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Nearly 25% of patients maintain diabetes control 5 years after obesity surgery
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Among adults prescribed intensive lifestyle and medical management for obesity, those who also underwent Roux-en-Y gastric bypass surgery were more likely to achieve healthy HbA1c, LDL cholesterol and systolic blood pressure targets at 5 years, according to study results.
“Whether the gastric bypass surgery is an appropriate treatment for diabetes is a matter of perspective,” Charles J. Billington, MD, chief, section of endocrinology and metabolism at Minneapolis VA Health Care System and professor of medicine at the University of Minnesota in Minneapolis, told Endocrine Today. “The improvement in achievement of the triple endpoint is significant, but may not be large enough to warrant the adverse events. The surgery group did get better blood sugar control at the price of more adverse events.”
Billington and colleagues evaluated 120 adults (mean age, 49 years; 60% women) with HbA1c at least 8% and BMI between 30 kg/m2 and 39.9 kg/m2 to compare the durability of Roux-en-Y gastric bypass (RYGB) added to intensive lifestyle and medical management in achieving the composite triple endpoint of HbA1c less than 7%, LDL cholesterol less than 100 mg/dL and systolic BP less than 130 mm Hg. Follow-up was 5 years.
Participants were randomly assigned to lifestyle intervention and intensive medical management (n = 60) or RYGB in addition to lifestyle intervention and intensive medical management (n = 60).
At 1 year, the composite endpoint was achieved by 50% of the RYGB group and 16% of the intensive management group (P = .003). At 5 years, the composite endpoint was achieved by 23% of the RYGB group and 4% of the intensive management group (P = .01).
More participants in the RYGB group achieved HbA1c less than 7% compared with the intensive management group at 5 years (55% vs. 14%; P = .002). The RYGB was also more likely to achieve LDL cholesterol less than 100 mg/dL (77% vs. 47%; P = .02) and systolic BP less than 130 mm Hg (73% vs. 49%; P = .06) at 5 years.
More adverse events occurred in the RYGB group than in the intensive management group (66 events vs. 38 events) and were most frequently gastrointestinal events and surgical complications.
“We wanted to know if adding gastric bypass to intensive lifestyle and medical therapy would improve overall diabetes treatment as represented by the triple endpoint of blood sugar, blood pressure and cholesterol control,” Billington said. “We found that adding gastric bypass did provide significant benefit at 5 years after surgery, but that the size of the benefit declined substantially from the first to the fifth year. We also found that gastric bypass did provide significantly better blood sugar control throughout the 5 years, but the rate of diabetes remission at 5 years was low. There were many more adverse events in the gastric bypass group.”
Billington said longer follow-up periods and analyses of baseline patient characteristics are needed to determine durability of any diabetes benefit and for whom. – by Amber Cox
For more information:
Charles J. Billington , MD, can be reached at billi005@umn.edu.
Disclosures: Billington reports he receives consulting fees from Novo Nordisk, Optum and ReShape. The study was supported by an unrestricted grant from Covidien (now Medtronic). Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Five-year outcomes from the Diabetes Surgery Study by Ikramuddin and colleagues were published in JAMA. The study was a multicenter randomized control trial of 120 patients with type 2 diabetes with moderate obesity (mean BMI 35 kg/m2) randomly assigned to gastric bypass and intensive lifestyle therapy vs. intensive lifestyle therapy alone. The primary outcome was the rate of achieving American Diabetes Association standards for glycemic, lipid and blood pressure control as a triple composite outcome. The results at 5 years demonstrate that 23% of gastric bypass patients vs. only 4 % in the non-surgical group achieved the primary endpoint. Moreover, 55% of the gastric bypass patients achieved HbA1c less than 7% vs. 14% in the non-surgical group. As expected, there were greater frequencies of gastrointestinal events and surgical complications and nutritional deficiencies noted in the gastric bypass group vs. the non-surgical group.
This trial has significant clinical implications for the treatment of type 2 diabetes in the setting of class II obesity, both of which herald high cardiovascular risk and renal disease. We expect that the better long-term control of glucose, lipids and BP and the need for fewer CV and diabetes agents will ultimately result in lower CVD-related morbidity and microvascular complications in patients with type 2 diabetes. Future studies are warranted to examine the incidence of diabetes complications from bariatric surgery. Although gastric bypass is associated with significant adverse events and nutritional deficiencies, when performed in high-volume centers in multidisciplinary teams, good outcomes can be expected for patients with type 2 diabetes. Bottom line: Bariatric surgery lowers CV risk in patients with obesity and type 2 diabetes over intensive lifestyle therapy and is indicated for medically refractory patients.
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