Weight-loss Surgery Improves Diabetes Goals

In the Short-Term, Weight-loss (Bariatric) Surgery Improves Diabetes Goals Better Than Lifestyle Changes

In mild to moderately obese patients with diabetes, the use of bariatric surgery is more likely to meet established diabetes goals in the short-term than lifestyle-medical management alone, but with more complications, according to a 1-year, prospective study published in the June 5 issue of JAMA.

“We need to conduct a long-term, large study weighing the risks and benefits. That is the real call to action. We will need to follow these patients to monitor for complications and other side effects to see if they are related to surgery or diabetes,” said lead author Sayeed Ikramuddin, MD, Professor of Surgery at the University of Minnesota Medical Center in Minneapolis.

“The study speaks to the importance of not treating to remission or the expectation that patients will come off medications, but rather to treat to goal and use surgery as a tool to help carefully selected patients,” said Dr. Ikramuddin, MD. Also, while intensive medical management “is a lot of work,” the findings show it can improve outcomes even in patients with severe diabetes, he said.

Effects on Comorbid Metabolic Risk Factors

A total of 120 patients with diabetes (BMI, 30-39.9) were randomized to gastric bypass or lifestyle-intensive medical management. The patients had inadequate glycemic control (hemoglobin A1C, ≥8.0%) despite previous treatment with standard medical therapy.

At 1 year, 28 patients (49%) in the surgical group and 11 patients (19%) in the control group achieved the composite triple endpoint of A1C <7.0%, LDL cholesterol <100 mg/dL, and systolic blood pressure <130 mmHg (odds ratio, 4.8). Patients in the surgical group required approximately 3 fewer medications (mean, 1.7 vs 4.8). Regression analysis suggested that weight loss was primarily responsible for achieving the composite goal in both groups.

“The study showed that weight loss appeared to be a big driver of success. That is very exciting because we saw those results very positively in both the surgical and medical group. It is just that the surgical group lost so much more weight,” Dr. Ikramuddin said. Participants in the gastric bypass group lost 26.1% of their initial body weight compared with a weight loss of 7.9% in the lifestyle-medical management group.

While previous studies have shown similar findings, “One of the advantages of this trial is that it was prospective,” commented Walter Pories, MD, Professor of Surgery and Director of the Metabolic Institute, East Carolina University, Greenville, North Carolina. “Also, it is interesting that the authors included people from two countries—the United States and Taiwan—because quite often Asians have a very different relationship to diabetes than Caucasians. A number of Asians are much lighter in terms of weight, yet have a high rate of diabetes. The authors distributed Asians and Caucasians equally in both groups, so that is important,” Dr. Pories said.

Weighing the Risks and Benefits of Surgery

Serious adverse events occurred in 22 patients in the surgical group and 15 in the control group. One bariatric surgery patient experienced a leak that was not immediately apparent and resulted in brain damage and lower extremity amputation. Dr. Ikramuddin noted that these adverse events “need to be factored into the equation before a policy decision is made.”

“I respect them for being so honest,” Dr. Pories said commenting on the patient who experienced brain damage. “We’ve performed bariatric surgery on more than 9,000 patients and I don’t recall a patient who has had a brain injury. So that is a rather unusual complication. But whether we say it is unusual or not, the fact is that it is there.”

The overall findings are “very encouraging,” said Melinda Maggard-Gibbons, MD, a surgeon at the David Geffen School of Medicine at the University of California, Los Angeles. “It is very forthcoming of Ikramuddin et al to detail the adverse event that occurred because we need to learn more about the associated risks of surgery in this population of diabetic patients, many of whom fell into the lower weight range at baseline (BMI <35). Larger sample sizes are needed to confirm that rates of severe adverse events are rare,” she added.

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