The advantages and disadvantages of sleeve gastrectomy; clinical laboratory to bedside review

Das Lipodem ist weit mehr als einfach nur dickere und schmerzhafte Beine! Die Erkrankung Lipodem ist mit zahlreichen Mythen behaftet. Im ersten Teil dieser Ubersicht werfen wir einen kritischen Blick auf zwei populare Statements zum Lipodem; Statements, die vor Jahrzehnten schon Eingang in wissenschaftliche Publikationen gefunden haben und seither unkritisch und stetig wiederholt werden; Statements, die inzwischen zum selbstverstandlichen Wissensallgemeingut von Lipodempatientinnen und vor allem auch von Lipodem-Selbsthilfegruppen geworden sind. In unserer Darstellung uber die Mythen des Lipodems fokussieren wir uns in diesem Beitrag vor allem auf zwei Aspekte, die aufs Engste mit dem Lipodem verbunden sind: auf die Adipositas sowie auf die psychische Situation von Lipodempatientinnen – die wiederum eng mit der Adipositas in Zusammenhang steht. Dabei uberprufen wir zwei haufig publizierte Statements auf wissenschaftliche Evidenz: 1. „Das Lipodem ist eine progrediente Erkrankung”, 2. „Ein Lipodem macht psychisch krank”. Beide Statements widersprechen in hohem Mase unserer seit Jahren bestehenden taglichen klinischen Erfahrung mit diesem speziellen Patientengut. Gleichzeitig haben wir im Rahmen unserer umfangreichen Literaturrecherche festgestellt, dass es auch keine Evidenz fur diese in den „Lipodemsprachgebrauch” eingegangenen Behauptungen gibt. Tatsachlich ist das Lipodem in der Regel keine progrediente Erkrankung! Vielmehr liegt bei Lipodempatientinnen haufig eine Gewichtsprogredienz (meist eine Adipositasprogredienz) vor, in deren Folge sich auch das Lipodem verschlechtern kann. Unsere Pilotstudie zum 2. Statement macht deutlich, dass in der Regel nicht das Lipodem Ursache von psychischen Erkrankungen ist. Hier weisen unsere Ergebnisse in die umgekehrte Richtung: Eine – vorbestehende – psychische Vulnerabilitat kann ganz wesentlich zum Krankheitsbild Lipodem beitragen. Um das Lipodem in seiner ganzen Komplexitat und Vielfalt zu erfassen, braucht es mehr als nur Medizin. Psychosoziale Therapieansatze sollten integraler Bestandteil eines wirksamen multimodalen Behandlungskonzepts sein. Neben den beiden dargestellten Mythen gibt es weitere, die sich um das Lipodem ranken. Diese werden in weiteren Ausgaben dieser Zeitschrift diskutiert werden.

/pdf/lipodem-mythen-und-fakten-teil-1-1lmb3amz02.pdf

Lipödem – Mythen und Fakten Teil 1

Objective In addition to adipocytes, adipose tissue contains large numbers of immune cells. A wide range of evidence links the activity of these cells to regulation of adipocyte and systemic metabolic function. Bariatric surgery improves several aspects of metabolic derangements and at least some of these effects occur in a weight-loss independent manner. We sought to investigate the impact of vertical sleeve gastrectomy (VSG) on adipose immune cell frequencies. Methods We analyzed the frequencies of immune cells within distinct adipose tissue depots in obese mice that had VSG or sham surgery with a portion of the latter group pair-fed such that their body mass was matched to the VSG animals. Results We demonstrate that VSG induced a shift in the epididymal adipose tissue leukocyte profile including increased frequencies of CD11c − macrophages, increased frequencies of T cells (CD4 + , CD8 + , and CD4 − /CD8 − T cells all increased), but a significantly decreased frequency of adipose tissue dendritic cells (ATDC) that, despite the continued high fat feeding of the VSG group, dropped below control diet levels. Conclusions These results indicate that VSG induces substantial changes in the immune populations residing in the adipose depots independent of weight loss.

Weight loss independent changes in adipose tissue macrophage and T cell populations after sleeve gastrectomy in mice.

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease in the United States and worldwide. The progressive form of NAFLD, nonalcoholic steatohepatitis (NASH), is a leading indication for liver transplant. Comorbidities associated with NAFLD development and NASH include type 2 diabetes, obesity, metabolic syndrome, and dyslipidemia. Extrahepatic morbidity and mortality are considerable as NAFLD is associated with an increased risk of cardiovascular disease and chronic kidney disease. Once NAFLD is diagnosed, the presence of liver fibrosis is the central determinant of hepatic prognosis. Severe liver fibrosis requires aggressive clinical management. No pharmacologic agents have regulatory approval in the United States for the treatment of NAFLD or NASH. Management is centered on efforts to reduce underlying obesity (lifestyle, medications, surgical or endoscopic interventions) and metabolic derangements (prediabetes, type 2 diabetes, hypertension, hyperlipidemia, and others). Current pharmacologic therapy for NAFLD is limited mainly to the use of vitamin E and pioglitazone, although other agents are being investigated in clinical trials. Cardiovascular and metabolic risk factors must also be assessed and managed. Here, NAFLD evaluation, diagnosis, and management are considered in the primary care setting and endocrinology clinics. 

http://www.mayoclinicproceedings.org/article/S0025619622002440/pdf

Nonalcoholic Fatty Liver Disease: Review of Management for Primary Care Providers.

The mammalian body is a complex physiologic "ecosystem" in which cells compete for calories (i.e., nutrient-energy). Axiomatically, cell-types with competitive advantages acquire a greater number of consumed calories, and when possible, increase in size and/or number. Thus, it is logical and parsimonious to posit that obesity is the competitive advantages of fat-cells (adipocytes) driving a disproportionate acquisition and storage of nutrient-energy. Accordingly, we introduce two conceptual frameworks. Asymmetric Nutrient-Energy Partitioning describes the context-dependent, cell-specific competition for calories that determines the partitioning of nutrient-energy to oxidation, anabolism, and/or storage; and Effective Caloric Intake which describes the number of calories available to constrain energy-intake via the inhibition of the sensorimotor appetitive cells in the liver and brain that govern ingestive behaviors. Inherent in these frameworks is the independence and dissociation of the energetic demands of metabolism and the neuro-muscular pathways that initiate ingestive behaviors and energy intake. As we demonstrate, if the sensorimotor cells suffer relative caloric deprivation via asymmetric competition from other cell-types (e.g., skeletal muscle- or fat-cells), energy-intake is increased to compensate for both real and merely apparent deficits in energy-homeostasis (i.e., true and false signals, respectively). Thus, we posit that the chronic positive energy balance (i.e., over-nutrition) that leads to obesity and metabolic diseases is engendered by apparent deficits (i.e., false signals) driven by the asymmetric inter-cellular competition for calories and concomitant differential partitioning of nutrient-energy to storage. These frameworks, in concert with our previous theoretic work, the Maternal Resources Hypothesis, provide a parsimonious and rigorous explanation for the rapid rise in the global prevalence of increased body and fat mass, and associated metabolic dysfunctions in humans and other mammals inclusive of companion, domesticated, laboratory, and feral animals.

/pdf/cell-specific-competition-for-calories-drives-asymmetric-3kof9kq4s8.pdf

Cell-Specific "Competition for Calories" Drives Asymmetric Nutrient-Energy Partitioning, Obesity, and Metabolic Diseases in Human and Non-human Animals.

Background Bariatric surgery is known to be an effective treatment for extreme obesity but access to these procedures is currently limited. Objective This study aimed to evaluate the costs and outcomes of increasing access to bariatric surgery for severe and morbid obesity. Design and methods Primary care electronic health records from the UK Clinical Practice Research Datalink were analysed for 3045 participants who received bariatric surgery and 247,537 general population controls. The cost-effectiveness of bariatric surgery was evaluated in severe and morbid obesity through a probabilistic Markov model populated with empirical data from electronic health records. Results In participants who did not undergo bariatric surgery, the probability of participants with morbid obesity attaining normal body weight was 1 in 1290 annually for men and 1 in 677 for women. Costs of health-care utilisation increased with body mass index category but obesity-related physical and psychological comorbidities were the main drivers of health-care costs. In a cohort of 3045 adult obese patients with first bariatric surgery procedures between 2002 and 2014, bariatric surgery procedure rates were greatest among those aged 35–54 years, with a peak of 37 procedures per 100,000 population per year in women and 10 per 100,000 per year in men. During 7 years of follow-up, the incidence of diabetes diagnosis was 28.2 [95% confidence interval (CI) 24.4 to 32.7] per 1000 person-years in controls and 5.7 (95% CI 4.2 to 7.8) per 1000 person-years in bariatric surgery patients (adjusted hazard ratio was 0.20, 95% CI 0.13 to 0.30; p < 0.0001). In 826 obese participants with type 2 diabetes mellitus who received bariatric surgery, the relative rate of diabetes remission, compared with controls, was 5.97 (95% CI 4.86 to 7.33; p < 0.001). There was a slight reduction in depression in the first 3 years following bariatric surgery that was not maintained. Incremental lifetime costs associated with bariatric surgery were £15,258 (95% CI £15,184 to £15,330), including costs associated with bariatric surgical procedures of £9164 per participant. Incremental quality-adjusted life-years (QALYs) were 2.142 (95% CI 2.031 to 2.256) per participant. The estimated cost per QALY gained was £7129 (95% CI £6775 to £7506). Estimates were similar across gender, age and deprivation subgroups. Limitations Intervention effects were derived from a randomised trial with generally short follow-up and non-randomised studies of longer duration. Conclusions Bariatric surgery is associated with increased immediate and long-term health-care costs but these are exceeded by expected health benefits to obese individuals with reduced onset of new diabetes, remission of existing diabetes and lower mortality. Diverse obese individuals have clear capacity to benefit from bariatric surgery at acceptable cost. Future work Future research should evaluate longer-term outcomes of currently used procedures, and ways of delivering these more efficiently and safely. Funding The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. Martin C Gulliford and A Toby Prevost were supported by the NIHR Biomedical Research Centre at Guy’s and St Thomas’ Hospitals. Peter Littlejohns was supported by the South London Collaboration for Leadership in Applied Health Research and Care. The funders did not engage in the design, conduct or reporting of the research.

https://njl-admin.nihr.ac.uk/document/download/2004137

Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records

What is the probability of an obese person attaining normal body weight

Impact of bariatric surgery on clinical depression

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Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records

What is the probability of an obese person attaining normal body weight

Impact of bariatric surgery on clinical depression