NEWS & VIEWS CEE + MPA for women who have not used MHT before. These treatments might not prevent chronic disease, as anticipated when the WHI studies were designed, but they do alleviate major symptoms and improve quality of life. With the availability of formulations that confer even more favourable safety profiles than those studied in WHI, such as nonoral estrogen, progesterone and bazedoxifene plus CEE,10 MHT should be considered for all highly symptomatic women at menopause. Women’s Health Program, School of Public Health and Preventive Medicine, Monash University, Level 6, 99 Commercial Road, Melbourne, Vic 3004, Australia. [email protected] Acknowledgements S. R. Davis would like to acknowledge the support of an NHMRC research grant (grant number 1041853). Competing interests The author has declared associations with the following companies: Lawley Pharmaceutical, Trimel Pharmaceuticals. See the article online for full details of the relationships. 1.
Davis, S. R. et al. Understanding weight gain at menopause. Climacteric 15, 419–429 (2012). 2. Rossouw, J. et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative Randomised Controlled Trial. JAMA 288, 321–333 (2002). 3. Lobo, R. A. Where are we 10 years after the Women’s Health Initiative? J. Clin. Endocrinol. Metab. 98, 1771–1780 (2013). 4. Manson, J. E. et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA 310, 1353–1368 (2013). 5. de Villiers, T. J. et al. Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health. Climacteric 16, 316–337 (2013). 6. Geukes, M., van Aalst, M. P., Nauta, M. C. & Oosterhof, H. The impact of menopausal symptoms on work ability. Menopause 19, 278–282 (2012). 7. Mishra, G. D. & Dobson, A. J. Using longitudinal profiles to characterize women’s symptoms through midlife: results from a large prospective study. Menopause 19, 549–555 (2012). 8. Connolly, B. S. et al. A meta-analysis of published literature on waist‑to‑hip ratio and risk of breast cancer. Nutr. Cancer 44, 127–138 (2002). 9. Reeves, G. K. et al. Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study. BMJ 335, 1134 (2007). 10. Stovall, D. W., Tanner-Kurtz, K. & Pinkerton, J. V. Tissue-selective estrogen complex bazedoxifene and conjugated estrogens for the treatment of menopausal vasomotor symptoms. Drugs 71, 1649–1657 (2011).
8 | JANUARY 2014 | VOLUME 10
DIABETES
Bariatric surgery for T2DM —cure, or remission and relapse? Allison B. Goldfine and Mary Elizabeth Patti
The increased prevalence of obesity has led to rising numbers of bariatric surgical procedures being performed annually. Postoperative metabolic improvements in glucose levels, blood pressure and lipids have led to the recognition that surgery can be a highly effective therapy for type 2 diabetes mellitus. A recent report evaluates durability of diabetes remission and metabolic improvements. Goldfine, A. B. & Patti, M. E. Nat. Rev. Endocrinol. 10, 8–9 (2014); published online 29 October 2013; doi:10.1038/nrendo.2013.222
Bariatric surgery represents an appropriate therapeutic approach for type 2 diabetes mellitus (T2DM) and weight management in patients with reasonable surgical risk who are otherwise unable to achieve or sustain health goals, a position supported by the Intern ational Diabetes Federation 1 and the American Diabetes Association.2 How ever, many consider bariatric surgery as a draconian last resort for T2DM manage ment,3 owing partly to surgical risks and because long-term efficacy rates have been uncertain. A new study by Brethauer and colleagues adds to our knowledge about the efficacy and durability of bariatric surgery effects on T2DM remission. 4 Although T2DM improved in the majority of patients undergoing bariatric surgery, recurrence after initial remission was observed in 19% over 6 years, particularly in those with prolonged disease duration. Lifestyle modification, weight loss and medical therapies are the foundation of disease management for T2DM. Yet weight loss is difficult to achieve and sustain in the long term, and progressive hyper glycaemia requiring additional medication use is common. Emerging data over the past several years have demonstrated that bariatric surgery provides an additional therapeutic option, particularly in individuals early in the course of T2DM. Bariatric surgeries lead to substantial and sustained weight loss for most patients, with the magnitude varying according to the procedure performed. For example, the Swedish Obesity Subjects (SOS) study, a long-term, prospective, controlled trial, demonstrated a mean weight loss in surgical patients of 23% after 2 years, which was sustained at 18% by 20 years.5 In comparison, matched controls receiving usual medical care had no significant weight change over the same interval.
Furthermore, bariatric surgery was associated with improvements in obesity-related comorbidities, including hypertension and dyslipidaemia, and reduced incidences of myocardial infarction (29%), stroke (34%) and cancer in women (42%).5
‘‘
...two-thirds remain in remission over 5 years
’’
Up to 80% of individuals with T2DM at the time of surgery show improved glycaemic control or achieve disease remission, that is, normal glucose levels without the use of medication. The efficacy of bariatric surgery to improve T2DM is particularly notable for those with short disease duration (
Davis, S. R. et al. Understanding weight gain at menopause. Climacteric 15, 419–429 (2012). 2. Rossouw, J. et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative Randomised Controlled Trial. JAMA 288, 321–333 (2002). 3. Lobo, R. A. Where are we 10 years after the Women’s Health Initiative? J. Clin. Endocrinol. Metab. 98, 1771–1780 (2013). 4. Manson, J. E. et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA 310, 1353–1368 (2013). 5. de Villiers, T. J. et al. Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health. Climacteric 16, 316–337 (2013). 6. Geukes, M., van Aalst, M. P., Nauta, M. C. & Oosterhof, H. The impact of menopausal symptoms on work ability. Menopause 19, 278–282 (2012). 7. Mishra, G. D. & Dobson, A. J. Using longitudinal profiles to characterize women’s symptoms through midlife: results from a large prospective study. Menopause 19, 549–555 (2012). 8. Connolly, B. S. et al. A meta-analysis of published literature on waist‑to‑hip ratio and risk of breast cancer. Nutr. Cancer 44, 127–138 (2002). 9. Reeves, G. K. et al. Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study. BMJ 335, 1134 (2007). 10. Stovall, D. W., Tanner-Kurtz, K. & Pinkerton, J. V. Tissue-selective estrogen complex bazedoxifene and conjugated estrogens for the treatment of menopausal vasomotor symptoms. Drugs 71, 1649–1657 (2011).
8 | JANUARY 2014 | VOLUME 10
DIABETES
Bariatric surgery for T2DM —cure, or remission and relapse? Allison B. Goldfine and Mary Elizabeth Patti
The increased prevalence of obesity has led to rising numbers of bariatric surgical procedures being performed annually. Postoperative metabolic improvements in glucose levels, blood pressure and lipids have led to the recognition that surgery can be a highly effective therapy for type 2 diabetes mellitus. A recent report evaluates durability of diabetes remission and metabolic improvements. Goldfine, A. B. & Patti, M. E. Nat. Rev. Endocrinol. 10, 8–9 (2014); published online 29 October 2013; doi:10.1038/nrendo.2013.222
Bariatric surgery represents an appropriate therapeutic approach for type 2 diabetes mellitus (T2DM) and weight management in patients with reasonable surgical risk who are otherwise unable to achieve or sustain health goals, a position supported by the Intern ational Diabetes Federation 1 and the American Diabetes Association.2 How ever, many consider bariatric surgery as a draconian last resort for T2DM manage ment,3 owing partly to surgical risks and because long-term efficacy rates have been uncertain. A new study by Brethauer and colleagues adds to our knowledge about the efficacy and durability of bariatric surgery effects on T2DM remission. 4 Although T2DM improved in the majority of patients undergoing bariatric surgery, recurrence after initial remission was observed in 19% over 6 years, particularly in those with prolonged disease duration. Lifestyle modification, weight loss and medical therapies are the foundation of disease management for T2DM. Yet weight loss is difficult to achieve and sustain in the long term, and progressive hyper glycaemia requiring additional medication use is common. Emerging data over the past several years have demonstrated that bariatric surgery provides an additional therapeutic option, particularly in individuals early in the course of T2DM. Bariatric surgeries lead to substantial and sustained weight loss for most patients, with the magnitude varying according to the procedure performed. For example, the Swedish Obesity Subjects (SOS) study, a long-term, prospective, controlled trial, demonstrated a mean weight loss in surgical patients of 23% after 2 years, which was sustained at 18% by 20 years.5 In comparison, matched controls receiving usual medical care had no significant weight change over the same interval.
Furthermore, bariatric surgery was associated with improvements in obesity-related comorbidities, including hypertension and dyslipidaemia, and reduced incidences of myocardial infarction (29%), stroke (34%) and cancer in women (42%).5
‘‘
...two-thirds remain in remission over 5 years
’’
Up to 80% of individuals with T2DM at the time of surgery show improved glycaemic control or achieve disease remission, that is, normal glucose levels without the use of medication. The efficacy of bariatric surgery to improve T2DM is particularly notable for those with short disease duration (
