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Weight Loss Surgery More Successful Than Usual Care in Treatment of Type 2 Diabetes

Diabetic patients who received bariatric surgery saw greater weight loss and fewer macrovascular and microvascular complications than those treated with usual care…. 

Swedish researchers reported in a study that fifteen years after having bariatric surgery, 30% of patients were no longer considered diabetic compared to only 7% of patients who received usual care.

Of patients recruited between September 1987 and January 2001, 260 of 2,037 control patients and 343 of 2,010 bariatric surgery patients had type 2 diabetes at baseline. The bariatric surgery patients had either vertical banded gastroplasty, non-adjustable or adjustable banding, or Roux-en-Y gastric bypass. The patients had a mean age of 50, a BMI of 41, 60% were women, and all participants chosen had had type 2 diabetes for an average of 3 years. Primary endpoints measured were diabetes remission, relapse, and incidence of diabetes related complications. Remission was characterized as having a fasting blood glucose level below 110mg/dL and not taking any antidiabetic medications. Study limitations were lack of randomization and a significant loss of participants after 15 years.

Patients in the control group received normal lifestyle and pharmacological treatment for both obesity and diabetes at their primary health facility. Both groups had identical follow-up throughout the study.

Those patients who received bariatric surgery had higher remission rates (30% vs 7% at 15 years) and greater weight loss (22.5kg vs 4.4kg at 10 years) as compared with those who received usual care. However, one thing to note was that 2 years post-surgery, 72% of patients were in remission. This tells us that a significant number of patients relapsed.

Bariatric surgery was also associated with a decreased risk for macrovascular (31.7 vs 44.2 in 1000 patients) and microvascular complications (20.6 vs 41.8 per 1000 patients). The study cited that bariatric surgery was associated with a 20 year reduced incidence of myocardial infarction. Tight glycemic control with lifestyle changes and pharmacologic treatment may reduce the incidence of microvascular disease but this kind of control is hard for many patients to achieve. Lifestyle changes have not statistically reduced diabetes-associated macrovascular disease.

Dr. Anne Cappola, from the Perelman School of Medicine at the University of Pennsylvania and an associate editor for JAMA believes these findings "validate the expectations of bariatric surgery."

Practice Pearls:
  • Bariatric surgery was associated with more frequent remission and fewer complications in patients with type 2 diabetes than usual care.
  • Due to ethical considerations a randomized design was not approved because of high post-op mortality rates in preceding bariatric surgeries and therefore brings in some questions as to the validity of the study.
  • Data on complications associated with diabetes was limited in the study and only included complications severe enough to be treated by a specialist and not more minor complications that were treated by primary care.

Sjostrom, Lars MD, Peltonen, Markku PhD, Jacobson, Peter MD, et al. Association of Bariatric Surgery With Long-term Remission of Type 2 Diabetes and With Microvascular and Macrovascular Complications. JAMA. 2014;311(22):2297-2304.