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Individuals with diabetes and those whose stomach pouches are larger appear less likely to successfully lose weight after gastric bypass surgery, according to a report in the recent issue of Archives of Surgery, one of the JAMA/Archives journals.

Roux-en-Y gastric bypass surgery is the most common bariatric procedure in North America, according to background information in the article. During the procedure, surgeons create a smaller stomach pouch that restricts food intake and bypasses large sections of the digestive system. "When performed in high-volume centers and with a low rate of complications, gastric bypass provides sustained and meaningful weight loss, significant improvement in quality of life, improvement or resolution of obesity-associated comorbidities and extended life span," the authors write. "However, 5 percent to 15 percent of patients do not lose weight successfully, despite perceived precise surgical technique and regular follow-up".

Guilherme M. Campos, M.D., and colleagues at the University of California, San Francisco, examined data from 361 patients who underwent gastric bypass at one institution between 2003 and 2006. Poor weight loss was defined as losing 40 percent or less of excess body weight after 12 months and good weight loss as losing more than 40 percent of excess weight.

Twelve-month follow-up data were available for 310 of the patients, who had an average body mass index (BMI) of 52 before surgery. At follow-up, they had an average BMI of 34 and had lost an average of 60 percent of their excess body weight. A total of 38 patients (12.3 percent) had poor weight loss. After adjusting for other related factors, diabetes and having a larger size of the stomach pouch after gastric bypass surgery were independently associated with poor weight loss.

Individuals with diabetes may take insulin or other drugs that stimulate the production of fat and cholesterol, the authors note. "Other factors that may lead to weight gain in patients with diabetes include a 'protective' increase in caloric intake to treat episodes of hypoglycemia [low blood sugar], reduction of urinary glucose losses and sodium and water retention that are a direct effect of insulin on the distal tubule in the kidney," the authors write.

The restriction on dietary intake imposed by a small stomach pouch is one of the most important aspects of gastric bypass surgery, they note. Surveys suggest that many surgeons estimate pouch size using anatomical landmarks rather than using a sizing balloon. "As the use of gastric bypass continues to grow, we believe it is critical to stress the importance of and to teach the creation of the small gastric pouch and to better standardize the technique used for pouch creation," the authors write.

"We conclude that gastric bypass provides good or excellent weight loss for most patients," they continue. "However, diabetes mellitus and larger pouch size are independently associated with poor weight loss after gastric bypass. Changes in the use of diabetes medications may reduce the risk of poor weight loss among diabetics undergoing gastric bypass. Detailed attention to the creation of a small gastric pouch is essential for achieving the best results".


Posted by: Evelyn    Source

A study by researchers at the University of Southern California (USC) found that overweight Hispanic children are at significant risk for pre-diabetes, a condition marked by higher than normal blood glucose levels that are not yet high enough for a diagnosis of diabetes. The persistence of pre-diabetes during growth is associated with progression in risk towards future diabetes, according to the study, which will be published in an upcoming issue of the journal Diabetes, and is now available online.

With a population of more than 35 million, Hispanics are the largest and fastest growing minority group in the United States. Despite the fact that Hispanics are at high risk for developing type 2 diabetes, few previous studies have looked at physiological causes of the disease within this population.

Researchers led by Michael I. Goran, Ph.D., professor of preventive medicine, physiology and biophysics and pediatrics, and director of the USC Childhood Obesity Research Center at the Keck School of Medicine of USC, followed a cohort of 128 overweight Hispanic children in East Los Angeles. The children were tested over four consecutive years for glucose tolerance, body mass index, total body fat and lean mass and other risk factors for type 2 diabetes. The study found that an alarming 13% of the children had what the scientists termed "persistent pre-diabetes".

Most prior studies examining pre-diabetes in overweight and obese children looked at a one-time assessment of metabolic risk factors for type 2 diabetes, but fluctuations over time led to poor reliability for these tests. In the new study, Goran and colleagues examined longitudinal data to look at a progression of risk factors over four years. Children were identified as having persistent pre-diabetes if they had three to four positive tests over four annual visits. The children who had persistent pre-diabetes had signs of compromised beta-cell function, meaning that their bodies were unable to fully compensate to maintain blood glucose at an appropriate level, and they had increasing accumulation of visceral fat or deposition of fat around the organs. Both of these outcomes point towards progression in risk towards type 2 diabetes.

"What this study shows is that doctors should be doing regular monitoring of these children over time, because a one-time checkup might not be enough to tell if they are at risk for developing diabetes," Goran says.

Visceral fat, which pads the spaces between abdominal organs, has been linked to metabolic disturbances and increased risk for cardiovascular disease and type 2 diabetes.

Increased obesity has been identified as a major determinant of insulin resistance. Lower beta-cell function is a key component in the development of type 2 diabetes, as the cells are unable to produce enough insulin to adequately compensate for the insulin resistance.

"To better treat at-risk children we need better ways to monitor beta-cell function and visceral fat buildup," Goran says. "Those are tough to measure but are probably the main factors determining who will get type 2 diabetes."

Future studies will examine different interventions, including improving beta-cell function and reducing visceral fat.

"The study provides great insight into the risk factors that lead to the progression towards type 2 diabetes in this population," says Francine Kaufman, professor of pediatrics at the Keck School of Medicine at USC and head of the division of endocrinology and metabolism at Childrens Hospital Los Angeles, who was not directly involved in the study. "Only by understanding how this devastating disease develops will be able to begin taking steps to prevent it".


Posted by: Evelyn    Source

Bariatric surgery patients treated at highly rated hospitals have, on average, a 65 percent lower chance of experiencing serious complications in comparison to patients who undergo surgery at poorly rated hospitals as per a research studyreleased recently by HealthGrades, the nations leading independent healthcare ratings organization. As part of the study, the quality ratings of hospitals performing bariatric surgery in 17 states became available today at www.healthgrades.com.

HealthGrades' third annual Bariatric Surgery Trends in American Hospitals study, which reviewed bariatric surgical outcomes at every hospital that performed them in 17 states, also observed that the complication rate for these surgeries continues to rise, increasing six percent from 2004 to 2006. One possible reason: lower volume facilities have higher complication rates.

Bariatric surgery is a general term describing several types of weight loss procedures. HealthGrades study analyzed the outcomes of the most common, including traditional open surgical gastric bypass procedures as well as newer, less invasive procedures such as "lap-banding" and laparoscopic gastric bypass.

Complications linked to gastric bypass surgery accounted for the highest rise in complications, increasing 17 percent. Comparatively, complications from less invasive laparoscopic surgery increased by just more than one percent. Complications linked to bariatric surgery include heart attack, kidney failure, stroke and post-surgical infections.

The HealthGrades study found a significant shift toward laparoscopic bariatric procedures. From 2004 through 2006, open gastric bypass procedures declined by 81.82 percent while during the same time period laparoscopic procedures increased 418.86 percent.

Meanwhile, the total volume of bariatric surgical procedures in the U.S. continues to grow rapidly. The American Society for Bariatric Surgery estimates that such surgeries have increased 1,431 percent in the last decade to more than 250,000 annually.

"The tremendous variation we are seeing in quality among bariatric surgery providers underscores the importance of readily available quality data to help consumers make a truly informed decision about where to seek care," said Rick May, MD, a senior doctor advisor with HealthGrades and an author of the study.

Additionally, the third annual HealthGrades Bariatric Surgery Trends in American Hospitals study observed that:

• A typical patient having a bariatric surgical procedure at a five-star rated hospital in one of the 17 states studied has on average, a 65 percent lower chance of experiencing one or more inhospital complications than at a one-star rated hospital and a 41 percent lower chance than at a three-star rated hospital during 2004- 2006.
  
• Five-star (top rated) hospitals performed almost twice the volume of procedures in comparison to 1-star and 3-star facilitiesan average of 526 procedures from 2004 through 2006 compared with 266 and 283 respectively.
  
  
• Higher volume was linked to fewer risk-adjusted complications. Facilities with an annual case volume of 125 procedures had the lowest risk-adjusted complications. Facilities performing less than 25 cases per year had the highest rate of risk-adjusted complications.
  
• If all patients had received their bariatric surgery procedure at 5-star hospitals (from 2004 through 2006), 5,125 inhospital complications could have been potentially avoided in the 17 states studied.

HealthGrades Bariatric Surgery Ratings
HealthGrades' quality ratings for bariatric surgery at individual hospitals in 17 states were posted today to www.healthgrades.com as a free resource for consumers. Each hospital receives a star rating based on their patient outcomes for bariatric surgery. Hospitals with above-average outcomes receive a five-star rating. Hospitals with average outcomes receive a three-star rating, and hospitals with outcomes that are below average receive a one-star rating.

The study included a total of 154,451 bariatric inpatient surgery procedures performed in 680 hospitals in 17 states from 2004 through 2006. The majority of procedures were performed in four states: New York, Texas, Pennsylvania, and California.

• 93 hospitals stand out as "best" performers (5-star rated).
  
• 263 hospitals were rated as "as expected" performers (3-star rated).
  
• 99 hospitals were rated as "poor" performers (1-star rated)

Individuals contemplating bariatric surgery will find both quality and cost information at www.healthgrades.com. In addition to the free hospital-quality ratings, Web site visitors can also research surgeons who perform bariatric surgery as well as medical-cost reports that detail all of the costs, including out-of-pocket expenses, for the procedure.


Methodology
For this study, HealthGrades analyzed 154,451 bariatric procedures performed in the years 2004, 2005 and 2006. The states included in the study are: Arizona, California, Florida, Iowa, Maine, Maryland, Massachusetts, Nevada, New Jersey, New York, Oregon, Pennsylvania, Texas, Utah, Virginia, Washington, Wisconsin.

To make accurate and valid comparisons of clinical outcomes at different hospitals with different patient characteristics, HealthGrades risk adjusted the data using multivariate logistic regression to account for age, gender and underlying medical conditions that could increase the patient's risk of mortality or complication. The full study and individual hospital ratings for bariatric surgery and other procedures can be found at www.healthgrades.com.


Posted by: Evelyn    Source

Dr. Xingming Shi, bone biologist at the Medical College of Georgia Institute of Molecular Medicine and Genetics.

Credit: Phil Jones

A small protein may have a big role in helping you make more bone and less fat, researchers say.

"The pathways are parallel, and the idea is if you can somehow disrupt the fat production pathway, you will get more bone," says Dr. Xingming Shi, bone biologist at the Medical College of Georgia Institute of Molecular Medicine and Genetics.

He's found the short-acting protein GILZ appears to make this desirable shift and wants to better understand how it does it with the long-term goal of targeted therapies for osteoporosis, obesity and maybe more.

"Osteoporosis and obesity are two major public health problems, but people have no idea whether they have a connection," says Dr. Shi. Bone and fat do have a common source: both are derived from mesynchymal stem cells. Bone loss and fat gain also tend to happen with age and with use of the powerful, anti-inflammatory steroid hormones glucocorticoids. "When you age, your bone marrow microenvironment changes; the balance between the bone and fat pathway is broken," says Dr. Shi, a faculty member in the MCG Schools of Medicine and Graduate Studies. "You have more fat cells accumulate".

"The bones of elderly people or those who take glucocorticoids are yellow inside instead of red," he says. And it gets worse: in a classic vicious cycle, the more fat, the more cytokines that stimulate production of bone-destroying osteoclasts and inhibit bone-forming osteoblasts. He recently showed that even the stem cells change with age: their numbers and their ability to differentiate decrease.

Weight gain and bone loss are established side effects of glucocorticoids, whose wide-ranging uses include treatment for arthritis, asthma, infections and organ transplants. Ironically, glucocorticoids also induce a short burst of GILZ. GILZ, in turn, inhibits the transcription factor PPAR2, called the master regulator of adipogenesis, or fat production, as well as CCAAT/enhancer-binding proteins that turn on this fat-producing gene. One way GILZ does this is by binding to the regulatory region of PPAR2, Dr. Shi has shown.

To restore a healthier balance of bone and fat production, sustained GILZ action is needed. "When you permanently express GILZ, cells cannot differentiate into fat cells. Instead, you increase bone formation. People like this idea," says Dr. Shi, who has watched the mesynchymal stem cell production shift.

One point of controversy is that, at least in the lab, glucocorticoids seem to enhance bone formation. But Dr. Shi believes it's the short burst of GILZ at work there. He wants to know exactly how it works to see if it could offer a targeted therapy for osteoporosis and obesity and maybe a safer option for many who need glucocorticoids.

A recent $1.5 million, five-year grant from the National Institute of Diabetes and Digestive and Kidney Diseases is enabling Dr. Shi to further test his hypothesis about how GILZ represses PPAR2 and to see if GILZ over-expression in mice reduces PPAR2 expression and consequently increases bone and decreases fat. A long-term goal is to understand exactly how PPAR2 controls fat and bone production.

GILZ also is a powerful immune and inflammation suppressor. It inhibits two key inflammatory molecules, NF-kB and AP-1, which turn on inflammatory genes in response to cytokines, such as TNF- and IL-1, involved in rheumatoid arthritis and other inflammatory diseases, Dr. Shi showed in research published on the cover of the April 15 issue of Journal of Cellular Biochemistry That study notes GILZ's potential as a novel anti-inflammatory therapy.

In fact, Dr. Shi believes GILZ is a key factor mediating the anti-inflammatory effects of glucocorticoids. A long-acting version of GILZ or a similar substance would be needed to produce, for example, a powerful new arthritis treatment minus the undesirable effects. About 50 percent of arthritis patients who take glucocorticoids develop osteoporosis, he notes, worsening an already difficulty condition worse.

People can't take GILZ now, but another long-term goal is to develop a GILZ-like pill that would dramatically reduce fat production. Dr. Shi already has developed a cell line that continuously expresses GILZ.


Posted by: Evelyn    Source

Chips on the left are from potatoes infected with the zebra chip disease, which alters the sugar levels and causes the sugar to carmelize and give a burned appearance, according to Dr. Don Henne, Texas AgriLife Research assistant research scientist.

Credit: (Texas AgriLife Research photo by Kay Ledbetter)
Dr. Don Henne isn't wasting his degree when he's standing by the deep fryer waiting for potato slices to turn brown. He's conducting research that will help the potato industry and consumers.

Henne, an assistant research scientist in the Texas AgriLife Research plant pathology program in Amarillo, is one of a number of who are trying to find answers about zebra chip. Zebra chip is the latest disease to plague the potato industry, particularly those in the chipping business.

Dr. Charlie Rush, AgriLife Research plant pathologist and leader of the program, began working on the project at the request of local producers in early 2007. His work later became a part of the Zebra Chip State Initiative through the Texas Department of Agriculture.

The initiative brought together scientists from throughout the state and country to try to find answers for zebra chip, Rush said.

"When we first began working on it, the pathogen and vector were unknown," he said. "Only recently have scientists began pinning those down".

Rush said Henne was brought into the program in May because of his experience and background. His primary responsibility is to help understand the factors that impact disease onset and spread. Zebra chip is a disease that alters the sugar levels in the potato, Henne said. The sugar caramelizes and turns the chip brown when it is fried, giving it an off taste and burnt appearance. While it is not harmful, it is a cosmetic and taste concern for consumers.

Potato growers have had to abandon entire infected fields, costing as much as $2 million a year in damage, he said.

Henne, who has a degree in entomology, is trying to chase the potato psyllid, the insect that likely carries the pathogens which cause the disease. He is trying to find out what makes it move through a field, as well as when it moves and how fast.

He has visited grower fields from Weslaco to Pearsall and Olton to Dalhart already this year, as well as made contact with other zebra chip scientists around the nation to familiarize himself with this new chipping potato disease.

Zebra chip first appeared in Mexico and Guatemala in the early 2000s. It has been found in potato fields through South Texas and the Rio Grande Valley and now up into the South Plains and Panhandle regions.

The disease presents itself as curled leaves and stunted growth in the plant itself, and then the tubers exhibit a brown striped or mottled pattern when sliced, Henne said.

AgriLife Research and other researchers around the country have studied the vector or insect that transmits the pathogen, he said. Others are trying to identify the pathogen or bacteria that actually causes disease in the plant when the psyllid feeds on it.

Henne and other Amarillo-based scientists are working with commercial growers to monitor the movement of the insect and disease appearance. At the same time, they have established potato plots at the Texas AgriLife Research Station at Bushland and are doing some greenhouse work.

"We're focusing on the epidemiological aspects of the disease," Henne said. "We are trying to understand how the disease progresses in a potato field over time. We are looking at canopy structure, edge effect and how the insects are landing in fields and distributing the disease".

Henne and Dr. Fekede Workneh, an AgriLife Research quantitative plant disease epidemiologist, have planted six acres of potatoes at the Bushland station where they are looking at planting dates, canopy structure and insect dispersal.

Potatoes are planted in late March to early June in the Panhandle, so they are experimenting with planting dates May 2, May 28 and June 16 at Bushland to see if there is a relation between insect movement and disease severity.

"We are also working in the lab to graft diseased portions onto healthy plants to understand the movement of the disease through the plant," Henne said.

"We want to understand how the disease progresses so we can focus management practices on specific areas," he said. "Do the insects move up the plant, down or out from the stem? Some varieties have more canopy than others and is that acting as a natural bridge for insect movement?".

There is no adequate control for the insect or the disease at this time, he said.

Because there are other diseases that have similar symptoms as zebra chip, Henne said, one of the challenges they face is being able to correctly identify diseased plants in the field.

"When we find plants that appear to be infected, we bring the tubers back to the lab where they are sliced and fried to make the final determination," he said.

Henne said they hoped to have some management suggestions on how to help alleviate the problem for growers by the end of this year.


Posted by: Evelyn    Source