Insights from the Impact of Meal Composition on Glucose Profile Towards Post-bariatric Hypoglycemia Management

Marques, Ana Raquel; Lobato, Carolina B.; Pereira, Sofia S; Guimarães, Marta; Faria, Sandra F. G. de Lopes; Nora, Mário; Monteiro, Mariana P.

doi:10.1007/s11695-019-04147-1

Cited by 9 publications

(4 citation statements)

References 29 publications

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“…The fact that PBH frequency can be mitigated by dietary interventions (2,13,14) and pharmacological interventions that reduce carbohydrate digestion or absorption, delay gastro-intestinal transit time, limit insulin secretion or suppress incretin effects (10,15,16), suggests a role for entero-pancreatic hormone dynamics in this condition.…”

Section: Introductionmentioning

confidence: 99%

A Potential Role for Endogenous Glucagon in Preventing Post-Bariatric Hypoglycemia

et al. 2020

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Obesity and obesity-related diseases are major public health concerns that have been exponentially growing in the last decades. Bariatric surgery is an effective long-term treatment to achieve weight loss and obesity comorbidity remission. Post-bariatric hypoglycemia (PBH) is a late complication of bariatric surgery most commonly reported after Roux-en-Y gastric bypass (RYGB). PBH is the end result of postprandial hyperinsulinemia but additional endocrine mechanisms involved are still under debate. Our aim was to characterize entero-pancreatic hormone dynamics associated with postprandial hypoglycemia after RYGB. Individuals previously submitted to RYGB (N=23) in a single tertiary hospital presenting PBH symptoms (Sym, n=14) and asymptomatic weight-matched controls (Asy, n=9) were enrolled. Participants underwent a mixed-meal tolerance test (MMTT) to assess glucose, total amino acids (total AA), insulin, C-peptide, glucagon, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide-1 (GLP-1), and neurotensin (NT). We found that hypoglycemia during the MMTT was equally frequent in Sym and Asy groups (p=1.000). Re-grouped according to glucose nadir during the MMTT (Hypo n=11 vs NoHypo n=12; nadir <3.05 mmol/l vs ≥3.05 mmol/l), subjects presented no differences in anthropometric (BMI: p=0.527) or metabolic features (HbA1c: p=0.358), yet distinct meal-elicited hormone dynamics were identified. Postprandial glucose excursion and peak glucose levels were similar (p>0.05), despite distinct late glycemic outcomes (t=60 min and t=90 min: p<0.01), with overall greater glycemic variability in Hypo group (minimum-to-maximum glucose ratio: p<0.001). Hypo group meal-triggered hormone profile was characterized by lower early glucagon (t=15 min: p<0.01) and higher insulin (t=30 min: p<0.05, t=45 min: p<0.001), C-peptide (t=30 min: p<0.01, t=45 min: p<0.001, t=60 min: p<0.05), and GLP-1 (t=45 min: p<0.05) levels. Hyperinsulinemia was an independent risk factor for hypoglycemia (p<0.05). After adjusting for hyperinsulinemia, early glucagon correlated with glycemic nadir (p<0.01), and prevented postprandial hypoglycemia (p<0.05). A higher insulin to glucagon balance in Hypo was observed (p<0.05). No differences were observed in total AA, GIP or NT excursions (p>0.05). In sum, after RYGB, postprandial hyperinsulinemia is key in triggering PBH, but a parallel and earlier rise in endogenous glucagon might sustain the inter-individual variability in glycemic outcome beyond the effect of hyperinsulinism, advocating a potential pivotal role for glucagon in preventing hyperinsulinemic hypoglycemia.

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Section: Introductionmentioning

confidence: 99%

A Potential Role for Endogenous Glucagon in Preventing Post-Bariatric Hypoglycemia

et al. 2020

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“…A daily macronutrient distribution of 45% carbohydrates, 25% proteins and 30% fats is recommended [ 43 , 44 ]. Hypoglycemic episodes are more likely to be triggered by meals that are low in protein and high in sugar content [ 45 ]. Indeed, according to the Society for Endocrinology guidelines for the diagnosis and management of PBH [ 46 ], it is recommended to consume at least 60 g/day of protein, although higher intake may be necessary.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Cholecystectomy in Patients with Post-Bariatric Surgery Hypoglycemia

Sardão,

Santos-Sousa,

Peleteiro

et al. 2024

OBES SURG

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Background Metabolic surgery is the foremost treatment for obesity and its associated medical conditions. Nonetheless, post-bariatric hypoglycemia (PBH) emerges as a prevalent complication. PBH pathophysiology implicates heightened insulin and glucagon-like peptide 1 (GLP-1) levels, with bile acids (BA) contributing to GLP-1 release. A plausible association exists between cholecystectomy and PBH, which is attributed to alterations in BA metabolism and ensuing hormonal responses. The objective of this retrospective cohort study was to evaluate the impact of cholecystectomy on PBH pharmacological treatment, diagnostic timelines and metabolic parameters. Materials and methods Patients diagnosed with PBH after bariatric surgery were evaluated based on their history of cholecystectomy. Demographic, anthropometric and clinical data were collected. Mixed meal tolerance tests (MMTT) results were compiled to assess metabolic responses. Results Of the 131 patients with PBH included in the study, 29 had prior cholecystectomy. The time to PBH diagnosis was similar across groups. Patients with prior cholecystectomy required higher doses of acarbose (p = 0.046), compared to those without prior cholecystectomy. Additionally, MMTT revealed higher insulin (t = 60 min: p = 0.010 and t = 90 min: p = 0.034) and c-peptide levels (t = 60 min: p = 0.008) and greater glycemic variability in patients with prior cholecystectomy (p = 0.049), highlighting the impact of cholecystectomy on glucose metabolism. Conclusion Our study offers novel insights into PBH pharmacotherapy, indicating that PBH patients with a history of cholecystectomy require elevated doses of acarbose for symptom control than PBH patients without such surgical history. Furthermore, our findings underscore the pivotal role of hyperinsulinism in PBH aetiology, emphasizing the significance of the BA-GLP-1-insulin axis. Graphical Abstract

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“…One study using continuous glucose monitoring showed hypoglycemic episodes of < 55 mg/dL in 75 % of the patients with RYGB [27]. Within months to years after metabolic surgery, hypoglycemic symptoms occur 1-3 hours after eating, especially after ingesting high glycemic index carbohydrates [28,29]. Post-bariatric hypoglycemia is mainly reported after RYGB [30].…”

Section: Novel Insight Into the Mechanism Of Metabolic Surgery Causin...mentioning

confidence: 99%

Novel Insight into the Mechanism of Metabolic Surgery Causing the Diversity in Glycemic Status in Type 2 Diabetes

Zhou

Wang

Zhou

et al. 2022

Exp Clin Endocrinol Diabetes

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Metabolic surgery results in diverse glycemic status in patients with type 2 diabetes (T2D), including hyperglycemia without remission, significant amelioration of hyperglycemia with partial remission, complete restoration of euglycemia, or with prolonged remission, hyperglycemia recurrence in relapses after remission, or post-bariatric hypoglycemia. Unfortunately, it is not known how metabolic surgery leads to this diverse consequence. Here, we discuss the diversity of glycemic status associated with metabolic surgery and the potential mechanisms of T2D remission. We also highlight the relationship between the change in low-grade inflammation and T2D remission after metabolic surgery. We hypothesize that the level of inflammatory and anti-inflammatory cytokines controls the efficacy of metabolic surgery in patients with T2D. This hypothesis may provide further insight into the mechanism of the beneficial effects of metabolic surgery patients with T2D.

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Insights from the Impact of Meal Composition on Glucose Profile Towards Post-bariatric Hypoglycemia Management

Cited by 9 publications

References 29 publications

A Potential Role for Endogenous Glucagon in Preventing Post-Bariatric Hypoglycemia

A Potential Role for Endogenous Glucagon in Preventing Post-Bariatric Hypoglycemia

The Impact of Cholecystectomy in Patients with Post-Bariatric Surgery Hypoglycemia

Novel Insight into the Mechanism of Metabolic Surgery Causing the Diversity in Glycemic Status in Type 2 Diabetes

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