Bariatric surgery is more effective than medical and lifestyle modifications for achieving weight loss control and remission, according to new research by a surgeon-scientist at the University of Pittsburgh School of Medicine. type 2 diabetes long-term.
The study was published in JAMA.
The benefits of bariatric surgery
In the largest and longest randomized follow-up study to date, researchers also found that bariatric surgery improved cholesterol and triglyceride levels more effectively than medical and lifestyle modifications. Because diabetes and cholesterol are major risk factors for heart disease, managing both can help reduce heart attacks, strokes, and other complications.
“This analysis is the strongest evidence we have to date that bariatric surgery is a safe and effective tool for achieving diabetes control and remission,” said lead author Anita Courcoulas, MD, MPH, professor at Pitt's Department of Surgery and head of the Minimally Invasive Laboratory. Bariatric Surgery Program at UPMC.
The researchers compared various outcomes – measures of blood sugar control (HbA1c), weight loss, as well as use of insulin and other diabetes medications – for participants enrolled in four separate randomized clinical trials conducted between May 2007 and August 2013.
All four studies included patients with type 2 diabetes and obesity who underwent bariatric surgery or participated in a medical and lifestyle program based on established interventions that have been shown to reduce the risk of diabetes. The researchers then pooled the data in a study completed in 2022. Long-term outcomes were analyzed seven and, when possible, 12 years after randomization.
Patients in the bariatric surgery group consistently had lower HbA1c levels, reflecting better blood sugar control, than the medical/lifestyle group at each follow-up point, despite entering the study with higher baseline values.
By year seven, 18.2% of participants in the surgery group had achieved diabetes remission, compared to 6.2% in the medical/lifestyle group. At year 12, the difference was even more stark: No patients in the medical/lifestyle group were in diabetes remission, compared to 12.7% in the surgery group.
Even in those who did not experience remission, bariatric surgery resulted in superior blood sugar control with less use of diabetes medications compared with medical/lifestyle treatment.
The results were consistent across weight class groups, demonstrating that surgery is equally beneficial for patients with body mass indices (BMIs) below and above 35 kg/m2, the typical limit for bariatric surgery treatment.
“This indicates that people with type 2 diabetes, even those below the BMI threshold for bariatric surgery for weight loss alone, should be offered bariatric surgery as a treatment for inadequately controlled diabetes,” Courcoulas said . “These findings further support the need for flexible, patient-centered care based on an individual's health concerns and goals.”
While the goal of this study was to analyze diabetes control and remission rates, researchers also found that bariatric surgery was superior to medical/lifestyle interventions in terms of lasting weight loss. By year 12, patients who underwent surgery had experienced an average weight loss of 19.3%, compared to 10.8% for patients in the medical intervention/lifestyle group.
The researchers found no differences in mortality or major cardiovascular events between the two groups. However, anemia, fractures, and adverse gastrointestinal symptoms such as nausea and abdominal pain were more common among participants who underwent bariatric surgery.
The analysis used data from randomized clinical trials conducted at Pitt, Cleveland Clinic, Joslin Diabetes Center and Brigham and Women's Hospital, as well as at the University of Washington and Kaiser Permanente Washington.
Taken together, the studies included 355 patients with type 2 diabetes. The studies were conducted before the widespread availability of GLP-1 agonist drugs for diabetes management and weight loss.
Medical and lifestyle interventions at all four sites were based on national standards for intensive diabetes management and included physical activity and nutrition monitoring, increased engagement with the health care team, stress management, support groups, and medications available at the time of study enrollment. Bariatric surgery procedures included Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding.
Bariatric surgery shows long-term success compared to standard diabetes management
Metabolic or bariatric surgery results in superior glycemic control, lower medication use, and high remission rates of type 2 diabetes compared with medical or lifestyle intervention in patients with class 1 obesity, as described in a report recently published by researchers at the Pennington Biomedical Research Center and others.
The study, which evaluated more than 250 participants for up to 12 years, represents the largest cohort of people evaluated for the long-term durability of the two treatments. The findings were presented at the American Diabetes Association's 83rd Scientific Sessions Conference in San Diego.
“The longer the study lasts, the stronger the message will be in terms of remission of type 2 diabetes,” said ARMMS-T2D principal investigator John Kirwan, MSc, Ph.D., executive director and George A. Bray, Jr. Endowed Super Chair of Nutrition, Pennington Biomedical Research Center.
“The study addressed the durability of glycemic control after surgery, long-term efficacy and safety, and potential reasons why some patients experience relapse.”
The study is the longest running of its kind. From May 2007 to August 2013, 262 participants with type 2 diabetes were recruited and randomized to either the metabolic surgery group or the medical/lifestyle intervention group.
With a median follow-up of 11 years, participants in the metabolic surgery group experienced greater reductions in blood sugar, higher rates of diabetes remission, and significantly greater weight loss than those in the medical intervention/lifestyle group. .
“These landmark findings further strengthen the confidence we have in the success and effectiveness of metabolic and bariatric surgery.
For those patients who have a serious need to lose weight and for whom diet, exercise and medications have not produced the desired results, these patients we can be confident that this operation is safe and that the results are well established,” said Dr. Philip Schauer, director of the Metamor Metabolic Institute at Pennington Biomedical.
At the American Diabetes Association conference, Dr. Sangeeta Kashyap, deputy chief of clinical affairs in the division of endocrinology, diabetes and metabolism at Weill Cornell Medicine in New York, Presbyterian, introduced the study and presented the case for a randomized trial of surgery metabolic and type 2 diabetes. Dr. Mary-Elizabeth Patti, associate professor of medicine at Harvard Medical School and a physician-scientist, reviewed and shared the study design.
Dr. Anita Courcoulas, MPH, FACS and chief of the Division of Minimally Invasive Bariatric and General Surgery at the University of Pittsburgh, discussed the long-term outcomes and diabetes remission from the study. Dr. Robert H. Eckel, former ADA President, Medicine and Science, shared the implications of the clinical management of type two diabetes.
Greater weight loss after bariatric surgery linked to diabetes remission
According to a study published in Diabetes Care, remission of type 2 diabetes after bariatric surgery peaks at a total weight loss (TWL) of 20%.
Douglas Barthold, Ph.D., of the University of Washington in Seattle, and colleagues evaluated the amount of weight loss needed to achieve initial remission of type 2 diabetes mellitus (T2DM) after bariatric surgery. The analysis included 5,928 individuals (73% female; mean age, 49.8 years; mean body mass index, 43.8 kg/m2) undergoing bariatric surgery (57% Roux-en-Y gastric bypass), with an average follow-up of 5.9 years.
The researchers found that 71% of patients had an initial remission of T2DM (mean time to remission, 1.0 year). Patients were more likely to go into remission with every 5% increase in TWL up to 20% TWL (risk range, 1.97 to 2.92) compared with those with 0 to 5% TWL. Patients with TWL >25% had a similar probability of initial remission as those with TWL 20 to 25%.
Even among patients using insulin at the time of surgery, those who achieved a TWL >20% were more likely to achieve initial T2DM remission than patients with a TWL between 0 and 5%.
Our findings can be used to help providers and patients discuss realistic expectations for weight loss after bariatric surgery and how this will affect their T2DM remission,” the authors write.
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