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Objective: Hepatic insulin clearance is a significant regulator of glucose homestasis. We hypothesized that the improvement in insulin clearance rates (ICRs) under fasting conditions and in response to oral and intravenous (IV) glucose would improve similarly after Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) as a function of weight loss; the difference in ICR after oral and IV glucose stimulation will be enhanced after RYGB compared with AGB, an effect mediated by glucagon-like peptide 1 (GLP-1)., Research Design and Methods: In study 1, the ICR was calculated under fasting condition (F-ICR), after oral glucose (O-ICR), and after an isoglycemic IV glucose clamp (IV-ICR) in individuals from an established cohort with type 2 diabetes mellitus (T2DM) before, after 10% matched weight loss, and 1 year after either RYGB ( n = 22) or AGB ( n = 12). In study 2, O-ICR was studied in a separate cohort of individuals with T2DM ( n = 22), before and 3 months after RYGB, with and without exendin(9-39) infusion., Results: In study 1, age, BMI, T2DM duration and control, and ICR did not differ between RYGB and AGB preintervention. Weight loss at 1 year was two times greater after RYGB than after AGB (31.6 ± 5.9% vs. 16.6 ± 9.8%; P < 0.05). RYGB and AGB both significantly increased F-ICR, O-ICR, and IV-ICR at 1 year. ICR was inversely associated with insulinemia. The difference between IV-ICR and O-ICR was significantly greater after RYGB versus AGB. GLP-1 antagonism with exendin(9-39) led to an increase in O-ICR in subjects post-RYGB., Conclusions: Weight loss increased ICR, an effect more pronounced after RYGB compared with AGB. Our data support a potential role for endogenous GLP-1 in the control of postprandial ICR after RYGB., (© 2018 by the American Diabetes Association.)

The goal of this study was to understand the mechanisms of greater weight loss by gastric bypass (GBP) compared to gastric banding (GB) surgery. Obese weight- and age-matched subjects were studied before (T0), after a 12 kg weight loss (T1) by GBP (n = 11) or GB (n = 9), and at 1 year after surgery (T2). peptide YY(3-36) (PYY(3-36)), ghrelin, glucagon-like peptide-1 (GLP-1), leptin, and amylin were measured after an oral glucose challenge. At T1, glucose-stimulated GLP-1 and PYY levels increased significantly after GBP but not GB. Ghrelin levels did not change significantly after either surgery. In spite of equivalent weight loss, leptin and amylin decreased after GBP, but not after GB. At T2, weight loss was greater after GBP than GB (P = 0.003). GLP-1, PYY, and amylin levels did not significantly change from T1 to T2; leptin levels continued to decrease after GBP, but not after GB at T2. Surprisingly, ghrelin area under the curve (AUC) increased 1 year after GBP (P = 0.03). These data show that, at equivalent weight loss, favorable GLP-1 and PYY changes occur after GBP, but not GB, and could explain the difference in weight loss at 1 year. Mechanisms other than weight loss may explain changes of leptin and amylin after GBP.

Objective: Obesity management is focused at weight loss to obtain health, psychological and social benefits. Outcomes from controlled trials, however, do not reflect the everyday routine practice. Therefore, we aimed to investigate the results from surgically induced weight loss in patients devoid of a protocol-wise follow-up, who were visited at home., Patients and Methods: Patients who underwent a vertical banded gastroplasty or a gastric bypass between 1980 and 1997 were eligible. Body weight and height were measured. Patients filled out questionnaires on health status (Nottingham Health Profile (NHP)), psychological symptoms (Symptom Check List (SCL-90-R)), personality traits (Dutch Personality Questionnaire (DPQ)) and eating behaviour (Dutch Eating Behaviour Questionnaire (DEBQ))., Results: Out of 451 operated patients the addresses of 313 subjects could be traced and 236 (75%) agreed to participate. They maintained a mean (s.d.) loss of 32.1 (22.6) kg and 45.2 (29.3) % of excess weight, 8.2 (4.5) years after the operation, about two-third of the largest weight loss they achieved after 17 months postoperatively. The NHP and SCL-90-R conformed to norm values in males except for energy, sleep and emotional reactions. Females differed from norm values in every aspect and even women achieving a BMI<30 kg/m(2) did not catch up to norm values. Weight loss was inversely related to physical immobility and pain. Personality traits (DPQ) showed a higher grievance and dominance and a lower rigidity and self-esteem compared to norm values. Females scored higher in inadequacy and lower in social inadequacy. Eating patterns (DEBQ) showed mainly emotional eating and restrained eating. Effect sizes of >/=0.8 s.d. were chosen to reflect the clinical relevance of statistically significant findings. Pain, disturbances in sleep, energy and mobility and emotional and restrained eating proved to be clinically relevant. In subjects operated >5 years ago, a higher sensitivity, a higher inadequacy and a lower social inadequacy were observed compared to more recently operated subjects. A more restrained eating pattern was related to an operation of recent date., Conclusions: Surgically induced weight losses are satisfactory in the long-term, even in patients not attending a strict follow-up protocol. Health, psychological symptoms, personality traits and eating behaviour were related to weight loss and time lapse since the operation and did not return to reference normal-weight subject values.

Because of the increased incidence of obesity today, bariatric surgery is now considered to be an acceptable treatment modality. However, much of the information that exists in the media focuses on the procedure itself, not on the preoperative and postoperative issues that can be just as important to address. As a certified registered nurse practitioner who deals with these patients on a daily basis, and as a patient who has had both the vertical banded gastroplasty and the Roux-en-Y gastric bypass, I consider myself as having a better understanding of the entire process than most. Everyone who chooses bariatric surgery has his or her own motivating factors, whether it be to feel better, to get off his or her medications, or to better control or resolve his or her comorbid conditions; the list is endless. The most important factor is educating oneself and knowing all there is to know about whatever procedure is desired. Insurance companies are now requiring nutritional consults preoperatively that lay the foundation for bariatric patients postoperatively. It is imperative as a healthcare consumer to ask questions, attend classes and support groups, and follow the guidelines that the surgeon has established so as to be successful. I have been through it all and understand the process from beginning to end. I also have extraordinary compassion, sensitivity, and empathy for the bariatric patients, because of my previous experiences. People who have never had a weight problem cannot begin to understand the plight of those who do. I try to guide the patients and point them in the right direction; however, the decisions that they make are ultimately theirs.