Bariatric Times

MAR 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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13 Interview Bariatric Times • March 2017 r emission. But once you start regaining weight, you gain fat, and that is when blood sugars start rising again." I think we have to be really aggressive with weight loss— e ven after surgery is done—that is the important point for clinicians and patients. To get patients back into T2DM remission, I usually have to put t hem on medications, such as metformin. We might also consider utilizing anti-obesity drugs, such as glucagon-like peptide-1 receptor agonists (GLP-1) and SGLT-2 i nhibitors, which may alleviate cravings or weight gain. Do investigators believe there is a reason as to why gastric bypass shows better glycemic control versus sleeve gastrectomy? Dr. Kashyap: Again, our results s how that the driving factor is weight loss—the greater the weight loss, the greater the improvement in T2DM. In this trial, we got the most weight loss with RYGB. I think RYGB is still gold standard for improving diabetes, but obviously LSG did fairly well too. I think that is one reason LSG is on the rise. Patients seem to like it more than the bypass. I think most patients will prefer to have a sleeve perhaps because it is technically easier for the surgeon to perform and appears to have less gastrointestinal complications .In STAMPEDE, LSG did well, but the RYGB showed superior results when it came to improving insulin secretion and sensitivity. When you look at just the surgical groups, people with earlier duration of diabetes have a better outcome. This makes sense because the pancreas and beta cells are still somewhat functional and able to make insulin. With the RYGB, the amount of fat in the abdominal organs—pancreatic fat, abdominal fat, liver fat—may be reduced more than with LSG. Our previous STAMPEDE results showed that at two years, weight loss being observed from both procedures was fairly similar, but we started seeing greater abdominal weight loss in the RYGB group. I think there's better fat loss in the pancreas and liver and this is why we are getting better blood sugar control/not needing medications with the RYGB. It all boils down to body weight and fat loss. It's just better with RYGB, and I believe it may have something to do with bypassing the intestine. I'm currently involved in research observing the following patient groups following bariatric surgery: 1) those who hit T2DM remission, 2) those who never o btained remission following surgery, and 2) those who hit remission but then fell out of it after the first year. I can tell you the answer is weight—the amount o f weight loss is critical. I think the abdominal fat loss, and not so much body mass index (BMI), is what is really linked to T2DM. You bring up an interesting point—measuring weight loss success using BMI. Did STAMPEDE measure BMI? What are your thoughts on its use? Dr. Kashyap: I think BMI is crude and possibly not the best measure of weight loss success. For patients with metabolic disease, waist c ircumference and fasting insulin levels are indicators of insulin resistance and metabolic disease. During STAMPEDE planning, when we looked at all the factors at b aseline and asked which factors really account for remission versus non-remission, BMI was not among them. When you looked at people with BMI under 35kg/m 2 versus I think we have to be really aggressive with weight loss—even after surgery is d one—that is the important point for clinicians and patients.

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