Laparoscopic Roux-En-Y Gastric Bypass vs Laparoscopic Sleeve Gastrectomy for Weight Loss, Type 2 Diabetes and Comorbidities

More and more U.S. citizens are obese, and many U.S. citizens have been diagnosed with type 2 diabetes. In general, bariatric surgery is used to treat obesity. However, some forms of bariatric surgery can lead to type 2 diabetes remission. Two types of bariatric surgical methods in use for weight loss are laparoscopic roux-en-y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). These two surgical methods are often considered to be treatment options for type 2 diabetes. And while LRYGB may be the most effective treatment for weight loss, a recent study indicates that LSG is as effective as LRYGB for type 2 diabetes treatment.

LRYGB and LSG are similar in some ways: For example, both surgeries "modify the upper gastrointestinal tract anatomy." And this characteristic may make LRYGB and LSG more effective at weight loss and type 2 diabetes management than some other forms of bariatric surgery. However, depending on the disease condition, there are differences in the outcomes associated with the two surgical methods.

The study, mentioned above, showed that both LRYGB and LSG were equally effective in type 2 diabetes remission, obstructive sleep apnoea and quality of life (QoL) improvement. However, LRYGB produced better remission in hypertension, but was associated with a higher complication rate.

Specifically, the researchers concluded that "Although LRYGB induced greater weight loss and better amelioration  of hypertension than LSG, there was no difference in remission of T2DM,  obstructive sleep apnoea, or QoL at 5 years. There were more complications after  LRYGB, but the individual burden for patients with complications was similar  after both operations."

It is also important to remember that there may be contraindications and other potential issues to consider when deciding on the appropriate form of bariatric surgery. The possibility of reintervention should be kept in mind, for example. Indeed, one study demonstrated that "[LSG] has significantly lower risk of reintervention in all categories studied when compared with RYGB at 5-year follow-up."

So, depending on the desired treatment outcome, the healthcare provider and the patient should work together to make the appropriate decision when it comes to bariatric surgery. 

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A Need for a More Restrictive Diabetes Prevention Program Inclusion Criteria

Prediabetes affects approximately 88 million adults in the U.S. And most of these people don’t know they have the condition. So, to some extent, there is a lack of treatment for prediabetes because of a lack of knowledge. Further, the inclusion criteria used to refer individuals to a National Diabetes Prevention Program (National DPP) may need some modification. The current National DPP inclusion criteria may not be restrictive enough to realize the optimum value from the prediabetes treatment.

A recent study, using simulation methods, looked at how placing restrictions in the National DPP inclusion criteria, similar to those used in the DPP trial, may improve the value of the DPP services.

The researchers, performing the study, concluded that the three-year risk of developing type 2 diabetes in the National DPP eligible population ranges from 1% to more than 90%. This means that the National DPP treats individuals who have very little risk of progressing to type 2 diabetes.

The researchers suggested that comparing the original DPP trial inclusion criteria with the National DPP inclusion criteria shows a loosening of National DPP restrictions. For example, in the DPP trial, the criteria did not include HbA1c measurements, whereas the National DPP does. The National DPP also allows participation from individuals starting at 18 years of age, where the DPP trial's starting age was 25. The National DPP allows participation by persons who had gestational diabetes, where the DPP trial did not.

To be included in the DPP trial, an individual had to have "Impaired glucose tolerance (fasting plasma glucose 95-125 mg/dL and 2hr plasma glucose 140-199 mg/dL)" These criteria are more restrictive than the criteria used by the National DPP.

The researchers determined that being more restrictive in the National DPP selection process would be more beneficial. Specifically, the researchers concluded that “Targeting active diabetes prevention to patients at highest risk could improve health outcomes and reduce costs compared to providing the same intervention to a similar number of patients with pre-diabetes without targeted selection."

Primary care organizations, offering Diabetes Prevention Programs, might want to place more restrictions on candidates for DPP programs. This might improve outcomes and lower cost.

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HbA1c May be Superior to FBG in Diagnosing Prediabetes

 FPG (fasting plasma glucose), HbA1c, and the OGTT (oral glucose tolerance test) are used in determining if someone has prediabetes or diabetes. Indeed, all three measures are employed by the National Diabetes Prevention Program (National DPP) to determine eligibility for the National DPP. So, these blood based tests are important, and understanding which one of the three measurements is the most valid in assessing prediabetes and diabetes is a worthwhile undertaking. One recent study has focused on determining the validity of the measurements.

The OGTT is considered by some to be the gold standard for diagnosing diabetes and prediabetes. However, it is not always practical to perform the test, and results are not always reproducible. Therefore, while the OGTT is considered to be more accurate for some high risk patients than the HbA1c test, the HbA1c test is widely used since it is more practical and it is considered to be a valid test. So, determining how the test stacks up against the FPG test is high on the priority list.

In the above mentioned study, 201 patients were looked at. And the investigators concluded that “HbA1c is a more sensitive test compared to FPG in the diagnosis of DM. Prospective studies with broad participation at national and international levels are needed to redefine HbA1c cut-off points for the diagnosis of DM and prediabetes." When this is done, "it will be possible to revise the diagnostic guidelines accordingly.”

While work needs to be done in the area of defining the cut-off points for HbA1c to improve the diagnostic value of the measurement, the above study does seem to indicate that engaging in additional research to define the Hba1c cut-off points is worth the effort.

Healthcare providers should pay attention to this study and other studies related to diabetes and prediabetes measurements. If we can increase the validity of the measurements already in place, this will lead to improved assessment of prediabetes and diabetes. This endeavor will help providers deliver more accurate assessments to patients, enabling patients to take the appropriate actions.

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The Green Mediterranean Diet

During the 1960s, countries such as Italy and Greece followed the diet that has become known as the Mediterranean diet. And people in Mediterranean countries that followed the diet were very healthy compared to Americans who follow common American diets. The Mediterranean diet has been found to improve health and lower premature death. Further, a recent study found that a modified version of the diet, called the green Mediterranean diet, may be healthier.

The Mediterranean diet consists mostly of fruits, vegetables, whole foods, and a moderate amount of meat products, including cheese, poultry and eggs. There is also very infrequent use of red meat, and no use of sugar sweetened beverages or processed foods.

The green Mediterranean diet is not substantially different from the original Mediterranean diet. It essentially replaces the red meat with plant protein, and reduces the amount of all animal protein. A person replaces the animal protein with things like quinoa, soy milk and other sources of protein.

In the study mentioned above, participants were assigned to three groups. One of the groups was the healthy diet guidance (HDG) group; another group was the Mediterranean diet group, and the other group was the green Mediterranean diet group. In the study, all three of the diets were combined with physical activity. After six months, participants in the Mediterranean and the green Mediterranean diet groups had similar weight loss.

However, participants in the green Mediterranean group had greater improvement in the cholesterol, diastolic blood pressure, insulin resistance, and other metabolic parameters. The researchers concluded that “the green MED diet, supplemented with walnuts, green tea and Mankai and lower [helpings of meat and poultry] may amplify the beneficial cardio metabolic effects of Mediterranean diet.”

It appears that while the Mediterranean diet is a very healthy diet, the green Mediterranean diet, which is more plant-based with increased intake of plants that are heavy in protein, may be even healthier. Healthcare providers should consider the green Mediterranean diet when counseling patients.

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Superiority of Lifestyle Intervention for Weight Loss in a Group Setting

The CDC’s National Diabetes Prevention Program (DPP) uses group sessions to deliver the prevention program. The primary goal of the group sessions is weight loss. The desired outcome is delaying or preventing diabetes. The National DPP is based on the diabetes prevention study in which the coaches met one-on-one with each study participant. The results were that intensive lifestyle intervention, focusing on weight loss, lowered the risk of diabetes by 58%.

However, researchers felt that the program was not sustainable, because the cost to deliver the program was too high. So, the program was modified so that it could be delivered in a group setting, which is how the current National DPP is delivered. But some may still question the group delivery approach.

The original Diabetes Prevention Program study ended in 2001. And for several years after the end of the study, translational research was done to determine if the original DPP study's one-on-one lifestyle intervention could be effective in a group setting. One of the translational investigations was done by researchers at the Indiana University School of Medicine.

The researchers concluded that using weight loss as the goal in lifestyle intervention could indeed be effective in a group setting. Participants in the lifestyle intervention group lost 6% of their weight compared to 2% for the participants in the control group.

And a more recent study has, again, demonstrated the effectiveness of lifestyle intervention in a group setting. In fact, the researchers suggested that group lifestyle intervention is actually superior to one-on-one delivery for weight loss. According to the researchers, “Group multi-component lifestyle interventions are superior for weight loss compared to one-to-one interventions with respect to adult weight management.”

So, providers should consider group settings for weight loss and weight maintenance. The providers should also consider group settings for other chronic disease treatments. The actions could increase patient health. 

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Diet Can Cause an Increase in Ghrelin

Ghrelin is sometimes called the  hunger gene. It is called the hunger gene because it plays a large role in regulating appetite. The hormone is produced in the gastrointestinal system -- mainly in the stomach. Ghrelin can cause feelings of hunger and fullness, and it can cause our bodies to store fat. In fact, controlling ghrelin in our body and the ghrelin production  can enable us to lose weight and maintain weight loss.

Ghrelin is very important in weight management. And one study has shown that weight loss resulting from diet can cause an increase in ghrelin, thereby, producing weight regain. It has been known for some time that one of the reasons that some types of weight loss surgery are effective is because the surgeries reduce the size of the stomach, limiting the production of ghrelin. But anything that increases ghrelin may cause weight gain.

The ghrelin-related study was a post hoc analysis, associated with a study called the Diabetes Remission Clinical Trial or DiRECT. The study was done in Scotland. The aim of the DIRECT was to “assess the effect of weight loss on type 2 diabetes remission.” The aim of the post hoc analysis was to “To investigate whether appetite-related hormones were predictors of weight regain in the Diabetes Remission Clinical Trial (DiRECT)." In the post hoc analysis, the researchers looked at the hormones leptin, ghrelin, GLP-1 and PYY. The researchers looked at these hormones at baseline, and at 5, 12 and 24 months.

For the post hoc analysis, 253 participants were included. The intervention group consisted of 144 participants and the control group consisted of 99 participants. The researchers concluded that “the rise in ghrelin (but not any other measured hormone) during the diet -induced weight loss was a predictor of weight regain during follow-up, and concentrations remain elevated over time, suggested a small but significant compensatory drive to regain weight. Attenuating the effects of ghrelin may improve [weight-loss maintenance].”

These are important findings, and, again, the findings confirm the role that ghrelin plays in weight loss and weight gain. Further, by finding ways to lower the amount of ghrelin in our bodies, we stand a good chance of losing weight and maintaining weight loss.

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Prediabetes and Cardiac Autonomic Neuropathy

Prediabetes is a condition where an individual has abnormally high blood glucose, while not high enough to be diagnosed as diabetes. Prediabetes can cause heart and kidney problems. Cardiac autonomic neuropathy (CAN) may be defined as “the impairment of autonomic control of the cardiovascular system.” While the condition is frequently not given much focus, CAN is frequently associated with type 1 and type 2 diabetes. CAN may also be associated with heart problems and mortality. Further, at least one recent study has concluded that CAN is also associated with prediabetes.

The investigators involved in the study did a search, electronically, to find individuals, in other studies, with prediabetes, normal glucose and type 2 diabetes. The researchers searched the following databases: Medline, MBASE, Pubmed, Web of science, Scopus and Cochrane.

As a result of the database search, the researchers found 4431 participants who satisfied the analysis’ inclusion criteria. The participants included 1730 individuals with prediabetes. There were 1999 individuals who had normal glucose. And there were 702 individuals with type 2 diabetes. And there was a higher than normal number of individuals experiencing CAN.

Further, the researcher concluded that “There [was] a higher than expected prevalence of CAN in prediabetes. Early detection of CAN in prediabetes through population screening needs careful consideration in view of the excess morbidity and mortality risk associated with this condition.”

The above study underlines the importance of diagnosing prediabetes. And once prediabetes is diagnosed, screening for other known prediabetes comorbidities should then occur -- including screening for CAN. Providers should make it a point to screen for prediabetes. The providers should counsel patients who do have predicates on how to lower the chances of getting type 2 diabetes. The providers should then advise the patients on other prediabetes-associated conditions. This can benefit a patient by potentially improving the patient’s health.

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