title: Modified Roux-en-Y gastric bypass for type 2 diabetes mellitus in China. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Outcomes of bariatric surgery in patients with body mass index <35 kg/m2. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Diabetes Remission and Insulin Secretion After Gastric Bypass in Patients with Body Mass Index <35 kg/m2 Treatment of Mild to Moderate Obesity with Laparoscopic Adjustable Gastric Banding or an Intensive Medical Program Laparoscopic Roux-en-Y Gastric Bypass for the Treatment of Type II Diabetes Mellitus in Chinese Patients with Body Mass Index of 25–35 Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Bariatric surgery and long-term cardiovascular events. Laparoscopic adjustable gastric banding for patients with body mass index of <or=35 kg/m2. Hyperoxaluric nephrolithiasis is a complication of Roux-en-Y gastric bypass surgery. The Effects of Biliopancreatic Diversion on Type 2 Diabetes Mellitus in Patients with Mild Obesity (BMI 30–35 kg/m2) and Simple Overweight (BMI 25–30 kg/m2): A Prospective Controlled Study Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m(2). Acute effects of gastric bypass versus gastric restrictive surgery on β-cell function and insulinotropic hormones in severely obese patients with type 2 diabetes The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study Safety and Efficacy of Roux-en-Y Gastric Bypass to Treat Type 2 Diabetes Mellitus in Non-severely Obese Patients Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. Effect of Laparoscopic Mini-Gastric Bypass for Type 2 Diabetes Mellitus: Comparison of BMI >35 and <35 kg/m2 Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35 kg/m2
abstract: BACKGROUND / AIMS This study aim ed to evaluate the efficacy of modified Roux-en-Y gastric bypass for type 2 diabetes mellitus . METHODOLOGY Forty-five type 2 diabetes mellitus patients underwent modified Roux-en-Y gastric bypass at WeiFang People 's Hospital . Data on patient demographics , fasting plasma glucose ( FPG ) , body mass index ( BMI ) , medication use , remission and hemoglobin A1c ( HbAlc ) were prospect ively collected and analyzed . RESULTS At 6 months after surgery , all of these 45 patients obtained remission or a marked improvement . FPG was in the normal range in 39 ( 86.7 % ) patients stopping medicine treatment for their diabetes . Six patients ( 13.3 % ) had an obvious reduced abnormal FPG and they only required lower drug dosage . No statistically significant differences were found between the obese or non-obese groups ( p=0.311 ) . The mean BMI dropped from 28.9±3.0 kg/m2 to 27.4±2.8 kg/m2 ( p=0.000 ) at the third month and 26.3±2.5 kg/m2 ( p=0.000 ) at the sixth month . HbAlc decreased from their preoperative values of 7.4%±2.2 % to 6.3%±1.5 % ( p=0.000 ) at the third month and 5.1%±0.9 % ( p=0.000 ) at the sixth month . CONCLUSIONS Modified Roux-en-Y gastric bypass was effective in treating  type 2 diabetes mellitus , independent of body mass index OBJECTIVE Our purpose was to measure the agreement , reliability , construct validity , and feasibility of a measurement tool to assess  systematic review s ( AMSTAR ) . STUDY DESIGN AND SETTING We r and omly selected 30 systematic review s from a data base . Each was assessed by two review ers using : ( 1 ) the enhanced quality assessment question naire ( Overview of Quality Assessment Question naire [ OQAQ ] ) ; ( 2 ) Sacks ' instrument ; and ( 3 ) our newly developed measurement tool ( AMSTAR ) . We report on reliability ( interobserver kappas of the 11 AMSTAR items ) , intraclass correlation coefficients ( ICCs ) of the sum scores , construct validity ( ICCs of the sum scores of AMSTAR compared with those of other instruments ) , and completion times . RESULTS The interrater agreement of the individual items of AMSTAR was substantial with a mean kappa of 0.70 ( 95 % confidence interval [ CI ] : 0.57 , 0.83 ) ( range : 0.38 - 1.0 ) . Kappas recorded for the other instruments were 0.63 ( 95 % CI : 0.38 , 0.78 ) for enhanced OQAQ and 0.40 ( 95 % CI : 0.29 , 0.50 ) for the Sacks ' instrument . The ICC of the total score for AMSTAR was 0.84 ( 95 % CI : 0.65 , 0.92 ) compared with 0.91 ( 95 % CI : 0.82 , 0.96 ) for OQAQ and 0.86 ( 95 % CI : 0.71 , 0.94 ) for the Sacks ' instrument . AMSTAR proved easy to apply , each review taking about 15 minutes to complete . CONCLUSIONS AMSTAR has good agreement , reliability , construct validity , and feasibility . These findings need confirmation by a broader range of assessors and a more diverse range of review OBJECTIVE To examine the effect of a large , long st and ing and intentional weight reduction on the incidence of diabetes , hypertension and lipid disturbances in severely obese individuals as compared to weight-stable obese controls . RESEARCH METHODS AND PROCEDURES The ongoing prospect i ve SOS ( Swedish Obese Subjects ) intervention consists of a surgically treated group and a matched control group obtaining conventional obesity treatment . This report is based on 845 surgically treated patients and 845 controls ( BMI 41.0+/-4.6 kg/m2 ( mean+/-st and ard deviation [ S ] ) ) followed for 2 years . RESULTS Surgically treated patients lost 28+/-15 kg and controls 0.5+/-8.9 kg ( p<0.0001 ) . Two-year incidence of hypertension , diabetes , hyperinsulinemia , and lipid disturbances was compared in the two treatment groups . Adjusted odds ratios ( 95 % CI ) for the surgically treated group versus controls were 0.38 ( 0.22 , 0.65 ) for hypertension , 0.02 ( 0.00 , 0.16 ) for diabetes , 0.10 ( 0.03 , 0.28 ) for hyperinsulinemia , 0 . 10 ( 0.04 , 0.25 ) for hypertriglyceridemia , 0.28 ( 0.16 , 0.49 ) for low HDL-cholesterol and 1.24 ( 0.84 , 1.8 ) for hypercholesterolemia . Compared to controls , the 2-year recovery rates from hypertension , diabetes , hypo-HDL , and hypertriglyceridemia were significantly higher in the surgically treated group . DISCUSSION Intentional weight loss in the obese causes a marked reduction in the 2-year incidence of hypertension , diabetes and some lipid disturbances . The results suggest that severe obesity can and should be treated BACKGROUND Patients who are categorized with class I obesity have a body mass index ( BMI ) of 30 - 34.99 kg/m(2 ) . This population of patients has a predisposition to diabetes , hypertension , and dyslipidemia . The aim of the present study was to investigate the improvements of these co-morbidities in a class I obese population that had undergone a bariatric procedure . METHODS After internal review board approval and with adherence to the Health Insurance Portability and Accountability Act guidelines , a retrospective review was performed of a prospect ively maintained data base of 42 class I obese patients who underwent a bariatric procedure at our institution during a 10-year period , from February 2000 to May 2010 . The fasting glucose level , glycosylated hemoglobin level , lipid profile , initial weight , and BMI were measured in the preoperative and postoperative periods . RESULTS Our patient population consisted of 30 women and 12 men , with a preoperative mean BMI of 33.9 kg/m(2 ) .  Laparoscopic sleeve gastrectomy was performed in 24 patients ( 57 % ) , laparoscopic Roux-en-Y gastric bypass in 8 ( 19 % ) , and laparoscopic adjustable gastric b and ing in 10 ( 24 % ) . Of these 42 patients , 25 ( 60 % ) had type 2 diabetes , 1 patient was glucose intolerant , 27 ( 64 % ) had arterial hypertension , 25 ( 60 % ) had dyslipidemia , 17 ( 40 % ) had sleep apnea , and 8 ( 19 % ) had osteoarthritis . The postoperative findings included a mean BMI of 26.5 kg/m(2 ) and a mean weight loss of 41.4 lb . Of the 25 diabetic patients , 5 ( 20 % ) gained remission and 12 ( 48 % ) improvement of their diabetic status . The single patient with glucose intolerance showed improvement . Of the 27 patients with arterial hypertension , 9 ( 33 % ) showed remission and 13 ( 52 % ) improvement . Dyslipidemia resolved in 5 patients ( 20 % ) and improved in 13 ( 52 % ) . Obstructive sleep apnea resolved in 10 ( 59 % ) and improvement was seen in 1 patient ( 6 % ) . Finally , osteoarthritis resolved in 1 patient ( 12 % ) and improved in 5 ( 63 % ) . CONCLUSION Bariatric surgery can significantly improve or resolve co-morbid metabolic conditions in patients with class I obesity BACKGROUND In the 2.8 years of the Diabetes Prevention Program ( DPP ) r and omised clinical trial ,  diabetes incidence  in high-risk adults was reduced by 58 % with intensive lifestyle intervention and by 31 % with metformin , compared with placebo . We investigated the persistence of these effects in the long term . METHODS All active DPP participants were eligible for continued follow-up . 2766 of 3150 ( 88 % ) enrolled for a median additional follow-up of 5.7 years ( IQR 5.5 - 5.8 ) . 910 participants were from the lifestyle , 924 from the metformin , and 932 were from the original placebo groups .  On the basis of the benefits from the intensive lifestyle intervention in the DPP , all three groups were offered group-implemented lifestyle intervention . Metformin treatment was continued in the original metformin group ( 850 mg twice daily as tolerated ) , with participants unmasked to assignment , and the original lifestyle intervention group was offered additional lifestyle support . The primary outcome was development of diabetes according to American Diabetes Association criteria . Analysis was by intention-to-treat . This study is registered with Clinical Trials.gov , number NCT00038727 . FINDINGS During the 10.0-year ( IQR 9.0 - 10.5 ) follow-up since r and omisation to DPP , the original lifestyle group lost , then partly regained weight . The modest weight loss with metformin was maintained . Diabetes incidence rates during the DPP were 4.8 cases per 100 person-years ( 95 % CI 4.1 - 5.7 ) in the intensive lifestyle intervention group , 7.8 ( 6.8 - 8.8 ) in the metformin group , and 11.0 ( 9.8 - 12.3 ) in the placebo group . Diabetes incidence rates in this follow-up study were similar between treatment groups : 5.9 per 100 person-years ( 5.1 - 6.8 ) for lifestyle , 4.9 ( 4.2 - 5.7 ) for metformin , and 5.6 ( 4.8 - 6.5 ) for placebo . Diabetes incidence in the 10 years since DPP r and omisation was reduced by 34 % ( 24 - 42 ) in the lifestyle group and 18 % ( 7 - 28 ) in the metformin group compared with placebo . INTERPRETATION During follow-up after DPP , incidences in the former placebo and metformin groups fell to equal those in the former lifestyle group , but the cumulative incidence of diabetes remained lowest in the lifestyle group . Prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years . FUNDING National Institute of Diabetes and Digestive and Kidney Diseases ( NIDDK ) Background Most morbidly obese patients who undergo gastric bypass  experience rapid remission of type 2 diabetes mellitus ( T2DM ) but the response in non-morbidly obese patients is not clear . This trial prospect ively assessed the effect of diabetes remission , glucose metabolism , and the serial changes of insulin secretion after gastric bypass in inadequately controlled T2DM patients with a BMI of 23–35 kg/m2 . Methods A total of 62 consecutive patients with T2DM and a BMI of 23–35 kg/m2 underwent gastric bypass .  Data were prospect ively collected before surgery and 1 , 4 , 12 , 26 , and 52 weeks and 2 years after surgery . Insulin secretion was measured by insulinogenic index and area under the curve ( AUC ) during a st and ard oral glucose tolerance test ( OGTT ) . Remission of type 2 diabetes was defined as fasting glucose level < 110 mg/dl and HbA1c < 6.0 % without any glycemic therapy . Results Of the 62 patients , 24 were men and 38 were women ( age 43.1 ± 10.8 years ) . Their preoperative characteristics were as follows : BMI 30.1 ± 3.3 kg/m2 , waist circumference 99.6 ± 9.6 cm , C-peptide 3.1 ± 1.4 ng/ml , and duration of T2DM 5.4 ± 5.1 years . The mean BMI decreased postoperatively to 22.6 ± 2.3 kg/m2 in 1 year and 23.0 ± 2.7 kg/m2 in 2 years . The mean HbA1c decreased from 9.7 ± 1.9 % to 5.8 ± 0.5 % in 1 year and 5.9 ± 0.5 % in 2 years . Complete remission of T2DM was achieved in 57 % in 1 year and 55 % in 2 years after surgery . Before surgery , the OGTT test showed a blunted insulin secretion pattern with an insulinogenic index of 0.1 ± 0.2 and AUC of 2,324 ± 1,015 μIU min/ml . In 1 week after surgery , the insulinogenic index increased to 0.16 and AUC decreased to 1,366 μIU min/ml along with a rapid drop of insulin resistance . The insulinogenic index and AUC gradually increased to 0.27 and 3,220 , respectively , 1 year after surgery and remained stable up to 2 years with a very low insulin resistance . Conclusions Laparoscopic gastric bypass facilitates immediate improvement in the glucose metabolism of inadequately controlled non-severe  obese T2DM patients , and the benefit is sustained up to 2 years after surgery . The benefit is regulated by the decrease in insulin resistance , increase in early insulin response , and total insulin secretion to glucose load Context Observational studies have shown sustained weight loss after surgery for extreme obesity . No r and omized trial of contemporary surgical methods has been performed . Contribution The authors r and omly assigned 80 mildly to moderately obese ( body mass index , 30 to 35 kg/m2 ) adults to laparoscopic placement of an adjustable gastric b and or to an intensive nonsurgical weight loss program . After 2 years , the surgical group had lost 21.6 % of initial weight , and the nonsurgical group had lost 5.5 % of initial weight . Four patients required laparoscopic revision of the gastric b and . Caution s The study was not design ed to detect uncommon adverse events . Implication s Laparoscopic gastric b and ing is effective treatment for mild to moderate obesity . The Editors The development of a safe and effective treatment for obesity is a leading challenge in health care today . Obesity is an increasing health problem across the world with a prevalence of more than 20 % among the adult population in Western countries and more than 30 % in the United States ( 1 , 2 ) . The increasing prevalence is associated with a parallel increase of several obesity-related diseases , in particular , the diseases of the metabolic syndrome ( 3 , 4 ) , which include type 2 diabetes , hypertension , and dyslipidemia , and are linked to nonalcoholic steatohepatitis , obstructive sleep apnea , and the polycystic ovary syndrome . For obese individuals , the options are limited . Behavioral therapies of reduced energy intake , improved eating practice s , and increased exercise and activity , supplemented by pharmacotherapy , generally achieve only modest and often transient effects ( 5 , 6 ) . Observational studies have shown that bariatric surgical therapies involving gastric restriction by various forms of stapling with or without diversion of the gut to generate malabsorption of food are effective in achieving major weight loss and clinical ly significant improvements in health and quality of life ( 7 - 11 ) . Strong direct evidence from r and omized , controlled trials of the relative benefits of nonsurgical and surgical therapies is lacking . We are aware of only a single study , performed in the 1980s , in which 60 morbidly obese patients were r and omly assigned , without informed consent , to diet plus an early form of gastric stapling or to diet alone ( 12 ) . The maximum weight losses did not differ between the groups . However , the weight regain was greater in the diet-only group . The advent of the laparoscopic adjustable gastric b and has provided a new bariatric surgical option , which has proved to be safe , minimally invasive in its application , gentle in its use through its adjustability and easy reversibility , and similarly effective to the other bariatric procedures ( 10 , 13 , 14 ) . Figure 1 shows the LAP-B AND System ( INAMED Health , Santa Barbara , California ) and demonstrates the key feature of adjustability of the area within the b and through which it induces satiety ( 15 ) . Patients require no more than an overnight hospital stay , and the procedure has been shown to be markedly safer than gastric bypass surgery ( 13 ) . Figure 1 . The laparoscopic adjustable gastric b and ( LAP-B AND System , INAMED Health , Santa Barbara , California ) with no added fluid ( top ) and with 2 mL of fluid added ( bottom ) . We hypothesized that surgical therapy would induce more weight loss , health benefit , and improvement in quality of life than nonsurgical therapy and have conducted a r and omized , controlled trial comparing the effectiveness of current nonsurgical therapy with laparoscopic adjustable gastric b and ing in a group of mildly to moderately obese adults ( body mass index , 30 kg/m2 to 35 kg/m2 ) . We did not study patients with a body mass index greater than 35 kg/m2 because current observational data suggest that outcomes after nonsurgical treatment were unlikely to be equal to those after surgical care for these patients . The principal outcome measures were weight change , health , quality of life , and complications of therapy . Methods Patient Recruitment We recruited patients for the study through a newspaper advertisement . All patient assessment s and outpatient treatments were conducted at a community clinic dedicated to obesity management or in the clinics of a university department of surgery . Surgical procedures were conducted at a private community hospital experienced in the care of bariatric surgical patients . Patients in both groups did not pay any medical costs generated by the study . The human ethics committees of The Alfred Hospital and The Avenue Hospital approved the study in accordance with the guidelines of the National Health and Medical Research Council ( www.nhmrc.gov.au/publications/synopses/e35syn.htm ) and with the Helsinki Declaration of 1975 , as revised in 2000 ( www.wma.net/e/ethicsunit/pdf/draft_historical_contemporary_perspectives.pdf ) . Inclusion Criteria We considered patients to be eligible if they were between 20 and 50 years of age ; had a body mass index of 30 kg/m2 to 35 kg/m2 ; had identifiable problems , including an obesity-related comorbid condition ( such as hypertension , dyslipidemia , diabetes , obstructive sleep apnea , or gastroesophageal reflux disease ) , severe physical limitations , or clinical ly significant psychosocial problems associated with their obesity ; had attempted to reduce weight over at least the previous 5 years ; could underst and the options offered and the r and omization process ; and were willing to comply with the requirements of each program . Exclusion Criteria We excluded c and i date s with a history of bariatric surgery or medical problems that contraindicated treatment in either study group , such as impaired mental status , drug or alcohol addiction , or portal hypertension . In addition , we excluded participants if they had undergone an intensive , physician-supervised program that used very-low-calorie diets or pharmacotherapy or if they did not attend the 2 initial patient information visits . Assessment We provided detailed information about the problems of obesity and about the 2 study groups through at least 2 discussion periods and a patient information booklet . Initial assessment included anthropometric measures ; identification of medical , physical , or psychosocial problems ( both weight-related and other ) ; and a discussion of previous weight loss efforts . The assessment included a detailed dietary history by the trial dietitian and a review by a specialist physician to determine the presence and severity of associated medical conditions . Initial investigations included measurements of fasting blood glucose level ; serum insulin level ; and a lipid profile , including HDL cholesterol and LDL cholesterol levels . After initial assessment , we instituted a program of advice on appropriate eating patterns and exercise and followed each patient on a monthly basis for 3 months . During this time , we assessed the patients ' fulfillment of tasks , such as completion of a food diary , and overall adherence to appointments . R and omization Process We r and omly allocated eligible patients to receive a conventional , intensive , nonsurgical program or laparoscopic adjustable gastric b and ing .  A computer-derived r and om allocation sequence , without blocking or stratification , performed the r and omization . This was prepared at the trial office . The trial coordinator enrolled participants and informed them of the trial allocation . After assessment had confirmed a participant 's suitability for r and omization , the coordinator contacted the trial office by telephone for allocation . The study was not blinded . Description of Nonsurgical and Surgical Interventions Common Program We instructed and encouraged all patients to follow appropriate lifestyle behavior of good eating practice s and increased exercise and activity . We also encouraged them to exercise for at least 200 minutes per week . Nonsurgical Program This program centered on the use of behavioral modification , very-low-calorie diet , and pharmacotherapy with education and professional support on appropriate eating and exercise behavior . During the 2-year period , 3 trained physicians developed a program using all the available modalities for each individual on the basis of guidelines prepared and continually review ed by a panel of experienced bariatric physicians . The program began with an intensive 6-month period of very-low-calorie diet ( 500 to 550 kcal/d ) using 1 to 3 packets of Optifast ( Novartis , Fremont , Michigan ) daily for 12 weeks , followed by a transition phase over 4 weeks combining some very-low-calorie meals with 120 mg of orlistat before nonvery-low-calorie diet meals , and then 120 mg of orlistat before all meals until the completion of the intensive phase . This intensive 6-month program was followed by further courses of very-low-calorie diets or orlistat as tolerated , as well as continual behavioral , dietary , and exercise advice to assist the participant in maintaining weight loss over a prolonged period . Sibutramine was not approved for use in Australia during the first 12 months of the study and , therefore , was not incorporated into the medical program . The management program for each individual was design ed to reflect good clinical practice . A physician saw each patient every 2 weeks during the very-low-calorie diet program and every 4 to 6 weeks during the rest of the study . All patients were seen at least every 6 weeks . Surgical Program Two experienced surgeons performed the laparoscopic adjustable gastric b and ( LAP-B AND System ) procedure , by a st and ardized method ( 14 ) , within 1 month of r and omization . The b and was placed along the perigastric pathway in all cases ( 16 ) . The treating surgeon review ed patient progress every 4 to 6 weeks during the study period and made adjustments to the volume of saline within the b and in the office by using st and ard clinical criteria ( 17 ) . Adverse Events All patients in the study were question ed about the occurrence of adverse events at each consultation , and physicians recorded the Background Laparoscopic Roux-en-Y gastric bypass ( LRYGB ) can dramatically ameliorate  type 2 diabetes mellitus ( T2DM ) in morbidly obese patients . However , there is little evidence supporting the effectiveness of LRYGB in low body mass index ( BMI ) patients . The study was design ed to evaluate the safety and results of LRYGB for achieving T2DM remission in patients with BMI in the range of 25–35 kg/m2 . Methods Twenty-two patients ( two men and 20 women ) with T2DM underwent LRYGB .  Data on patient demographics , BMI , co-morbidities , and details of diabetes mellitus , including disease duration , family history , medication use , and remission , were prospect ively collected and analyzed . Results The mean age was 47 years ( range , 28–63 years ) , mean BMI was 30.81 ( range , 25.00–34.80 kg/m2 ) , and mean duration of T2DM onset was 6.57 years ( range , 1–20 years ) . Sixteen ( 72.27 % ) patients had a family history of T2DM . There was no mortality , but two ( 9 % ) patients experienced complications : an early gastrojejunostomy hemorrhage and frequent loose stools that required revision surgery . At 12 months , 14 ( 63.6 % ) patients showed T2DM remission , six ( 27.3 % ) showed glycemic control , and two ( 9.1 % ) showed improvement . The group achieving remission had a higher BMI ( p = 0.001 ) , younger age ( p = 0.002 ) , and shorter duration of diabetes ( p = 0.001 ) . These three factors may be predictors of diabetes resolution at 12 months . Conclusion Early intervention in low- BMI patients yields better remission rates because age , BMI , and duration of T2DM predict glycemic outcomes OBJECTIVES To determine the efficacies of 2 weight-reducing operations on diabetic control and the role of duodenum exclusion . DESIGN Double-blind r and omized controlled trial . SETTING Department of Surgery of the Min-Sheng General Hospital , National Taiwan University . PATIENTS We studied 60 moderately obese patients ( body mass index > 25 and < 35 ) aged > 30 to < 60 years who had poorly controlled type 2 diabetes mellitus ( T2DM ) ( hemoglobin A(1c ) [ HbA(1c ) ] > 7.5 % ) after conventional treatment ( > 6 months ) from September 1 , 2007 , through June 30 , 2008 . Patients and observers were masked during the follow-up , which ended in 2009 , 1 year after final enrollment . INTERVENTIONS Gastric bypass with duodenum exclusion ( n = 30 ) vs sleeve gastrectomy without duodenum exclusion ( n = 30 ) . MAIN OUTCOME MEASURES The primary outcome was remission of T2DM ( fasting glucose < 126 mg/dL and HbA(1c ) < 6.5 % without glycemic therapy ) . Secondary measures included weight and metabolic syndrome . Analysis was by intention to treat . RESULTS Of the 60 patients enrolled , all completed the 12-month follow-up . Remission of T2DM was achieved by 28 ( 93 % ) in the gastric bypass group and 14 ( 47 % ) in the sleeve gastrectomy group ( P = .02 ) . Participants assigned to gastric bypass had lost more weight , achieved a lower waist circumference , and had lower glucose , HbA(1c ) , and blood lipid levels than the sleeve gastrectomy group . No serious complications occurred in either group . CONCLUSIONS Participants r and omized to gastric bypass were more likely to achieve remission of T2DM . Duodenum exclusion plays a role in T2DM treatment and should be assessed . Trial Registration clinical trials.gov Identifier : NCT00540462 ( http://www . clinical trials.gov ) CONTEXT Obesity is a risk factor for cardiovascular events . Weight loss might protect against cardiovascular events , but solid evidence is lacking . OBJECTIVE To study the association between bariatric surgery , weight loss , and cardiovascular events . DESIGN , SETTING , AND PARTICIPANTS The Swedish Obese Subjects ( SOS ) study is an ongoing , nonr and omized , prospect i ve , controlled study conducted at 25 public surgical departments and 480 primary health care centers in Sweden of 2010 obese participants who underwent bariatric surgery and 2037 contemporaneously matched obese controls who received usual care . Patients were recruited between September 1 , 1987 , and January 31 , 2001 . Date of analysis was December 31 , 2009 , with median follow-up of 14.7 years ( range , 0 - 20 years ) . Inclusion criteria were age 37 to 60 years and a body mass index of at least 34 in men and at least 38 in women . Exclusion criteria were identical in surgery and control patients . Surgery patients underwent gastric bypass ( 13.2 % ) , b and ing ( 18.7 % ) , or vertical b and ed gastroplasty ( 68.1 % ) , and controls received usual care in the Swedish primary health care system . Physical and biochemical examinations and data base cross-checks were undertaken at preplanned intervals . MAIN OUTCOME MEASURES The primary end point of the SOS study ( total mortality ) was published in 2007 . Myocardial infa rct ion and stroke were predefined secondary end points , considered separately and combined . RESULTS Bariatric surgery was associated with a reduced number of cardiovascular deaths ( 28 events among 2010 patients in the surgery group vs 49 events among 2037 patients in the control group ; adjusted hazard ratio [ HR ] , 0.47 ; 95 % CI , 0.29 - 0.76 ; P = .002 ) . The number of total first time ( fatal or nonfatal ) cardiovascular events ( myocardial infa rct ion or stroke , whichever came first ) was lower in the surgery group ( 199 events among 2010 patients ) than in the control group ( 234 events among 2037 patients ; adjusted HR , 0.67 ; 95 % CI , 0.54 - 0.83 ; P < .001 ) . CONCLUSION Compared with usual care , bariatric surgery was associated with reduced number of cardiovascular deaths and lower incidence of cardiovascular events in obese adults BACKGROUND Many mild-to-moderately obese individuals ( body mass index [ BMI ] 30 - 35 kg/m(2 ) ) have serious diseases related to their obesity . Nonoperative therapy is ineffective in the long term , yet surgery has never been made widely available to this population . METHODS Between 1996 and 2004 , 93 patients with a BMI of 30 - 35 kg/m(2 ) underwent laparoscopic adjustable gastric b and ing with the LAP-B AND . All patients were referred by their primary physician , entered into a comprehensive bariatric surgery program at one Australian center , and operated on by one surgeon . Data on all patients were collected prospect ively and entered into an electronic registry . The study parameters included preoperative age , gender , BMI , presence of co-morbidities , percentage of excess weight loss , and resolution of co-morbidities . RESULTS The mean age was 44.6 years ( range 16 - 76 ) , mean weight was 98 kg , and the mean BMI was 32.7 kg/m(2 ) ( range 30 - 34 ) . Of the 93 patients , 42 ( 45 % ) had co-morbidities , including asthma , diabetes , hypertension , and sleep apnea .  The proportion of patients in follow-up was 79 % , 85 % , and 89 % at 1 , 2 , and 3 years , respectively . The mean weight was reduced to 71 kg at 1 year , 72 kg at 2 years , and 72 kg at 3 years . The mean BMI was reduced to 27.2 + /- 2.2 , 27.3 + /- 3.1 , and 27.6 + /- 3.7 kg/m(2 ) , respectively , and the mean percentage of excess weight loss was 57.9 % + /- 24.5 % , 57.6 + /- 29.3 % , and 53.8 % + /- 32.8 % at 1 , 2 , and 3 years , respectively . At 3 years , the BMI was 18 - 24 kg/m(2 ) in 34 % , 25 - 29 kg/m(2 ) in 51 % , and 30 - 35 kg/m(2 ) in 10 % . At 3 years , the percentage of excess weight loss was < 25 % in 10 % , 25 - 50 % in 24 % , 50 - 75 % in 51 % , and > 75 % in 10 % . The co-morbidities improved or completely resolved in most patients . No mortality occurred . CONCLUSION We are very encouraged by this series of low BMI patients treated with the LAP-B AND . Their weight loss has been good , the complications have been minimal , and the co-morbidities have partially or wholly resolved . With additional study , it is reasonable to expect the weight guidelines for bariatric surgery to be altered to include patients with a BMI of 30 - 35 kg/m(2 ) Roux-en-Y bypass surgery is the most common bariatric procedure currently performed in the United States for medically complicated obesity . Although this leads to a marked and sustained weight loss , we have identified an increasing number of patients with episodes of nephrolithiasis afterwards . We describe a case series of 60 patients seen at Mayo Clinic-Rochester that developed nephrolithiasis after Roux-en-Y gastric bypass ( RYGB ) , including a subset of 31 patients who had undergone metabolic evaluation in the Mayo Stone Clinic . The mean body mass index of the patients before procedure was 57 kg/m(2 ) with a mean decrease of 20 kg/m(2 ) at the time of the stone event , which averaged 2.2 years post-procedure . When analyzed , calcium oxalate stones were found in 19 and mixed calcium oxalate/uric acid stones in two patients . Hyperoxaluria was a prevalent factor even in patients without a prior history of nephrolithiasis , and usually presented more than 6 months after the procedure . Calcium oxalate supersaturation , however , was equally high in patients less than 6 months post-procedure due to lower urine volumes . In a small r and om sampling of patients undergoing this bypass procedure , hyperoxaluria was rare preoperatively but common 12 months after surgery . We conclude that hyperoxaluria is a potential complicating factor of RYGB surgery manifested as a risk for calcium oxalate stones Background Beneficial effects of BPD on T2DM in BMI > 35 kg/m2 patients are far better than those in patients with BMI 25–35 . This study was aim ed at investigating if a similar difference exists between patients with mild obesity ( OB , BMI 30–35 ) or simple overweight ( OW , BMI 25–30 ) . Methods Fifteen OB ( six M ) and 15 OW ( 13 M ) , diabetic for ≥3 years , with HbA1c ≥7.5 % despite medical therapy , underwent BPD . OB/OW : age 55.1 ± 8.0/57.8 ± 6.7 years , BMI 33.1 ± 1.5/28.0 ± 1.3 kg/m2 , diabetes duration 11.6 ± 8.0/11.1 ± 6.1 years , insulin therapy 4/8 p. FSG and HbA1c were determined preoperatively and up to 2 years . Insulin resistance and beta-cell function were explored by means of HOMA-IR and IVGTT ( AIR ) . Thirty-eight diabetic patients on medical therapy served as controls . Results Mean BMI stabilized around 27 since the 4th month in OB , and 24 since 1st month in OW . FSG in OB/OW preop , 1 , 12 , 24 months : 234 ± 76/206 ± 62 mg/dL , 154 ± 49/176 ± 75 , 131 ± 32/167 ± 48 , 134 ± 41/154 ± 41 ( cross-sectional n.s . at all times ) ; HbA1c : 9.5 ± 1.6/9.1 ± 1.3 , 7.3 ± 1.1/7.3 ± 1.2 , 5.9 ± 0.6/7.1 ± 1.1 ( p < 0.01 ) , 5.9 ± 0.9/6.9 ± 1.1 ( p < 0.01 ) . HOMA-IR , preoperatively 10.7 ± 5.8/7.5 ± 5.4 , went below 3.0 at 1 month and remained such until 2 years in both groups . AIR , preoperatively 1.11 ± 3.17/1.27 ± 2.68 μIU/mL , in OB significantly increased at 4 months to 7.63 ± 5.79 , maintained up to 2 years with 6.95 ± 3.19 , whereas in OW , statistical significance was reached only at 2 years with 5.02 ± 4.87 . Conclusions Significantly different BPD effect , thus biological severity of T2DM , also exists between mildly obese and simply overweight patients . The rise of AIR allows hoping that an increase of beta-cell mass may occur in the long run . Clinical Trials.gov Identifier : BACKGROUND Roux-en-Y gastric bypass ( RYGB ) benefits patients with type 2 diabetes mellitus ( T2DM ) and a body mass index ( BMI ) > 35 kg/m(2 ) ; however , its effectiveness in patients with T2DM and a BMI < 35 kg/m(2 ) is unclear . Asian Indians have a high risk of T2DM and cardiovascular disease at relatively low BMI levels . We examined the safety and efficacy of RYGB in Asian Indian patients with T2DM and a BMI of 22 - 35 kg/m(2 ) in a tertiary care medical center . METHODS A total of 15 consecutive patients with T2DM and a BMI of 22 - 35 kg/m(2 ) underwent RYGB .  The data were prospect ively collected before surgery and at 1 , 3 , 6 , and 9 months postoperatively . RESULTS Of the 15 patients , 8 were men and 7 were women ( age 45.6 + /- 12 years ) . Their preoperative characteristics were BMI 28.9 + /- 4.0 kg/m(2 ) , body weight 78.7 + /- 12.5 kg , waist circumference 100.2 + /- 6.8 cm , and duration of T2DM 8.7 + /- 5.3 years . At baseline , 80 % of subjects required insulin , and 20 % controlled their T2DM with oral hypoglycemic medication . The BMI decreased postoperatively by 20 % , from 28.9 + /- 4.0 kg/m(2 ) to 23.0 + /- 3.6 kg/m(2 ) ( P < .001 ) . All antidiabetic medications were discontinued by 1 month after surgery in 80 % of the subjects . At 3 months and thereafter , 100 % were euglycemic and no longer required diabetes medication . The fasting blood glucose level decreased from 233 + /- 87 mg/dL to 89 + /- 12 mg/dL ( P < .001 ) , and the hemoglobin A1c decreased from 10.1 % + /- 2.0 % to 6.1 % + /- 0.6 % ( P < .001 ) . Their waist circumference , presence of dyslipidemia , and hypertension improved significantly . The predicted 10-year cardiovascular disease risk ( calculated using the United Kingdom Prospect i ve Diabetes Study equations ) decreased substantially for fatal and nonfatal coronary heart disease and stroke . No mortality , major surgical morbidity , or excessive weight loss occurred . CONCLUSION RYGB safely and effectively eliminated T2DM in Asian Indians with a BMI < 35 kg/m(2 ) . Larger , longer term studies are needed to confirm this benefit Context : Hyperglycemia resolves quickly after bariatric surgery , but the underlying mechanism and the most effective type of surgery remains unclear . Objective : To examine glucose metabolism and β-cell function in patients with type 2 diabetes mellitus ( T2DM ) after two types of bariatric intervention ; Roux-en-Y gastric bypass ( RYGB ) and gastric restrictive ( GR ) surgery .  Design : Prospect i ve , nonr and omized , repeated- measures , 4-week , longitudinal clinical trial . Patients : In all , 16 T2DM patients ( 9 males and 7 females , 52±14 years , 47±9 kg m−2 , HbA1c 7.2±1.1 % ) undergoing either RYGB ( N=9 ) or GR ( N=7 ) surgery . Outcome measures : Glucose , insulin secretion , insulin sensitivity at baseline , and 1 and 4 weeks post-surgery , using hyperglycemic clamps and C-peptide modeling kinetics ; glucose , insulin secretion and gut-peptide responses to mixed meal tolerance test ( MMTT ) at baseline and 4 weeks post-surgery . Results : At 1 week post-surgery , both groups experienced a similar weight loss and reduction in fasting glucose ( P<0.01 ) . However , insulin sensitivity increased only after RYGB , ( P<0.05 ) . At 4 weeks post-surgery , weight loss remained similar for both groups , but fasting glucose was normalized only after RYGB ( 95±3 mg 100 ml−1 ) . Insulin sensitivity improved after RYGB ( P<0.01 ) and did not change with GR , whereas the disposition index remained unchanged after RYGB and increased 30 % after GR ( P=0.10 ) . The MMTT elicited a robust increase in insulin secretion , glucagon-like peptide-1 ( GLP-1 ) levels and β-cell sensitivity to glucose only after RYGB ( P<0.05 ) . Conclusion : RYGB provides a more rapid improvement in glucose regulation compared with GR . This improvement is accompanied by enhanced insulin sensitivity and β-cell responsiveness to glucose , in part because of an incretin effect BACKGROUND Intensive lifestyle interventions can reduce the incidence of  type 2 diabetes in people with impaired glucose tolerance , but how long these benefits extend beyond the period of active intervention , and whether such interventions reduce the risk of cardiovascular disease ( CVD ) and mortality , is unclear . We aim ed to assess whether intensive lifestyle interventions have a long-term effect on the risk of diabetes , diabetes-related macrovascular and microvascular complications , and mortality . METHODS In 1986 , 577 adults with impaired glucose tolerance from 33 clinics in China were r and omly assigned to either the  control group or to one of three lifestyle intervention groups ( diet , exercise , or diet plus exercise ) . Active intervention took place over 6 years until 1992 . In 2006 , study participants were followed-up to assess the long-term effect of the interventions . The primary outcomes were diabetes incidence , CVD incidence and mortality , and all-cause mortality . FINDINGS Compared with control participants , those in the combined lifestyle intervention groups had a 51 % lower incidence of diabetes ( hazard rate ratio [ HRR ] 0.49 ; 95 % CI 0.33 - 0.73 ) during the active intervention period and a 43 % lower incidence ( 0.57 ; 0.41 - 0.81 ) over the 20 year period , controlled for age and clustering by clinic . The average annual incidence of diabetes was 7 % for intervention participants versus 11 % in control participants , with 20-year cumulative incidence of 80 % in the intervention groups and 93 % in the control group . Participants in the intervention group spent an average of 3.6 fewer years with diabetes than those in the control group . There was no significant difference between the intervention and control groups in the rate of first CVD events ( HRR 0.98 ; 95 % CI 0.71 - 1.37 ) , CVD mortality ( 0.83 ; 0.48 - 1.40 ) , and all-cause mortality ( 0.96 ; 0.65 - 1.41 ) , but our study had limited statistical power to detect differences for these outcomes . INTERPRETATION Group-based lifestyle interventions over 6 years can prevent or delay diabetes for up to 14 years after the active intervention . However , whether lifestyle intervention also leads to reduced CVD and mortality remains unclear The efficacy of Roux-en-Y gastric bypass ( RYGB ) to control  type 2 diabetes mellitus ( T2DM )  has been demonstrated in morbidly obese patients . Surgical procedures primarily focused on T2DM control in patients with body mass index ( BMI ) < 35 kg/m2 have shown to effectively induce remission of T2DM . However , only few reports have evaluated the safety and efficacy of RYGB in this group of patients . The aim of this study is to assess the safety and efficacy of RYGB in TD2 M patients with BMI < 35 kg/m2 . All T2DM patients with BMI < 35 kg/m2 and at least 12 months of follow-up who underwent laparoscopic RYGB were included . Safety of the procedure was evaluated according to mortality , need of reoperation/conversion , and complication rates . Metabolic parameters were evaluated at baseline and 6 , 12 , and 24 months after surgery . Thirty patients were included . Seventeen ( 56.6 % ) were women . Age , BMI , and duration of diabetes were 48 ± 9 years , 33.7 ± 1.2 kg/m2 , 4 ± 2.9 years , respectively . No mortality was observed . No conversion/reoperation was needed . Average length of stay was 3.2 ± 0.9 days . Early and late postoperative complications were observed in five ( 16.6 % ) and five ( 16.6 % ) patients , respectively . Twelve months after surgery , remission was observed in 25 of 30 patients ( 83.3 % ) . After 2 years , remission was achieved in 13 of 20 patients ( 65 % ) , and hemoglobin A1c decreased from 8.1 ± 1.8 % to 5.9 ± 1.1 % and homeostasis model assessment of insulin resistance from 5.7 ± 3.2 to 1.9 ± 0.8 after 12 months . RYGB is a safe and effective procedure to induce T2DM remission in otherwise not eligible patients for bariatric surgery . Evidence from prospect i ve studies is needed to vali date this approach BACKGROUND Weight loss is associated with short-term amelioration and prevention of metabolic and cardiovascular risk , but whether these benefits persist over time is unknown . METHODS The prospect i ve , controlled Swedish Obese Subjects Study involved obese subjects who underwent gastric surgery and contemporaneously matched , conventionally treated obese control subjects . We now report follow-up data for subjects ( mean age , 48 years ; mean body-mass index , 41 ) who had been enrolled for at least 2 years ( 4047 subjects ) or 10 years ( 1703 subjects ) before the analysis ( January 1 , 2004 ) . The follow-up rate for laboratory examinations was 86.6 percent at 2 years and 74.5 percent at 10 years . RESULTS After two years , the weight had increased by 0.1 percent in the control group and had decreased by 23.4 percent in the surgery group ( P<0.001 ) . After 10 years , the weight had increased by 1.6 percent and decreased by 16.1 percent , respectively ( P<0.001 ) . Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period . Two- and 10-year rates of recovery from diabetes , hypertriglyceridemia , low levels of high-density lipoprotein cholesterol , hypertension , and hyperuricemia were more favorable in the surgery group than in the control group , whereas recovery from hypercholesterolemia did not differ between the groups . The surgery group had lower 2- and 10-year incidence rates of diabetes , hypertriglyceridemia , and hyperuricemia than the control group ; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable . CONCLUSIONS As compared with conventional therapy , bariatric surgery appears to be a viable option for the treatment of severe obesity , result ing in long-term weight loss , improved lifestyle , and , except for hypercholesterolemia , amelioration in risk factors that were elevated at baseline Background Laparoscopic gastric bypass result ed in significant weight loss and resolution of type 2 diabetes mellitus ( T2DM ) .  The current indication for bariatric surgery is mainly applied for patients with body mass index ( BMI ) > 35 kg/m2 with comorbidity status . However , little is known concerning T2DM patients with BMI < 35 kg/m2 . Recent studies have suggested that T2DM patients with BMI < 35 kg/m2 might benefit from gastric bypass surgery . Methods From Jan 2002 to Dec 2006 , 820 patients who underwent laparoscopic mini-gastric bypass were enrolled in a surgically supervised weight loss program .  We identified 201 ( 24.5 % ) patients who had impaired fasting glucose or T2DM . All the clinical data were prospect ively collected and stored . Patients with BMI < 35 kg/m2 were compared with those of BMI > 35 kg/m2 . Successful treatment of T2DM was defined by HbA1C < 7.0 % , LDL < 100 mg/dl , and triglyceride < 150 mg/dl . Results Among the 201 patients , 44 ( 21.9 % ) had BMI < 35 kg/m2 , and 114 ( 56.7 % ) had BMI between 35 and 45 , 43 ( 21.4 % ) had BMI > 45 kg/m2 . Patients with BMI < 35 kg/m2 are significantly older , female predominant , had lower liver enzyme and C-peptide levels than those with BMI > 35 kg/m2 . The mean total weight loss for the population was 32.1 , 33.4 , 31.9 , and 32.8 % ( at 1 , 2 , 3 , 5 years after surgery ) , and percentage to change in BMI was 31.9 , 34.2 , 32.2 , and 29.5 % at 1 , 2 , 3 , and 5 years . One year after surgery , fasting plasma glucose returned to normal in 89.5 % of BMI < 35 kg/m2 T2DM and 98.5 % of BMI > 35 kg/m2 patients ( p = 0.087 ) . The treatment goal of T2DM ( HbA1C < 7.0 % , LDL < 150 mg/dl and triglyceride < 150 mg/dl ) was met in 76.5 % of BMI < 35 kg/m2 and 92.4 % of BMI > 350 kg/m2 ( p = 0.059 ) . Conclusion Laparoscopic gastric bypass result ed in significant and sustained weight loss with successful treatment of T2DM up to 87.1 % . Despite a slightly lower response rate of T2DM treatment , patients with BMI < 35 still had an acceptable DM resolution , and this treatment option can be offered to this group of patients Background Many mildly to moderately obese individuals with a body mass index ( BMI ) lower than 35 kg/m2 have serious diseases related to their obesity . Nonsurgical therapy is ineffective in the long term , yet surgery has never been made widely available to this population . Methods Between 2002 and 2007 , 53 patients with a BMI lower than 35 kg/m2 underwent laparoscopic adjustable gastric b and ing at our institution . Data on all these patients were collected prospect ively and entered into an institutional review board – approved electronic registry . The study parameters included preoperative age , gender , BMI , presence of comorbidities , percentage of excess weight loss ( % EWL ) , and resolution of comorbidities . Results The mean preoperative age of the patients was 46.9 years ( range , 16–68 years ) , and the mean preoperative BMI was 33.1 kg/m2 ( range , 28.2–35.0 kg/m2 ) . Of the 53 patients , 49 ( 92 % ) had at least one obesity-related comorbidity . The mean BMI decreased to 28.1 ± 2.4 kg/m2 , 25.8 ± 2.9 kg/m2 , and 25.8 ± 3.1 kg/m2 and mean % EWL was 48.3 ± 17.6 , 69.9 ± 28.0 , and 69.7 ± 31.7 at 0.5 , 1 , and 2 years , respectively . Substantial improvement occurred for the following comorbidities evaluated : hypertension , depression , diabetes , asthma , hypertriglyceridemia , obstructive sleep apnea , hypercholesterolemia , and osteoarthritis . There was one slip , two cases of b and obstruction ( from food ) , two cases of esophagitis , and two port leaks , but no mortality . Conclusion The authors are very encouraged by this series of low- BMI patients who underwent laparoscopic adjustable gastric b and ing .  Their weight loss has been excellent , and their complications have been acceptable . Their comorbidities have partially or wholly resolved . With further study , it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m2
target: In contrast , some RCT data of nonsurgical therapies show benefits at 10 years of follow-up or more .
  AND RELEVANCE Current evidence suggests that , when compared with nonsurgical treatments , bariatric surgical procedures in patients with a BMI of 30 to 35 and diabetes are associated with greater short-term weight loss and better intermediate glucose outcomes .
background: IMPORTANCE Bariatric surgery is beneficial in persons with a body mass index ( BMI ) of 35 or greater with obesity-related comorbidities .
  There is interest in using these procedures in persons with lower BMI and diabetes .
  OBJECTIVE To assess the association between bariatric surgery vs nonsurgical treatments and weight loss and glycemic control among patients with diabetes or impaired glucose tolerance and BMI of 30 to 35 .