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Purpose Obesity increases the risk of incident chronic kidney disease (CKD) and is one of the strongest risk factors for new-onset CKD even in the absence of metabolic risk factors. Weight loss has been shown to reduce renal hyperfiltration and proteinuria. Metabolic bariatric surgery (MBS) remains an effective treatment for obesity and its metabolic-related complications. However, literature on its impact on renal function remains limited. Materials and methods This was an observational retrospective study in a tertiary centre in Singapore. MBS cases performed at the centre between 2008 and 2019 were included. The primary outcome measures were estimated glomerular filtration rate (eGFR), calculated using the CKD epidemiology collaboration equation, and albuminuria (defined as urine albumin-creatinine ratio (uACR) > 3.5 mg/mmol) at baseline and 1-year post-MBS. Results Five hundred fifty-seven patients were included. One-year post-MBS, median eGFR increased from 110.9 mL/min/1.73 m2 (IQR 92.4 to 121.5) to 112.6 mL/min/1.73 m2 (IQR 97.3 to 122.3), p Conclusions MBS had a positive impact on renal function with modest but statistically significant improvement in eGFR and reduction in albuminuria at 1-year post-surgery. Longer-term data is required to investigate the durability of this impact.

Following bariatric surgery, accurate charting of weight loss and regain is crucial. Various preoperative factors affect postoperative weight loss, including age, sex, ethnicity, and surgical type. These are not considered by current weight loss metrics, limiting comparison of weight loss outcomes between patients or centers and across time. Patients (n=1022) who underwent sleeve gastrectomy (n=809) and gastric bypass (n=213) from 2008 to 2020 in a single center were reviewed. Weight loss outcomes (% total weight loss) were measured for 60 months postoperatively. Longitudinal centile lines were plotted using the post-estimation predictions of quantile regression models, adjusted for type of procedure, sex, ethnicity, and baseline BMI. Median regression showed that %TWL was 1.0% greater among males than females (β = +1.1, 95% CI: +0.6 to +1.7, P =

The adverse implications of obesity extend beyond physical health to include negative impact on quality of life (QoL), mood, and eating habits. While bariatric surgery provides successful weight loss and metabolic benefits, studies describe conflicting results on QoL and mood-related outcomes. Patients (n = 140) with class II/III obesity and T2DM were recruited from 2015 to 2019, and stratified based on medical or surgical treatment. Questionnaires including the Hospital Anxiety and Depression Scale, Euro QoL visual analogue scale (EQ-VAS), and Revised 21-item Three-Factor Eating Questionnaire (TFEQ-R21) were recorded at baseline, 6 months, and 12 months after treatment. At baseline, the surgical group (n = 55) and medical group (n = 85) had no significant difference in questionnaire outcomes. At 6 and 12 months, EQ-VAS was higher in the surgical group (12 months surgical 82.00 ± 12.64, medical 72.81 ± 16.56, p = 0.001), with greater improvement from baseline. HADS-D scores at 12 months were lower in the surgical group (surgical 2.60 ± 2.88, medical 3.90 ± 3.58, p = 0.025). At 12 months, the surgical group also had better TFEQ-R21 scores, with higher cognitive restraint scores (surgical 19.09 ± 3.00, medical 16.69 ± 3.61, p

Background Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, there is one shortcoming of LSG in the long-term follow-up, and this is the onset of gastro-esophageal reflux disease (GERD) and erosive esophagitis (EE). Conversion to Roux-en-Y gastric bypass (RYGB) is considered an option in patients unresponsive to medical therapy. Currently, there is no evidence of EE improvement or resolution after conversion surgery. In this study, we objectively evaluate the effectiveness of RYGB in management of EE with upper endoscopy (EGD) to identify the significant variables in patients with GERD symptoms post LSG refractory to medical therapy and require conversion surgery. Methods Over a period of 11 years (2008–2019) at Singapore General Hospital, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had conversion surgery to RYGB for refractory GERD and EE after LSG. Patient’s endoscopic findings and demographic and anthropometric data were analyzed. Results We identified a total of 14 patients who underwent LSG to RYGB conversions for endoscopic proven erosive esophagitis in our unit during the study period. Eight patients (57.1%) had concurrent hiatal hernia repaired. Nine (64.3%) patients were females. The median age of patients in this cohort was 44 (range 30–61) years. Mean weight and BMI were 87.7 kg (± 19.2) and 32.8 (± 3.09) kg/m2, respectively, on the day of conversion surgery. The median time between LSG and revision to RYGB was 36 (range 6–68) months. Seven patients (50%) had complete resolution of GERD symptoms after conversion, and 6 patients (42.9%) had partial resolution. Six out of 7 patients had complete resolution of EE. There were 4 anastomotic strictures (28.6%). Older patients, Indian ethnicity, present of hiatal hernia and lower weight loss after initial LSG were more likely to undergo conversion surgery. Conclusion Conversion to RYGB after LSG is clinically relevant and may be a feasible solution if patients have ongoing GERD refractory to medical therapy. Ninety-three percent of our patients achieved complete resolution of their GERD symptoms and significant improvement of erosive esophagitis with significant weight loss after conversion. This study has important implications as LSG is increasingly being performed and a proportion of these will need revision surgery for various reasons, particularly GERD which is extremely prevalent.

Background: Delayed initiation and inadequate titration remain critical challenges to optimizing insulin therapy in type 2 diabetes (T2D). We aimed to study whether hemoglobin A1c (HbA1c) can be lowered in people with insulin-treated T2D using telemonitoring. Methods: This single-center study recruited adults with greater than or equal to six months of diabetes, greater than or equal to three months of insulin therapy, HbA1c ≥8.5% and ≤12.5%, and body mass index (BMI) ≤40 kg/m2. All participants received a connected glucose meter and the accompanying smartphone application. Participants sent weekly blood glucose (BG) diary to their primary endocrinologist via email. Adjustments in insulin doses were communicated to the participants. HbA1c, proportion of BG readings in range (70-180 mg/dL, PIR), below range (180 mg/dL, PAR), and glycemic variability as the coefficient of variation (% CV) were measured at baseline, week 12, and week 24 and compared using repeated-measures analysis of variance (ANOVA) or Friedman’s ANOVA. Results: We recruited 40 people (55% women). Mean age was 57.9 years, BMI 27.8 kg/m2, and baseline HbA1c 9.8% (83.7 mmol/mol). Mean HbA1c improved by 1.7%, % CV reduced from 32.9% to 30.7%, PIR increased from 58.8% to 67.1% (all P Conclusion: Telemonitoring and titration of insulin using a connected glucose meter resulted in significant improvements in glycemia, characterized by a reduction in HbA1c, increase in PIR, and reduction in glycemic variability without any increase in hypoglycemia.

Data on attitudes and perceptions towards obesity are lacking in Asia. Participants who attended an obesity public forum were surveyed concerning obesity and its treatment options. Although obesity is generally accepted as a disease with biological underpinnings such as hormonal imbalances and slow metabolic rate, it is also regarded as an issue of personal responsibility. 65.1% believed that weight-loss medications are dangerous. 20.6% thought that pharmacotherapy is effective for weight loss, whereas 41.1% were unsure. Most believed that bariatric surgery could improve health (81.9%) and diabetes control (74.0%) although 64.1% were unsure of its risks.

Background: Bile acids (BAs) are traditionally associated with lipid absorption and phase II detoxification by forming various BA conjugates. Recently, it has been discovered that BAs also regulate glucose metabolism, and the increase in BAs in patients following bariatric surgery may contribute to the post-surgery improvement in insulin resistance (IR). However, while Roux-en-Y gastric bypass can increase BA concentrations post-surgery, this may not be the case after laparoscopic sleeve gastrectomy (LSG). We hypothesized that the profiling of BAs that include the conjugated BA species could detect post-surgery BA changes after LSG. To test our hypothesis, we performed comprehensive profiling of BAs in Asian individuals with morbid obesity at baseline, and at 6 months following LSG. Methods: Fourteen subjects scheduled for LSG were recruited. Anthropometric measurements, oral glucose tolerance test, and biochemistry tests were performed at baseline and at 6 months after LSG. BAs were profiled using liquid chromatography–mass spectrometry. Results: At 6 months, subjects lost significant weight from 117.4±5.4 to 92.1±3.8 kg and demonstrated significant improvement in IR. HOMA-IR decreased from 6.2±0.7 to 2.0±0.2 and the Matsuda index increased from 1.9±0.3 to 3.3±0.3. We did not detect any significant post-operative change in the levels of total BAs (5237.1±1219.4 vs. 3631.7±457.9, p=0.181) or non-sulfated BAs after LSG. However, sulfated BA species increased significantly after LSG. Conclusion: Our study showed that the serum concentrations of sulfated BA species in morbidly obese Asian individuals increased significantly 6 months after LSG; the increase in sulfated BAs after LSG might contribute to the post-surgery improvement of metabolic health.

Following bariatric surgery, accurate charting of weight loss and regain is crucial. Various preoperative factors affect postoperative weight loss, including age, sex, ethnicity, and surgical type. These are not considered by current weight loss metrics, limiting comparison of weight loss outcomes between patients or centers and across time.Patients (n=1022) who underwent sleeve gastrectomy (n=809) and gastric bypass (n=213) from 2008 to 2020 in a single center were reviewed. Weight loss outcomes (% total weight loss) were measured for 60 months postoperatively. Longitudinal centile lines were plotted using the post-estimation predictions of quantile regression models, adjusted for type of procedure, sex, ethnicity, and baseline BMI.Median regression showed that %TWL was 1.0% greater among males than females (β = +1.1, 95% CI: +0.6 to +1.7, P =0.0001). Participants who underwent SG had less %TWL compared to GB (β = -1.3, 95% CI: -1.9 to -0.8, P0.0001). There was a trend towards less %TWL among the Indian and Malay participants compared to Chinese. Age and diabetes were not significant predictors. Reference centile charts were produced for the overall cohort, as well as specific charts adjusted for type of bariatric procedure, sex, ethnicity, and baseline BMI.Centile charts provide a clinically relevant method for monitoring of weight trajectories postoperatively and aid in realistic and personalised goal setting, and the early identification of "poor responders". This is the first study to present post-bariatric surgery centile charts for an Asian cohort.

Obesity plays a pivotal role in the pathogenesis of obstructive sleep apnea (OSA) and as an exacerbating factor of OSA. Given the interlinking relationship of obesity and OSA, treatment of obesity is fundamental in the management of OSA. Weight loss of 7% to 11% significantly improves OSA with remission seen with greater weight loss. Weight loss also ameliorates the constellation of other obesity-related metabolic conditions, reducing the overall cardiovascular risk in an obese person with OSA. This article discusses specific weight loss interventions effective in improving OSA, including lifestyle interventions with dietary modification and physical activity, pharmacotherapy, and bariatric surgery.

Key Points Question Are bariatric interventions associated with serum micronutrients and metabolic hormones changes in the years after intervention, and do trajectories differ between laparoscopic sleeve gastrectomy vs gastric bypass procedures? Findings In this comparative effectiveness study of 499 patients who underwent sleeve gastrectomy and 189 patients who underwent one-anastomosis or Roux-en-Y gastric bypass, parameters associated with calcium metabolism did not differ between the groups. The extent of hemoglobin suppression was greater among patients who underwent gastric bypass compared with those who underwent laparoscopic sleeve gastrectomy, but the difference was not explained by differences in iron stores or vitamin B levels. Meaning The findings of this study suggest that micronutrient deficiencies after bariatric interventions are differentially associated with types of bariatric procedures., This comparative effectiveness study examines the association of bariatric interventions with micronutrient deficiencies and endocrine disturbances., Importance Few studies have described the longitudinal trajectories of serum levels of micronutrients whose deficiencies are associated with serious sequelae following bariatric procedures, such as anemia, osteoporotic fractures, and neuropathies. Furthermore, previous studies comparing laparoscopic sleeve gastrectomy (LSG) vs Roux-en-Y gastric bypass (LRYGB) or one-anastomosis gastric bypass (OAGB) procedures may have been limited by selection and confounding biases. Objective To appraise the spectrum and temporal course of micronutrient deficiencies associated with bone metabolism and erythropoiesis after LSG vs OAGB or LRYGB procedures, using the propensity score as a balancing score. Design, Setting, and Participants This prospective, longitudinal comparative effectiveness study was conducted at a high-volume bariatric unit in Singapore from September 1, 2008, to November 30, 2017, with a cutoff date for analysis of September 2018. Patients who underwent adjustable gastric banding, biliopancreatic diversion procedures, and intragastric balloon procedures were excluded. All other patients who underwent bariatric procedures were included. Data were analyzed from September 23 to 30, 2018. Main Outcomes and Measures Serial assessment of 13 biochemical parameters at 12 time points for up to 5 years after bariatric procedure. Inverse probability-of-treatment weights were used to obtain estimates of the mean associations of variables assessed with the bariatric surgical interventions. Longitudinal trajectories were analyzed using mixed-effects generalized linear models to apportion the temporal variation of serum micronutrients into fixed-effects and random-effects components. Results A total of 688 patients were included in this study, of whom 499 underwent LSG (mean [SD] age, 41.5 [11.3] years; 318 [63.7%] women) and 189 underwent OAGB or LRYGB (mean [SD] age, 48.6 [9.4] years; 112 [59.3%] women). There were no differences during follow-up among patients who underwent LSG vs those who underwent OAGB or LRYGB in intact parathyroid hormone levels (mean difference, 7.05 [95% CI, −28.67 to 42.77] pg/mL; P = .70), serum 25-hydroxyvitamin D levels (mean difference, −0.72 [95% CI, −1.56 to 0.12] ng/mL; P = .09), or phosphate levels (mean difference, 0.006 [95% CI, −0.052 to 0.064] mg/dL; P = .83). Hemoglobin levels were a mean 0.63 (95% CI, 0.41 to 0.85) g/dL higher among patients who underwent LSG compared with those who underwent OAGB or LRYGB (P

This review aims to evaluate the latest evidence on the treatment options for perceived poor responders to bariatric surgery and provide practitioners with a guide on when to consider revisional surgery and when to consider alternatives. The use of adjuvant pharmacotherapy has been increasingly described in the literature as an adjunct to primary bariatric surgery, in order to attain more weight loss or better control of obesity-related complications. The newer anti-obesity and anti-diabetes drugs also have cardiorenal benefits, which are shown in recent cardiovascular outcome trials. Revisional bariatric surgery has emerged as a distinctive entity and can be broadly organized into three categories: corrective, conversion, and reversal surgeries. Careful patient selection and preoperative optimization are needed to ensure long-term favorable outcomes. Newer treatment modalities involving the use of anti-obesity medications and endoscopic bariatric interventions provide patients and healthcare providers with more options, when faced with the challenge of poor response after bariatric surgery.

Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, there is one shortcoming of LSG in the long-term follow-up and this is the onset of GERD and erosive esophagitis (EE). Current evidence of the effect of SG on GERD did not consolidate to a consensus. In this study, we objectively evaluate the incidence of EE 1 year post-LSG with upper endoscopy (EGD) and try to identify the significant variables and possible underlying mechanisms of the EE post-LSG. Over a period of 5 years (2011–2016) at Singapore General Hospital, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had LSG by a single surgeon who routinely performed EGD pre-operative and 1 year post-operative to assess EE and hiatal hernia. Patient’s endoscopic findings and demographic and anthropometric data were analyzed. We identified a total of 97 obese patients who underwent LSG at our hospital by studied surgeon. Sixty-three patients (64.9% of original sample) were finally evaluated in the present study, 40 (59.7%) of whom were female. The mean (range) age of patients was 38.2 (18–66) years, and mean BMI was 36.3 ± 4.1 kg/m2. Median time to follow-up EGD was 13 months (range, 12–15). Following LSG, there was a significant decrease in both BMI (42.1 ± 1.2 vs. 29.9 ± 1.0 kg/m2) and percentage excess weight loss of 56.6 ± 3.6%. The prevalence of EE on endoscopy increased from 9 (14.3%) to 28 (44.4%) patients. Of which 15 (23.8%) were grade A, 11 (17.5%) were grade B, and 2 (3.2%) were grade C. There was no correlation between GERD symptoms with EE; however, our study found a trend suggesting higher prevalence of EE with a sleeve diameter measuring > 2 cm wide (p = 0.069). Although LSG is effective in treating obesity and its metabolic syndromes, the prevalence of EE increased significantly 1 year after the surgery. Since we do not fully understand the long-term impact of chronic esophagitis in post-sleeve population, we recommend follow-up EGD assessment post-operatively and treat the esophagitis if present.

INTRODUCTION Obesity is a key risk factor in the development of Type 2 diabetes mellitus (T2DM). Bariatric surgery causes a large amount of durable weight loss in those with clinically severe obesity. We reported the effect of weight loss via bariatric surgery on DM prevention in those at high risk of developing DM. METHODS This was a retrospective cohort study of 44 patients with obesity (mean body mass index 43.8 kg/m2) and pre-DM who underwent bariatric surgery and were followed up for up to three years. We also reviewed a non-surgical cohort of patients with obesity and pre-DM seen at the weight management clinic. RESULTS 91% of patients attained normal glycaemic status at one year after bariatric surgery. At the three-year follow-up, 87.5% of the patients maintained normoglycaemia. None of the patients developed T2DM after surgery. 26.9% of patients achieved absolute weight loss at one year after bariatric surgery and maintained this at two and three years post surgery (p < 0.001 vs. baseline). The homeostatic model assessment-insulin resistance index in patients also decreased from 5.50 at baseline to 1.20, 1.14 and 1.44 at one, two and three years, respectively (p < 0.001). CONCLUSION Bariatric surgery produces significant weight loss, and leads to reversion from the pre-diabetic state to normal glycaemic status and reduction of the incident DM rate in those with pre-DM and morbid obesity.

Over the past decade, several new medications have been developed to treat type 2 diabetes mellitus. Large-scale outcome trials have been performed with patients at high cardiovascular risk to assess the cardiovascular safety of these agents. These trials are changing the landscape of diabetes therapy with evidence beyond safety to cardiovascular benefits of sodium-glucose cotransporter 2 (SGLT-2) inhibitors and some glucagon-like peptide-1 receptor agonists. This review provides an overview of incretin-based therapies and SGLT-2 inhibitors with a particular focus on the results of published cardiovascular outcome trials, which have also provided unique opportunities to evaluate uncommon but potentially serious adverse events of these newer agents. The cardiovascular benefits of SGLT-2 inhibitors and some glucagon-like peptide-1 receptor agonists suggest that they may be the preferred choice, usually as an add-on to metformin, for patients with type 2 diabetes mellitus at high cardiovascular risk.

In Asia, metabolic-bariatric surgery (MBS) rates have grown rapidly in parallel with rising prevalence of obesity and type 2 diabetes (T2D). The objective of this study was to identify factors that influence glycemic outcomes and diabetes remission 12 months after sleeve gastrectomy (SG) or gastric bypass (GB) in a multiethnic Asian cohort. The study’s setting was in a tertiary hospital in Singapore. Data from 145 T2D patients who had SG (37%) or GB (63%) and at least 1-year follow-up were analyzed. Diabetes remission was defined as hemoglobin A1c ≤ 6.0% without diabetes medications. Analysis involved binary logistic regression to identify predictors and general linear regression for variables associated with glycemic improvement after surgery. Baseline parameters are as follows: BMI 40.0 ± 7.6 kg/m2, A1c 8.4 ± 1.6%, diabetes duration 9.3 years, ethnic composition: Chinese (51.7%), Malay (23.4%), Indian (20.7%), Others (4.1%). 55.9% achieved diabetes remission at 1 year. Baseline A1c, baseline BMI, and diabetes duration were significant pre-operative factors for remission (cumulative R 2 = 0.334). At 12 months, percentage weight loss was similar after SG (24.1 ± 7.4%) and GB (25.4 ± 7.4%, p = 0.31). Greater A1c decrease was seen with GB compared to SG (2.7 ± 1.6 vs 2.0 ± 1.5%, p = 0.006), significant even after adjustment for weight loss, age, BMI, baseline A1c, and diabetes duration (p = 0.033). Weight loss at 12 months also correlated independently with A1c reduction. Ethnicity did not influence weight loss, diabetes remission, or glycemic control after MBS. Baseline A1c, baseline BMI, and diabetes duration independently predict diabetes remission after MBS. GB is more effective in controlling T2D compared to SG despite similar weight loss, whereas ethnicity does not play a significant role in the multiethnic Asian cohort.

OBJECTIVE This study aimed to evaluate the real-world safety and effectiveness of the LAP-BAND (Apollo Endosurgery Inc., Austin, Texas) adjustable gastric banding system (LBS) for 5 years following implantation. METHODS This prospective, longitudinal, phase 4, multicenter study involved 652 patients who had implantation of the LBS system. The primary outcome was the percentage of subjects who had LBS explant over 5 years. The secondary outcomes included the rate of reoperations, clinical and biochemical measures, and patient-reported outcome measures over 5 years. RESULTS The study cohort consisted of 79.3% females with a mean age of 44 years and a mean BMI of 45.4 kg/m2 . The primary end point was met with an explant rate of 8.74% (95% CI: 6.6%-10.9%) at 5 years. The rates for completer-only analysis and imputed missing data analysis were 12.81% (95% CI: 9.7%-15.9%) and 12.85% (95% CI: 10.2%-15.5%), respectively. All were significantly lower than the historic rate of 39.4% (P

Objectives To quantify patients’ maximum acceptable risk (MAR) of urinary and genital tract infections (UGTI) in exchange for benefits associated with treatments for managing type 2 diabetes mellitus (T2DM). Methods In a discrete choice experiment, adult patients with T2DM and currently on metformin and/or sulphonylurea (first-line treatments) were asked to choose between 2 hypothetical medications defined by 6 attributes: years of medication effectiveness in controlling blood glucose, weight reduction, UGTI risk, risk of hospitalization from heart failure, all-cause mortality risk, and out-of-pocket medication cost. We used latent class logistic regression parameters to estimate the conditional relative importance of treatment attributes and MAR of UGTI for various treatment benefits. Results A 2-class latent class model was identified as the best fit for the responses from 147 patients. The first class (49% of sample), termed as “survival-conscious,” stated that they were willing to accept 46% (95% confidence interval [CI]: 2%-90%) UGTI risk in exchange for a reduction from 6% to 1% in all-cause mortality risk. The second class (51% of sample), termed as “UGTI/cost-conscious” were willing to accept significantly lower (6%; CI: 2%-11%, and 5%; CI: 2%-8%) UGTI risk in exchange for the same reduction in all-cause mortality and hospitalization risks, respectively. Conclusions On average, patients were willing to trade higher UGTI risk for a more effective medication. Our findings suggest that physicians should present the benefits and potential side effects of all available treatments and consider patient preferences in their treatment recommendations.

Introduction: Obesity increases the risk of incident chronic kidney disease (CKD), being one of the strongest risk factors for new-onset CKD even in the metabolically normal obese. Weight loss has been shown to reduce renal hyperfiltration and proteinuria. Metabolic Bariatric Surgery (MBS) remains an effective treatment for obesity and its metabolic related complications. However, literature on its impact on long term renal function remains limited. Methods: This was an observational retrospective study in a tertiary centre in Singapore. MBS cases performed at the centre between 2008 and 2019 were included. The primary outcome measure was estimated Glomerular Filtration Rate (eGFR), calculated using the CKD Epidemiology Collaboration equation, and albuminuria (defined as urine Albumin-Creatinine Ratio (uACR) >3.5 mg/mmol) at baseline and at one-year post surgery. Results: 557 patients were included. Baseline parameters are as follows: mean age 41.7 ±10.1 years; female 65.4%; ethnic composition: Chinese (35.2%), Malay (33.0%), Indian (26.9%); BMI 42.5 ±7.9 kg/m²; glycaemic status: Diabetes Mellitus (34.5%), Pre-diabetes (13.5%), Non-diabetic (52.1%); Hypertensive status: Hypertension (55.2%), Pre-Hypertension (1.9%), Normotensive (42.9%). Median eGFR was 110.9 (92.4 - 121.5) mL/min/1.73 m² and median uACR was 1.00 (0.40 - 3.55) mg/mmol. At one-year post surgery, patients achieved statistically significant reductions in mean BMI (-11.3 ±4.2 kg/m2), systolic BP (-3.24 ±19.3 mmHg), diastolic BP (-5.23 ±13.8 mmHg), fasting glucose (-1.95 ±2.89 mmol/L) and improvement in HDL (0.29 ±0.26 mmol/L). In addition, statistically significant reductions in the proportion of patients on anti-hypertensive (48.8% to 14.4%), anti-diabetic (34.1% to 12.7%) and lipid-lowering medications (37.8% to 20.4%) were seen. In particular, ACE-inhibitor and/or angiotensin receptor blocker (32.9% to 9.2%, p< 0.001) usage was reduced. At one-year post surgery, median eGFR increased by 1.66 mL/min/1.73 m² (p Conclusions: Metabolic bariatric surgery had a positive impact on renal function as shown by the improvement in eGFR in the non-diabetic group, and the reduction in albuminuria in the diabetes and pre-diabetes group at one-year post surgery. More adequately powered, longer-term data is required to investigate the durability of this impact.

Obesity plays a pivotal role in the pathogenesis of obstructive sleep apnea (OSA) and as an exacerbating factor of OSA. Given the interlinking relationship of obesity and OSA, treatment of obesity is fundamental in the management of OSA. Weight loss of 7% to 11% significantly improves OSA with remission seen with greater weight loss. Weight loss also ameliorates the constellation of other obesity-related metabolic conditions, reducing the overall cardiovascular risk in an obese person with OSA. This article discusses specific weight loss interventions effective in improving OSA, including lifestyle interventions with dietary modification and physical activity, pharmacotherapy, and bariatric surgery.

Obesity-induced insulin resistance leads to abnormalities in glucose, lipid, and amino acid metabolism. Our study examined the differences in insulin-mediated glucose, amino acid, and lipid metabolism between morbidly obese subjects with non-obese controls and the associated changes following sleeve gastrectomy (SG). Non-obese controls and individuals with morbid obesity and scheduled for SG were recruited. Metabolic assessments were performed for all subjects at baseline and at 6 months after SG for eight subjects. The hyperinsulinemic-euglycemic clamp technique together with comprehensive metabolomic profiling was used to quantify insulin-mediated glucose, amino acid, and lipid metabolism. Eleven morbidly obese non-diabetic subjects scheduled for SG and nine non-obese controls were recruited. Compared to controls, obese subjects had significantly lower glucose uptake (4.4 ± 0.6 vs. 17.3 ± 2.4 mg/kg FFM/min per μU/mL·100) and higher concentration of branched-chain amino acids (BCAAs, 332.5 ± 26.8 vs. 235.3 ± 11.0 μM), non-esterified fatty acid (52.9 ± 9.9 vs. 25.6 ± 6.7 μM), and lipid-related acylcarnitines (intermediate chain 389.8 ± 32.5 vs. 285.9 ± 20.5; long chain 301.7 ± 22.1 vs. 236.0 ± 13.3 nM) during insulin clamp. Body weight significantly reduced at 6 months after bariatric surgery (92.5 ± 6.3 vs. 115.2 ± 6.9 kg), together with improvements in insulin-mediated glucose uptake, and suppression of BCAAs, non-esterified fatty acids, and lipid-related metabolites. Morbid obesity in Asian individuals was associated with impairment in the regulatory actions of insulin on glucose, amino acid, and lipid metabolism, and these obesity-induced regulatory dysfunctions improved significantly 6 months after SG.

Background: Metabolic-bariatric surgery (MBS) leads to durable weight loss and significant metabolic improvement in type 2 diabetes mellitus (T2DM) patients with obesity. However, data on durability of control is often lacking in Asia. Aim: We report 5-year glycemic and metabolic outcomes in a T2DM cohort who had MBS from 2008-2012 at a tertiary center in Singapore. Methodology: Patient demographics and biochemical parameters were retrieved from a web-based data repository. DM remission was defined as HbA1c ≤6% without DM medications. Results: There were 59 patients with a mean age of 43.0±9.5 years and 37.3% were males (Table 1). Most (76.3%) had gastric bypass while 23.7% had sleeve gastrectomy. Baseline mean weight and BMI were 114.4±27.4 kg and 42.5±10.5 kg/m2 respectively. Mean weight loss of 26% was achieved at 1 year and sustained over 5 years. Mean HbA1c decreased from 8.3% to 5.8% and 6.3% at 1 and 5 years respectively, with use of fewer DM, anti-hypertensive and lipid-lowering medications. At 5 years, 18 of 43 (41.9%) patients achieved sustained remission of diabetes with 6 (14.0%) having relapse of DM after initial remission at 1 year. Conclusion: MBS is effective therapy for obesity and DM with durable glycemic and metabolic control associated with lower medication use over 5 years in this Asian population.Table 1. Characteristics of subjects at baseline and over 5-year follow upPatient characteristicsPre-surgery (n=59)12 months (n=47)24 months (n=40)36 months (n=37)48 months (n=38)60 months (n=43)GenderMaleFemale22(37.3%)37(62.7%)NANANANANAAge (years)43.0 ± 9.5NANANANANAEthnicityChineseMalayIndianOther24 (40.7%)20 (33.9%)14 (23.7%)1 (1.7%)NANANANANADiabetes mellitus duration (months)92.1±96.3NANANANANATypes of surgerySleeve gastrectomyMini gastric bypassRoux-en-Y gastric bypass14(23.7%)16(27.1%)29(49.2%)NANANANANAWeight (kg)114.4±27.484.9±20.5*84.5±21.0*87.5±23.0*83.0±19.9*83.8±21.5*Body Mass Index (BMI) (%)42.5±10.531.9±8.3*31.3±7.4*32.5±8.2*31.3±8.06*32.0±8.67*Systolic blood pressure (mmHg)127.0±14.6125.6±17.3125.8±18.2130.2±17.7129.7±13.3135.4±19.2Diastolic blood pressure (mmHg)77.0±9.577.5±11.878.3±10.880.5±8.778.8±10.775.8±8.7Fasting blood glucose (mmol/L)8.51±3.125.51±1.93*5.99±2.11*6.59±2.57*6.72±2.51*6.73±2.55*HbA1c (%)8.32±1.385.82±0.82*6.09±1.09*6.51±1.31*6.53±1.11*6.32±1.02*Lipid panel (mmol/L)Total cholesterolLDLTriglycerideHDL4.56±0.882.75±0.811.69±0.741.05±0.264.77±0.942.83±0.611.19±0.56*1.32±0.29*4.81±0.77*2.84±0.731.30±0.51*1.46±0.54*4.79±0.86*2.78±0.701.42±0.68*1.37±0.32*4.54±0.912.52±0.801.41±0.76*1.38±0.28*4.17±0.522.28±0.451.30±0.70*1.30±0.28*Number of DM medications1.90±1.030.42±0.79*0.31±0.68*0.45±0.93*0.57±1.10*0.60±1.19*Antihypertensive medications1.64±1.210.42±0.70*0.39±0.72*0.37±0.79*0.40±0.83*0.45±0.95*Lipid-lowering medications0.81±0.570.17±0.38*0.25±0.44*0.31±0.50*0.27±0.49*0.33±0.51*Diabetes remission (n)NA2824121218Continuous data as mean ± SD; categorical data as n (%)* Presence of significant difference when compared to pre-surgery data (p Disclosure Z. Liew: None. A. Maung: None. S. Ganguly: Advisory Panel; Self; Novo Nordisk Inc.. P. Lee: None. K. Tham: None.

Hyperglycemia rarely manifests as hemichorea-hemiballism (HH), which is characterized by simple partial motor seizures. One of the difficulties in the management of hyperglycemia-induced HH is the failure to recognize this entity due to its relatively uncommon presentation. We herein present a case series of hyperglycemia-associated dyskinesias, highlighting the different possible clinical presentations of this entity. Both hyperglycemia and hyperosmolality are probable predisposing factors, while ketoacidosis has a protective role in preventing the dyskinesias. One of our patients had ketotic hyperglycemia leading to HH, a previously unreported finding. Early recognition of this entity is crucial as prompt glycemic control leads to the resolution of symptoms and signs.

This review examines the food addiction model and the role of food hedonic pathways in the pathogenesis and treatment of obesity. The hedonic pathway interacts with the obesogenic environment to override homeostatic mechanisms to cause increase in body weight. Weight gain sustained over time leads to “upward setting” of defended level of body-fat mass. There are neurobiological and phenotypic similarities and differences between hedonic pathways triggered by food compared with other addictive substances, and the entity of food addiction remains controversial. Treatment for obesity including pharmacotherapy and bariatric surgery impacts on neural pathways governing appetite and hedonic control of food intake. The food addiction model may also have significant impact on public health policy, regulation of certain foods, and weight stigma and bias. Recent rapid progress in delineation of food hedonic pathways advances our understanding of obesity and facilitates development of effective treatment measures against the disease.

Over the past decade, several new medications have been developed to treat type 2 diabetes mellitus. Large-scale outcome trials have been performed with patients at high cardiovascular risk to assess the cardiovascular safety of these agents. These trials are changing the landscape of diabetes therapy with evidence beyond safety to cardiovascular benefits of sodium-glucose cotransporter 2 (SGLT-2) inhibitors and some glucagon-like peptide-1 receptor agonists. This review provides an overview of incretin-based therapies and SGLT-2 inhibitors with a particular focus on the results of published cardiovascular outcome trials, which have also provided unique opportunities to evaluate uncommon but potentially serious adverse events of these newer agents. The cardiovascular benefits of SGLT-2 inhibitors and some glucagon-like peptide-1 receptor agonists suggest that they may be the preferred choice, usually as an add-on to metformin, for patients with type 2 diabetes mellitus at high cardiovascular risk.

Obesity is a major public health concern that leads to numerous metabolic, mechanical and psychological complications. Although lifestyle interventions are the cornerstone of obesity management, subsequent physiological neurohormonal adaptations limit weight loss, strongly favour weight regain and counteract sustained weight loss. A range of effective therapies are therefore needed to manage this chronic relapsing disease. Bariatric surgery delivers substantial, durable weight loss but limited access to care, perceived high risks and costs restrict uptake. Medical devices are uniquely positioned to bridge the gap between more conservative lifestyle intervention and weight-loss pharmacotherapy and more disruptive bariatric surgery. In this Review, we examine the range of gastrointestinal medical devices that are available in clinical practice to treat obesity, as well as those that are in advanced stages of development. We focus on the mechanisms of action as well as the efficacy and safety profiles of these devices. Many of these devices are placed endoscopically, which provides gastroenterologists with exciting opportunities for treatment.

Obesity is a serious, chronic, relapsing disease of energy regulation, with strong genetic and early-life environmental determinants. Pharmacotherapy can be a useful adjunct to lifestyle intervention in effecting and maintaining clinically meaningful weight loss.The aim of this article is to discuss the role of pharmacotherapy in obesity management. The efficacy, side effects and contraindications of available weight-loss medications are reviewed.Long-term pharmacotherapy options, which can be effective in providing moderate weight loss, are available to treat obesity. Pharma-cotherapy should be considered an adjunct to lifestyle intervention in those with a body mass index (BMI)30 kg/m30 kg/m2, or in those with a BMI of 27-30 kg/m2 and obesity-related complications. Safety and efficacy should be monitored closely on commencement, and the medication should be discontinued if there are safety or tolerability issues, or if.

Bariatric-metabolic surgery has emerged as an attractive option that offers significant and durable weight loss in the treatment of clinically severe obesity. Given the high prevalence of obesity, and growing numbers of bariatric-metabolic surgeries performed, primary care physicians increasingly encounter patients who have had, or are considering, bariatric-metabolic surgery.The aim of this article is to provide guidance on common issues pertaining to bariatric-metabolic surgery that general practitioners (GPs) face, including patient selection, preoperative work-up, acute and long-term complications following the surgery, and long-term lifestyle and nutritional support.In properly selected patients with clinically severe obesity, there is clear net benefit in terms of improved health outcomes and reduced mortality following bariatric-metabolic surgery. Similarly to other chronic conditions, GPs play a crucial role in the management of obesity, and in the multidisciplinary, long-term postoperative support and monitoring that is important for optimal outcomes after surgery.

Post-operative bleeding is a major but infrequent complication in laparoscopic sleeve gastrectomy (LSG). There is paucity in the literature on management of this complication. This paper seeks to review the presentation of post-operative bleeding complications after LSG in a single cohort of patients and highlight the surgical and non-surgical methods of treatment. A retrospective study of 409 LSG patients performed in a tertiary hospital, Singapore General Hospital (SGH) since 2008. Patients who encountered post-operative bleeding complications, defined as requiring blood transfusion or re-laparoscopy for haemostasis, were identified from a prospectively recorded database. The presentation, source of bleeding and management were recorded and presented. Five out of 409 (1.2%) patients were diagnosed with post-operative bleeding. Two patients were treated conservatively requiring only blood transfusion and 3 patients were surgically explored with laparoscopy, 2 were from staple line bleeding (SLB) and suture haemostasis performed. In 1 patient, the source of bleeding was not identified intraoperatively and CT angiography performed post-operatively showed active contrast bleeding near short gastric arteries and gastroepiploic artery. Gel foam and coil embolization was performed and the bleeding was controlled. Average hospitalization stay due to post-operative bleeding was 7.3 days compared to 2.3 days for those without. Post-operative bleeding after LSG occurred at the staple line and branches of the right gastro-epiploic artery and short gastric arteries. Bleeding may stop spontaneously or require haemostasis by operative or endovascular means. CT angiogram is proposed to locate the source of bleed and subsequent embolization of bleeding arteries maybe possible, avoiding the need for re-operation. Bleeding from the staple line requires surgical haemostasis.

INTRODUCTION: Obesity is a risk factor for type 2 diabetes mellitus (T2DM). Metabolic-bariatric surgery (MBS) results in significant weight loss with dramatic improvement in T2DM. This study analysed the effects of MBS on patients with T2DM in a tertiary centre in Singapore. METHODS: Individuals with T2DM who underwent MBS in a single centre from September 2008 to May 2012, with at least 12 months of regular follow-up, were included in our study. The primary outcome measure was good glycaemic control (glycated haemoglobin [HbA1c] < 6.5%, with or without medications) 12 months after surgery. Secondary outcome measures were partial DM remission (fasting blood glucose [FBG] < 7.0 mmol/L and HbA1c < 6.5% without DM medications), complete DM remission (FBG < 5.6 mmol/L and HbA1c < 6.0% without DM medications), weight, body mass index, blood pressure, and fasting serum lipid, serum glucose and serum insulin levels. RESULTS: Of the 19 patients who met the inclusion criteria, 14 underwent gastric bypass and 5 underwent sleeve gastrectomy. At 12 months postoperatively, 17 (89.5%) patients achieved good glycaemic control. DM remission was achieved in 14 (73.7%) patients, with 10 (52.6%) attaining complete remission. CONCLUSION: In Singapore, MBS is an effective treatment modality for obese patients with T2DM. Despite the small sample size and lack of matched controls, the present study suggests that MBS is effective in achieving significant weight loss and eliciting a significant and sustainable improvement in the glycaemic control of patients with T2DM, for up to 12 months.