Phong Ching Lee

Metabolic bariatric surgery and type 2 diabetes mellitus: an endocrinologist's perspective.

Abstract Traditional treatment of T2DM consisting of modification of diet, an exercise regimen, and pharmacotherapy has problems of poor lifestyle modifications and fail tend of treatment over time, now bariatric surgery is recommended for treatment of obese patients with T2DM because its great improvements on weight loss and metabolic. In this article, effects of bariatric surgery on diabetes and diabetes-related complications are reviewed.

Medical devices for the treatment of obesity

Obesity is a major public health concern that leads to numerous metabolic, mechanical and psychological complications. Although lifestyle interventions are the cornerstone of obesity management, subsequent physiological neurohormonal adaptations limit weight loss, strongly favour weight regain and counteract sustained weight loss. A range of effective therapies are therefore needed to manage this chronic relapsing disease. Bariatric surgery delivers substantial, durable weight loss but limited access to care, perceived high risks and costs restrict uptake. Medical devices are uniquely positioned to bridge the gap between more conservative lifestyle intervention and weight-loss pharmacotherapy and more disruptive bariatric surgery. In this Review, we examine the range of gastrointestinal medical devices that are available in clinical practice to treat obesity, as well as those that are in advanced stages of development. We focus on the mechanisms of action as well as the efficacy and safety profiles of these devices. Many of these devices are placed endoscopically, which provides gastroenterologists with exciting opportunities for treatment.

A Smartphone Application to Deliver a Treat-to-Target Insulin Titration Algorithm in Insulin-Naive Patients With Type 2 Diabetes: A Pilot Randomized Controlled Trial.

An emerging trend in telemedicine has been the development of health applications (apps) for smartphones. Apps focusing on insulin dose calculators are widely available, but the majority of them may contribute to incorrect dose recommendations that put patients at risk for overdose or hypoglycemic events (1). Published data evaluating the effectiveness of using an app in purposely guiding insulin dose titration among patients with type 2 diabetes mellitus (T2DM) is scarce. In this pilot study, we developed a smartphone app called “Diabetes Pal” and investigated its feasibility to deliver an insulin titration algorithm in insulin-naive T2DM patients. A 24-week, randomized, open-label, parallel-group trial was conducted at the Singapore General Hospital between March 2013 and March 2015. The study was approved by the ethics board of the Singapore Health Services and registered with ClinicalTrials.gov (NCT01950676). Insulin-naive T2DM patients with suboptimal glycemic control (HbA1c ≥7.5% [58 mmol/mol]) despite use of two or more oral glucose-lowering drugs were recruited and randomized in a 1:1 ratio into the intervention and control groups. The randomization list was computer generated with a fixed block size of four within each of five endocrinologists. Treatment allocation codes were concealed in sequentially numbered envelopes that were opened each time a patient was enrolled. Participants received a one-time individual educational session with a diabetes nurse educator. Participants were instructed to start with 10 units of insulin detemir at bedtime, self-monitor fasting blood glucose (FBG) daily, and self-titrate insulin every 3 days using a prescribed algorithm to reach a target FBG of 72–126 mg/dL (4.0–7.0 mmol/L). The algorithm was based on the mean FBG (mFBG) over 3 days; +4 when mFBG exceeded 180 mg/dL (10 mmol/L) and +2 when mFBG was 126–180 mg/dL (7.0–10.0 mmol/L). If FBG was <72 mg/dL (<4.0 mmol/L), the dose was …

Hyperglycemia-associated Hemichorea-hemiballism: The Spectrum of Clinical Presentation

Hyperglycemia rarely manifests as hemichorea-hemiballism (HH), which is characterized by simple partial motor seizures. One of the difficulties in the management of hyperglycemia-induced HH is the failure to recognize this entity due to its relatively uncommon presentation. We herein present a case series of hyperglycemia-associated dyskinesias, highlighting the different possible clinical presentations of this entity. Both hyperglycemia and hyperosmolality are probable predisposing factors, while ketoacidosis has a protective role in preventing the dyskinesias. One of our patients had ketotic hyperglycemia leading to HH, a previously unreported finding. Early recognition of this entity is crucial as prompt glycemic control leads to the resolution of symptoms and signs.

Food for Thought: Reward Mechanisms and Hedonic Overeating in Obesity

Purpose of ReviewThis review examines the food addiction model and the role of food hedonic pathways in the pathogenesis and treatment of obesity.Recent FindingsThe hedonic pathway interacts with the obesogenic environment to override homeostatic mechanisms to cause increase in body weight. Weight gain sustained over time leads to “upward setting” of defended level of body-fat mass. There are neurobiological and phenotypic similarities and differences between hedonic pathways triggered by food compared with other addictive substances, and the entity of food addiction remains controversial. Treatment for obesity including pharmacotherapy and bariatric surgery impacts on neural pathways governing appetite and hedonic control of food intake. The food addiction model may also have significant impact on public health policy, regulation of certain foods, and weight stigma and bias.SummaryRecent rapid progress in delineation of food hedonic pathways advances our understanding of obesity and facilitates development of effective treatment measures against the disease.

Health Outcomes and Explant Rates After Laparoscopic Adjustable Gastric Banding: A Phase 4, Multicenter Study over 5 Years: Gastric Banding Health Outcomes

This study aimed to evaluate the real‐world safety and effectiveness of the LAP‐BAND (Apollo Endosurgery Inc., Austin, Texas) adjustable gastric banding system (LBS) for 5 years following implantation.

Making sense of newer treatment options for type 2 diabetes: Clinical Perspectives

Over the past decade, several new medications have been developed to treat type 2 diabetes mellitus. Large‐scale outcome trials have been performed with patients at high cardiovascular risk to assess the cardiovascular safety of these agents. These trials are changing the landscape of diabetes therapy with evidence beyond safety to cardiovascular benefits of sodium‐glucose cotransporter 2 (SGLT‐2) inhibitors and some glucagon‐like peptide‐1 receptor agonists. This review provides an overview of incretin‐based therapies and SGLT‐2 inhibitors with a particular focus on the results of published cardiovascular outcome trials, which have also provided unique opportunities to evaluate uncommon but potentially serious adverse events of these newer agents. The cardiovascular benefits of SGLT‐2 inhibitors and some glucagon‐like peptide‐1 receptor agonists suggest that they may be the preferred choice, usually as an add‐on to metformin, for patients with type 2 diabetes mellitus at high cardiovascular risk.