MRI Monitors Liver Fat Response to Bariatric Surgery

Quantitative chemical shift-encoded magnetic resonance imaging (CSE-MRI) is an effective, noninvasive way to monitor liver fat levels over time after bariatric surgery, a study published today in Radiology reports.

Common in obese people, nonalcoholic fatty liver disease (NAFLD) can progress to fibrosis, cirrhosis, and cancer. Although weight loss can reduce the extent of NAFLD, biopsy has been the only possible method of assessing the long-term impact of weight loss on hepatic steatosis.

B. Dustin Pooler, MD, an adjunct assistant professor at the University of Wisconsin School of Medicine and Public Health and a radiologist at Madison Radiologists, S.C., in Madison, Wisconsin, and colleagues used the noninvasive MRI technique to measure average liver proton density fat fraction (PDFF) in 50 patients before bariatric surgery and at several points during the year afterward. They compared this MRI biomarker with postsurgical changes in body mass index (BMI), weight, and waist circumference.

The study cohort, which included 43 women and seven men and was recruited from 2010 to 2015 from medical centers at the University of California San Diego and the University of Wisconsin-Madison, had a mean age of 51.0 years and a mean BMI of 44.9 kg/m2.

Presurgical preparation entailed a very low-calorie diet of 600 to 900 calories per day, started at a mean of 2.6 weeks before surgery. Bariatric procedures included gastric banding (n = 2), gastric bypass (n = 28), gastric sleeve (n = 19), and gastric plication (n = 1). PDFF was assessed presurgically before and after the diet, and along with anthropomorphic measurements was assessed at 1, 3, and 6 months after surgery.

Liver fat content began to normalize early during the low-calorie diet and soon after surgery, suggesting metabolic disturbances of NAFLD begin to correct rapidly in response to the caloric deficit of the presurgical diet even before substantial weight loss.

Overall, 32 (64%) of 50 study participants saw their liver fat normalized and an estimated 90% reached that goal by 42 weeks. Six to 10 months postsurgery, patients’ mean PDFF had returned to the normal range of < 5%, falling from 18.1% to 4.9%, with a mean estimated time to normalization of 22.5 weeks.

Mean BMI fell to 34.5 kg/m2 (mean decrease 10.4), and the cohort’s final mean weight of 91.6 kg represented am overall reduction of 29.9 kg. The final mean waist circumference of 110.9 cm represented a mean decrease of 21.3 cm. All reductions were statistically significant (P < .0001)

Rohit Loomba, MD, director of the NAFLD Research Center at the University of California San Diego and chair of the NAFLD Special Interest Group for the American Association for the Study of Liver Diseases, told Medscape Medical News the findings are an important contribution to the field of liver study.

“Previously the MOZART trial conducted by our group demonstrated the role of MRI-PDFF in assessing treatment response in [nonalcoholic steatohepatitis; NASH] trials. This excellent study clearly extends those findings to examine longitudinal changes in liver fat by MRI-PDFF specifically after bariatric surgery,” said Loomba, who was not involved in the research.

Loomba noted that further studies are needed to examine longitudinal changes that might suggest progressive NAFLD, including biomarkers of fibrosis and inflammation.

Earlier this year, Duke University researchers confirmed MRI’s utility for detecting NAFLD, but concluded it was not sufficiently accurate to replace biopsy in distinguishing between NAFLD and its more advanced relative, nonalcoholic steatohepatitis.

Interestingly, whereas initial PDFF level strongly predicted both rate of liver fat change and time to normalization, body anthropometrics did not predict either outcome. “Decreases in liver fat content were only weakly correlated with starting weight and the amount of overall weight loss, suggesting possible utility in monitoring liver fat with MRI following bariatric surgery, independent of monitoring weight loss,” Pooler and colleagues write.

They suggest that PDFF measurements could also help identify appropriate candidates for bariatric surgery as a result of this robust association between liver fat reduction and pretreatment steatosis levels.

According to the authors, their study is the first longitudinal analysis of changes in liver fat over time in a bariatric surgery population.

The Impact of Bariatric Surgery on Cancer Incidence

What is the impact of bariatric surgery on cancer incidence? To answer this question, the authors of a study published in the British Journal of Surgery[1] compared cancer frequency following various types of obesity surgery in 8794 obese patients in England (average age, 42 years) who were operated versus in an equal number of nonoperated patients.

During a median follow-up period of 55 months, the risk for hormone-related cancers was significantly reduced in the operated group compared with the nonoperated group (odds ratio [OR], 0.23; 95% confidence interval [CI], 0.18-0.30). In contrast, for colorectal cancer following gastric bypass (but not banding or sleeve gastrectomy), there was an overall increase in the risk for colorectal cancer (OR, 2.63; 95% CI, 1.17-5.95).

Gastric Bypass Increased the Risk for Colorectal Cancer

This report provides valuable information about cancer risk following bariatric surgery, one of the most common procedures performed by general surgeons. The risk reduction for hormonally dependent cancers was seen in both males (prostate) and females (breast, endometrium), and the benefit became more pronounced with increasing duration of follow-up. On the basis of a total of 16 patients with colorectal cancer, gastric bypass resulted in a more than twofold increased risk.

If confirmed with studies with longer follow-up and more patients, the findings in this report suggest that the age for screening for colorectal cancer following bariatric surgery should be lowered. One study weakness is that the dataset only listed obesity as a comorbidity and did not include actual information to calculate body mass index. Nevertheless, the results seem biologically plausible and are consistent with those from other research reports.

Alcohol Abuse After Bariatric Surgery Common, Concerning

Individuals who undergo bariatric surgery, particularly Roux-en-Y gastric bypass (RYGP), have a significantly increased risk of developing a substance use disorder (SUD), in particular alcohol use disorder (AUD), new research shows.

The increased risk is not observed until after the first postoperative year, and risk factors include a preoperative history of substance use, especially alcohol; younger age; male sex; and smoking, said lead investigator Cameron Risma, MD, Pine Rest Christian Mental Health Services, Grand Rapids, Michigan.

In addition, people who chronically used opiates before the surgery tend to continue chronic use after surgery, Risma said.

Dr Cameron Risma

“We got the idea to study substance use disorders after bariatric surgery because we see a lot of it in our detox program at Pine Rest. It’s common. People come in years after surgery, and they never realized that this was an issue,” he told Medscape Medical News.

The findings were presented here at the American Academy of Addiction Psychiatry (AAAP) 29th Annual Meeting.

Fivefold Increased Risk

For the study, investigators conducted a PsychINFO and Web of Science search for articles published from 1996 to 2018 on the relationship between gastric bypass surgery and SUD.

They found that a 2013 prospective study that followed more than 4000 obese patients showed those who underwent bariatric surgery were nearly five times more likely to receive a diagnosis of alcohol abuse during a follow-up period of 8 to 22 years.

Another 2012 prospective study that followed almost 2500 bariatric surgery patients showed a significantly increased prevalence of symptoms of AUD during the second postoperative year compared to the first postoperative year (9.6% vs 7.3%).  There was no difference between the year immediately before (7.6%) or after (7.3%) the surgery.

The same study identified preoperative variables independently associated with increased risk of developing an AUD after bariatric surgery.  These included previous AUD, regular alcohol use (defined as >2 drinks per week), smoking, recreational drug use, male sex, RYGB, younger age, and low sense of belonging.

Two systematic reviews showed that approximately 8% of patients were chronic opiate users at the time of surgery, and that most continued using opioids in the year following surgery.

However, use of other substances after bariatric surgery remained unchanged.

Three hypotheses have been proposed to account for the link between bariatric surgery and addiction, Risma said.

“No one really knows exactly why, but one hypothesis is this idea of addiction transfer.  Binge eating can lead to obesity, so you get addicted to food. But after you have surgery, you can’t binge on food anymore so you turn to something else which happens to be a substance, to replace food. The idea is that you are using a substance to cope with a negative emotional state,” Risma said.

The next hypothesis is based on neurobiological mechanisms, supported by evidence from PET scans, which have shown similarly reduced D2 receptors in both pathologic obesity and addiction.

“It is possible that reduced striatal D2 receptors predispose an individual to search for strong dopaminergic reinforcement as a compensatory mechanism for dopamine hyposensitivity. This dopamine-based hypothesis is supported by neuroimaging studies showing that a rapid dopamine release is produced both by binge eating and IV alcohol infusion,” the authors write.

The third hypothesis is based on pharmacokinetic changes after RYGB, leading to a hypersensitivity to alcohol’s reinforcing effects.

“This is really interesting,” Risma said. “After Roux-en-Y gastric bypass, you get a hypersensitivity to alcohol’s effects, where even a small amount of alcohol can achieve very high blood alcohol concentrations.

“One drink can put you over the legal limit in less than 15 minutes, so it reaches a higher blood alcohol content and it takes longer for the alcohol to get out of your system. Some people report that even after a few sips they can feel a buzz. They go back to drinking the same amount, they get more drunk, and they can become addicted that way,” he said.

These changes are only observed in RYGB, and no other bariatric surgeries such as gastric banding or sleeve gastrectomy, Risma said.

“The results of our survey show that it’s primarily alcohol that becomes the substance of abuse,” he added. “But clinically, I’ll tell you, we see a lot of opiate use in our detox unit. This is something we would to like to investigate going forward, because we are seeing so much of it. People who have surgery have chronic pain, they can’t get off their opioids, and they come to us addicted and needing withdrawal and treatment afterwards.

“We would like to work with local bariatric surgical centers and ask how they are identifying people based on the risk factors we found in our survey, and then once they are identified, ask how they are treating them. Are you offering them classes, are you following up with them more often? We think that’s an area where we can make a clinical impact.”

A Growing Problem

Commenting on the findings for Medscape Medical News, Cornel N. Stanciu, MD, assistant professor of psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, said the number of individuals undergoing bariatric weight loss procedures is expected to grow by 6% to 8% annually in the coming years.

“Positive outcomes can be quite striking. However, there are certain aspects which could worsen or emerge. With both obesity and addictions being stigmatized and overlooked as disorders of poor self-control, with perhaps common genetic, behavioral, social, neurobiological and pharmacokinetic factors, one emerging issue noted has been the association of bariatric surgery with development of postoperative addictions,” Stanciu said.

Dr Cornel Stanciu

As with other surgeries, the biggest focus has been on limiting opioid use to prevent addictive tendencies, but here the biggest association seems to be with the development of risky alcohol use, he added.

“Some studies report this rate to be as high as 21% when the procedure is done via the RYGB method, and 11% when banding is done,” Stanciu said.

The finding of a delay in developing alcohol abuse patterns a year after surgery has significant implications. Historically, the most rigorous follow-up and aftercare occur immediately after the procedure and tapers off throughout the coming years.

“In an era that is shifting towards the ambulatory setting, providing prolonged aftercare and monitoring may present challenges,” he added.

Identifying factors that predispose individuals to alcohol abuse after their bypass should prompt implementation of additional safety nets, Stanciu said.

“Here, they found [that patients with] a history of alcohol use, undergoing the RYGB type of procedure, young age, male gender, and smokers may be predisposed. It’s important to implement better screening focused on these risk factors, as well as a more robust pre- and post-surgical education and closer follow-up.

“Also, because alcohol problems may not appear for years after the procedure, it is critical for all clinicians involved in the care of bariatric surgery patients to proactively assess alcohol consumption and be able to intervene early,” he said.

However, he added, the frequency of RYGB is decreasing, he noted.

“Initially, RYGB was more popular than banding as it led to more drastic weight loss. However, newer approaches such as sleeve gastrectomy and endoscopic modalities are rapidly taking over. Whether these may have a greater association with alcohol and other addictive behaviors is a great unknown at this time,” Stanciu said.

Calcium supplement formulations similarly ineffective for normalizing parathyroid hormone following bariatric surgery

In adults with slightly elevated parathyroid hormone following Roux-en-Y gastric bypass surgery, supplementation with either calcium carbonate or calcium citrate did not restore normal PTH level, according to findings published in Clinical Endocrinology.

“Despite clinical recommendations of lifelong vitamin D and calcium supplementation, elevated levels of PTH, which is potentially harmful to bone health, are frequent following RYGB,” Lene Ring Madsen, MD, a doctoral student in the department of endocrinology and internal medicine at Aarhus University Hospital, Denmark, and colleagues wrote in the study background. “Besides vitamin D and calcium malabsorption, an altered diet including less dairy products may also influence the calcium intake after [Roux-en-Y gastric bypass surgery].”

In a 12-week randomized double-blind, controlled trial, researchers enrolled 39 adults (mean age, 49 years; 13 women) who had undergone Roux-en-Y gastric bypass surgery a mean of 6.2 years before study entry. Participants had elevated PTH levels after adhering for at least the previous 12 months to daily multivitamin supplement use (including 400-500 mg elementary calcium plus 400-800 IU of vitamin D3) plus use of a calcium carbonate (800 mg elementary calcium) and vitamin D3 (1,520 IU) supplement. The multivitamin was continued through the study period, whereas the other calcium carbonate and D3 supplement was discontinued at the start of the trial. Participants had PTH greater than 6.9 pmol (normal range, 1.6-6.9 pmol/L), 25-hydroxyvitamin D level greater than 20 ng/ml and normal levels of plasma ionized calcium (1.18-1.32 mmol/L).

Participants were randomly assigned at baseline to received either 1,200 mg elementary calcium daily in combination with 2,280 IU vitamin D3 (3,000 mg calcium carbonate daily as one tablet and one calcium-free placebo tablet 3 times daily with meals) or 1,200 mg elementary calcium in combination with 2,400 IU vitamin D3 (5,712 mg tricalcium citrate daily as 2 two tablets 3 times per day with meals). The primary outcome was the change in PTH from baseline to week 12.

Based on tablet count, both groups showed a high level of adherence to their regimens, according to researchers. Overall, the two calcium regimens were well-tolerated, although the calcium citrate group reported more symptoms of constipation vs. the calcium carbonate group (37% vs.10%; P = .047). At baseline, the calcium carbonate group self-reported lower daily intake of dietary calcium (791 g vs. 996; P = .042) whereas the calcium citrate group had somewhat higher levels of the bone-turnover markers CTX, osteocalcin and bone-specific alkaline phosphatase.

At 12 weeks, the researchers found no difference between the groups in changes to mean PTH levels or number of participants with PTH greater than 6.9 pmol/L. During the intervention, the calcium citrate-treated group showed more significant decreases in the bone turnover markers P1NP (-16.6% vs. -3.2%; P = .021), osteocalcin (-17.2% vs. -4.3%; P = .007) and bone-specific alkaline phosphatase (-4.0% vs. 3.7%; P = .027), and these differences remained significant after adjusting for daily intake of dietary calcium, the use of loop diuretics and thiazide. No difference in urinary calcium excretion was observed between the groups.

No significant changes in mean PTH levels were seen among the entire cohort during the intervention. However, in a subgroup of 12 participants with PTH greater than pmol/L at baseline, the added calcium supplementation did lower mean PTH levels by 1.25 pmol/L; P = .005) regardless of the type of supplement used.

A study with longer follow-up will be valuable in further investigating this topic, Larsen told Endocrine Today.

“The take-home message of this study is that based on current evidence, we cannot recommend calcium citrate over calcium carbonate as vitamin supplementation after Roux-en-Y gastric bypass. This is opposite to existing recommendations,” she said. “In Denmark, calcium citrate is not only more expensive, but requires more pills every day to get the amount of calcium recommended. We can now tell our patients that they can stick to calcium carbonate.” – by Jennifer Byrne

Bariatric Surgery Might Increase Risk for Suicide and Nonfatal Self-Harm

In two observational studies, bariatric surgery patients had higher risk for suicide than nonsurgical patients, although absolute risk was small.

Bariatric surgery attenuates adverse cardiovascular events, complications of diabetes, and early mortality, but some studies have shown excess suicides and nonfatal self-harm among patients who have undergone bariatric surgery. A new analysis of data from two Swedish cohorts supports these concerns. In one study, in which candidates were recruited for bariatric surgery between 1987 and 2001, researchers compared risk for suicide or nonfatal self-harm in about 2000 patients who elected surgery (68% vertical-banded gastroplasty, 19% gastric banding, 13% gastric bypass) with risk in 2000 matched controls who declined surgery and received routine care. Researchers also used a registry, which includes data on nearly all bariatric procedures performed in Sweden since 2007, to compare >20,000 patients who underwent gastric bypass with >16,000 matched patients who enrolled in a contemporaneous 12-month commercial, nonsurgical, intensive weight-loss program.

In both comparisons, numbers of suicides or nonfatal self-harm were significantly higher in the surgical group than among nonsurgical controls (87 vs. 49 and 341 vs. 84, respectively). More suicides occurred in the surgical groups in both comparisons, but events were too few to reach statistical significance. In the first study, results were similar for all three bariatric procedures.


Despite extensive adjustment for potential confounders, selection bias might have influenced these nonrandomized comparisons. The authors point out that the benefits of bariatric surgery far exceed risk for self-harm, but they advise that patients and clinicians address these risks both before and after bariatric procedures.

4 fold reduction in Diabetic microvascular complications after Bariatric surgery

Restoration of euglycemia and normal acute insulin response to glucose in obese subjects with type 2 diabetes following bariatric surgery.

Insulin resistance and loss of glucose-stimulated acute insulin response (AIR) are the two major and earliest defects in the course of type 2 diabetes. We investigated whether weight loss after bariatric surgery in patients with morbid obesity and type 2 diabetes could restore euglycemia and normal AIR to an intravenous glucose tolerance test (IVGTT). We studied 25 morbidly obese patients-12 with type 2 diabetes, 5 with impaired glucose tolerance, and 8 with normal glucose tolerance (NGT)-before and after a biliopancreatic diversion (BPD) with Roux-en-Y gastric bypass (RYGBP). Twelve individuals with normal BMI served as control subjects. Twelve months after surgery, in the diabetes group, BMI decreased from 53.2 +/- 2.0 to 29.2 +/- 1.7 kg/m(2), fasting glucose decreased from 9.5 +/- 0.83 to 4.5 +/- 0.13 mmol/l, and fasting insulin decreased from 168.4 +/- 25.9 to 37.7 +/- 4.4 pmol/l (mean +/- SE; P < 0.001). AIR, the mean of insulin concentration at 2, 3, and 5 min over basal in the IVGTT, increased by 770 and 935% at 3 and 12 months after surgery, respectively (from 24.0 +/- 22.7 to 209 +/- 43.4 and 248 +/- 33.1 pmol/l, respectively; P < 0,001). Conversely, in the NGT group, the AIR decreased by 40.5% (from 660 +/- 60 to 393 +/- 93 pmol/l; P = 0.027) 12 months after surgery. BPD with RYGBP performed in morbidly obese patients with type 2 diabetes leads to significant weight loss, euglycemia, and normal insulin sensitivity; but most importantly, it restores a normal beta-cell AIR to glucose and a normal relationship of AIR to insulin sensitivity. This is the first study to demonstrate that the lost glucose-induced AIR in patients with type 2 diabetes of mild or moderate severity is a reversible abnormality.


Pain Sensitization Declines After Bariatric Tx in Obese Patients

Decreased knee pain linked with central sensitization

Action Points

Weight loss following bariatric surgery was associated with improvements in pain sensitization among obese patients with chronic knee pain, a year-long study found.

One year after bariatric surgery, the pressure pain threshold increased by 38.5% at the patella and by 30.9% at the wrist among patients who had undergone either laparoscopic roux-en-y gastric bypass or sleeve gastrectomy, whereas no changes in the pressure pain threshold were observed among patients who had medical/lifestyle management, according to Joshua J. Stafanik, PhD, MSPT, of Northeastern University in Boston, and colleagues.

 “Improvement in pressure point threshold at the wrist suggests that the pain improvement in the surgical subjects was at least in part mediated through central sensitization,” the researchers wrote online in Arthritis Care & Research.

Obese individuals typically report more musculoskeletal pain than do those of normal weight, particularly at the knees, which has been attributed to mechanical stresses from excess loading at the weight-bearing joints and also to the release of adipokines from adipose tissue and the resulting low-grade joint inflammation.

But it has not been established whether additional pain relief at sites beyond the knee is provided by changes in central and peripheral pain sensitization, defined as “increased responsiveness of the peripheral and central nervous systems to nociceptive input,” according to the authors. So they sought to examine this possibility among individuals seen at the Nutrition and Weight Management Center at Boston Medical Center.

They recruited 87 participants who met the eligibility criteria for bariatric surgery, which were a BMI of 35 plus a weight-associated comorbidity, or a BMI >40. They all had knee pain on most days of the previous month.

Those receiving medical management were prescribed a low-fat diet of 1,200 to 1,800 calories per day plus medications such as phentermine, lorcaserin, and bupropion/naltrexone. Exercise, including walking 30 minutes daily, also was encouraged.

Knee pain was evaluated according to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and pressure pain thresholds were assessed with a hand-held algometer applied at a rate of 0.5 kg/sec to the radioulnar joint and index patella.

The radioulnar joint of the right wrist was considered a control site, as it is not usually affected by osteoarthritis. The researchers also recorded the number of joints other than the knees with frequent pain in the past month.

A lower pressure pain threshold reflects higher sensitivity to pain.

A total of 45 patients in the surgery group and 22 in the medical group completed the 1-year follow-up.

Among the surgery group, mean age was 43.8, 97.8% were women, and baseline BMI was 42.1. Their WOMAC pain score was 9.5 out of 20, and the average number of painful joints was 7.1. The pressure pain thresholds were 346.5 kilopascals at the patella and 335.6 at the wrist.

 In the medical management group, mean age was 48.1, 86.4% were women, and BMI was 40.7. WOMAC pain score was 11.5, mean number of painful joints was 6.3, and pressure pain thresholds were 450.7 and 387.7 at the patella and wrist, respectively.

At 1 year, the mean weight loss in the surgery group was 32.7 kg (about 72 lbs) compared with 4.6 kg in the medical management group.

Mean change in WOMAC pain score from baseline in the surgery group was -4.9, which was statistically significant (P<0.0001), while the -1.5 change in the medical management group was not significant. The change from baseline in number of painful joints was -2.3 in the surgery group (P=0.002), but +0.9 in the medical management group.

At 1 year, the change in pressure point threshold was +133.3 at the patella and +103.8 at the wrist, compared with changes of -56.4 and +44.4 in the medical group.

Changes in weight correlated with differences in WOMAC pain (r=0.50, P<0.0001) and in pressure point threshold at the patella (r=-0.33, P=0.006), although not with changes in pressure point threshold at the wrist (r=-0.04, P=0.77). There also was a moderate inverse correlation between WOMAC pain changes and changes in pressure point thresholds at both patella (r=-0.4, P=0.007) and wrist (r=-0.4, P=0.002).

 The improved pressure point thresholds at the wrist and decrease in number of painful joints support the possibility that central pain sensitization is a mediator of pain reduction in the patients who had bariatric surgery, the authors noted.

“In the presence of sensitization, nociceptors respond to stimuli that they would normally not respond to. However, due to neuroplasticity, removal of the stimuli that contribute to sensitization may normalize nociceptor functioning,” they explained.

They also pointed out that other factors also may contribute to changes in pain after weight loss surgery, such as increased physical activity and improvements in mood and quality of sleep. In addition, further research will be needed to account for the potential influence of inflammatory markers such as C-reactive protein and metabolic factors on pain following bariatric surgery.

Bariatric Surgery Linked to Prolonged Post-op Opioid Use


San Diego—Roughly one in 12 bariatric patients who did not take opioid pain medications until their weight loss surgery, or the month before it, reported that they are still using prescription opioids one year postoperatively, a rate of prolonged use that is more than 45% higher than people who underwent other general surgery procedures.

Among all bariatric patients, including those who reported using opioids before their particular procedure, nearly one in four was still taking opioid pain medications one year after surgery.

The study, presented at the American College of Surgeons 2017 Clinical Congress, provides further evidence that bariatric patients are more prone to persistent opioid use than others, said senior investigator Amir A. Ghaferi, MD, associate professor of surgery at the University of Michigan, in Ann Arbor.

“Surgeons must identify patients who may be at higher risk for addiction to opioids so they can adjust prescribing for postoperative pain,” said Dr. Ghaferi, who directs the Ann Arbor–based Michigan Bariatric Surgery Collaborative, a quality improvement program that supplied the study data.

“Patients undergoing bariatric surgery may be particularly vulnerable to opioid dependence, possibly because of chronic knee and back pain associated with morbid obesity,” he said.

Dr. Ghaferi and his co-investigators used the Michigan Bariatric Surgery Collaborative database, which collects data on 95% of bariatric surgeries performed in the state. They identified 14,063 patients undergoing first-time bariatric surgical procedures who completed surveys about their use of prescription painkillers preoperatively and again one year after the procedure. The researchers initially administered the survey by email and, if there was no response after several reminders, by mail or phone. The survey listed commonly prescribed opioid medications, such as hydrocodone and oxycodone.

Patients undergoing weight loss procedures routinely receive an opioid prescription for postoperative pain, and most patients discontinue using opioid medications earlier than two weeks after their operation. The study, however, found a minority who continued taking the medications much longer.

Three-fourths of survey respondents stated they had not taken opioid medications in the one to 12 months before their surgical treatment. Of these opioid-naive patients, 8.8% said they were still using their opioids one year after starting them for postoperative pain.

The rates of newly persistent opioid use were significantly higher than the 6% rate reported among opioid-naive patients in the general surgery population, Dr. Ghaferi said. The general surgery data came from the Michigan Opioid Prescribing Engagement Network, or Michigan-OPEN, an initiative that aims to prevent surgery-related opioid abuse.

Richard M. Peterson, MD, MPH, director of the University of Texas Health San Antonio Weight Loss Center, said the rates of opioid use in the study were far higher than expected. “It’s kind of eye-opening. I don’t believe this is what I’m seeing in my own patients, but if this is truly happening, we need to look at why.”

Drs. Peterson and Ghaferi said the theory of addiction transfer might explain why bariatric patients continue to use opioids long after surgery. Some data support this concept in bariatric surgery patients: Patients who used overeating as a coping mechanism before surgery may resort to other means postoperatively, relying on alcohol, drugs or other maladaptive behaviors.

But the physiologic explanation behind the persistent use of opioids, such as a difference in bioavailability or absorption patterns of medications after weight loss surgery, could result in increased likelihood of addiction, Dr. Ghaferi noted.

Although the cause remains unknown, providers should pay special attention to opioid use during the postsurgical period, he said.

Based on these findings, Dr. Ghaferi and his colleagues have made changes in their bariatric surgery practice that they hope will reduce the risks of long-term opioid use. They moved away from a one-size-fits-all approach to prescribing, and use patients’ pain scores and inpatient opioid requirements to guide prescriptions.

They recommend that surgeons screen patients for substance abuse risk factors, such as excessive alcohol use or a family history of substance use disorder; prescribe fewer opioid pills in the first prescription; and perform local nerve blocks in the operating room to minimize the need for postoperative opioid medications.

In the next year, Dr. Ghaferi and his colleagues hope to publish evidence-based prescribing recommendations for bariatric patients. Researchers from Michigan-OPEN, working with the Michigan Surgical Quality Collaborative, developed the Opioid Prescribing Recommendations for Surgery (, which provides guidance for prescriptions following 11 common general surgery procedures. The recommendations were developed using data and surveys from patients across the state.

Several studies from the University of Michigan published over the last year have shown newly persistent opioid use to be a problem after minor and major surgical procedures in U.S. adults. In one study published this summer, opioid use one year after surgery ranged from 5.9% to 6.5%, depending on the procedure. Risk factors independently associated with new persistent opioid use included preoperative tobacco use, alcohol and substance abuse disorders, mood disorders, anxiety and preoperative pain disorders

Type 2 Diabetes Has Been “Reversed” in 40% of Patients for 3 Months.

No surgery required.


Type 2 diabetes is generally considered to be a chronic health condition that can’t be cured once it develops, and can only be managed with a combination of medication and healthy living – assisted by gastric band (bariatric) surgery in some cases.

But new research suggests that people may actually be able to beat the disease for set periods, by undertaking an intensive short-term course of medical treatment that’s been shown to reverse type 2 diabetes in a significant proportion of patients.

 “By using a combination of oral medications, insulin, and lifestyle therapies to treat patients intensively for two to four months, we found that up to 40 percent of participants were able to stay in remission three months after stopping diabetes medications,” says one of the researchers, Natalia McInnes from McMaster University in Canada.

“The findings support the notion that type 2 diabetes can be reversed, at least in the short term – not only with bariatric surgery, but with medical approaches.”

Type 2 diabetes is caused by the body not producing enough insulin – the hormone that enables cells to absorb glucose – or becoming insulin resistant. As a consequence, blood sugars build up in the body, and can lead to serious health problems like organ damage and heart disease.

Over 29 million Americans have type 2 diabetes, and estimates indicate that it could cost the US health care system as much as US$512 billion annually by 2021 – so any interventions that can effectively treat the condition are desperately needed.

To investigate whether intensive health treatments could trigger remission in type 2 diabetes patients, the researchers recruited 83 participants with the condition and randomly divided them into three groups.

Two of these groups received the short-term interventions – lasting for eight weeks or 16 weeks respectively – where they were given personalised exercise plans, meal plans that lowered their calorie intake by 500 to 750 calories a day, and regular meetings with a nurse and dietitian.

During the treatment period, they also took insulin and a set course of oral medications to help them manage the condition.

The third group of participants acted as controls, and received standard blood sugar management and health advice during the same period.

Three months after the experiment, 11 out of 27 patients in the 16-week intervention group showed complete or partial diabetes remission, as did six out of 28 individuals in the eight-week group.

Comparatively, only four of the participants in the control group showed signs of remission as a result of receiving standard, non-intensive health advice – and the team thinks this gap is evidence that there’s a lot more we can do to try and fight off, rather than just manage, the disease.

“The research might shift the paradigm of treating diabetes from simply controlling glucose to an approach where we induce remission and then monitor patients for any signs of relapse,” says McInnes.

“The idea of reversing the disease is very appealing to individuals with diabetes. It motivates them to make significant lifestyle changes and to achieve normal glucose levels with the help of medications.”

To be clear, that motivation and sense of purpose has to be kept up in the long term for the health gains – and subsequent diabetes reversal – to actually persist for longer than three months.

A year after the trial, the difference between participants who received the treatment and those that did not had become negligible, indicating that more work is needed to figure out how to make type 2 diabetes remission a permanent proposition.

“If you don’t sustain the lifestyle intervention, then the disease is going to come back,” endocrinologist Philip Kern from University of Kentucky, who wasn’t involved with the study, told HealthDay News.

While the remission did not persist – and the results reported here are based on only a small sample of participants in the trial – the findings are the latest to give scientists hope that type 2 diabetes can be beaten if patients commit to dietary and lifestyle changes.

Last month, a study by researchers from the University of Southern California found that a fasting diet in mice could reverse diabetes and repair the pancreas.

And in Britain, researchers being funded by charity Diabetes UK are currently running a large clinical trial to investigate whether diabetes can be reversed in the long term if people stick to a low calorie diet.

“We’re looking forward to seeing the results in 2018. In the meantime, we encourage people with type 2 diabetes to follow a healthy diet that is low in sugar, saturated fats, and salt,” Diabetes UK spokesperson Emily Burns told Sarah Knapton at the The Telegraph.

“We know that diet, exercise, and medications can help people with Type 2 diabetes to manage their condition. We’re starting to see mounting evidence that putting type 2 diabetes into remission is feasible as well.”