In the JournalsPerspective

Diabetes, hypertension remission greater among teens vs. adults after bariatric surgery

Adolescents with severe obesity were 27% more likely than adults with obesity to experience type 2 diabetes remission 5 years after undergoing Roux en Y gastric bypass, as well as 51% more likely to experience hypertension remission vs. adults, according to findings published in The New England Journal of Medicine.

Thomas Inge

“I hope these findings lead to less bias against using these kinds of therapies for teenagers,” Thomas Inge, MD, PhD, associate surgeon-in-chief for research, professor and director of pediatric surgery and founder of the adolescent bariatric surgery center at Children’s Hospital Colorado in Aurora, told Endocrine Today. “We have repeatedly heard from insurers who are denying coverage for bariatric surgery, even when a family has benefits for bariatric surgery, because their internal guidelines don’t recognize teenagers. I hope this moves the needle a bit to provide more access to the care that adolescents need. They not only lose similar amounts of weight on average when compared with adults — weight loss that is durable over time — but we are now finding that there is a better opportunity to make them healthier vs. when we use these same therapies in adults.”

For the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study, Inge and colleagues analyzed data from 161 adolescents with severe obesity (mean baseline BMI, 50 kg/m²; mean age, 17 years; 78% girls) and compared their data with those from the LABS study on 396 adults (baseline BMI, 50 kg/m²; mean age, 38 years; 76% women) who reported having had obesity since at least age 18 years. Both groups underwent Roux-en-Y gastric bypass for the treatment of severe obesity — teens between 2006 and 2012 and adults between 2006 and 2009. Researchers used linear mixed and Poisson mixed models to compare weight and coexisting conditions between the cohorts 5 years after surgery, as well as rates of death, subsequent abdominal operations and selected micronutrient levels up to 2 years after surgery.

During the 5-year study, 96% of adolescents and 96% of adults remained as active study participants, according to researchers. At baseline, 14% of adolescents and 31% of adults had type 2 diabetes; 57% of adolescents and 68% of adults used antihypertensive medications at baseline.

At 5 years, there was no between-group difference in mean percent weight change for adolescents vs. adults (–26% vs. –29%), with 60% of adolescents and 76% of adults maintaining a weight reduction of at least 20% (P = .02) during the study period.

Among participants with type 2 diabetes at baseline, 86% of adolescents and 53% of adults no longer met the criteria for diabetes at 5 years. The percentage of participants using antidiabetes medications declined from 88% to zero for adolescents and from 79% to 26% for adults (P < .001), according to researchers. In adjusted analyses, adolescents were 27% more likely vs. adults to experience diabetes remission after surgery (RR = 1.27; 95% CI, 1.03-1.57).

Among participants with hypertension at baseline, 68% of adolescents and 41% of adults were in remission at 5 years. In adjusted analyses, adolescents were 51% more likely to experience hypertension remission after surgery vs. adults (RR = 1.51; 95% CI, 1.21-1.88).

“Treatments that can reverse type 2 diabetes early in life should save lives in the long run,” Inge said. “We know type 2 diabetes, when it appears in childhood, cuts the life expectancy for these individuals.”

In a press release announcing the findings, Phil Zeitler, MD, PhD, chair of endocrinology at Children’s Hospital Colorado and study chair of the TODAY study, called the surgical findings encouraging.

“Adolescents with type 2 diabetes treated with medications rarely experience reversal of their disease and more commonly experience progression of the diabetes,” Zeitler said in the release. “Progression of diabetes includes development of the complications of diabetes, such as cardiovascular disease, kidney disease, poor circulation, nerve damage and blindness.”

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Adolescents with severe obesity were 27% more likely than adults with obesity to experience type 2 diabetes remission 5 years after undergoing Roux en Y gastric bypass, as well as 51% more likely to experience hypertension remission vs. adults.

Deaths, complications

In the 5 years after surgery, three adolescents and seven adults died (1.9% vs. 1.8%). Among adolescents, causes were not attributed to bariatric surgery; three adults deaths were related to the procedure, all occurring within 2 weeks of surgery, according to researchers.

Adolescents were more likely to require abdominal reoperations vs. adults (19 vs. 10 reoperations per 500 person-years; P = .003). Additionally, at 2 years, 48% of adolescents and 29% of adults had low ferritin levels (P = .004).

In commentary accompanying the study, Ted D. Adams, PhD, MPH, program and research director at the Intermountain Live Well Center in Salt Lake City, wrote that the negative health outcomes of bariatric surgery reported in adolescents mirror those observed in adults, including an increased risk for alcohol or drug abuse, and that the decision to undergo surgery should be carefully considered.

“Adolescent patients may not have fully developed the capacity for decision-making, especially about a procedure that will have lifetime consequences,” Adams wrote. “The current data are incomplete, though long-term data on bariatric surgery in adolescents are beginning to emerge. ... For now, while we hope to identify new, effective and less-invasive therapies and effective adjuncts to bariatric surgery in adolescents, decisions should be made on a case-by-case basis, with the knowledge that the 5-year data look promising but that the lifetime outcome is unknown.” – by Regina Schaffer

For more information:

Thomas Inge, MD, PhD, can be reached at Children’s Hospital Colorado, Department of Surgery, 13123 E. 16th Ave., Box 323, Aurora, CO 80045; email: thomas.inge@ucdenver.edu.

Disclosures : Inge reports he has received grants from the NIH as well as personal fees from Biomedical Insights, Independent Medical Expert Consulting Services, L&E Research, Standard Bariatrics, UpToDate and Zafgen Corporation. Please see the study for all other authors relevant financial disclosures. Adams reports he has received research grants from Ethicon Endo-Surgery, the Intermountain Research Foundation and the NIH.

Adolescents with severe obesity were 27% more likely than adults with obesity to experience type 2 diabetes remission 5 years after undergoing Roux en Y gastric bypass, as well as 51% more likely to experience hypertension remission vs. adults, according to findings published in The New England Journal of Medicine.

Thomas Inge

“I hope these findings lead to less bias against using these kinds of therapies for teenagers,” Thomas Inge, MD, PhD, associate surgeon-in-chief for research, professor and director of pediatric surgery and founder of the adolescent bariatric surgery center at Children’s Hospital Colorado in Aurora, told Endocrine Today. “We have repeatedly heard from insurers who are denying coverage for bariatric surgery, even when a family has benefits for bariatric surgery, because their internal guidelines don’t recognize teenagers. I hope this moves the needle a bit to provide more access to the care that adolescents need. They not only lose similar amounts of weight on average when compared with adults — weight loss that is durable over time — but we are now finding that there is a better opportunity to make them healthier vs. when we use these same therapies in adults.”

For the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study, Inge and colleagues analyzed data from 161 adolescents with severe obesity (mean baseline BMI, 50 kg/m²; mean age, 17 years; 78% girls) and compared their data with those from the LABS study on 396 adults (baseline BMI, 50 kg/m²; mean age, 38 years; 76% women) who reported having had obesity since at least age 18 years. Both groups underwent Roux-en-Y gastric bypass for the treatment of severe obesity — teens between 2006 and 2012 and adults between 2006 and 2009. Researchers used linear mixed and Poisson mixed models to compare weight and coexisting conditions between the cohorts 5 years after surgery, as well as rates of death, subsequent abdominal operations and selected micronutrient levels up to 2 years after surgery.

During the 5-year study, 96% of adolescents and 96% of adults remained as active study participants, according to researchers. At baseline, 14% of adolescents and 31% of adults had type 2 diabetes; 57% of adolescents and 68% of adults used antihypertensive medications at baseline.

At 5 years, there was no between-group difference in mean percent weight change for adolescents vs. adults (–26% vs. –29%), with 60% of adolescents and 76% of adults maintaining a weight reduction of at least 20% (P = .02) during the study period.

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Among participants with type 2 diabetes at baseline, 86% of adolescents and 53% of adults no longer met the criteria for diabetes at 5 years. The percentage of participants using antidiabetes medications declined from 88% to zero for adolescents and from 79% to 26% for adults (P < .001), according to researchers. In adjusted analyses, adolescents were 27% more likely vs. adults to experience diabetes remission after surgery (RR = 1.27; 95% CI, 1.03-1.57).

Among participants with hypertension at baseline, 68% of adolescents and 41% of adults were in remission at 5 years. In adjusted analyses, adolescents were 51% more likely to experience hypertension remission after surgery vs. adults (RR = 1.51; 95% CI, 1.21-1.88).

“Treatments that can reverse type 2 diabetes early in life should save lives in the long run,” Inge said. “We know type 2 diabetes, when it appears in childhood, cuts the life expectancy for these individuals.”

In a press release announcing the findings, Phil Zeitler, MD, PhD, chair of endocrinology at Children’s Hospital Colorado and study chair of the TODAY study, called the surgical findings encouraging.

“Adolescents with type 2 diabetes treated with medications rarely experience reversal of their disease and more commonly experience progression of the diabetes,” Zeitler said in the release. “Progression of diabetes includes development of the complications of diabetes, such as cardiovascular disease, kidney disease, poor circulation, nerve damage and blindness.”

#
Adolescents with severe obesity were 27% more likely than adults with obesity to experience type 2 diabetes remission 5 years after undergoing Roux en Y gastric bypass, as well as 51% more likely to experience hypertension remission vs. adults.

Deaths, complications

In the 5 years after surgery, three adolescents and seven adults died (1.9% vs. 1.8%). Among adolescents, causes were not attributed to bariatric surgery; three adults deaths were related to the procedure, all occurring within 2 weeks of surgery, according to researchers.

Adolescents were more likely to require abdominal reoperations vs. adults (19 vs. 10 reoperations per 500 person-years; P = .003). Additionally, at 2 years, 48% of adolescents and 29% of adults had low ferritin levels (P = .004).

In commentary accompanying the study, Ted D. Adams, PhD, MPH, program and research director at the Intermountain Live Well Center in Salt Lake City, wrote that the negative health outcomes of bariatric surgery reported in adolescents mirror those observed in adults, including an increased risk for alcohol or drug abuse, and that the decision to undergo surgery should be carefully considered.

“Adolescent patients may not have fully developed the capacity for decision-making, especially about a procedure that will have lifetime consequences,” Adams wrote. “The current data are incomplete, though long-term data on bariatric surgery in adolescents are beginning to emerge. ... For now, while we hope to identify new, effective and less-invasive therapies and effective adjuncts to bariatric surgery in adolescents, decisions should be made on a case-by-case basis, with the knowledge that the 5-year data look promising but that the lifetime outcome is unknown.” – by Regina Schaffer

PAGE BREAK

For more information:

Thomas Inge, MD, PhD, can be reached at Children’s Hospital Colorado, Department of Surgery, 13123 E. 16th Ave., Box 323, Aurora, CO 80045; email: thomas.inge@ucdenver.edu.

Disclosures : Inge reports he has received grants from the NIH as well as personal fees from Biomedical Insights, Independent Medical Expert Consulting Services, L&E Research, Standard Bariatrics, UpToDate and Zafgen Corporation. Please see the study for all other authors relevant financial disclosures. Adams reports he has received research grants from Ethicon Endo-Surgery, the Intermountain Research Foundation and the NIH.

    Perspective
    Steven B. Heymsfield

    Steven B. Heymsfield

    The study could serve as milestone in terms of identifying a treatment option for what I consider really severe obesity — a BMI of 50 kg/m² in some cases. This is a very important piece of work showing what can be done for children with a high mortality risk disease.

    The remission rates reported here for hypertension and type 2 diabetes are impressive. The longer you have morbid obesity, the greater the long-term risk for conditions like heart failure. Early intervention is critical. However, having worked with pediatricians, there is a huge amount of sensitivity in that age group. Gastric bypass in adolescents is not trivial. This is a major procedure with lifelong effects, and that gives people pause. There is a 1% to 2% mortality rate. If it was my child, I would be thinking long and hard about going through with it.

    If you look at the follow-up BMI data for these adolescents, it is around 37 kg/m². They are not “cured” of obesity, they are just no longer morbidly obese after surgery. I would like to see longer-term data on the outcomes of this cohort.

    • Steven B. Heymsfield, MD, FTOS
    • Professor,
      Department of Metabolism and Body Composition,
      Pennington Biomedical Research Center,
      Louisiana State University
      President, The Obesity Society

    Disclosures: Heymsfield reports he serves on an advisory board for Medifast.