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Timing of bariatric surgery in people with obesity and diabetes
Full text linkThe use of bariatric surgery in the clinical management of type 2 diabetes in severely obese subjects has been included in the clinical practice recommendations released by the most influential diabetologic associations. However, the timing during the diabetic course in which this use may have the better benefit/risk ratio remains debated. Is it better to use surgery very early in the course of the disease in order to anticipate clinical deterioration, or we should favour a delayed approach in which we reserve the more risky surgery only to patients not adequately controlled with the maximal pharmacologic strategy? In this paper, past and recent evidences about the role of bariatric surgery in the different stages of the clinical course of type 2 diabetes have been revised, starting from pre-diabetes and ending to long-standing diabetic state with established or end-stage macro- and micro-vascular complications. Available evidences strongly advocate in favor of the application of bariatric surgery in the early phase of this course, possibly in the pre-diabetic or in very early diabetic stages. To reserve surgery to more advanced and complicated stages of the disease seems to confer less benefits for the clinical course of diabetes and exposes these more frail patients to the possible side effects of a rapid weight loss
Visceral obesity and the metabolic syndrome: effects of weight loss
No full textA large body of experimental and epidemiological evidence has established an association between visceral obesity and the metabolic syndrome, which retains its power throughout the spectrum of adiposity and is still clinically meaningful in severe obesity. The association may be due to an overload of liver free fatty acids (FFA) produced by the high lipolytic activity of omental fat. A substantial improvement in all aspects of the metabolic syndrome with only a moderate degree of weight loss has been observed in a large number of randomised controlled studies and can also be obtained in severe obesity, despite the fact that the patients remain obese. The reasons for this apparent dissociation between weight loss and metabolic improvement are not yet clearly understood, but may involve the relationship between visceral fat and metabolic alterations. The results of some studies suggest that the favourable metabolic changes observed in obese patients with weight loss may be directly attributable to a reduction in visceral fat, and other studies have recently shown that a rapid and preferential reduction in visceral fat mass occurs during the first phase of weight loss in morbidly obese patients possibly as a result of sympathetic nervous system activation. It is therefore possible that the apparent dissociation between weight loss and metabolic improvement is partially due to a difference in the responsiveness of visceral and subcutaneous adipose tissue to energy restriction: i.e. the fact that the metabolic profile of patients with visceral obesity may substantially improve after the loss of only a few kilograms of body weight could be related to a greater relative reduction in the amount of visceral rather than other fat. In this respect, the characteristically high rate of visceral fat mobilisation can also be seen as a good target for interventions aimed at reducing cardiovascular risk factors
Reply to a Letter to the Editor: Bariatric Surgery in Class I Obesity. A Position Statement from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)—Obesity Surgery 2014;24:487–519
Full text linkReply to a letter to the Edito
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