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1.  Changes in Serum Levels of Bone Morphogenic Protein 4 and Inflammatory Cytokines after Bariatric Surgery in Severely Obese Korean Patients with Type 2 Diabetes 
Serum bone morphogenic protein- (BMP-) 4 levels are associated with human adiposity. The aim of this study was to investigate changes in serum levels of BMP-4 and inflammatory cytokines after Roux-en-Y gastric bypass (RYGB). Fifty-seven patients with type 2 diabetes underwent RYGB. Serum levels of BMP-4 and various inflammatory markers, including high-sensitivity C-reactive protein (hsCRP), free fatty acids (FFAs), and plasminogen activator inhibitor- (PAI-) 1, were measured before and 12 months after RYGB. Remission was defined as glycated hemoglobin <6.5% for at least 1 year in the absence of medications. Levels of PAI-1, hsCRP, and FFAs were significantly decreased at 1 year after RYGB. BMP-4 levels were also significantly lower at 1 year after RYGB than at baseline (P = 0.024). Of the 57 patients, 40 (70%) had diabetes remission at 1 year after surgery (remission group). Compared with patients in the nonremission group, patients in the remission group had lower PAI-1 levels and smaller visceral fat areas at baseline. There was a difference in the change in the BMP-4 level according to remission status. Our data demonstrate a significant beneficial effect of bariatric surgery on established cardiovascular risk factors and a reduction in chronic nonspecific inflammation after surgery.
doi:10.1155/2013/681205
PMCID: PMC3792548  PMID: 24170999
2.  2014 Clinical Practice Guidelines for Overweight and Obesity in Korea 
Endocrinology and Metabolism  2014;29(4):405-409.
The dramatic increase in the prevalence of obesity and its accompanying comorbidities are major health concerns in Korea. Obesity is defined as a body mass index ≥25 kg/m2 in Korea. Current estimates are that 32.8% of adults are obese: 36.1% of men and 29.7% of women. The prevalence of being overweight and obese in national surveys is increasing steadily. Early detection and the proper management of obesity are urgently needed. Weight loss of 5% to 10% is the standard goal. In obese patients, control of cardiovascular risk factors deserves the same emphasis as weight-loss therapy. Since obesity is multifactorial, proper care of obesity requires a coordinated multidisciplinary treatment team, as a single intervention is unlikely to modify the incidence or natural history of obesity.
doi:10.3803/EnM.2014.29.4.405
PMCID: PMC4285036  PMID: 25559568
Clinical practice guidelines; Obesity; Korea
3.  Effects of bariatric surgery on metabolic and nutritional parameters in severely obese Korean patients with type 2 diabetes: A prospective 2‐year follow up 
Abstract
Aims/Introduction
Little is known about the long‐term effects of Roux‐en‐Y gastric bypass (RYGB) in severely obese Asian individuals.
Methods and Materials
A total of 33 severely obese patients with type 2 diabetes underwent RYGB. All patients were followed up for 2 years. Visceral and abdominal subcutaneous fat areas were assessed using computed tomography (CT) before, and 12 and 24 months after RYGB. The muscle attenuation (MA) of paraspinous muscles observed by CT were used as indices of intramuscular fat.
Results
The mean percentage weight loss was 22.2 ± 5.3% at 12 months, and 21.3 ± 5.1% at 24 months after surgery. Compared with the baseline values, the visceral fat area was 53.6 ± 17.1% lower 24 months after surgery, and the abdominal subcutaneous fat area was 32.7 ± 16.1% lower 24 months after surgery. The MA increased from 48.7 ± 10.0 at baseline to 52.2 ± 8.9 (P = 0.009) 12 months after surgery. The MA after the first 12 months maintained changes until 24 months. Triglycerides and free fatty acids were reduced after surgery, whereas the high‐density lipoprotein cholesterol levels were increased significantly after surgery. At the last follow‐up visit, 18 patients (55%) had diabetes remission. The percentage of iron and vitamin D deficiency was 30% and 52%, respectively.
Conclusions
We found that patients subjected to RYGB had significant sustained reductions in visceral and intramuscular fat. There were durable improvements in the cardiometabolic abnormalities without any significant comorbidities. However, there were mild nutritional deficiencies in these patients despite daily supplementation with multivitamins and minerals.
doi:10.1111/jdi.12137
PMCID: PMC4023587  PMID: 24843764
Bariatric surgery; Visceral fat; Intramuscular fat
4.  Sarcopenia as a Determinant of Blood Pressure in Older Koreans: Findings from the Korea National Health and Nutrition Examination Surveys (KNHANES) 2008–2010 
PLoS ONE  2014;9(1):e86902.
Background
Blood pressure (BP) is directly and causally associated with body size in the general population. Whether muscle mass is an important factor that determines BP remains unclear.
Objective
To investigate whether sarcopenia is associated with hypertension in older Koreans.
Participants
We surveyed 2,099 males and 2,747 females aged 60 years or older.
Measurements
Sarcopenia was defined as an appendicular skeletal muscle mass divided by body weight (ASM/Wt) that was <1 SD below the gender-specific mean for young adults. Obesity was defined as a body mass index (BMI) ≥25 kg/m2. Subjects were divided into four groups based on presence or absence of obesity or sarcopenia. Hypertension was defined as a systolic BP (SBP) ≥140 mmHg, a diastolic BP (DBP) ≥90 mmHg, or a self-reported current use of antihypertensive medications.
Results
The overall prevalence of hypertension in the four groups was as follows 49.7% for non-obese non-sarcopenia, 60.9% for non-obese sarcopenia, 66.2% for obese non-sarcopenia and 74.7% for obese sarcopenia. After adjustment for age, gender, regular activity, current smoking and alcohol use, the odds ratio (OR) for having hypertension was 1.5 (95% confidence interval (CI) = 1.23–1.84) in subjects in the non-obese sarcopenia group, 2.08 (95% CI = 1.68–2.57) in the obese non-sarcopenia group and 3.0 (95% CI = 2.48–3.63) in the obese sarcopenia group, compared with the non-obese non-sarcopenia group (p for trend <0.001). Controlling further for body weight and waist circumference did not change the association between hypertension and sarcopenia. The association between sarcopenia and hypertension was more robust in the subjects with diabetes mellitus.
Conclusion
Body composition beyond BMI has a considerable impact on hypertension in elderly Koreans. Subjects with sarcopenic obesity appear to have a greater risk of hypertension than simply obese or sarcopenia subjects.
doi:10.1371/journal.pone.0086902
PMCID: PMC3906091  PMID: 24489804
5.  Natural Course of Cytologically Benign Thyroid Nodules: Observation of Ultrasonographic Changes 
Endocrinology and Metabolism  2013;28(2):110-118.
Background
The natural course of cytologically benign thyroid nodules remains unclear. The aim of this study was to evaluate whether ultrasonographic (US) changes are associated with changes in nodule volume during follow-up.
Methods
We retrospectively reviewed over 4 years of clinical records of patients with benign thyroid nodules as confirmed by fine needle aspiration (FNA). In total, 186 patients with 202 benign thyroid nodules were included for study. We assessed for changes in nodule volume and examined the cystic portion of the nodule as well as four US features (echogenicity, margin, calcification pattern, and shape).
Results
During follow-up (mean, 21.7±10.7 months) and using 50% as a cutoff value, nodule volumes increased in 11.8%, exhibited no change in 79.9%, and decreased in 8.3% of patients. Proportion of nodules demonstrating at least one US change was 20.8% (42/202). The most common US changes (in descending order of frequency) were cystic change, margin change, and calcification pattern change. Nodule shape and echogenicity rarely changed. Increased nodule volume was not significantly associated with any US features or with the number of FNAs but was associated with younger age at time of diagnosis.
Conclusion
Although a portion of thyroid nodules confirmed as benign showed US changes or volume changes during the follow-up period, these findings may only represent the natural course of benign nodules. Frequent follow-up with US might be needed for only a small number of cases with suspicious US findings.
doi:10.3803/EnM.2013.28.2.110
PMCID: PMC3811716  PMID: 24396664
Thyroid nodule; Neoplasms; Ultrasonography; Growth; Tumor burden
6.  Influence of Visceral Adiposity on Cardiovascular Autonomic Neuropathy in Patients with Type 2 Diabetes Mellitus 
Diabetes & Metabolism Journal  2012;36(4):285-292.
Background
The aim of this study was to investigate the influences of visceral adiposity on cardiovascular autonomic neuropathy (CAN) in patients with type 2 diabetes mellitus.
Methods
Two hundred eleven patients with type 2 diabetes participated in this study. Anthropometric and metabolic parameters were measured, and the visceral fat area was assessed using computed tomography. CAN was diagnosed using a cardiovascular reflex test. We analyzed the correlation between the visceral fat area and each parameter in this test.
Results
The mean age, body mass index (BMI), and duration of diabetes of the study population were 60±14 years (mean±standard deviation), 25.1±4.2 kg/m2, and 12.3±8.9 years, respectively. The visceral fat area showed positive correlations with age, BMI, waist circumference, and subcutaneous fat area. There was no statistically significant difference in the cardiovascular reflex test outcome between genders. Univariate linear regression analysis showed that an increased visceral fat area diminished good heart rate response to a Valsalva maneuver (R2=4.9%, P=0.013 in an unadjusted model), but only in women. This statistical association was preserved after adjusting for age and BMI (R2=9.8%, P=0.0072).
Conclusion
The results of this study suggest that visceral adiposity contributes to an autonomic imbalance to some degree, as demonstrated by the impaired cardiovascular reflex test among women with type 2 diabetes.
doi:10.4093/dmj.2012.36.4.285
PMCID: PMC3428417  PMID: 22950060
Cardiovascular autonomic neuropathy; Diabetes mellitus, type 2; Intra-abdominal fat; Obesity
7.  Relationship between Vitamin D, Parathyroid Hormone, and Bone Mineral Density in Elderly Koreans 
Journal of Korean Medical Science  2012;27(6):636-643.
There is controversy regarding definition of vitamin D inadequacy. We analyzed threshold 25-hydroxyvitamin D (25[OH]D) below which intact parathyroid hormone (iPTH) increases, and examined age- and sex-specific changes of 25(OH)D and iPTH, and association of 25(OH)D and iPTH with bone mineral density (BMD) in elderly Koreans. Anthropometric parameters, serum 25(OH)D and iPTH, lumbar spine and femur BMD by dual-energy radiography absorptiometry (DXA) were measured in 441 men and 598 postmenopausal women. iPTH increased below serum 25(OH) of 36.7 ng/mL in men, but failed to reach plateau in women. Femur neck BMD above and below threshold differed when threshold 25(OH)D concentrations were set at 15-27.5 ng/mL in men, and 12.5-20 ng/mL in postmenopausal women. Vitamin D-inadequate individuals older than 75 yr had higher iPTH than those aged ≤ 65 yr. In winter, age-associated iPTH increase in women was steeper than in summer. In conclusion, vitamin D inadequacy threshold cannot be estimated based on iPTH alone, and but other factors concerning bone health should also be considered. Older people seemingly need higher 25(OH)D levels to offset age-associated hyperparathyroidism. Elderly vitamin D-inadequate women in the winter are most vulnerable to age-associated hyperparathyroidism.
doi:10.3346/jkms.2012.27.6.636
PMCID: PMC3369450  PMID: 22690095
Vitamin D; Intact Parathyroid Hormone; Bone Density; Age; Sex
8.  Effects of Thyroid Hormone on A1C and Glycated Albumin Levels in Nondiabetic Subjects With Overt Hypothyroidism 
Diabetes Care  2010;33(12):2546-2548.
OBJECTIVE
We aimed to determine the effects of thyroid hormone on A1C and glycated albumin (GA) in nondiabetic patients with overt hypothyroidism.
RESEARCH DESIGN AND METHODS
A1C levels were measured in 45 nondiabetic patients with overt hypothyroidism and 180 euthyroid control subjects. A1C, GA, fasting blood glucose (FBG), 1,5-anhydroglucitol, and erythrocyte indexes were determined in 30 nondiabetic patients with overt hypothyroidism before and after thyroid hormone replacement.
RESULTS
A1C levels were higher in patients with hypothyroidism compared with control subjects. A1C levels were decreased by thyroid hormone replacement. Thyroid hormone replacement increased serum erythropoietin, reticulocyte count, and mean corpuscular hemoglobin (MCH). The change in A1C level was significantly correlated with the change in reticulocyte count or MCH. Thyroid hormone replacement decreased serum levels of albumin and GA. However, FBG and 1,5-anhydroglucitol levels were not altered.
CONCLUSIONS
Levels of A1C and GA are spuriously high in nondiabetic patients with overt hypothyroidism.
doi:10.2337/dc10-0988
PMCID: PMC2992186  PMID: 20823345
9.  Exercise Treadmill Test in Detecting Asymptomatic Coronary Artery Disease in Type 2 Diabetes Mellitus 
Diabetes & Metabolism Journal  2011;35(1):34-40.
Background
The present study was designed to develop criteria for screening patients with type 2 diabetes mellitus (T2DM) for asymptomatic coronary artery disease (CAD).
Methods
A total of 213 patients with T2DM without typical angina or chest pain were studied between 2002 and 2007. We also evaluated 53 patients with T2DM who had reported chest discomfort using an exercise treadmill test (ETT).
Results
Thirty-one of the 213 asymptomatic patients had positive ETT results. We performed coronary angiography on 23 of the 31 patients with a positive ETT and found that 11 of them had significant coronary stenosis. The main differences between the patients with significant stenosis and those with a negative ETT were age (63.1±9.4 vs. 53.7±10.1 years, P=0.008) and duration of diabetes (16.0±7.5 vs. 5.5±5.7 years, P<0.001). The positive predictive value (PPV) of the ETT was calculated to be 47.8%. The PPV of the ETT increased to 87.5% in elderly patients (≥60 years) with a long duration of diabetes (≥10 years). The latter value is similar to that of patients with T2DM who presented with chest discomfort or exertional dyspnea. The PPV of the ETT in symptomatic patients was 76.9%.
Conclusion
In the interest of cost-effectiveness, screening for asymptomatic CAD could be limited to elderly patients with a duration of diabetes ≥10 years.
doi:10.4093/dmj.2011.35.1.34
PMCID: PMC3080575  PMID: 21537411
Diabetes mellitus; Duration of diabetes; Exercise treadmill test; Silent myocardial ischemia
10.  Long-Term Effects of Rosiglitazone on the Progressive Decline in Renal Function in Patients With Type 2 Diabetes 
Background/Aims
Thiazolidinediones reduce urinary albumin excretion and may prevent the development of renal injury. We evaluated the long-term effects of rosiglitazone on the progression of renal dysfunction in patients with type 2 diabetes mellitus.
Methods
We enrolled patients with type 2 diabetes mellitus who initially had normal or mildly impaired renal function, defined as an estimated glomerular filtration rate (eGFR) of 60-120 mL/min per 1.73 m2, and normoalbuminuria. Patients were divided into two groups according to their use of rosiglitazone during 3 years of follow-up: those treated with rosiglitazone (rosiglitazone group, n=52) and those treated without rosiglitazone (control group, n=85). Progression of renal dysfunction was defined as a decrease in eGFR of ≥9 mL/min per 1.73 m2 after 3 years.
Results
A greater difference was observed in the decrease in eGFR between the rosiglitazone and control groups after 3 years (3.8±9.9 vs. 12.6±10.5 mL/min per 1.73 m2, p<0.001). Seventeen of 52 (32.7%) patients in the rosiglitazone group and 53 of 85 (62.3%) patients in the control group showed progression of renal dysfunction (p=0.001). The progressors had a longer duration of diabetes (6.7±5.9 vs. 3.9±4.1 years, p=0.002), higher HbA1c levels (7.4±1.8 vs. 6.8±1.3%, p=0.023), and less frequent use of rosiglitazone (24.2 vs. 52.2%, p<0.001) compared to non-progressors. Multiple logistic regression analysis revealed that the use of rosiglitazone was a significant and independent predictor of the progression of renal dysfunction.
Conclusions
This study suggests that rosiglitazone theatment slows the progressive deterioration of renal function in patients with type 2 diabetes.
doi:10.3904/kjim.2009.24.3.227
PMCID: PMC2732782  PMID: 19721859
Diabetic nephropathies; Rosiglitazone; Renal insufficiency

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