轉自《國際糖尿病》
近些年，隨著技術的提升和人們觀念的改變，減重手術日益受到人們的關注。華盛頓大學醫學院Mihoko Yoshino博士進行了一項研究，旨在評估飲食與胃旁路術對糖尿病代謝功能的影響。2020年8月，該研究的結果發表在NEJM上。NEJM的Michael Brewer博士對該文獻進行了播講。
飲食與胃旁路術對糖尿病代謝功能的影響，作者為華盛頓大學醫學院Mihoko Yoshino博士。
Effects of Diet versus Gastric Bypass on Metabolic Function in Diabetes by Mihoko Yoshino from Washington university school of medicine, Saint Louis.
本研究評估了Roux-en-Y胃旁路術，是否對肥胖和2型糖尿病患者調節血糖控制的主要生理因素具有獨立於減肥的治療作用。在患者透過胃旁路術或單純飲食干預達到匹配的減重幅度（約18%）之前和之後，研究人員評估了患者的混合膳食攝入後的代謝反應、24小時血糖，遊離脂肪酸和胰島素譜、多器官胰島素敏感性和β細胞功能。
This study evaluated whether Roux-en-Y gastric bypass has therapeutic effects independent of weight loss on the major physiologic factors that regulate glycemic control in people with obesity and type 2 diabetes. The investigators assessed the metabolic response to mixed meal ingestion, 24-hour glucose，free fatty acid andinsulin profiles, multiorgan insulin sensitivity and beta-cell function before and after matched approximately 18% weight loss induced by gastric bypass surgery or therapy alone.
資料顯示，透過飲食療法或胃旁路手術大幅減重的患者，其身體狀況均有較大改善，體脂量、內臟脂肪體積、肝內甘油三酯含量、24小時血糖、遊離脂肪酸、胰島素狀況、β細胞功能、肝臟、骨骼肌和脂肪組織的胰島素敏感性等方面的改善，在兩組之間沒有顯著差異。這些結果強調了減肥對代謝功能的有效治療作用，並表明胃分流手術的代謝益處可能僅僅是減重的結果。
The data show that after a marked weight loss induced by either diet therapy or gastric bypass, there were considerable improvements in body composition, body fat mass, intraabdominal adipose tissue volume and intrahepatic triglyceride content, 24-hour plasma glucose, free fatty acid and insulin profiles, beta-cell function and insulin sensitivity in the liver, skeletal muscle and adipose tissue with no significant differences between the groups in any of these variables. These results underscore the potent therapeutic effects of weight loss on metabolic function and show that the metabolic benefits of gastric bypass surgery are probably the result of weight loss alone.
波士頓塔夫茨大學醫學院的Clifford Rosen和新英格蘭醫學雜誌的副主編Julie Ingelfinger就此文章共同撰寫了一篇評論。文章資料顯示，胃分流手術的代謝益處主要是由於整體肥胖減少導致的體重減輕。但該研究有幾項侷限性值得注意。首先，該試驗並非隨機。其次，試驗中每組的人數都很少。此外，在接受手術的患者和選擇低熱量飲食的患者之間可能存在一些混雜因素。還有，所有的手術均為Roux-en-Y術式，因此將此研究中葡萄糖耐量改善的結果，外推至目前最常見的垂直袖狀胃切除術時，必須謹慎進行。儘管如此，這項研究證實了肥胖的致病本質，即肥胖驅動胰島素抵抗，並最終導致2型糖尿病。此外，其為臨床醫生和患者傳遞了一個直接而重要的資訊，即無論用什麼方法，只要減少脂肪組織，就可能改善2型糖尿病患者的血糖控制。
In an editorial, Clifford Rosen from Tufts University school of medicine, Boston, and Julie Ingelfinger, deputy editor for the journal write the taken together. The data suggest that the metabolic benefits of gastric bypass surgery were principally a result of weight loss owing to reduced overall adiposity. Several study limitations are important to note. The trial was not randomized, and there were small numbers in each group. In addition, there was probably some confounding due to differences between patients who underwent surgery and those who chose a low- calorie diet. Furthermore, all operations were Roux-en-Y procedures, so extrapolating those findings to the improved glucose tolerance associated withvertical sleeve gastrectomy, currently the most frequent procedure, must be done with caution. Nevertheless, this study confirms that pathogenic nature of obesity in driving insulin resistance and ultimately type 2 diabetes. Furthermore, it delivers a straightforward and important message for both clinicians and patients reducing adipose tissue volume by whatever means, will likely improve blood glucose control in persons with type 2 diabetes.
Resources：
1. Yoshino M, Kayser BD, Yoshino J, Stein RI, Reeds D, Eagon JC, Eckhouse SR, Watrous JD, Jain M, Knight R, Schechtman K, Patterson BW, Klein S. Effects of Diet versus Gastric Bypass on Metabolic Function in Diabetes. N Engl J Med 2020; 383:721-732. DOI: 10.1056/NEJMoa2003697
2. Rosen CJ, Ingelfinger JR. Bariatric Surgery and Restoration of Insulin Sensitivity - It's Weight Loss. N Engl J Med 2020;383(8):777-778. doi: 10.1056/NEJMe2024212.
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