Bariatric Surgery A Cure For Diabetes?
People who could benefit from surgical control of diabetes may not be getting that opportunity. Surgical control of type 2 diabetes, although not the current standard of care for the disease, may be coming closer to the mainstream. The surgical treatment of obesity is associated with the subsequent resolution of type 2 diabetes, according to a meta-analysis published in the Journal of the American Medical Association . This widely reported result has prompted researchers to consider surgery a treatment modality for diabetes. Others have gone a controversial step further and suggested that type 2 diabetes, independent of obesity, is an operable disease. , Pories and colleagues determined gastric bypass to be effective and safe for obesity and its associated morbidities. No other therapy has produced such durable and complete control of diabetes, they concluded in the article. Since then, various research groups have sought to determine the mechanisms responsible for surgery-induced diabetes resolution, while clinicians in multiple disciplines continue to ponder whether surgery, despite its chronicled efficacy, is truly the optimal treatment modality for type 2 diabetes. Early clinical studies show that surgical control of diabetes can be achieved in patients with BMI below 35, said Francesco Rubino, MD, chief of Metabolic Surgery at New York Presbyterian Hospital-Weill Medical College of Cornell University. This does not necessarily mean that surgery should be offered to every patient and regardless of BMI. However, it suggests that the current NIH criteria do not adequately identify all ideal candidates for surgical treatment of diabetes and that many patients who may potentially benefit from surgery are actually being denied an opportunity. More research needs to be d Continue reading >>
Weight Loss Surgery Can Put Diabetes Into Remission. So Should Everyone At Risk Get It?
At 297 pounds, Pam Adams had diabetes, high blood pressure, high cholesterol, and rheumatoid arthritis. She'd spent her life trying—and failing—to lose weight with all the usual methods: Weight Watchers, Atkins, Nutrisystem, you name it. None of them had worked for long. By the time she was 42, her body mass index was an astronomical 49, well into the "morbidly obese" category, and as a result she'd had eight ministrokes and a major stroke, making her go partially blind. She decided to try a type of weight loss surgery called gastric bypass. comp-3939441-digestivesystem-lauren_nassef.jpg Roughly 900 miles away, a few years later, a similar story was starting to unfold for Jane Smith (who asked Prevention to change her last name). A big woman at 197 pounds, she nonetheless had a BMI of only 34, barely in the top quartile for Americans and not alarming to any doctor. But the 52-year-old pediatric nurse had just joined the estimated 28 million Americans diagnosed with type 2 diabetes. She too had been on every diet: "I never lost the baby weight after my pregnancies 20 years ago and was always yo-yoing," she says. Though she had no complications from her condition, Smith suspected that someday her health would deteriorate fast. "My numbers were getting worse," she says. So she chose weight loss surgery, too, in the form of a sleeve gastrectomy procedure. Both decisions took guts. To put it bluntly, Americans aren't very nice about weight loss surgery, also known as gastric or bariatric surgery. We still largely view getting fat as a personal failing and surgery as a lazy way out for those too undisciplined to eat right and exercise. A 2013 statement by the American Medical Association noted a widespread perception among Americans that obesity is simply the result of ba Continue reading >>
Metabolic Surgery: Gastric Bypass For The Treatment Of Type 2 Diabetes Mellitus
Metabolic surgery: gastric bypass for the treatment of type 2 diabetes mellitus Metabolic surgery: gastric bypass for the treatment of type 2 diabetes mellitus Metabolic surgery: gastric bypass for the treatment of type 2 diabetes mellitus Maria del Pilar Quevedo, Mariano Palermo, Edgardo Serra, Marianela A. Ackermann Division of Bariatric Surgery Centro CIEN, Diagnomed, Affiliated Institution to the University of Buenos Aires Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Mariano Palermo, MD, PhD, FACS. Coordinator Centro Cien, Diagnomed, Buenos Aires, Argentina. Email: Abstract: Type 2 diabetes mellitus (T2DM) is one of the largest health emergencies of the 21st century given the worldwide increase of obesity during the last decades and its close association. T2DM is an inherited, polygenic and chronic disease caused by the interaction between several genetic variants in genes and the environment. The continuous search for new and more effective tools to achieve appropriate glycemic control became imperative in order to reduce long-term complications and mortality rates related to T2DM. Treatment options includes lifestyle modifications and several pharmacotherapies as first step in the therapeutical algorithm, but high corps of evidence have shown that gastrointestinal (GI) operations, especially those that involve food rerouting through the GI tract, are safe interventions and achieve superior outcomes for improvement in glucose metabolism when compari Continue reading >>
Bariatric Surgery And Diabetes Remission: Sleeve Gastrectomy Or Mini-gastric Bypass?
Bariatric surgery and diabetes remission: Sleeve gastrectomy or mini-gastric bypass? Number of Hits and Downloads for This Article Oct 21, 2013 (publication date) through May 1, 2018 Baishideng Publishing Group Inc, 7901 Stoneridge Drive, Suite 501, Pleasanton, CA 94588, USA Copyright 2013 Baishideng Publishing Group Co., Limited. All rights reserved. World J Gastroenterol.Oct 21, 2013;19(39): 6590-6597 Published online Oct 21, 2013.doi: 10.3748/wjg.v19.i39.6590 Bariatric surgery and diabetes remission: Sleeve gastrectomy or mini-gastric bypass? Marco Milone, Matteo Nicola Dario Di Minno, Maddalena Leongito, Paola Maietta, Paolo Bianco, Caterina Taffuri, Dario Gaudioso, Roberta Lupoli, Silvia Savastano, Francesco Milone, Mario Musella Marco Milone, Matteo Nicola Dario Di Minno, Maddalena Leongito, Paola Maietta, Paolo Bianco, Caterina Taffuri, Dario Gaudioso, Roberta Lupoli, Silvia Savastano, Francesco Milone, Mario Musella, Department of Advanced Biomedical Science, University of Naples Federico II, 80131 Naples, Italy Author contributions: Musella M and Milone M designed experiments; Musella M and Milone M performed research; Di Minno MND, Milone M, Lupoli R, Leongito M, Maietta P, Bianco P, Taffuri C, and Gaudioso G collected and analyzed the data; Milone M and Di Minno MND wrote the paper; Milone F and Musella M critically revised the manuscript. Correspondence to: Dr. Marco Milone, MD, Department of Advanced Biomedical Science, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy. AIM: To investigate the weight loss and glycemic control status [blood glucose, hemoglobin A1c (HbA1c) and hypoglycaemic treatment]. METHODS: The primary risk factor for type 2 diabetes is obesity, and 90% of all patients with type 2 diabetes are overweight or obese. Alth Continue reading >>
Ranking Factors Involved In Diabetes Remission After Bariatric Surgery Using Machine-learning Integrating Clinical And Genomic Biomarkers
Ranking factors involved in diabetes remission after bariatric surgery using machine-learning integrating clinical and genomic biomarkers npj Genomic Medicine volume 1, Articlenumber:16035 (2016) As weight-loss surgery is an effective treatment for the glycaemic control of type 2 diabetes in obese patients, yet not all patients benefit, it is valuable to find predictive factors for this diabetic remission. This will help elucidating possible mechanistic insights and form the basis for prioritising obese patients with dysregulated diabetes for surgery where diabetes remission is of interest. In this study, we combine both clinical and genomic factors using heuristic methods, informed by prior biological knowledge in order to rank factors that would have a role in predicting diabetes remission, and indeed in identifying patients who may have low likelihood in responding to bariatric surgery for improved glycaemic control. Genetic variants from the Illumina CardioMetaboChip were prioritised through single-association tests and then seeded a larger selection from proteinprotein interaction networks. Artificial neural networks allowing nonlinear correlations were trained to discriminate patients with and without surgery-induced diabetes remission, and the importance of each clinical and genetic parameter was evaluated. The approach highlighted insulin treatment, baseline HbA1c levels, use of insulin-sensitising agents and baseline serum insulin levels, as the most informative variables with a decent internal validation performance (74% accuracy, area under the curve (AUC) 0.81). Adding information for the eight top-ranked single nucleotide polymorphisms (SNPs) significantly boosted classification performance to 84% accuracy (AUC 0.92). The eight SNPs mapped to eight genes A Continue reading >>
Hormonal And Metabolic Mechanisms Of Diabetes Remission After Gastrointestinal Surgery
Hormonal and Metabolic Mechanisms of Diabetes Remission after Gastrointestinal Surgery Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, Diabetes and Obesity Center of Excellence and Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, Washington 98195 Search for other works by this author on: Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, Diabetes and Obesity Center of Excellence and Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, Washington 98195 Address all correspondence and requests for reprints to: David E. Cummings, M.D., Deputy Director, Diabetes Endocrinology Research Center, Investigator, Diabetes and Obesity Center of Excellence, University of Washington, Box 358280 (mail stop 111), Seattle, Washington 98195. Search for other works by this author on: Endocrinology, Volume 150, Issue 6, 1 June 2009, Pages 25182525, Joshua P. Thaler, David E. Cummings; Hormonal and Metabolic Mechanisms of Diabetes Remission after Gastrointestinal Surgery, Endocrinology, Volume 150, Issue 6, 1 June 2009, Pages 25182525, Bariatric surgery is the most effective available treatment for obesity. The most frequently performed operation, Roux-en-Y gastric bypass (RYGB), causes profound weight loss and ameliorates obesity-related comorbid conditions, especially type 2 diabetes mellitus (T2DM). Approximately 84% of diabetic patients experience complete remission of T2DM after undergoing RYGB, often before significant weight reduction. The rapid time course and disproportional degree of T2DM improvement after RYGB compared with equivalent weight loss from other interventions suggest surgery-specific, weight-independent effects on glucose homeostasis. Potential me Continue reading >>
Bariatric surgery (weight loss surgery) was pioneered to treat intractable severe obesity, and was initially associated with high morbidity and mortality. With greater experience it has become a relatively safe and highly effective means of achieving weight loss, and it is also a highly effective means of reversing type 2 diabetes. Bariatric surgery is often able to restore euglycaemia, allowing medication to be withdrawn. These benefits emerge rapidly following surgery, and appear to be due both to calorie restriction and to changes in gut physiology. Controlled trials confirm that bariatric surgery has advantages over medical diabetes treatment in the short term, but medium-to-long term relapse rates indicate that it is often not curative. By-pass surgery, although very effective in producing weight loss, also results in permanent loss of gut tissue and absorptive capacity, with a permanent requirement for dietary supplements and a range of possible undesirable consequences. It is however a cost-effective option and undoubtedly effective when all other strategies have failed. Bariatric surgery now has an important place in the management of diabetes, but there is ongoing debate as to the extent to which it suitable or desirable for larger numbers of people with diabetes. Although bariatric surgery now has an established place in the management of diabetes, many questions remain. Should it, for example, be restricted to the overweight? Enthusiasts point to benefits in non-obese people with diabetes, but the place of metabolic surgery in the non-obese is hotly debated. Patient and professional perspectives may differ concerning surgical intervention, which is often welcomed by the intractably obese but may seem less attractive by those with diabetes and lesser degree o Continue reading >>
Gastric Bypass Surgery And Glycemic Control In Type 2 Diabetes Mellitus: Who Benefits And Why?
Condition Center Home > Clinical Essentials Gastric Bypass Surgery and Glycemic Control in Type 2 Diabetes Mellitus: Who Benefits and Why? Bariatric surgery for the treatment of obese patients with type 2 diabetes mellitus is associated with variable rates of remission and relapse. Reviewed by Clifton Jackness, MD, Attending Physician in Endocrinology and Internal Medicine, Lenox Hill Hospital and the Mount Sinai Medical Center, New York, NY Weight loss achieved through dietary modification, physical activity, and pharmacotherapy is an essential component of the treatment of type 2 diabetes mellitus (T2DM).1 Lifestyle modifications present a significant challenge to patients, however, and make it difficult to achieve and sustain benefits over the long-term. Further, it is estimated that 90% of patients treated with medications do not meet the recommended goals for glycemic control.1 Results from randomized controlled trials evaluating the impact of bariatric surgery on weight loss in T2DM suggest that laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy, and biliopancreatic diversion are associated with greater weight loss and better glycemic control compared with medical therapy.1 A longitudinal study examined the rate and preoperative predictors of diabetes remission (A1C <6%) at 12 months following bariatric surgery performed at a single institution in a cohort of 154 ethnic Chinese patients with T2DM.2 The diabetes remission rate at 1 year was 69.5%, with an 85.5% remission rate for mini gastric bypass, a simplified version of RYGB involving a single anastomosis, compared with 48.5% for RYGB (odds ratio, 2.4; 95% confidence interval [CI], 1.73.4; P <.001). Significant predictors of remission at 12 months were younger Continue reading >>
- The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus
- Association of Glycemic Variability in Type 1 Diabetes With Progression of Microvascular Outcomes in the Diabetes Control and Complications Trial
- Metabolic surgery for treating type 2 diabetes mellitus: Now supported by the world's leading diabetes organizations
Better Diabetes Remission After Weight Loss Surgery Than Other Methods
Better diabetes remission after weight loss surgery than other methods NEW YORK (Reuters Health) More than 20 years of evidence suggests that bariatric surgery produces greater weight loss and more type 2 diabetes remissions than nonsurgical treatments for the obese, according to a review. The results, from a National Institutes of Health (NIH) symposium held last year, support the idea that weight loss surgeries are effective and safe, at least within the first two to five years after surgery. But more studies of long term effects are needed, the authors say. The NIH last held a consensus panel on the issue in 1991. Since then, bariatric surgeries have become much more routine and more small clinical trials and large observational studies on the outcomes of surgery have been done. In a new clinical review in JAMA Surgery, experts from the National Institute of Diabetes and Digestive and Kidney Diseases and the National Heart, Lung, and Blood Institute at the NIH in Bethesda, Maryland, as well as the Group Health Cooperative in Seattle and the University of Pittsburgh Medical Center summarize the evidence since 1991. Several small trials have found greater weight loss and type 2 diabetes remission after bariatric surgeries compared to nonsurgical methods like dieting and behavioral therapies, they write. Most bariatric surgeries are only approved for patients who have failed to lose significant weight with diet and exercise. People who get the surgery tend to lose around 20 to 30 percent of their body weight in the following years, compared to little or no weight loss for similar people who do not get the surgery, according to recent long-term studies. But there are still gaps in bariatric surgery research, the authors point out. More studies are needed to determine ho Continue reading >>
Bariatric Surgery And Diabetes Remission: Who Would Have Thought It?
Indian J Endocrinol Metab. 2015 Sep-Oct;19(5):563-76. doi: 10.4103/2230-8210.163113. Bariatric surgery and diabetes remission: Who would have thought it? Department of Consultant Endocrinologist, G.D Hospital and Diabetes Institute, Kolkata, West Bengal, India. Consultant Gynecologist, G.D Hospital and Diabetes Institute, Kolkata, West Bengal, India. Diabetes and Endocare Clinic, Berhampur, Odisha, India. Type 2 diabetes mellitus (T2DM) and obesity are increasingly common and major global health problems. The Edmonton obesity staging system clearly pointed towards increased mortality proportionate to the severity of obesity. Obesity itself triggers insulin resistance and thereby poses the risk of T2DM. Both obesity and T2DM have been associated with higher morbidity and mortality and this calls for institution of effective therapies to deal with the rising trend of complications arising out of this dual menace. Although lifestyle changes form the cornerstone of therapy for both the ailments, sustained results from this modalities is far from satisfactory. While Look AHEAD (action for HEAalth in diabetes) study showed significant weight loss, reduction in glycated hemoglobin and higher remission rate of T2DM at 1(st) year following intensive lifestyle measures; recurrence and relapse rate bounced back in half of subjects at 4 years, thereby indicating that weight loss and glycemic control is difficult to maintain in the long term with lifestyle interventions. Same recurrence phenomenon was also observed with pharmacotherapy with rimonabant, sibutramine and orlistat. Bariatric surgery has been seen to associate with substantial and sustained weight loss in morbidly obese patients. Interestingly, bariatric surgeries also induce higher rates of short and long-term diabetes Continue reading >>
Bariatric Surgery In Patients With Type 2 Diabetes: Benefits, Risks, Indications And Perspectives - Em|consulte
Bariatric surgery in patients with Type 2 diabetes: benefits, risks, indications and perspectives , J.De Flines a , A.De Roover b , N.Paquot a aDivision of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Sart Tilman, University of Lige, Lige, Belgium bDivision of Gastrointestinal Surgery, Department of Surgery, CHU Sart Tilman, Lige, Belgium Obesity plays a key role in the pathophysiology of type 2 diabetes (T2DM), and weight loss is a major objective, although difficult to achieve with medical treatments. Bariatric surgery has proven its efficacy in obtaining marked and sustained weight loss, and is also associated with a significant improvement in glucose control and even diabetes remission. Roux-en-Y gastric bypass appears to be more effective in diabetic patients than the restrictive gastroplasty procedure. This may be explained not only by greater weight reduction, but also by specific hormonal changes. Indeed, increased levels of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) may lead to improved -cell function and insulin secretion as well as reduced insulin resistance associated with weight loss. The presence of T2DM in obese individuals is a further argument to propose bariatric surgery, and even more so when diabetes is difficult to manage by medical means and other weight-related complications may occur. Bariatric surgery is associated with a better cardiovascular prognosis and reduced mortality, even though acute and long-term complications are present. The observation that surgical rerouting of nutrients triggers changes in the release of incretin hormones that, in turn, ameliorate the diabetic state in the absence of weight loss has led to the recent development of innovative surgical proced Continue reading >>
Bariatric Surgery For Type 2 Diabetes Reversal: The Risks
The twin epidemics of obesity and type 2 diabetes are on the rise. From 1986 to 2000, the prevalence of BMI 30 kg/m2 doubled, whereas that of BMI >40 kg/m2 quadrupled, and even extreme obesity of BMI 50 kg/m2 increased fivefold (1). Of particular concern is the alarming increasing prevalence of obesity among children, suggesting that the epidemic will worsen (2). The impact of obesity on longevity has been well documented. In the world, over 2.5 million deaths annually can be attributed to obesity; in the U.S. alone over 400,000 deaths attributable to obesity occur per year—second only to those attributable to cigarette smoking. There is a direct relationship between increasing BMI and relative risk of dying prematurely, as evidenced in the Nurses’ Health Study with a 100% increase in relative risk as BMI increased from 19 to 32 kg/m2. Annual risk of death can be as high as 40-fold that of an age- and sex-matched nonobese cohort (3,4). The Framingham data revealed that for each pound gained between ages 30 and 42 years there was a 1% increased mortality within 26 years, and for each pound gained thereafter there was a 2% increased mortality. Only one in seven obese individuals will reach the U.S. life expectancy of 76.9 years. In the morbidly obese population, average life expectancy is reduced by 9 years in women and by 12 years in men. It has been over 10 years since the resolution of type 2 diabetes was observed as an additional outcome of surgical treatment of morbid obesity. Moreover, it has been shown unequivocally that diabetes-related morbidity and mortality have declined significantly postoperatively, and this improvement in diabetes control is long lasting. Bypass procedures, the Roux-en-Y gastric bypass (RYGBP) and the biliopancreatic diversion (BPD), are Continue reading >>
Bariatric Surgery: A Cure For Diabetes?
The lifetime risk of developing diabetes for persons born in 2000 is around 35%  and the NHANES database has suggested a greater than fourfold increase in prevalence over the last three generations. While bariatric surgery has become the most effective treatment for obesity, it has also been found to be an extremely effective treatment for type 2 diabetes. It was initially thought that the weight loss experienced by patients after bariatric surgery was responsible for improved glycemic control. However, patients experience improvement after only a few days, suggesting that hormonal changes are partly responsible .  Discovering exactly which hormones are involved and how they cure diabetes has proven difficult. The major players seem to be the incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP); peptide YY (PYY); and ghrelin. GLP-1 is secreted by the L cells of the distal ileum in response to ingested nutrients, and acts as a potent insulin secretagogue .  It has also been shown to slow gastric emptying and induce satiety in the central nervous system .  GLP-1 increases lipogenesis in adipocytes and glycogenesis in liver cells and skeletal muscle .  GIP is secreted by the K cells of the duodenum and jejunum in response to carbohydrate and fat intake, and acts on pancreatic beta cells as an insulin secretagogue. However, it has no effect on gastric emptying or satiety. Like GLP-1, PYY is secreted by the L cells of the ileum, increases satiety, and slows gastric emptying through binding of receptors in the central and peripheral nervous systems .  Ghrelin is a hormone secreted by cells in the gastric fundus and proximal gut that acts on the hypothalamus to stimulate appetite and food intake, as well Continue reading >>
Cpe Monthly: Bariatric Surgery In Diabetes Management - Today's Dietitian Magazine
CPE Monthly: Bariatric Surgery In Diabetes Management Suggested CDR Learning Codes: 4140, 5125, 5190 Suggested CDR Performance Indicators: 8.1.5, 8.3.1, 8.3.6 Take this course and earn 2 CEUs on our Continuing Education Learning Library The latest National Health and Nutrition Examination Survey data indicate that between 2009 and 2010, roughly 35% of adults (78 million) and 16.9% of children and adolescents (12.5 million) were obese.1 Excess weight is associated with an increased prevalence of type 2 diabetes, and both diabetes and obesity are associated with an increased risk of mortality and higher health care costs.2 Since obesity is considered a modifiable risk factor for diabetes, preventing it is ideal, but treatment for those who are currently obese is critical. Diet, exercise, and medications are the cornerstones of therapy for type 2 diabetes, but outcomes remain disappointing.3 Fewer than 50% of people with moderate to severe diabetes achieve and maintain therapeutic thresholds for glycemic control. Diet, exercise, and behavioral therapy are first-line treatment modalities for obesity, but results also are inadequate.4 In addition, many diabetes medications (eg, insulin, sulfonylureas, thiazolidinediones) promote weight gain, further exacerbating obesity among people with diabetes.5 This continuing education course reviews the research on bariatric surgery as a treatment option for type 2 diabetes. The course reviews the types of interventions, remission rates, and the mechanisms for diabetes resolution and outlines practical applications for dietitians. The choice of surgery type for a particular patient often is discussed with diabetes resolution in mind. Because diabetes is one of the primary reasons patients elect to have bariatric surgery, surgeons typi Continue reading >>
Predictors Of Diabetes Remission After Bariatric Surgery In Asia - Sciencedirect
Volume 35, Issue 2 , April 2012, Pages 67-73 Predictors of diabetes remission after bariatric surgery in Asia Author links open overlay panel Wei-JeiLeea Obesity and type II diabetes mellitus (T2DM) are closely related and difficult to control by current medical treatment. Bariatric surgery has been proposed for inadequately controlled T2DM in association with obesity. However, prediction of successful T2DM remission after surgery has not been clearly studied in Asian patients. This information might be helpful for applying gastrointestinal surgery as metabolic surgery for T2DM. This was a retrospective clinical study. From January 2002 to December 2008, 88 consecutive patients with morbid obesity, who were enrolled into a surgically supervised weight loss program, and who had T2DM before surgery with at least 1 year complete follow-up data were included. Sixty-eight (77.2%) patients received gastric bypass procedures, and the remaining 20 (22.8%) received restrictive procedures. We analyzed the available information during the initial evaluation of patients who were referred for bariatric surgery, by logistic regression analysis and data mining methods for predictors of successful diabetes remission after surgery. Overall, 68 (77.2%) of the 88 patients had remission of their T2DM 1 year after surgery. Patients in the bypass group had a higher remission rate than those in the restrictive group [59/68 (86.7%) vs. 9/20 (45.0%), p=0.000]. In univariate analysis, patients who had T2DM remission after surgery were younger, heavier, had a wider waist, less severe disease, shorter duration, and higher C-peptide levels than those without remission. Type of operation and T2DM duration remained independent predictors of success after multivariate logistical regression analysis ( Continue reading >>