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Bariatric surgery yields greater metabolic benefits than intensive medical therapy

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February 12, 2018

Donald C. Simonson
Donald C. Simonson

Adults with type 2 diabetes and obesity assigned to Roux-en-Y gastric bypass were more likely to experience improvements in HbA1c and fasting plasma glucose as well as greater reductions in weight vs. those assigned to an intensive medical diabetes- and weight-management intervention, according to a study.

Donald C. Simonson, MD, MPH, ScD, of the division of endocrinology, diabetes and hypertension at Brigham and Women’s Hospital and Harvard Medical School, and colleagues evaluated data from the SLIMM-T2D study on 38 adults with obesity and type 2 diabetes (15 men; mean weight, 104 kg; mean BMI, 36.3 kg/m2, mean age, 52 years; mean HBA1c, 8.5%) randomly assigned to laparoscopic Roux-en-Y gastric bypass (RYGB; n = 19) or intensive medical diabetes- and weight-management (n = 19) to compare the effects on changes in weight, HbA1c and self-reported health status. Participants were followed for 3 years.

The medical intervention consisted of a multidisciplinary diabetes- and weight-management program incorporating diabetes medication adjustment to help with weight loss, a structured modified dietary intervention, individualized exercise program, cognitive behavioral intervention and group education.

“It is important to emphasize that gastric bypass surgery and the medical/lifestyle intervention program are both routinely available to patients at our medical center, and comparable programs exist at many other hospitals and health care facilities,” Simonson told Endocrine Today.

Forty-two percent of the RYGB group achieved HbA1c less than 6.5% and FPG less than 126 mg/dL, whereas none of the medical intervention group achieved those goals (P = .005) at 3 years.

More participants in the RYGB group achieved HbA1c less than 7% compared with the medical intervention group (58% vs. 11%; P = .011). At the end of year 1, change of HbA1c –1.97% was achieved in the RYGB group and was sustained at 3 years (–1.79%), whereas change in HbA1c in the medical intervention group did not differ from baseline at any time from year 1 to year 3. The RYGB group had greater changes in weight at year 3 compared with the medical intervention group (change of –24.9 kg vs. –5.2 kg; P < .001).

No differences existed between the two groups for self-reported health status assessed by the SF-36 survey for improvements in the total, physical component and mental component scores during the 3 years. Similarly, scores on the Problem Areas in Diabetes questionnaires improved without differences between the groups. The RYGB group reported better improvements on the Impact of Weight on Quality of Life instrument compared with the medical intervention group (P < .001), particularly in the domains of physical functioning, self-esteem and work performance.

“Our study adds to a growing body of work showing metabolic and cardiovascular benefits of RYGB, even compared with an intensive multidisciplinary, multimodality medical diabetes and weight intervention,” the researchers wrote. “Our randomized trial also adds to the relatively scant existing data to support use of metabolic surgery in surgically appropriate patients with less severe-grade obesity and supports the recent American Diabetes Association guidelines to consider metabolic surgery in this setting. While surgery is not without adverse events, improved patient-reported outcomes provide further evidence that serious consideration be given to RYGB for treatment of diabetes in obese patients. Finally, our study demonstrates the relative importance of weight compared with other metabolic measures on the patient’s perception of quality of life.” – by Amber Cox

For more information:

Donald C. Simonson, MD, MPH, ScD, can be reached at dsimonso@hsph.harvard.edu.

Disclosures: Simonson reports he serves on advisory panels for GI Windows and Medtronic. Please see the study for all other authors’ relevant financial disclosures.

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Charles Billington
Perspective

Simonson and colleagues report on the 3-year outcomes in a randomized trial comparing Roux-en-Y gastric bypass to intense lifestyle and medical management. Similar to other reports, they found better blood sugar control with gastric bypass and inconsistent effects on blood pressure and lipids. Also, similar to other reports, the glycemic improvement from gastric bypass was significant at 3 years, but less than had been seen at 1 year. Gastric bypass patients had more adverse events. What this report adds is an assessment that shows improved quality of life, particularly on weight-related indices, among the gastric bypass patients. For patients and their doctors considering gastric bypass to improve blood sugar control, improved quality of life may increase the value of the surgical approach.

Charles J. Billington, MD

Chief, Section of Endocrinology and Metabolism
Minneapolis VA Health Care System
Professor of Medicine University of Minnesota in Minneapolis

Disclosure: Billington reports he is a consultant for Novo Nordisk, Optum and ReShape.