ damage and LDL-C ≥100 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe, 2. Adults with familial hypercholesterolemia (FH) without established cardiovascular disease and LDL-C ≥130 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe (evolocumab is also indicated in children above 12 years with homozygous FH), and 3. Adults at high or very high cardiovascular risk who are statin intolerant and have an LDL-C ≥100 and ≥130 mg/dL, respectively, while on any tolerated hypolipidemic treatment.

The effect of bariatric surgery on patient HRQOL and sexual health during a 1-year postoperative period.

BACKGROUND: Negative consequences of the obesity epidemic include decreased physical, psychological, and sexual health. Bariatric surgery is a well-tolerated and effective treatment for morbid obesity. This study aimed to determine the effect of bariatric surgery on health-related quality of life (HRQOL) and sexual functioning and to identify potential predictors of this effect. METHODS: Eighty morbidly obese patients (50 women) completed the study. HRQOL was measured using the Short Form 36 questionnaire (SF-36). Sexual functioning was assessed using the Female Sexual Functioning Index (FSFI) and the International Index of Erectile Function (IIEF). All participants were evaluated four times as follows: presurgery (T1), 1 month (T2), 6 months (T3), and 1 year (T4) after surgery. RESULTS: Body mass index (BMI) significantly decreased over time (p < 0.001). Apart from male orgasm, all sexual functioning components as well as all SF-36 sub-scales improved between T1 and T4. The maximum improvement was observed between T2 and T3. Baseline HRQOL scores correlated with postoperative improvement in all HRQOL components. BMI improvement was correlated with improvement in role physical, bodily pain, and mental health scores. Baseline total sexual satisfaction score independently predicted total satisfaction improvement in both genders. CONCLUSIONS: The present findings indicate that bariatric surgery represents an effective obesity treatment, leading to significant BMI reduction and improvement in HRQOL and sexual functioning, especially in the first 6 months postoperatively.

Comparison of DXA, QCT and trabecular structure in beta-thalassaemia.

Osteopathy, as a major feature of homozygous beta-thalassaemia, is a multifactorial disorder, not fully understood. We studied the lumbar vertebrae of 48 patients using Dual-Energy X-ray Absorptiometry (DXA) and Quantitative Computed Tomography (QCT), and we focused on structural properties, assessed by High Resolution Computed Tomography (HRCT). Bone Mineral Density (BMD) values were expressed as Z-scores and the results were correlated. The effect of age, sex, and type of thalassaemia and hormonal factors on BMD was assessed. We estimated, with HRCT, the cortex integrity and the number and thickness of trabeculae; the latter were classified to a three-grade scale. Our results showed the overall prevalence of osteoporosis to be 44% with DXA and 6% with QCT. Both techniques revealed an inverse correlation between age and BMD, whereas hormonal factors demonstrated associations with QCT and DXA measurements. The correlation coefficient between DXA's BMD and QCT's trabecular BMD was 0.545 (P < 0.001) whereas the corresponding value for Z-scores was r = 0.491 (P < 0.001). The classification of the patients into normal, osteopenic and osteoporotic categories, using QCT's Z, was in better agreement with the assignment based on trabecular number (K = 0.209, P = 0.053) than the classification using DXA's Z (K = 0.145, P = 0.120). Cortex evaluation by HRCT showed discontinuity in 15 patients. Both methods indicate a progression of osteoporosis with age. Hormonal deficiency is associated with thalassaemic osteoporosis whereas the visual estimation of cortex indicates that Thalassaemia Intermedia (TI) patients could be more affected than Thalassaemia Major (TM). Using the trabecular number as an indicator of osteoporosis, it seems that QCT may evaluate osteopathy better than DXA. Since the former has the ability to measure trabecular and cortical BMD separately, it could give early indication of which changes more rapidly and to what degree.