LIPID AND METABOLIC EFFECTS OF GASTROINTESTINAL SURGERY (FR RUBINO, SECTION EDITOR) Role of Metabolic Surgery in Less Obese or Non-Obese Subjects with Type 2 Diabetes: Influence Over Cardiovascular Events Ricardo Cohen & Pedro Paulo Caravatto & Tarissa Petry & David Cummings # Springer Science+Business Media New York 2013 Abstract Bariatric surgery was initially developed as a tool for weight reduction only, but it is gaining increasing popu- larity because of its remarkable effect on glucose metabolism in morbidly obese and less obese patients. Recent publica- tions have shown the good results of metabolic surgery, creating a new field of clinical research that is currently overflowing in the medical community with outstanding high-quality data. In morbidly obese population, there is compelling data on long term cardiovascular risk reduction and mortality, coming from longitudinal prospective studies and systematic reviews. Numbers range from 33 to 92 % of decrease in fatal and nonfatal cardiovascular events . In low body mass index (BMI) diabetics, there is an increasing number of reported good outcomes after metabolic surgery with the aim to treat type 2 diabetes (T2DM). There is scarce information on cardiovascular outcomes in non–morbidly obese subjects, but the extraordinary glucose, lipid and blood pressure control in the published series are suggesting good long-term effects on cardiovascular risk profile and mortal- ity. The papers review was comprehensive, including the available randomized controlled trials, long-term prospec- tive series and systematic reviews. Keywords Type 2 diabetes mellitus . Metabolic surgery . Bariatric surgery . Obesity . Gastrointestinal surgery Introduction During the past decades, the prevalence of type 2 diabetes (T2DM) in the United States has more than doubled, affect- ing more than 25 million Americans (nearly 8.3 % of the population) in 2010. By 2050, T2DM could affect as many as one in three adults in the United States [1, 2]. Worldwide, the World Health Organization estimates that by 2030, ap- proximately 336 million individuals will have T2DM [3]. T2DM is associated with a high incidence of cardiovascular events and macrovascular complications, such as strokes and amputations, which represent an enormous economic burden [4]. Several clinical risk factors for T2DM patients such as hypertension, hyperglycemia, and dyslipidemia are associat- ed with poor outcomes. In order to prevent cardiovascular complications, aiming to reduce mortality, a broader man- agement, focusing not only on glucose control, but also on lipid and blood pressure control, is necessary [5, 6]. Current treatment goals proposed by the American Diabetes Associ- ation are: glycated hemoglobin (A1c) below 7 %; blood pressure below 130 × 80 mm Hg; and low-density lipoprotein cholesterol levels below 100 mg/dL [7]. Although we have seen an important improvement in the last decade following the development of new types of antidiabetic drugs, T2DM control remains suboptimal [8•, 9, 10] (Table 1). Conventional strategies to treat T2DM, including medication and lifestyle interventions, may have delayed cardiovascular events and other major complications, yet results continue to be frustrating; explained perhaps by patients’ low compliance with complex treatments that require regular medical visits and lifelong medication [11, 12•]. Early glycemic control has been reported after metabolic surgery, even before significant weight loss occurred, pre- cluding a direct antidiabetic effect. This remarkable effect has been described not only in morbidly obese patients but also with class I obesity and even overweight patients [13–18], This article is part of the Topical Collection on Lipid and Metabolic Effects of Gastrointestinal Surgery R. Cohen (*) : P. P. Caravatto : T. Petry The Center of Excellence of Metabolic and Bariatric Surgery, Oswaldo Cruz Hospital, São Paulo, Brazil e-mail: ricardo.cohen@haoc.com.br D. Cummings Diabetes and Obesity Center of Excellence and Veterans Affairs Puget Sound Health Care System, University of Washington School of Medicine, Seattle, WA, USA Curr Atheroscler Rep (2013) 15:355 DOI 10.1007/s11883-013-0355-3