Provider Practice Habits And Barriers To Care In Obesity Management In A Large Multicenter Health System

Objective: To identify provider recommendations and barriers in obesity management in a multicenter academic health system with extensive weight-loss management resources.Methods: A 26-question online survey was sent to attending physicians, trainees, and advanced practice providers in primary care specialties (internal medicine, family medicine, women's health) and endocrinology.Results: The survey response rate was 26% (111/430). Of respondents, 50% were internal medicine, 24% family medicine, 16% women's health, and 9% endocrinology. The majority were attending physicians (54%) and residents (40%). About 50% of respondents advised weight loss for a body mass index (BMI) >30 kg/m² in >50% of clinic visits. Limited time (82%) was the most common reason for not discussing weight loss, followed by the perception that discussion would not change patient behavior, insufficient knowledge, and discomfort broaching the subject. Common barriers to prescribing anti-obesity medications included limited experience (57%) and concern for adverse reactions (26%). Only 44% offered bariatric surgery to >50% of their patients who met criteria. Primary reasons for not referring included concerns of high surgical risk from comorbidities (57%) and potential adverse events (32%). Endocrinology had the highest referral to surgery. Attending physicians and fellows were more likely than residents to advise weight loss at lower BMI, offer medications, and refer to bariatric surgery.Conclusion: Our study reveals reluctance and lack of primary care confidence in managing obesity with pharmacotherapy and bariatric surgery, especially in the earlier stages of obesity. Barriers to care include lack of clinic time, limited experience, and concerns about treatment risks.Abbreviations: BMI = body mass index; HbA1c = hemoglobin A1c; IRB = Institutional Review Board     

Goals for Medical Treatment in Obesity and Prediabetes: Improving Outcomes for Both

Objective: The purpose of this review is to expose the surprising prevalence of diabetes-related complications in people with persistent prediabetes, and hence, to expand the paradigm of diabetes prevention to include the prevention of complications related to both hyperglycemia and obesity.Methods: Published literature was reviewed.Results: Approximately 84 million Americans have prediabetes, 85% of whom are overweight or obese. Although the incidence of diabetes-related complications is lower in people with prediabetes versus those with type 2 diabetes, the overall prevalence is virtually identical. Furthermore, many people with prediabetes not only suffer from the complications related to hyperglycemia, they also experience complications of obesity. Treating obesity as a disease has the potential to prevent complications of both hyperglycemia and obesity. Emerging data reveal the untapped potential for clinicians to enhance the effectiveness of anti-obesity medications through a mindful health care delivery style. This involves an understanding and ethical utilization of the placebo effect in conjunction with active medical therapy. This approach is not intended to mislead patients but rather to activate neurocircuitry that synergizes with the central action of the approved anti-obesity medications to potentiate weight loss.Conclusion: Mindful administration of anti-obesity medications has the potential for widespread health benefits in people with obesity and prediabetes.Abbreviations: ADA = American Diabetes Association; DPP = Diabetes Prevention Program; CVD = cardiovascular disease     

Metabolic surgery for type 2 diabetes mellitus

Background: Metabolic surgery for morbid obesity induces significant weight loss and resolution of many obesity-related comorbidities, the most notable of which is remission of type 2 diabetes mellitus (DM). Such changes seem to precede significant weight loss in this population shortly after undergoing diversionary procedures.Objective: This article explores the evidence for salutary metabolic benefits of bariatric surgery, with special emphasis on glycemic control and remission of type 2 DM.Methods: We conducted a query of the PubMed database for articles published in English within the past 15 years using the search terms bariatric surgery, obesity, type 2 diabetes, gastric bypass, gastric banding, incretins, enteroinsular axis, GLP-1 (glucagon-like peptide-1), and GIP (glucose-dependent insulinotropic polypeptide). We targeted review articles as well as those discussing the effects of bariatric surgery on the enteroinsular axis and the respective effects on glyce-mic control.Results: Most of the clinical reports indicated a high remission rate (≥85%) for type 2 DM, and relatively higher rates in patients who underwent diversionary procedures. Studies with small cohorts and laboratory data suggested a role for gastrointestinal hormones in the regulation of glucose homeostasis after bariatric surgery.Conclusions: Gastrointestinal surgery for severe obesity, through restrictive and/or neurohormonal effects, is an effective treatment for type 2 DM. Surgically induced weight loss was found to be sustainable, durable, and associated with remission of type 2 DM, a reduction in mortality, and improvement in quality of life.     

The Relationship Between Adverse Childhood Experiences and Diabetes in Central Michigan Adults

Objective: Adverse childhood experiences (ACEs) predispose individuals to poor health outcomes as adults. Although a dose-response relationship between the number of ACEs and certain chronic illnesses has been shown, the impact of ACEs on diabetes is not thoroughly understood. We investigated the prevalence of ACEs in patients with diabetes and the potential relationship to the severity of diabetes.Methods: Patients with diabetes (both type 1 and type 2) or obesity were surveyed from the Endocrinology & Diabetes Center at McLaren Central Michigan in Mount Pleasant, Michigan. A validated, standard ACE questionnaire was administered to quantify the number of adverse childhood events that patients have experienced. A retrospective chart analysis was then conducted, addressing the relationship of ACEs with the severity of disease in the diabetes group and the obesity group. The number of ACEs was correlated with disease comorbidities, complications, and measurable quantities, such as body mass index (BMI) and hemoglobin A1c (HbA1c).Results: ACE scores in both diabetes and obesity groups were shown to have a greater prevalence compared to the general ACE average in Michigan. ACE scores also positively correlated to BMI and HbA1c in the diabetes group. Those with higher ACE scores in the diabetes group were also more likely to have depression and anxiety.Conclusion:ACE screening may lead to a greater understanding of the severity of and progression of diabetes. Ultimately, these results could provide support to potential interventional studies leading to the altered management of diabetes in patients with ACEs, or preventative intervention to children with ACEs.Abbreviations: ACE = adverse childhood experiences; BMI = body mass index; HbA1c = hemoglobin A1c; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus     

Appropriateness Criteria for Bariatric Surgery: Beyond the NIH Guidelines

Careful selection of bariatric patients is critical for successful outcomes. In 1991, the NIH first established patient selection guidelines; however, some surgeons operate on individuals outside of these criteria, i.e., extreme age groups. We developed appropriateness criteria for the spectrum of patient characteristics including age, BMI, and severity of eight obesity‐related comorbidities. Candidate criteria were developed using combinations of patient characteristics including BMI: ≥40 kg/m², 35–39, 32–34, 30–31, <30; age: 12–18, 19–55, 56–64, 65+ years old; and comorbidities: prediabetes, diabetes, hypertension, dyslipidemia, sleep apnea, venous stasis disease, chronic joint pain, and gastroesophageal reflux (plus severity level). Criteria were formally validated on their appropriateness of whether the benefits of surgery clearly outweighed the risks, by an expert panel using the RAND/UCLA modified Delphi method. Nearly all comorbidity severity criteria for patients with BMI ≥40 kg/m² or BMI = 35–39 kg/m² in intermediate age groups were found to be appropriate for surgery. In contrast, patients in the extreme age categories were considered appropriate surgical candidates under fewer conditions, primarily the more severe comorbidities, such as diabetes and hypertension. For patients with a BMI of 32–34, only the most severe category of diabetes (Hgb A1c >9, on maximal medical therapy), is an appropriate criterion for those aged 19–64, whereas many mild to moderate severity comorbidity categories are “inappropriate.” There is overwhelming agreement among the panelists that the current evidence does not support performing bariatric surgery in lower BMI individuals (BMI <32). This is the first development of appropriateness criteria for bariatric surgery that includes severity categories of comorbidities. Only for the most severe degrees of comorbidities were adolescent and elderly patients deemed appropriate for surgery. Patient selection for bariatric procedures should include consideration of both patient age and comorbidity severity.     

Use of Electronic Health Records to Characterize a Rare Disease in The U.S.: Treatment,Comorbidities, and Follow-Up Trends Among Patients With a Confirmed Diagnosis of Acromegaly

Objective: Understanding of acromegaly disease management is hampered in the U.S. by the lack of a national registry. We describe medical management in a population with confirmed acromegaly.Methods: Inpatient and outpatient electronic health records (EHRs) were used to create a database of de-identified patients assigned the Acromegaly and Gigantism International Classification of Diseases, 9^th revision (ICD-9) code and/or an appropriate pituitary procedure code at 1 of 4 regional hospital systems over a 6- to 11-year period. Information regarding demographics, medical history, labs, procedures, and medications was collected and supplemented with a chart review to validate the diagnosis of acromegaly.Results: Of 367 patients with validated acromegaly, available records showed that during the years studied, pituitary surgery was performed on 31%, 4% received radiosurgery, and 22% were prescribed a drug indicated for acromegaly. Insulin-like growth factor-1 (IGF-1) levels were measured in 62% of patients, 83% of whom had at least 1 normal value. Coded comorbidities reflect those reported previously in patients with acromegaly, with the exception of esophageal reflux in 20% of patient records. Fewer data regarding acromegaly-specific medications and testing were available for patients aged 65 and older.Conclusion: AcroMEDIC is a U.S. multisite retrospective study of acromegaly that captured medical management in the majority of patients included in the cohort. Chart review highlighted the importance of verification of coded diagnoses. Most of the acromegaly-related comorbidities identified here are known to increase with age and obesity. Patients ≥65 appeared to have less active management/monitoring of their disease. Medical attention should be directed to this population to address evolving needs over time.Abbreviations: AcroMEDIC = Acromegaly Multisite Electronic Data Innovative Consortium; BMI = body mass index; CCI = Charlson Comorbidity Index; EHR = electronic health record; GH = growth hormone; GHRA = growth hormone receptor antagonist; ICD-9 = International Classification of Diseases, 9^th revision; IGF-1 = insulin-like growth factor-1; SSA = somatostatin analogue     

New Tools for Weight-Loss Therapy Enable a More Robust Medical Model for Obesity Treatment: Rationale for a Complications-Centric Approach

ObjectiveRecent advances in lifestyle intervention programs, pharmacotherapy, and bariatric surgery have enabled the development of medical models for the treatment of obesity. Regarding pharmacotherapy, in 2012 the U.S. Food and Drug Administration approved two new effective and safe weight-loss medications, phentermine/ topiramate extended release and lorcaserin, which has greatly augmented options for medically assisted weight loss.MethodsThe rationale for advantages of a complications-centric medical model over current body mass index (BMI)-centric indications for therapy is examined.ResultsCurrently, the baseline BMI level is the principle determinant of indications for obesity treatment using medication and surgery. However, the BMI-centric approach fails to target therapy to those obese patients who will benefit most from weight loss. In contrast, a complications-centric medical model is proposed that will earmark the modality and intensity of the therapeutic intervention based on the presence and severity of complications that can be ameliorated by weight loss.ConclusionThe complications-centric approach to “medicalizing” obesity care employs weight loss primarily as a tool to treat obesity-related complications and promotes the optimization of health outcomes, the benefit/risk ratio, and the cost-effectiveness of therapy. (Endocr Pract. 2013;19:864-874)     

Clinical Recognition and Management of Patients with Prediabetes

Objective: Early identification and management of prediabetes is critical to prevent progression to diabetes. We aimed to assess whether prediabetes is appropriately recognized and managed among patients with impaired fasting glucose (IFG).Methods: We carried out an observational study of Olmsted County residents evaluated at the Mayo Clinic between 1999–2017. We randomly selected 108 subjects with biochemical criteria of IFG and 105 normoglycemic subjects. We reviewed their health records at baseline (1999–2004) and during follow up (2005–2017) collecting demographic and clinical data including vitals, diagnoses, laboratory, and medications associated with cardiovascular comorbidities. The main outcome was documentation of any recognition of prediabetes and management recommendations (lifestyle changes and/or medications).Results: At baseline (1999–2004), 26.85% (29/108) of subjects with IFG were recognized as having prediabetes, and of these 75.86% (22/29) received management recommendations with 6.9% (2/29) getting metformin. During follow-up (2005–2017), 26.67% (28/105) of initial cohort of normoglycemic subjects developed incident IFG and of these, 85.71% (24/28) were recognized as having prediabetes, and 58.33% (14/24) received management recommendations. During the entire study period, 62.50% (85/136) were recognized as having prediabetes of which 75.29% (64/85) had documented management recommendations. High body mass index (BMI) (≥35) was associated with increased recognition (odds ratio &lsqb;OR] 3.66; confidence interval &lsqb;CI] 1.065, 12.500; P = .0395), and normal BMI (<25) was associated with a lack of recognition (OR 0.146; CI 0.189, 0.966; P = .0413).Conclusion: Despite evidence supporting the efficacy of lifestyle changes and medications in managing prediabetes, this condition is not fully recognized in routine clinical practice. Increased awareness of diagnostic criteria and appropriate management are essential to enhance diabetes prevention.Abbreviations: BMI = body mass index; CI = confidence interval; EHR = electronic health records; FBG = fasting blood glucose; IFG = impaired fasting glucose; IGT = impaired glucose tolerance; OR = odds ratio     

Application Of The Aace/Ace Advanced Framework For The Diagnosis Of Obesity And Cardiometabolic Disease Staging In A General Population From 3 Regions Of Venezuela: The Vemsols Study Results

Objective: To determine the prevalence of obesity according to the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) framework based on a complications-centric model with further application of the Cardiometabolic Disease Staging (CMDS) system in a Venezuelan population.Methods: A total of 1,320 adults were randomly selected from 3 regions. The AACE/ACE framework definitions were as follows: overweight, body mass index (BMI) 25 to 29.9 kg/m² and no obesity-related complications (ORC); obesity stage 0, BMI ≥30 and no ORC; stage 1, BMI ≥25 and 1 or more mild-to-moderate ORC; and stage 2, BMI ≥25 and 1 or more severe ORC. CMDS definitions were as follows: stage 0, no metabolic syndrome (MS) components; stage 1, 1 to 2 MS components without impaired fasting glucose (IFG); stage 2, IFG or ≥3 MS components but without IFG; stage 3, IFG and MS; and stage 4, type 2 diabetes (T2D) or cardiovascular disease.Results: The mean age was 44.8 ± 0.4 years, and 68.5% were female. The prevalence of obesity according to the AACE/ACE framework was 63.1%: overweight 3.0% (95% confidence interval &lsqb;CI]: 2.1–3.9); obesity stage 0: 0.1% (0.07–0.27); obesity stage 1: 26.6% (24.2–29.0); and obesity stage 2: 36.4% (33.8–39.0). Most subjects with a BMI <25 were CMDS 0 or 1. In those with BMI ≥ 25, only 4.6% were CMDS 0. The prevalence of obesity according to the World Health Organization (WHO, BMI ≥30) was 29.3% (24.7–33.7).Conclusion: In a general population study, applying the AACE/ACE framework for obesity and CMDS increased the detection of ORC and therefore higher risk subjects compared to classic anthropometric measurements.Abbreviations: AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; BMI = body mass index; CMDS = Cardiometabolic Disease Staging; DALY = disability-adjusted life years; LA = Latin America; MS = metabolic syndrome; ORC = obesity-related complications; WC = waist circumference; WHO = World Health Organization     

The Benefit of Short-Term Weight Loss with Anti-Obesity Medications in Real-World Clinical Practice

Objective: The effectiveness of anti-obesity medications (AOMs) outside of clinical trials is unclear. The objective of this study was to compare the short-term effectiveness of AOMs in real-world practice.Methods: This retrospective study included adults aged ≥18 years, with body mass index ≥30 kg/m² or ≥27 kg/m² with at least one obesity-related comorbidity who were prescribed phentermine hydrochloride, phenterminetopiramate, bupropion-naltrexone, or lorcaserin for 12 consecutive weeks between 2006 and 2016 at a large tertiary healthcare system. Propensity score–matched cohorts were created for each pair of AOMs. The primary outcomes were percent and absolute weight loss from baseline after 12 weeks. A prediction model was constructed to estimate weight loss with different AOMs based on demographic and clinical data.Results: Of the 3,411 patients included in this study, patients lost an average of 3.45% of body weight from baseline. All AOMs were associated with a significant weight loss from baseline (P<.0001). Patients lost the highest percentage of body weight on phentermine hydrochloride (3.75 ± 5.66%), followed by phentermine-topiramate (3.63 ± 5.7%), bupropion-naltrexone (2.66 ± 5.03%), and lorcaserin (1.84 ± 6.69%). In propensity-matched cohorts, patients taking phentermine hydrochloride lost more weight than those taking lorcaserin or bupropion-naltrexone, and patients taking phentermine topiramate lost more weight than patients taking lorcaserin.Conclusion: In real-world practice, AOMs are associated with clinically meaningful weight loss of 2 to 4% after 12 weeks. In this study, phentermine hydrochloride and phentermine topiramate produced the most weight loss. AOMs should be seriously considered as part of the armamentarium to treat patients with obesity.Abbreviations: AOM = anti-obesity medication; BMI = body mass index; EMR = electronic medical record; FDA = Food and Drug Administration; T2D = type 2 diabetes     

High Body Mass Index is A Significant Barrier to Gender-Confirmation Surgery for Transgender and Gender-Nonbinary Individuals

Objective: Transgender and gender-nonbinary individuals (TGNB) are disproportionately impacted by obesity. In addition to the associated health impact, obesity represents a significant barrier to accessing gender-confirmation surgery (GCS). The purpose of this study was to determine the prevalence of obesity among TGNB surgical candidates at an urban academic medical center and evaluate the efficacy of self-monitored weight management.Methods: The study was conducted at the Center for Transgender Medicine and Surgery at Mount Sinai in New York City. Data abstraction from a quality improvement database was completed for patients with a documented body mass index (BMI) and a GCS consult from October 2015 through February 2019. A total of 1,457 TGNB patients with a documented BMI and a GCS consult in the historical period of review were included in analysis. Data were abstracted to determine the prevalence of obesity among GCS candidates and evaluate the current default pre-operative self-monitored weight management protocol.Results: Of 1,457 TGNB patients, 382 (26%) were obese (BMI ≥30 kg/m²) at initial surgical consult. In addition, 369 (27%) were obese at a subsequent follow-up, suggesting no statistically significant change in the rate of obesity among evaluated TGNB despite self-monitored weight management (P = .5272).Conclusion: Obesity is a significant barrier to gender affirming surgery for transgender individuals. Self-monitored weight management is an unsuccessful strategy for improvement even among individuals who would be predicted to be motivated.Abbreviations: BMI = body mass index; CTMS = Center for Transgender Medicine and Surgery (at Mount Sinai); GCS = gender confirmation surgery; TGNB = transgender and gender-nonbinary     

Long-Term,Sustained, Lifestyle-Induced Weight Loss in Severe Obesity: the Get-Real Program

Objective: To study the long-term effectiveness of a patient-centered, multidisciplinary lifestyle intervention treatment in patients medically eligible for bariatric surgery.Methods: Using a case-control study design, we compared treatment results for 98 adults (mean body mass index [BMI], 44.2 kg/m²) with the outcomes of 148 controls (mean BMI, 43.0 kg/m²) receiving standard care. The approach included a phased triage for inclusion, followed by 12 lifestyle intervention group sessions alternating with individual visits for behavior, diet, and exercise instructions.Results: At 2 years, weight loss averaged 15.3 ± 1.4 kg (P<.0010) (12 ± 1% of initial body weight [IBW], P<.001; 21 ± 2% of excess body weight [EBW], P<.001) in an intention-to-treat (ITT) analysis; in completers, weight loss was 18.8 ± 1.5 kg (P<.001) (15 ± 1% IBW, P<.001; 26 ± 3% EBW, P<.001). A total of 42 patients lost ≥10% IBW. Controls remained weight stable (P =.35); 3% lost ≥10% IBW. Patients achieving weight loss that would be considered satisfactory for bariatric surgery included 20% who achieved ≥35% EBW loss, 29% who achieved a BMI <35 kg/m² (if starting BMI <50 kg/m²) or BMI <40 kg/m² (if starting BMI ≥50 kg/m²), and 37% who achieved EBW loss ≤50%. These values for completers were 31, 39, and 48%, respectively. In the 55 patients starting the program ≥4 years ago, weight loss maintenance of 12 ± 1% IBW (ITT, 16 ± 1% in completers) was observed.Conclusion: Substantial nonsurgical weight loss, maintained at 2 to 4 years, is achievable in severely obese patients using comprehensive lifestyle approaches; the efficacy/safety trade-off in obesity treatment is an important consideration in interpreting these results.Abbreviations: BMI = body mass index EBW = excess body weight HbA_1c = glycated hemoglobin IBW = initial body weight LOCFA = last observation carried forward analysis     

Impact of surgically induced weight loss on cardiovascular autonomic function: one-year follow-up

Objective: To determine the impact of surgically induced weight loss on cardiovascular autonomic function in subjects with severe obesity and examine whether the effect was comparable for persons with and without diabetes. Research Methods and Procedures: Twenty‐six severely obese individuals (BMI = 48 ± 7 kg/m²) underwent bariatric surgery (laparoscopic Roux‐en‐Y gastric bypass, n = 21; laparoscopic adjustable gastric banding, n = 5). Cardiovascular autonomic function (heart rate variation during deep breathing and the Valsalva maneuver) was assessed before and 6 and 12 months after surgery. Results: Twelve months after bariatric surgery, there was a 28% decrease in BMI. There was an increase in all parasympathetic indices of autonomic function (all assessment modalities, p < 0.05) with weight loss. The amount of improvement from baseline for all measures of autonomic function did not differ for those with or without diabetes. Discussion: Surgically induced weight loss 12 months after surgery has a favorable effect on cardiovascular autonomic function in severely obese individuals with and without diabetes.     

Increased Bone Turnover in Type 2 Diabetes Patients Randomized to Bariatric Surgery Versus Medical Therapy at 5 Years

Objective: The aim of our study was to determine the 5-year outcomes of bariatric surgery versus intensive medical therapy on bone turnover in patients with type 2 diabetes mellitus (T2DM) from the STAMPEDE trial.Methods: This was an ancillary investigation of a 5-year randomized control trial at a single tertiary care center involving 95 patients aged 48.5 ± 8 years with obesity (body mass index &lsqb;BMI], 36.5 ± 3.6 kg/m²) and uncontrolled T2DM (glycated hemoglobin 9.3 ± 1.6% &lsqb;78 mmol/mol]). Patients were randomized to intensive medical therapy (IMT; n = 25), Roux-en-Y gastric bypass (RYGB; n = 37), or sleeve gastrectomy (SG; n = 33) for diabetes treatment. Bone formation marker osteocalcin (OC), bone resorption marker serum C-telopeptide of type 1 collagen (CTX), and intact parathyroid hormone (PTH) were assessed at baseline and 5 years postintervention. Analysis with key clinical parameters and outcomes (i.e., age, menopausal status, gender, weight loss) was performed.Results: Percent change in CTX at 5 years increased in both surgical groups, by 137 ± 108% in RYGB (P<.001) and 61.1 ± 90% in SG (P<.001) compared to 29.8 ± 93% in IMT (P = .12). OC also increased from baseline in the surgical cohorts, by 138 ± 19% in RYGB (P<.001) and 71 ± 69% in SG (P<.001) compared to 43.8 ± 121.1% in IMT (P = .83). Increases in both CTX and OC correlated linearly with increases in PTH levels in RYGB patients (P<.001). Increase in CTX correlated with decreased BMI in SG patients (P = .039).Conclusion: In patients with T2DM, bone turnover remains chronically elevated at 5 years following RYGB, and to a lesser extent in SG patients.Abbreviations: BMI = body mass index; BTM = bone turnover marker; CTX = C-telopeptide of type 1 collagen; HbA1c = glycated hemoglobin; IMT = intensive medical therapy; OC = osteocalcin; PPI = proton-pump inhibitor; PTH = parathyroid hormone; RYGB = Roux-en-Y gastric bypass; SG = sleeve gastrectomy; T2DM = type 2 diabetes mellitus; TZD = thiazolidinedione     

Anti-Obesity Pharmacotherapy and the Potential for Preventing Progression from Prediabetes to Type 2 Diabetes

Objective: Type 2 diabetes and its associated complications place heavy burdens on affected individuals, their caregivers, and society. The prevalence of type 2 diabetes is increasing worldwide. Attempts to combat this problem have been extended to the treatment of obesity and prevention of progression from prediabetes to type 2 diabetes. As such, weight loss is an important component of type 2 diabetes prevention. However, successful strategies for achieving sustained weight loss have remained elusive. Although lifestyle modification remains a cornerstone of this approach, it has become clear that changes to lifestyle alone will not suffice for many patients. A pragmatic approach includes consideration of pharmacotherapeutic options.Methods: This review discusses the different pharmacotherapeutic options for the treatment of obesity and prediabetes.Results: Approved anti-obesity therapies and antihyperglycemic agents associated with weight loss may prove effective earlier in the treatment paradigm, and other promising agents that are in clinical development for chronic weight management show promise for both weight reduction and a reduction in the risk of type 2 diabetes in high-risk individuals.Conclusion: Long-term evaluation of safety and efficacy is required for many of these agents before we can begin to optimize their use in clinical practice, but treatment choices for obese or prediabetic patients are increasing.Abbreviations: AACE = American Association of Clinical Endocrinologists ADA = American Diabetes Association AE = adverse event AMA = American Medical Association BMI = body mass index CI = confidence interval CR = controlled release DPP = Diabetes Prevention Program IFG = impaired fasting glucose IGT = impaired glucose tolerance FDA = Food and Drug Administration FPG = fasting plasma glucose GLP-1 = glucagon-like peptide-1 GLP-1 RA = glucagon-like peptide-1 receptor agonist HbA_1c= glycosylated hemoglobin ITT-LOCF = intention-totreat with last observation carried forward LS = least squares NB = naltrexone/bupropion OR = odds ratio PHEN = phentermine PYE = patient years of exposure PYY = peptide YY SGLT-2 = sodium glucose cotransporter 2 TPM = topiramate TZD = thiazolidinedione     

Vascular Complications in Patients with Type 2 Diabetes: Prevalence and Comorbidities in 6 Countries of Latin America (A Cohort of the Discover Study Program)

Objective: To provide real world observational data about glucose control, the burden of diabetes, comorbidities, and cardiovascular risk factors among patients initiating second-line therapy in Latin America (LA).Methods: This report is a cross-sectional analysis of the LA cohort of the DISCOVER study, describing the regional prevalence of microvascular and macrovascular complications in Mexico, Costa Rica, Panama, Colombia, Argentina, and Brazil.Results: One thousand six hundred and sixteen patients were included in 69 investigational sites. Hemoglobin A1c was >7% (42 mmol/mol) in 81.3% of subjects. Macrovascular complications were reported by 13.8% of the subjects. Microvascular conditions were reported in 15.2% of the subjects. The prevalence of hypertension and of hyperlipidemia was 55.5% and 45.9%, respectively. Blood pressure, total cholesterol, and low-density lipoprotein were out of target levels in 38.5%, 51.2%, and 81.7% of the patients, respectively. Overweight or obesity was reported in 83.8% of the cases.Conclusion: Our study shows that patients with type 2 diabetes in LA are not reaching their glucose, lipids, blood pressure, and weight targets. The prevalence of microvascular (15.2%), macrovascular (13.8%), and uncontrolled comorbidities in patients at an early stage of the disease (initiating a second-line therapy) highlights the need for more aggressive risk factor screening as well as treatment in LA.Abbreviations: CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; HbA1c = hemoglobin A1c; LA = Latin America/Latin American; LDL = low density cholesterol; T2DM = type 2 diabetes mellitus     

Prevalence and Clinical Determinants of Obesity in Adults With Type 1 Diabetes Mellitus: A Single-Center Retrospective Observational Study

ObjectiveTo determine the prevalence of obesity and assess the cardiometabolic risk profile and treatments associated with obesity management in the type 1 diabetes mellitus adult population.MethodsWe reviewed the records of all patients with type 1 diabetes mellitus seen in our institution’s outpatient endocrinology clinic between 2015 and 2018. We stratified the patients into 4 weight categories on the basis of body mass index (BMI) (normal, overweight, obesity class I, and combined obesity class II and III) and evaluated their associated clinical characteristics and relevant medications.ResultsOf 451 patients, 64% had a BMI of >25 kg/m², and 25% had a BMI of ≥30 kg/m². Over 40% of patients with a BMI of >30 kg/m² had a history of cardiovascular disease. The off-label use of the glucagon-like peptide 1 receptor agonist was 12% and the sodium glucose cotransporter 2 inhibitor use was 5% in those with obesity. Only 2 patients were prescribed phentermine and 3 had undergone bariatric surgery. Hemoglobin A1C and low-density lipoprotein did not significantly differ between the normal weight and obesity groups. The obesity groups had significantly higher levels of median triglycerides and lower high-density lipoprotein than the normal weight group.ConclusionObesity was prevalent in a population of patients with type 1 diabetes mellitus seen in a specialty clinic. Those with obesity had a higher prevalence of cardiovascular disease than their normal weight counterparts. The use of weight loss medications was scarce. Studies exploring the safety and efficacy of obesity-targeted therapy in the type 1 diabetes mellitus population are needed.     

Bariatric Surgery and the Role of the Clinical Endocrinologist: 2011 Update

ObjectiveTo discuss the emerging roles of bariatric surgery and clinical endocrinology within the context of obesity and diabetes mellitus comprehensive care plans and cost-effective strategies.MethodsRelevant literature is reviewed and clinical cases are presented.ResultsThe global obesity epidemic poses many challenges to clinical endocrinologists and has fomented a coordinated effort among specialists to revolutionize management paradigms. Technologic innovation drives the need for accelerated learning and research efforts in bariatric surgery. The national shortage of physicians with expertise in nutritional medicine compounds the management problems for this expanding patient population. Certain issues merit continued attention and research, such as gastric banding for mild obesity, surgery for treatment of diabetes, sleeve gastrectomy, and nutritional and metabolic consequences.ConclusionClinical endocrinologists should have a central role in the perioperative decision-making for patients undergoing bariatric surgery. (Endocr Pract. 2011;17:788-797)     

Cardiovascular risk reduction over time in patients with diabetes or pre-diabetes undergoing bariatric surgery: data from a single-center retrospective observational study

Background

Bariatric surgery is effective in remission of obesity comorbidities. This study was aimed at comparing CVD risk between morbidly obese patients with type 2 diabetes and pre-diabetes before and after bariatric surgery as well as assessing comorbidities.

Methods

This is a retrospective observational study with 105 patients with type 2 diabetes (DMbaseline) and prediabetes (preDMbaseline) who underwent Roux-en-Y gastric bypass. Data were collected preoperative and then at 3,6,12,18,24,36,48, and 60?months after surgery. Anthropometric, cardiovascular and glycemic parameters were assessed. CVD risk was calculated using the Framingham Risk Score.

Results

Prior to surgery, 48 patients had type 2 diabetes, while 57 had pre-diabetes. Mean age was 48 (9.2) and mean BMI was 52 (7.4). 26.1% of patients had a high CVD risk. CVD risk decreased in patients with type 2 diabetes and prediabetes at month 12 after surgery compared to the baseline risk (p?<?0.001). BMI, body fat percentage, fasting plasma glucose, HbA1c, c-peptide, HOMA-IR, LDL-c, systolic blood pressure, and diastolic blood pressure decreased during the first year after surgery. From the 12th month until the 60th, they showed a flat trend, or a very mild increase in some cases. 3.2% of patients maintained high CVD risk at 60?months. Type 2 diabetes remission was 92%. No patient of the preDMbaseline group developed type 2 diabetes.

Conclusion

Bariatric surgery reduces CVD risk in type 2 diabetes and pre-diabetes. Given that patients with type 2 diabetes benefit the most, more studies are necessary to consider pre-diabetes as a criterion for metabolic surgery in patients with BMI?≥?35?kg/m².

     

Diabetes and Prediabetes are Significantly Higher in Morbidly Obese Children Compared With Obese Children

Objective: The objective of this study was to examine the prevalence and characteristics of comorbidities in obese and morbidly obese children with a comparison between the 2 sets of children.Methods: This was a retrospective electronic chart review of obese and morbidly obese children and adolescents as defined by body mass index. We evaluated medical history of comorbid conditions, medication use, and cardiovascular risk markers, including blood pressure, lipid profile, and glycosylated hemoglobin.Results: There were 1,111 subjects (African American = 635; non-Hispanic white = 364; Hispanic = 36; others = 86), of which 274 were obese and 837 were morbidly obese children with a mean age of 12.7 ± 3.37 years. Morbidly obese children had a higher prevalence of prediabetes (19.5% of obese versus 27.3% of morbidly obese; P<.0001) and type 2 diabetes (39.8% of obese versus 52.4% of morbidly obese; P<.0001). Use of medications for treatment of asthma was significantly higher in the morbidly obese group compared with the obese group (21% versus 14%; P = .01).Conclusion: Morbidly obese children have a higher prevalence of diabetes, prediabetes, and use of asthma medications compared with obese children.Abbreviations: AA = African American ADHD = attention deficit hyperactivity disorder BMI = body mass index BP = blood pressure CVD = cardiovascular disease DBP = diastolic blood pressure EMR = electronic medical record GERD = gastroesophageal reflux disease HbA_1c = glycated hemoglobin HDL = high-density lipoprotein HTN = hypertension LDL = low-density lipoprotein NHW = non-Hispanic white SBP = systolic blood pressure T2DM = type 2 diabetes mellitus