High Glycemic Variability Assessed by Continuous Glucose Monitoring After Surgical Treatment of Obesity by Gastric Bypass

Hanaire, H.; Bertrand, Monelle; Guerci, Bruno; Anduze, Y.; Guillaume, Eric; Ritz, Patrick

doi:10.1089/dia.2010.0203

Cited by 59 publications

(63 citation statements)

References 18 publications

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“…Others have documented higher and earlier postprandial glucose peaks after RYGB, presumably caused by rapid deliveryofcarbohydratetothejejunum. 23,24 The altered glucose kinetics may complicate matching of insulin administration with glucose excursions, which can lead to increased hyperglycemia or hypoglycemia. Patients may also choose to take insulin postprandially because of the risk of food intolerance and gastrointestinal symptoms.…”

Section: Discussionmentioning

confidence: 99%

Bariatric Surgery for Severe Obesity in Two Adolescents With Type 1 Diabetes

Chuang

Zeller²,

Inge

et al. 2013

Pediatrics

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Bariatric surgery has been effective in treating type 2 diabetes mellitus (T2DM); it has not been used frequently in obese patients with type 1 diabetes mellitus (T1DM). This is the first case series reporting on the effect of bariatric surgery on diabetes control in adolescents with T1DM. Patient A is a 19-year-old obese man with T1DM who underwent vertical sleeve gastrectomy. At 12 months after surgery he demonstrated 28% reduction in BMI. His daily total insulin requirement had decreased; however, hemoglobin A1c remained primarily unchanged at 8.8%. Patient B is a 13-year-old obese girl with an initial clinical diagnosis of T2DM controlled on only metformin. She underwent Roux-en-Y gastric bypass; at 1 month after surgery she presented in diabetic ketoacidosis and was found to have positive islet cell antibodies, which were also present before surgery. Her diagnosis was revised to T1DM, and she was started on insulin. By 28 months after surgery her BMI had decreased by 42%. Since initiation of insulin, her daily total insulin requirement had decreased, but hemoglobin A1c had significantly worsened from 6.3% to 10%. We found that despite significant weight loss, improvements in cardiovascular risk factors (dyslipidemia and obstructive sleep apnea), and quality of life in our patients, bariatric surgery does not necessarily lead to improved glycemic control of T1DM. Patients with T1DM have ongoing dependency on exogenous insulin, and optimal glycemic control still depends on patient compliance with diabetes care. Pediatrics 2013;132:e1031-e1034 Dr Chuang conceptualized the case series and drafted the initial manuscript; Dr Zeller interpreted the quality of life measurements used in the case series, wrote the interpretations for the manuscript, and reviewed and revised the manuscript; Dr Inge helped obtain data used in the case series and critically reviewed and revised the manuscript; Dr Crimmins help conceptualize and design the outline for the case series and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

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Section: Discussionmentioning

confidence: 99%

Bariatric Surgery for Severe Obesity in Two Adolescents With Type 1 Diabetes

Chuang

Zeller²,

Inge

et al. 2013

Pediatrics

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“…The absolute IG values were reduced from 2.5 to 0.18%, and the time with IG below 60 mg/dl (3.3 mmol/l) also decreased. Hanaire et al (19) compared three groups -post-GBP, diabetic, and healthy controls -of ten patients each with CGM. Post-surgery patients had shorter timeto-postprandial-peak-glucose levels and also higher peak levels per se.…”

Section: Introductionmentioning

confidence: 99%

Hypoglycemia in everyday life after gastric bypass and duodenal switch

Abrahamsson

Engström

Sundbom

et al. 2015

European Journal of Endocrinology

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Design: Gastric bypass (GBP) and duodenal switch (DS) in morbid obesity are accompanied by marked metabolic improvements, particularly in glucose control. In recent years, episodes of severe late postprandial hypoglycemia have been increasingly described in GBP patients; data in DS patients are scarce. We recruited three groups of subjects; 15 GBP, 15 DS, and 15 non-operated overweight controls to examine to what extent hypoglycemia occurs in daily life. Methods: Continuous glucose monitoring (CGM) was used during 3 days of normal activity. The glycemic variability was measured by mean amplitude of glycemic excursion and continuous overall net glycemic action. Fasting blood samples were drawn, and the patients kept a food and symptom log throughout the study. Results: The GBP group displayed highly variable CGM curves, and 2.9% of their time was spent in hypoglycemia (!3.3 mmol/l, or 60 mg/dl). The DS group had twice as much time in hypoglycemia (5.9%) and displayed CGM curves with little variation as well as lower HbA1c levels (29.3 vs 35.9 mmol/mol, P!0.05). Out of a total of 72 hypoglycemic episodes registered over the 3-day period, 70 (97%) occurred in the postprandial state and only about one-fifth of the hypoglycemic episodes in the GBP and DS groups were accompanied by symptoms. No hypoglycemias were seen in controls during the 3-day period. Conclusion: Both types of bariatric surgery induce marked, but different, changes in glucose balance accompanied by frequent, but mainly unnoticed, hypoglycemic episodes. The impact and mechanism of hypoglycemic unawareness after weight-reduction surgery deserves to be clarified.

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“…At the same time, a higher mean amplitude of glucose excursions (MAGE), a shorter time to the post-prandial peak of interstitial glucose occur (with maximum glucose levels above 200 mg/dL, but with normal fasting and 2-hour post meal levels in most patients with a diabetes background before surgery), and symptoms of hypoglycemia usually were more related to the speed of glucose decrease than to the glucose level achieved, since hypoglycemic episodes were not registered on all occasions. Being so, the early post-prandial hyperglycemia may underestimate the diagnosis of diabetes if glucose measurement is done 2-hours post-meal (10).…”

mentioning

confidence: 99%

“…Furthermore, glucose variability is exaggerated after Roux-en-Y gastric bypass, combining typically high and early hyperglycemic peaks and rapid glucose decreases with symptoms mimicking hypoglycemia (but on occasion being true severe hypoglycemia) (10). There are high quality evidence criteria associating postmeal and post-challenging glucose hyperglycemia and macrovascular disease, retinopathy, increased carotid intima-media thickness, oxidative stress, inflammation and endothelial dysfunction, impaired cognitive function in elderly people with type 2 diabetes, as well as decreased myocardial blood flow, and increased risk of some types of cancer.…”

mentioning

confidence: 99%

“…There is evidence suggesting that employing only fasting blood glucose and glycated hemoglobin levels to diagnose diabetes in patients undergoing bariatric surgery leads to underestimation, since the glycated hemoglobin may be falsely minimized or normal in patients with higher MAGE (especially with concomitant both hypoglycemic and hyperglycemic events) (10). Although these parameters provide good specificity, the sensitivity is poor in the diagnosis of dysglycemia (12).…”

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confidence: 99%

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Dealing with diabetes and pregnancy following bariatric surgery: a double-edged sword?

Mancini

2016

Arch. Endocrinol. Metab.

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Bariatric surgery offers substantial and sustained weight loss for most patients, with diabetes improvement or remission and also reduction in weight-related comorbidities in patients with a BMI of 35 kg/m² or more. The same benefits have not yet been established for patients with a BMI of less than 35 kg/m 2 , since there is still limited evidence based in very few studies investigating less than one hundred patients with class I obesity. Moreover, in larger studies involving patients with higher baseline BMI such as the Swedish Obese Subjects Study, the degree of weight loss has been significantly associated with glycemic improvement, independently of the surgical procedure when stratified by weight. In spite of this, delegates of International Bariatric Surgery and Diabetes Organizations during the 2 nd Diabetes Surgery Summit in London recently approved a joint statement where surgery should be considered (consider should not have the same strength of a recommendation) for patients with type 2 diabetes and BMI between 30.0 and 34.9 kg/m 2 if hyperglycemia is inadequately controlled despite optimal treatment with either oral or injectable medications, including insulin; and these BMI thresholds should be reduced by 2.5 kg/m 2 for Asian patients (in spite of short duration of diabetes, good glycemic control and absence of insulin therapy be preoperative predictive factors of diabetes remission) (1). Recently, some cardiovascular safety trials with diabetes medications have demonstrated that these drugs offer cardiovascular protection (2); more data on hard outcomes are required to better assess not only the efficacy, but mainly the safety in very large series before endorsing the widespread indication of bariatric surgery in the subpopulation of type 2 diabetics with a BMI below 35 kg/m 2 . A significant proportion of individuals undergoing bariatric surgery experiment weight regain, residual diabetes or diabetes relapse (i.e., around one third of initial remitters over five years do not achieve remission or have diabetes recurrence), requiring to cope with the residual diabetes and emerging obesity (2,3) and also to deal with lifelong nutritional deficiencies and other potential long-term complications, such as vomiting, adhesions, strictures, gallstones, hernias, drinking problems, and small-bowel obstruction (4,5). In the scope under discussion, it is essential that the diagnosis of diabetes in patients undergoing bariatric surgery be reliable and safe.In this issue of Archives of Endocrinology and Metabolism, a study examined the adverse effects of the oral glucose tolerance test (OGTT) in 128 patients who underwent bariatric surgery, of which more than 90% were women and nearly 30% pregnant. Around two thirds of patients experienced one to four or more limiting adverse effects such as nausea, dizziness, weakness, diarrhea, tachycardia, sweating or hypoglycemia during the test. The main reasons for ordering an OGTT were presence of symptoms suggestive of hypoglycemia, pregnancy, type 2 diabetes prior to su...

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High Glycemic Variability Assessed by Continuous Glucose Monitoring After Surgical Treatment of Obesity by Gastric Bypass

Cited by 59 publications

References 18 publications

Bariatric Surgery for Severe Obesity in Two Adolescents With Type 1 Diabetes

Bariatric Surgery for Severe Obesity in Two Adolescents With Type 1 Diabetes

Hypoglycemia in everyday life after gastric bypass and duodenal switch

Dealing with diabetes and pregnancy following bariatric surgery: a double-edged sword?

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