T2DM patients should have bariatric surgery earlier

13 July 2021

T2DM patients should have bariatric surgery earlier


Hi All,

The Scandinavian Obesity Surgery Registry has to be joined by every patient who has Bariatric Surgery in Scandinavian countries.  Because of the wide inclusion of patients it makes it a very powerful tool for analysing outcomes.  Any analysis relies on including as close to 100% of eligible patients as possible - and the SOSR achieves that.  This analysis demonstrates the danger of type 2 diabetes - even for people considered pre-diabetic only.  What follows is that the more successful a treatment is at preventing diabetes altogether, the more powerful it is.  Weight loss surgery is the only treatment known that prevents people from becoming diabetic.  And that is why it is becoming so popular for both patients, their medical specialists and their GPs. 

Happy researching and I look forward to meeting you soon.

Kind regards,




The latest findings from the annual Scandinavian Obesity Surgery Registry (SOReg) report could challenge existing recommendations and clinical practice for bariatric surgery and type 2 diabetes (T2DM) patients, according to the authors of a summary paper of the report, ‘Bariatric Surgery: There Is a Room for Improvement to Reduce Mortality in Patients with Type 2 Diabetes’, published in Obesity Surgery.

"SOReg provides a large high-quality database which gives the opportunity to better explore the associations between diabetes, weight loss after surgery, remission of diabetes and mortality," explained co-author of the paper, Professor Carel le Roux from the Diabetes Complications Research Center, University College Dublin, Dublin, Ireland. "Novel data which can only be obtained from these large datasets now challenge current guidelines and practice, because it appears as if we can improve significantly on our current best practice."

The 2020 SOReg report, published in May, examined 65,345 patients with up to ten-year follow-up after primary bariatric surgery and looked at the outcomes of patients with and without T2DM prior to surgery and those patients who achieved T2DM remission within one year after surgery. Crucially, the report found that the impact of T2DM duration on glycaemic remission suggest that patients with T2DM should have bariatric surgery earlier. Nevertheless, the SOReg report also shows that there was no change in the percentage of people with diabetes having bariatric surgery before 2012 (19.9%) or after 2012 (17.5%), “despite overwhelming evidence that bariatric surgery is superior to nonsurgical treatment”, the authors of the paper note.

Of the 65,345 patients included in the report, 11,990 (18.1%) patients had T2DM prior to bariatric surgery (gastric bypass or sleeve gastrectomy) and 19,281 (29.5%) had prediabetes. At 6.3 years after surgery, the report found that the mortality rate was 4.1% (487/11,990) in patients with T2DM prior to surgery, compared with 0.15% (798/53,355) in patients without T2DM prior to surgery (p<0.001).

“Thus, bariatric surgery reduces mortality compared with non-surgical medical care, but preoperative T2DM increases mortality 27-fold even after bariatric surgery. Therefore, more is needed to make bariatric surgery even better,” they write.

Moreover, in those patients with T2DM prior to surgery demonstrated improved survival if they achieved glycaemic remission one year after surgery. Some 2.9% (204/7,130) of patients died within 6.3 years despite achieving remission compared with 174 out of 3,379 patients (5.1%) who did not achieve glycaemic remission (p<0.001), meaning suboptimal glycaemic control one year after surgery was associated with a 1.7-fold increase in mortality.

They also noted that standard medications for T2DM with proven mortality benefits such as metformin, GLP-1 agonists etc are stopped after surgery - because the reduction in medication after surgery is a driver of the health economic benefit of bariatric surgery - without considering the impact on mortality. Therefore, the authors call for a “move away from the idea of surgery against medicine, but rather consider surgery with medicine.”

"We are getting better insight in what matters for the chance for remission and risk for relapse, but we could optimise this by improving collaboration between surgery and medicine," le Roux added. "Even if it seems possible to stop all drugs after surgery should we really do this? The question now is if we are keeping medications then which drug, which dose, and what metabolic targets should we aim for in the short and longer term? More work is needed, but we are on the right track."

The ‘healthy obesity’ myth

22 June 2021

The ‘healthy obesity’ myth

Hi again,

This is an interesting piece of basic science that disproves the notion of being morbidly obese but 'healthy'.  I do hear that a lot.  "I'm actually really healthy."  It's nice to 'feel' healthy but in reality the damage caused by obesity is still being done at a microscopic level.  This does mean that the inevitability of developing medical problems associated with being overweight is a certainty unless a drastic intervention kicks in.  The final statement about following these people who had the fat biopsy prior to Bariatric surgery to re-take a sample after weight loss following Bariatric surgery will be an exciting observation.  This will show microscopic changes back to a healthy appearance with significant weight loss, would be my guess... Watch this space!

Fire away with any questions if you have any.

Look forward to meeting soon.

Kind regards,



The term "healthy obesity" has gained traction over the past 15 years, but scientists have recently questioned its very existence. A study published in the journal Cell Reports provides further evidence against the notion of a healthy obese state, revealing that white fat tissue samples from obese individuals classified as either metabolically healthy or unhealthy actually show nearly identical, abnormal changes in gene expression in response to insulin stimulation.

"The findings suggest that vigorous health interventions may be necessary for all obese individuals, even those previously considered to be metabolically healthy," said first author, Dr Mikael Rydén of the Karolinska Institutet, Solna, Sweden. "Since obesity is the major driver altering gene expression in fat tissue, we should continue to focus on preventing obesity."

Obesity has reached epidemic proportions globally, affecting approximately 600 million people worldwide and significantly increasing the risk of heart disease, stroke, cancer, and type 2 diabetes. Since the 1940s, evidence supporting the link between obesity and metabolic and cardiovascular diseases has been steadily growing. But in the 1970s and 80s, experts began to question the extent to which obesity increases the risk for these disorders. Subsequent studies in the late 90s and early 2000s showed that some obese individuals display a relatively healthy metabolic and cardiovascular profile.

Recent estimates suggest that up to 30% of obese individuals are metabolically healthy and therefore may need less vigorous interventions to prevent obesity-related complications. A hallmark of metabolically healthy obesity is high sensitivity to the hormone insulin, which promotes the uptake of blood glucose into cells to be used for energy. However, there are currently no accepted criteria for identifying metabolically healthy obesity, and whether or not such a thing exists is now up for debate.

To address this controversy, in their study ‘The Adipose Transcriptional Response to Insulin Is Determined by Obesity, Not Insulin Sensitivity’,Rydén, Carsten Daub, and Peter Arner of the Karolinska Institutet assessed responses to insulin in 15 healthy, never-obese participants and 50 obese subjects enrolled in a clinical study of gastric bypass surgery. The researchers took biopsies of abdominal white fat tissue before and at the end of a two-hour period of intravenous infusion of insulin and glucose. Based on the glucose uptake rate, the researchers classified 21 obese subjects as insulin sensitive and 29 as insulin resistant.

Surprisingly, mRNA sequencing of white fat tissue samples revealed a clear distinction between never-obese participants and both groups of obese individuals. White fat tissue from insulin-sensitive and insulin-resistant obese individuals showed nearly identical patterns of gene expression in response to insulin stimulation. These abnormal gene expression patterns were not influenced by cardiovascular or metabolic risk factors such as waist-to-hip ratio, heart rate, or blood pressure. The findings show that obesity rather than other common risk factors is likely the primary factor determining metabolic health.

"Our study suggests that the notion of metabolically healthy obesity may be more complicated than previously thought, at least in subcutaneous adipose tissue," added Rydén. "There doesn't appear to be a clear transcriptomic fingerprint that differentiates obese subjects with high or low insulin sensitivity, indicating that obesity per se is the major driver explaining the changes in gene expression."

One limitation of the study is that it examined gene expression profiles only in subcutaneous white fat tissue, not other types of fat tissue or other organs. Moreover, all of the obese subjects were scheduled to undergo bariatric surgery, so the findings may only apply to individuals with severe obesity.

In future research, Rydén and his collaborators will track the study participants after bariatric surgery to determine whether weight loss normalises gene expression responses to insulin. They will also look for specific genes linked to improved metabolic health in these individuals.

In the meantime, the study has an important take-home message: "Insulin-sensitive obese individuals may not be as metabolically healthy as previously believed," he said. "Therefore, more vigorous interventions may be necessary in these individuals to prevent cardiovascular and metabolic complications."

Obesity affects the ability to work especially in women over 50

31 May 2021

Obesity affects the ability to work especially in women over 50

Hi all - this is an interesting but scary finding from a very simple study.  It highlights the vulnerability of women who are obese and in the older age bracket as far as being able to maintain a fulltime job.  The suggestion follows that an older lady's ability to maintain her independence - whether that be physically or financially - is directly dependent on having a healthy BMI as she ages.  Whilst the conclusion that workplaces should focus on their employee's health and fitness is logical, it is also unlikely to have as much of an impact as would be necessary to change outcomes.  Women in their 50's and 60's have usually put every effort into losing weight with conventional, non-surgical means during their lifetime.  If they haven't achieved longterm success in getting to a healthy BMI then this study presents another reason why thinking about Bariatric surgery may be beneficial from a financial perspective for women in their 50's and 60's.  Something to ponder ladies!

Nice chatting.

Steph Ulmer  

For men, there was a slightly increased risk of prolonged sickness absence amongst those with obesity but no evidence of an association between above-average BMI and health-related job loss

Older workers with obesity are at a higher risk of prolonged sickness absence or losing their jobs for health reasons than those of normal weight, with women affected significantly more than men, according to researchers from the University of Southampton. The study studied investigated the association between BMI and prolonged sickness absence, cutting down at work and health-related job loss among 2,299 men and 2,425 women aged between 50 and 64 years.

Obesity is a major and growing public health problem, with future projections estimating that there will be more than one billion people affected globally by 2030. Being obese or overweight is a major risk factor for non-communicable diseases including diabetes; cardiovascular diseases; musculoskeletal disorders and common mental health conditions. Although obesity is becoming more prevalent in children and adolescents, the highest prevalence is seen amongst men and women in their fifties, sixties and seventies.

The participants in the study reported their height and weight at the start of the study then provided information about their ability to work after 12 and 24 months as part of Medical Research Council's Health and Employment after Fifty (HEAF) Study.

The University of Southampton team analysed the data from this study and publishing their findings, ‘Body Mass Index (BMI) and Work Ability in Older Workers: Results from the Health and Employment after Fifty (HEAF) Prospective Cohort Study’, in the International Journal of Environmental Research and Public Health. The research has shown that the women with obesity or severe obesity had greater odds of prolonged sickness absence compared with women of normal weight. Those with severe obesity were also the most likely to cut down, avoid, or change what they did at work because of a health problems, and were almost three times as likely to lose their job because of their health.

Amongst the men taking part in the survey, there was a slightly increased risk of prolonged sickness absence amongst those with obesity but no evidence of an association between above-average BMI and health-related job loss.

"Our study demonstrates the link between obesity and health problems that affect people's ability to work, particularly in older female workers,” said Professor Karen Walker-Bone Director of the MRC Versus Arthritis Centre for Musculoskeletal Health and Work at the University of Southampton, who led the study. “As a result, the burden of obesity in an aging population can be expected to hinder attempts to encourage work to older ages. These results should give employers an incentive to introduce measures that can help their employees maintain a healthy weight."


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