OBES SURG (2017) 27:288–294

DOI 10.1007/s11695-016-2300-3

ORIGINAL CONTRIBUTIONS

Preoperative Beta Cell Function Is Predictive of Diabetes

Remission After Bariatric Surgery
Pedro Souteiro 1 & Sandra Belo 1,2,3 & João Sérgio Neves 1 & Daniela Magalhães 1,2,3 &
Rita Bettencourt Silva 1,2,3 & Sofia Castro Oliveira 1,2,3 & Maria Manuel Costa 1,2,3 &
Ana Saavedra 1,2,3 & Joana Oliveira 1,2,3 & Filipe Cunha 1,2,3 & Eva Lau 1,2,3 &
César Esteves 1,2,3 & Paula Freitas 1,2,3,4 & Ana Varela 1,2,3,4 & Joana Queirós 1,4 &
Davide Carvalho 1,2,3

Published online: 19 July 2016

# Springer Science+Business Media New York 2016

Abstract glucose AUC predicted diabetes remission even after adjust-

Background Bariatric surgery can improve glucose metabo-
lism in obese patients with diabetes, but the factors that can
predict diabetes remission are still under discussion. The pres-
ent study aims to examine the impact of preoperative beta cell
function on diabetes remission following surgery.
Materials and Methods We investigated a cohort of 363 obese
diabetic patients who underwent bariatric surgery. The impact
of several preoperative beta cell function indexes on diabetes
remission was explored through bivariate logistic regression
models.
Results Postoperative diabetes remission was achieved in
39.9 % of patients. Younger patients (p < 0.001) and those
with lower HbA1c (p = 0.001) at the baseline evaluation had
higher odds of diabetes remission. Use of oral anti-diabetics
and insulin therapy did not reach statistical significance when
they were adjusted for age and HbA1c. Among the evaluated
indexes of beta cell function, higher values of insulinogenix
index, Stumvoll first- and second-phase indexes, fasting C-
peptide, C-peptide area under the curve (AUC), C-peptide/
glucose AUC, ISR (insulin secretion rate) AUC, and ISR/
* Pedro Souteiro
pedrobsouteiro@gmail.com
1
Department of Endocrinology, Diabetes and Metabolism, Centro
Hospitalar São João, Alameda Prof. Hernâni Monteiro,
4200-319 Porto, Portugal
2
Faculty of Medicine of University of Porto, Porto, Portugal
3
Institute for Research and Innovation in Health, University of Porto,
Porto, Portugal
4
Multidisciplinary Group for Surgical Management of Obesity, Centro
Hospitalar São João, Porto, Portugal
ment for age and HbA1c. Among them, C-peptide AUC had
the higher discriminative power (AUC 0.76; p < 0.001).
Conclusions Patients’ age and preoperative HbA1c can fore-
cast diabetes remission following surgery. Unlike other stud-
ies, our group found that the use of oral anti-diabetics and
insulin therapy were not independent predictors of postopera-
tive diabetes status. Preoperative beta cell function, mainly C-
peptide AUC, is useful in predicting diabetes remission, and it
should be assessed in all obese diabetic patients before bariat-
ric or metabolic surgery.
Keywords Diabetes mellitus . Insulin-secreting cells .
C-peptide . Obesity . Bariatric surgery . Metabolic surgery
Introduction
Type 2 diabetes mellitus is a metabolic disease characterized
by a progressive decline in pancreatic beta cell function and
increased peripheral insulin resistance, leading to poor
glycaemic control and multiple micro and macrovascular
complications [1].
Obesity is closely related to the development of type 2
diabetes mellitus, and its incidence is growing worldwide [2,
3]. Bariatric surgery has proven itself as an effective strategy
to induce diabetes remission in obese patients [4, 5], and it has
achieved better results than pharmacologic therapy [6].
According to the American Diabetes Association (ADA), sur-
gery should be considered for adults with body mass index
(BMI) > 35 kg/m2 and diabetes, especially if diabetes is diffi-
cult to control with lifestyle measures and pharmacotherapy
[7]. Bariatric or metabolic surgery in individuals with lower
OBES SURG (2017) 27:288–294
BMIs has been increasingly discussed, and it was already
conducted with successful results [8–10].
In order to better select diabetic obese patients to bar-
iatric surgery, numerous studies have tried to identify
preoperative characteristics that can foresee an improved
glycaemic control after the surgical procedure. Patient
age, use of insulin therapy, diabetes duration, and
HbA1C levels have been recognized as predictors of di-
abetes remission [11–13]. Additionally, C-peptide [14,
15] and the C-peptide area under the curve (AUC) during
an oral glucose tolerance test (OGTT) [16] have been
also identified as useful predictors. These last findings
suggest that beta cell function at the time of the surgery
is an important determinant of postoperative diabetes sta-
tus. However, the predictive accuracy of these two mea-
sures has never been compared neither other beta cell
function indexes have been investigated.
The present study aims to investigate the preoperative fac-
tors associated with diabetes remission in obese patients, fo-
cusing mainly on validated surrogate markers of beta cell
function. In addition, we intend to compare these markers to
determine which of them performs the best.
Materials and Methods
Study Design and Participants
A retrospective cross-sectional study was conducted in a
population of obese patients evaluated in the multidisci-
plinary group for surgical treatment of obesity in Centro
Hospitalar São João, Porto, Portugal. A total of 1184 pa-
tients underwent bariatric surgery between January 2010
and July 2014. Among them, we have identified 363 type
2 diabetic patients that were enrolled in this study — 95
(26.2 %) performed laparoscopic adjustable gastric band
(LAGB), 203 (55.9 %) Roux-en-Y gastric bypass
(RYGB), and 65 (17.9 %) sleeve gastrectomy (SG).
Clinical, anthropometric (height, weight, BMI, abdominal,
and waist circumferences), and analytic measures
(HbA1C, fasting plasmatic glucose, insulin and C-
peptide, lipid profile, uric acid, and serum cortisol) were
obtained before surgery and at the follow-up visits.
Type 2 Diabetes Definition and Remission Criteria
To define type 2 diabetes mellitus, we used the 2015 ADA
guidelines criteria: fasting plasma glucose ≥7.0 mmol/l or
HbA1C ≥ 6.5 % (48 mmol/mol), or 2-h post-load plasmatic
glucose ≥11.1 mmol/l during an OGTT, or use of
hypoglycaemic agents [7]. Complete diabetes remission was
defined according to Buse et al. [17] criteria: (1) normal
glycaemic measures (HbA1C < 5.7 % [39 mmol/mol] and
289
fasting plasma glucose <5.6 mmol/l), (2) at least 1 year’s du-
ration, and (3) no active pharmacologic therapy or ongoing
procedures.
Insulin Resistance and Beta Cell Function Indexes
To evaluate insulin resistance/sensitivity, fasting and
OGTT-derived indexes were used: homeostasis model as-
sessment of insulin resistance (HOMA-IR) [18] and
Matsuda index [19], respectively. In order to study beta
cell function, we have used several indexes described in
the literature. Homeostatic model assessment of beta-cell
function (HOMA-%B) was considered as referred in
Matthews et al. [18]. Insulinogenic index (IGI) was ob-
tained by the equation ΔInsulin(0-30min)/Δglucose(0-30min)
[20]. First and second phase insulin secretion indexes
described by Stumvoll et al. [21, 22] were also assessed.
C-peptide AUC, insulin AUC, C-peptide/glucose AUC,
and insulin/glucose AUC ratios [23] were calculated by
the trapezoidal rule during the OGTT0-120min. The Insulin
SECretion (ISEC) deconvolution software program was
used to determine the insulin secretion rate (ISR) using
age, sex, weight, height, and C-peptide concentrations
[24, 25]. To calculate indexes that included insulin con-
centrations, patients on insulin therapy (40 individuals)
were excluded due to the confounding effect of exoge-
nous administration. Patients with severe renal failure
(seven individuals) were excluded too.
Statistical Analyses
Categorical variables were expressed as frequencies and
percentages and were compared by chi-square test.
Continuous variables were presented as means and stan-
dard deviations and its comparison was performed using
Student’s t test. Normal distribution was evaluated using
Shapiro-Wilk test or skewness and kurtosis. Pearson’s
correlation coefficient was used to assess association be-
tween continuous variables. Differences between three or
more groups were evaluated by ANOVA test, followed
by the Bonferroni test when findings with the ANOVA
model were significant. Independent predictors of diabe-
tes remission were identified by binary logistic regres-
sion and then included in several predictive models.
Models that presented a p > 0.05 on the Hosmer and
Lemeshow test were considered a good fit, and then their
predictive performance was measured with the area under
the curve of the receiver operating characteristic (ROC)
curve. Reported p values are two-tailed, and p < 0.05
was considered significant. Analyses were performed
with the use of SPSS Statistics 23®.
290
Results
Baseline Characteristics
Within the 363 patients with type 2 diabetes criteria that
underwent bariatric surgery, 295 (81.3 %) were females. The
mean age of the enrolled patients was 51.2 ± 9.64 years.
Average preoperative weight and BMI were 116.1 ± 19.0 kg
and 44.8 ± 6.19 kg/m2, respectively. Regarding diabetes, the
mean preoperative HbA1C was 6.63 ± 1.15 %
(49.0 ± 12.6 mmol/mol). A total of 282 (78.6 %) patients were
on oral hypoglycaemic agents (26.4 % of them needed more
than one oral anti-diabetic drug) and 40 (11.1 %) were on
insulin therapy. Fasting plasma insulin (r = 0.21; p = 0.001)
and C-peptide levels (r = 0.39; p < 0.001) increased continu-
ally with an escalating BMI (Fig. 1).
Postoperative Follow-up
Bariatric surgery provided a statistically significant
(p < 0.001) decrease in the weight and BMI (mean reductions
of 31.0 ± 14.5 kg and 12.1 ± 5.59 kg/m2, respectively). RYGB
led to a greater weight loss percentage both to SG (32.1 ± 7.54
vs. 26.8 ± 8.71 %; p < 0.001) and LAGB (32.1 ± 7.54 vs.
14.8 ± 7.86 %; p < 0.001). Surgery was associated with a
mean reduction of 10.8 ± 21.7 and 7.5 ± 13.8 mmHg on
systolic and diastolic blood pressure (p < 0.001), respectively,
and to a decrease in the use of anti-hypertensive agents
(p < 0.001). An improved lipid profile was observed:
Fig. 1 Distribution of C-peptide
levels across BMI. Best-fit line is
represented to illustrate
correlation between the two
variables (r = 0.39; p < 0.001).
BMI body mass index
OBES SURG (2017) 27:288–294
reduction of 0.53 ± 1.16 mmol/l on total cholesterol
(p < 0.001), 0.49 ± 0.97 mmol/l on LDL cholesterol
(p < 0.001), 0.63 ± 0.84 mmol/l on triglycerides (p < 0.001),
and an increase of 0.17 ± 0.27 mmol/l on HDL cholesterol
(p < 0.001). Regarding glycaemic control, HbA1C had a
1.10 ± 1.20 % (12.0 ± 13.1 mmol/mol) reduction after surgery
(p < 0.001); and the number of patients taking oral anti-
diabetics (p < 0.001) and insulin therapy (p = 0.004) decreased
as well.
Diabetes Remission
The comparison of preoperative features between patients that
achieved remission and those who did not is shown in Table 1.
Postoperative complete diabetes remission was attained in
39.9 % of patients. These patients were younger (mean differ-
ence of 6.48 ± 1.12 years; p < 0.001), had lower systolic blood
pressure (mean difference of 4.50 ± 2.19 mmHg; p = 0.039),
had lower HbA1C (mean difference of 0.90 ± 0.16 %
[9.80 ± 1.70 mmol/mol]; p < 0.001), and lower fasting plasma
glucose (mean difference of 1.35 ± 0.30 mmol/l; p < 0.001).
Furthermore, patients on remission took fewer oral anti-
diabetics (p = 0.001) and used less insulin therapy
(p < 0.001) preoperatively. Baseline BMI did not differ be-
tween both groups (p = 0.401). Calculated indexes of insulin
resistance (HOMA-IR) and insulin sensitivity (Matsuda in-
dex) were not different as well (p = 0.961 and p = 0.502,
respectively). On the other hand, most beta cell function in-
dexes were significantly higher in patients that achieved
OBES SURG (2017) 27:288–294 291

Table 1 Comparison of
preoperative characteristics in Baseline features No remission Remission p value
patients with and without diabetes
remission after bariatric surgery n 172 (60.1 %) 114 (39.9 %) –
Female sex—no. (%) 150 (87.2 %) 92 (80.7 %) 0.135
Age (years) 53.8 ± 8.0 47.3 ± 10.0 <0.001*
BMI (kg/m2) 44.5 ± 6.4 45.1 ± 5.8 0.401
Waist circumference (cm) 124.4 ± 12.4 127.2 ± 13.6 0.111
Hip circumference (cm) 132.3 ± 14.8 133.2 ± 12.1 0.644
Systolic blood pressure (mmHg) 138.5 ± 17.7 134.0 ± 16.7 0.039*
Diastolic blood pressure (mmHg) 84.4 ± 11.4 83.2 ± 11.8 0.404
Total cholesterol (mmol/l) 5.42 ± 1.20 5.32 ± 1.10 0.491
LDL cholesterol (mmol/l) 3.41 ± 1.04 3.37 ± 0.94 0.756
HDL cholesterol (mmol/l) 1.28 ± 0.29 1.24 ± 0.28 0.247
Triglycerides (mmol/l) 2.01 ± 1.61 1.72 ± 0.78 0.284
Serum cortisol (nmol/l) 458 ± 186 508 ± 262 0.287
Fasting plasma glucose (mmol/l) 7.21 ± 3.06 6.36 ± 1.85 <0.001*
HbA1C (%) 7.23 ± 1.5 6.35 ± 0.9 <0.001*
(mmol/mol) 56.5 ± 16.4 45.9 ± 9.8
Patients on oral anti-diabetics—no. (%) 146 (86.4 %) 79 (69.3 %) 0.001*
Patients on insulin therapy—no. (%) 28 (16.3 %) 4 (3.51 %) <0.001*
Insulin resistance/sensitivity indexes
HOMA-IR 6.53 ± 4.63 6.56 ± 5.14 0.961
Matsuda index 48.2 ± 64.5 41.6 ± 39.3 0.502
Beta cell function indexes
HOMA-%B (%) 162.9 ± 135.8 259.3 ± 265.5 0.003*
IGI (mU/mg) 0.73 ± 0.63 1.33 ± 1.52 0.005*
Stumvoll first-phase 1348 ± 814 1902 ± 1221 0.004*
Stumvoll second-phase 363 ± 197 496 ± 295 0.004*
Fasting insulin (pmol/l) 125 ± 78.0 143 ± 101 0.183
Insulin AUC (U/min/l) 11.2 ± 11.9 13.9 ± 8.85 0.169
Insulin/glucose AUC (mU/mg) 0.52 ± 0.70 0.68 ± 0.46 0.154
Fasting C-peptide (mU/l) 4.31 ± 1.15 4.79 ± 1.37 0.036*
C-peptide AUC (U/min/l) 1.17 ± 0.32 1.41 ± 0.40 0.001*
C-peptide/glucose AUC (nU/mg) 53.0 ± 19.9 68.9 ± 24.5 0.001*
ISR AUC (pmol/kg) 1041 ± 304 1221 ± 342 0.006*
ISR/glucose AUC (nmol/dl/min) 47.5 ± 19.0 59.5 ± 20.5 0.003*

BMI body mass index, IGI insulinogenic index, AUC area under the curve
*Statistically significant (p < 0.05)

remission: HOMA-%B (p = 0.003), IGI (p = 0.005), Binary Logistic Regression Models

Stumvoll first- and second-phase (p = 0.004 for both in-
dexes), fasting C-peptide (p = 0.036), C-peptide AUC
(p = 0.001), C-peptide/glucose AUC (p = 0.001), ISR
AUC (p = 0.006), and ISR/glucose AUC (p = 0.003).
Patients on remission have lost more 6.28 ± 1.25 kg over
the first postoperative year than non-remitting patients
(p < 0.001). After adjustment for age, basal HbA1c and
percentage of weight loss, RYGB conducted to a higher
probability of diabetes remission when compared to
LAGB (OR = 3.03; confidence interval - CI 1.13–8.11;
p = 0.028). No differences were identified between
LAGB and SG (OR = 1.19; CI 0.35–4.01; p = 0.783).
Baseline features that achieved statistical significance be-
tween remission and non-remission groups were included in
a binary logistic regression model as potential candidates to
remission predictors. Fasting plasma glucose was excluded
due to its collinearity with HbA1C. Data is displayed in
Table 2. Younger age (OR 0.93; p < 0.001) and lower
HbA1C (p = 0.001) at baseline were significant predictors,
while systolic blood pressure (p = 0.794), use of oral anti-
diabetics (p = 0.092), and insulin therapy (p = 0.811) did not
reach statistical significance when they were adjusted for the
other included variables.
292 OBES SURG (2017) 27:288–294

Table 2 Binary logistic regression analysis for prediction of diabetes Conclusions

remission after bariatric surgery

Predictor OR 95 % CI p value We have shown that patients with a better pancreatic beta cell
function had an increased chance of diabetes remission after
Age (years) 0.93 0.89–0.96 <0.001* bariatric surgery. Of the 12 evaluated surrogate markers of
HbA1C (%) 0.60 0.44–0.82 0.001* pancreatic function, models that included IGI, fasting plasma
(mmol/mol) 0.95 0.93–0.98
Systolic blood pressure (mmHg) 1.00 0.98–1.01 0.794
C-peptide, plasma C-peptide AUC, C-peptide/glucose AUC,
ISR AUC, and ISR/glucose AUC successfully predicted post-
Use of oral anti-diabetics 0.54 0.26–1.11 0.092
operative glycaemic control. Among them, C-peptide AUC
Use of insulin therapy 0.84 0.21–3.35 0.811
had the higher discriminating power. Additionally, age and
OR odds ratio, CI confidence interval baseline HbA1C were independent predictors too. Surgical
*Statistically significant (p < 0.05) procedures led to improved blood pressure, lipid, and
glycaemic profiles. We have also seen a significant reduction
in the use of anti-hypertensive medication, anti-
In what concerns beta cell function indexes, higher values dyslipidaemics, oral anti-diabetic drugs, and insulin therapy.
of IGI (p = 0.02), Stumvoll first- and second-phase indexes Our group observed a significant correlation between BMI
(p = 0.021), fasting C-peptide (p = 0.037), C-peptide AUC and baseline insulin, and C-peptide levels. Both have decreased
(p = 0.002), C-peptide/glucose AUC (p = 0.006), ISR AUC after bariatric surgery. This finding supports that elevated insu-
(p = 0.009), and ISR/glucose AUC (p = 0.027) were identified lin and C-peptide levels reflect obesity and type 2 diabetes
as independent predictors of diabetes remission even after mellitus underlying insulin resistance and that bariatric surgery
correcting for age and HbA1C, while HOMA-%B was not increases insulin sensitivity. Sjoström et al. [26] found that
(p = 0.416) (data not shown in the table). Those indexes iden- baseline insulin levels were predictive of cardiovascular disease
tified as predictors were included in eight different models to reduction after bariatric surgery, highlighting the importance of
evaluate which of them performed the best (Table 3). Models II evaluating beta cell function before the surgical procedure.
and III did not represent a good fit to predict our study outcome We found a 1-year diabetes remission rate of approximately
(p < 0.05 in the Hosmer and Lemeshow test). The remaining 40 %, proving that bariatric surgery is very effective in glu-
models were then compared to assess their predictive value. cose metabolism control in obese patients [27]. Our results are
Model V, that included C-peptide AUC, was the most useful in agreement with other studies that reported remission rates
one to predict diabetes remission (AUC 0.76; p < 0.001), between 21 and 63 % in the first postoperative year [11, 13].
followed by Model VII (AUC 0.75; p < 0.001), which included Several authors have proposed various contributors to im-
ISR AUC. Models I, IV, VI, and VIII provided an acceptable proved diabetes status after bariatric surgery: decreased calo-
discrimination power as well (AUCs ≥0.70; p < 0.001). ric intake and weight loss, changes in gut physiology,

Table 3 Comparison among eight proposed models for prediction of diabetes remission after bariatric surgery

Model Bivariate logistic regression ROC analysis

p value # AUC 95 % CI p value

I Age + HbA1C + IGI 0.17 0.70 0.60–0.79 p < 0.001*

II Age + HbA1C + Stumvoll first-phase 0.02* – – –
III Age + HbA1C + Stumvoll second-phase 0.02* – – –
IV Age + HbA1C + Fasting C-peptide 0.27 0.70 0.61–0.79 p < 0.001*
V Age + HbA1C + C-peptide AUC 0.55 0.76 0.66–0.86 p < 0.001*
VI Age + HbA1C + C-peptide/glucose AUC 0.84 0.74 0.64–0.84 p < 0.001*
VII Age + HbA1C + ISR AUC 0.61 0.75 0.65–0.85 p < 0.001*
VIII Age + HbA1C + ISR/glucose AUC 0.24 0.73 0.63–0.84 p < 0.001*

Only models that represented a good-fit (p > 0.05 on the Hosmer and Lemeshow test) were then assessed to their discrimination power using ROC
analysis
ROC receiver operating characteristics, AUC area under the curve, CI confidence interval
#
p value for Hosmer and Lemeshow test
*Statistically significant (p < 0.05)
OBES SURG (2017) 27:288–294
improved pancreatic function and insulin sensitivity, altered
bile acid metabolism, and changes in gut microbiota [28, 29].
Bariatric surgery has been increasingly seen as a metabolic
surgery and not only as a mean to reach weight reduction. This
procedure has been associated with a better control of hyper-
tension and diabetes and reduced cardiovascular events and
cardiovascular related deaths [26, 30]. In what concerns dia-
betes, bariatric surgery has been performed with good results
even in class I (BMI between 30 and 35 kg/m2) obese diabetic
patients [8]. In order to select patients best suited to bariatric
surgery, identifying preoperative predictors of diabetes remis-
sion can lead to improved outcomes. Still et al. [12] proposed
a score to predict the probability of diabetes remission follow-
ing RYGB (DiaRem Score) that included age, preoperative
HbA1C, use of insulin, and the type of oral anti-diabetic med-
ication. Beta cell function was not included in this score nor
evaluated in that study. Recently, studies have brought to light
the importance of beta cell function, showing that higher plas-
ma C-peptide levels and plasma C-peptide AUC correlated
with an increased probability of diabetes remission [15, 16].
Progressive pancreatic beta cell failure is a part of the nat-
ural course of diabetes and starts long before its diagnosis.
Therefore, it can be expected that patients with less preopera-
tive dysfunction of the beta cell have higher odds of diabetes
remission after surgery. Our study has proved by showing that
patients with higher indexes of beta cell function had a higher
chance of remission. All C-peptide derived indexes (fasting C-
peptide, C-peptide AUC, C-peptide/glucose AUC, ISR AUC,
and ISR/glucose AUC) were independent predictors of diabe-
tes remission, even after adjustment for age and HbA1C. On
the other hand, all insulin derived indexes, except for IGI,
were of no value in predicting postoperative glucose control.
We hypothesize this finding could be explained by the fact
that C-peptide provides a more reliable estimation of beta cell
function than insulin. This occurs because a variable percent-
age, up to 80 % in some studies, of the insulin that is
secreted by pancreas is removed during the first pass through
the liver, while there is a negligible C-peptide clearance by this
organ [31].
Several authors identified the use of oral anti-diabetics
and insulin therapy as having a negative effect on the at-
tainment of diabetes remission [12, 13, 32]. Our results do
not support this conclusion. None of those studies evaluat-
ed beta cell function indexes. As so, these two variables
may only reflect an advanced stage of diabetes and a poor
pancreatic reserve and they may not be true diabetes remis-
sion predictors per se. Our findings may also explain why a
longer disease duration and the presence of diabetes com-
plications have been found to reduce the odds of remission
[11, 13]. Reinforcing our hypothesis, Ramos-Levi [33]
found that diabetes duration was a predictor of diabetes
remission only as long as C-peptide levels were not con-
sidered in a multivariate analysis model.
293
Our study had a larger population than other series on
this matter and included patients that underwent either
restrictive or malabsorptive procedures. The use of logis-
tic regression allowed us to recognize beta cell function as
an independent predictor of better glycaemic control with-
out the interference of age and baseline HbA1C. As po-
tential limitations, diabetes duration should have been re-
corded and assessed as a potential predictor. Longer
follow-up would have been useful to look up for possible
recurrence predictors. DiGiorgi et al. [34] showed a 24 %
re-emergence rate of diabetes 3 years after RYGB.
Furthermore, our study has an odd distribution of sexes
with a higher prevalence of females, and the pre-operative
relatively good glycaemic control of our population limits
the generalization of our findings to patients with more
decompensated diabetes.
Future research should address the implementation and
dissemination of the assessment of beta cell function indexes
in routine practice, when considering bariatric surgery on
long-term management of diabetes. Studies evaluating the
usefulness of remission predictors on class I (BMI between
30 and 35 kg/m2) obese patients undergoing bariatric surgery
should also be considered.
In conclusion, preoperative beta cell function is an
independent predictor of diabetes remission after bariat-
ric surgery and should be evaluated prior to surgical
procedure in all diabetic patients. Of the 12 assessed
indexes, C-peptide AUC was the most useful in
predicting diabetes remission and should be included
in future prediction scores. Moreover, the importance
of beta cell function on disease remission reinforces
doctors not to postpone bariatric surgery too long since
waiting until beta cell failure has ensued will worsen
the surgery outcome.
Acknowledgments We would like to thank Sofia Souteiro, Industrial
Engineering and Management student, and Luis Silva, Software
Engineer, for their help with the ISEC program.
Compliance with Ethical Standards
Grant Support No grant support to declare.
Funding No funding to declare.
Conflict of Interest The authors declare that they have no conflicts of
interest.
Ethical Approval All procedures performed in this study involving
human participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent For this type of study formal consent is not
required.
294
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