Comment on: Prevalence of obstructive sleep apnea in an Asian bariatric population. An undiagnosed dilemma

The last decade has seen tremendous advances in the field of metabolic and bariatric surgery. Evidence from randomized trials continues to build showing, in addition to obesity, type 2 diabetes (T2D) and other diseases improve postoperatively [ 1 Peterli R. Wölnerhanssen B.K. Peters T. et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial. JAMA. 2018; 319: 255-265 Crossref PubMed Scopus (581) Google Scholar , 2 Salminen P. Helmiö M. Ovaska J. et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial. JAMA. 2018; 319: 241-254 Crossref PubMed Scopus (502) Google Scholar , 3 Schauer P.R. Bhatt D.L. Kirwan J.P. et al. for the STAMPEDE InvestigatorsBariatric surgery versus intensive medical therapy for diabetes — 5-year outcomes. N Engl J Med. 2017; 376: 641-651 Crossref PubMed Scopus (1443) Google Scholar ] at least partially via weight-independent mechanisms [ 4 Ryan K.K. Tremaroli V. Clemmensen C. et al. FXR is a molecular target for the effects of vertical sleeve gastrectomy. Nature. 2014; 509: 183-188 Crossref PubMed Scopus (684) Google Scholar , 5 Albaugh V.L. Banan B. Antoun J. et al. Role of bile acids and GLP-1 in mediating the metabolic improvements of bariatric surgery. Gastroenterology. 2019; 156: 1041-1051.e4 Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar , 6 Myronovych A. Kirby M. Ryan K.K. et al. Vertical sleeve gastrectomy reduces hepatic steatosis while increasing serum bile acids in a weight-loss-independent manner. Obesity (Silver Spring). 2014; 22: 390-400 Crossref PubMed Scopus (135) Google Scholar ]. Even though many attribute the degree of obesity with the severity of obesity-associated disease (e.g., diabetes, sleep apnea), this is not necessarily the case. Variables other than weight clearly affect T2D development and severity. A prime example is that individuals of Asian genetic background who develop T2D at much lower body mass index (BMI) compared with individuals from Western countries [ 7 Malapan K. Goel R. Tai C.M. Kao Y.H. Chang P.C. Huang C.K. Laparoscopic Roux-en-Y gastric bypass for nonobese type II diabetes mellitus in Asian patients. Surg Obes Relat Dis. 2014; 10: 834-840 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar , 8 Shah S.S. Todkar J.S. Shah P.S. Cummings D.E. Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index < 35 kg/m2. Surg Obes Relat Dis. 2010; 6: 332-338 Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar , 9 Lee W.-J. Ser K.-H. Chong K. et al. Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion. Surgery. 2010; 147: 664-669 Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar , 10 DePaula A.L. Macedo A.L.V. Schraibman V. Mota B.R. Vencio S. Hormonal evaluation following laparoscopic treatment of type 2 diabetes mellitus patients with BMI 20–34. Surg Endosc. 2008; 23: 1724-1732 Crossref PubMed Scopus (85) Google Scholar , 11 Du X. Fu X.-H. Shi L. Hu J.-K. Zhou Z.-G. Cheng Z. Effects of laparoscopic Roux-en-Y gastric bypass on Chinese type 2 diabetes mellitus patients with different levels of obesity: outcomes after 3 years’ follow-up. Obes Surg. 2017; 28: 702-711 Crossref Scopus (3) Google Scholar , 12 Wang G. Zhu L. Li W. Yang X. Li P. Zhu S. Can low BMI Chinese patients with type 2 diabetes benefit from laparoscopic Roux-en-Y gastric bypass surgery?. Surg Obes Relat Dis. 2016; 12: 1890-1895 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar ]. This has resulted in the T2D treatment algorithm now including metabolic surgery for patients with a BMI as low as 27.5 kg/m2 with Asian genetic background [ [13] Rubino F. Nathan D.M. Eckel R.H. et al. for the Delegates of the 2nd Diabetes Surgery SummitMetabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by International Diabetes Organizations. Diabetes Care. 2016; 39: 861-877 Crossref PubMed Scopus (549) Google Scholar ]. Prevalence of obstructive sleep apnea in an Asian bariatric population: an underdiagnosed dilemmaSurgery for Obesity and Related DiseasesVol. 16Issue 6PreviewObesity is a growing health problem that has become a global epidemic. Serial population studies have shown the same in Malaysia, where the prevalence of obesity increased rapidly in the last decade. Currently, bariatric surgery is the most effective treatment in patients with morbid obesity. Obstructive sleep apnea (OSA) is the most common type of sleep-related breathing disorder seen in obesity. Full-Text PDF