Clinical Studies and Practice

Changes in glycemia, insulin and gut hormone responses to a slowly ingested solid low-carbohydrate mixed meal after laparoscopic gastric bypass or band surgery

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Abstract

Objective:

To evaluate early changes in glycemia, insulin physiology and gut hormone responses to an easily tolerated and slowly ingested solid, low-carbohydrate mixed meal test (MMT) following laparoscopic adjustable gastric banding (LAGB) or Roux-en-Y gastric bypass (RYGB) surgery.

Subjects/Methods:

This was a prospective non-randomized study. Plasma glucose, insulin and c-peptide (to estimate hepatic insulin extraction; %HIE), incretins (GIP, aGLP-1) and pancreatic polypeptide (PP) responses to the MMT were measured at 4–8 weeks before and after surgery in obese, metabolically healthy patients (RYGB=10F or LAGB =7F/1M). Supplementary clamp data on basal endogenous glucose production (EGP) and peripheral insulin action (Rd=rate of glucose disposal) and metabolic clearance rates of insulin (MCR-INS) were available in five of the RYGB patients. Repeated measures were appropriately accounted for in the analyses.

Results:

Following LAGB surgery, C-peptide and insulin MMT profiles (P=0.004 and P=0.0005, respectively) were lower with no change in %HIE (P=0.98). In contrast, in RYGB subjects, both fasting glucose and insulin (Δ=−0.66 mmol l–1, P0.05 and Δ=−44.4 pmol l–1, P0.05, respectively) decreased, and MMT glucose (P<0.0001) and insulin (P=0.001) but not c-peptide (P= 0.69) decreased. Estimated %HIE increased at fasting (Δ=8.4%, P0.05) and during MMT (P=0.0005). Early (0–20 min) prandial glucose (0.27±0.26 versus 0.006±0.21 mmol l–1, P0.05) and insulin (63(48, 66) versus 18(12, 24) pmol l–1, P0.05) responses increased after RYGB. RYGB altered the trajectory of prandial aGLP-1 responses (treatment × trajectory P=0.02), and PP was lower (P<0.0001). Clamp data in a subset of RYGB patients showed early improvement in basal EGP (P=0.001), and MCR-INS (P=0.015).

Conclusion:

RYGB results in distinctly different changes in plasma glucose, insulin and gut hormone response patterns to a solid, slowly ingested low-carbohydrate MMT versus LAGB. Altered nutrient delivery, along with indirect evidence for changes in hepatic and peripheral insulin physiology, are consistent with the greater early improvement in glycemia observed after RYGB versus LAGB surgery.

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Acknowledgements

The authors acknowledge the contributions of the clinical and dietary staffs of the Scottsdale Bariatric Center and Phoenix NIDDK Obesity and Diabetes Clinical Research Unit. We are indebted to the bariatric surgery patients who participated as research volunteers. The study was funded by Intramural Research funding of NIDDK.

Author contributions

JB wrote the study design, collected metabolic data, did statistical analysis and wrote the manuscript. RB wrote the study design, performed the surgeries and wrote/edited the manuscript. MST assisted on statistical analysis, and reviewed/edited the manuscript. KLV wrote/edited the manuscript. SV designed and supervised meal administration, wrote/edited the manuscript. JK wrote the study design, assisted with statistical analysis and reviewed/edited the manuscript.

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Correspondence to J Krakoff.

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The authors declare no conflict of interest.

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Bunt, J., Blackstone, R., Thearle, M. et al. Changes in glycemia, insulin and gut hormone responses to a slowly ingested solid low-carbohydrate mixed meal after laparoscopic gastric bypass or band surgery. Int J Obes 41, 706–713 (2017) doi:10.1038/ijo.2017.22

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