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Determinants of the Resolution of Type 2 Diabetes After Bariatric Surgery
Abstract
Background: The association between body mass index (BMI) and the development of type 2 diabetes (T2DM) is well established. The determinants of the resolution of T2DM with weight reduction after bariatric surgery, however, are not fully understood. Objective: Examine the course of T2DM during weight loss after bariatric surgery. Methods: Through a retrospective chart review, 56 morbidly obese, diabetic patients who underwent bariatric surgery were followed for 12 months. Resolution of T2DM was defined as an initial elevated glycohemoglobin (HbA1C) > 6.0% that decreased to < 6.0% with weight loss allowing discontinuation of all diabetic medication. Results: Of the 56 with T2DM, 31 (55.4%) resolved T2DM. The mean age ± SD was 49.0 ± 7.3 and 53.1 ± 7.0 years for resolved and persistent T2DM, respectively (p = 0.04). The baseline BMI was higher in the resolved group, measuring, 51.3 ± 8.3 kg/m2 compared with the persisted group of 46.5 ± 4.9 kg/m2, p = 0.02. The final BMI was 33.6 ± 7.6 kg/m2 and 33.9 ± 5.2 kg/m2, p = 0.87 for the resolved and persistent cases, respectively. The absolute and relative reductions in BMI were -17.6 ± 3.6 kg/m2 and -12.6 ± 6.3 kg/m2, p < 0.0001; and -34.7 ± 6.3% and -26.6 ± 11.9%, p = 0.002, over a mean duration of 12.9 ± 1.4 and 10.8 ± 5.2 months for resolved and persistent cases, respectively. Multiple logistic regression found factors such as a higher baseline BMI, p = 0.006, and lower final BMI, p = 0.03, were independent predictors of the resolution of T2DM while lower baseline HbA1C, p = 0.09, approached significance. There was a spike in HbA1C at 6 weeks in those with resolution of T2DM while there was a curvilinear decline in HbA1C in persistent T2DM with failure to normalize. Conclusions: Resolution of T2DM after bariatric surgery is a dynamic process and is associated with substantial weight loss and good glycemic control during the pre- and post-operative periods beyond 6 weeks.
Bariatric surgery is effective in the management of type 2 diabetes (T2D) and obesity; however, it is not clear whether Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG) is the most effective procedure. This review compared T2D remission and weight loss in patients with T2D after GBP or SG. All human SG or GBP studies published in English between 1 Jan 2007 and 30 April 2012 reporting on BMI and T2D outcomes were included. Analyses were performed separately for the most frequent distinct time points reported after surgery. A total of 21 prospective (three randomised control trials) and 12 retrospective studies, involving 1375 patients met eligibility criteria. T2D remission defined by hemoglobin A1c of <6.5 % for GBP and SG respectively was 67 and 56 % at 3 months, 76 and 68 % at 12 months, and 81 and 80 % at 36 months. Greater percent excess BMI loss occurred at 12 months (72.5 % after GBP and 66.7 % after SG) compared with 3 months (45.9 % after GBP and 25.9 % after SG). There was no significant difference in either T2D remission or weight loss with GBP compared with SG. Both GBP and SG result in similar early remission of T2D in 67 and 56 % of patients at 3 months respectively with modest additional T2D remission with time, although weight loss with both procedures increase substantially between 3 and 12 months post-operatively. Further randomised controlled trials comparing SG and GBP in patients with T2D using comparable definitions of diabetes remission with long-term follow-up are needed to evaluate relative benefits.
Weight loss favorably modifies most cardiovascular risk factors, in particular the diagnostic criteria for metabolic syndrome, type 2 diabetes mellitus, and hypertension. Treating the spectrum of diabetes by promoting disease control or resolution invariably improves cardiovascular outcomes. However, in clinical trials and routine medical practice, long-term weight loss has been difficult to achieve due to wavering patient motivation, inadequate resources, ineffective medical treatments, lack of psychosocial support, recidivism, or combinations thereof. The issue is not information but rather methods, motivation, and behavioral changes. This article reviews surgical and nonsurgical methods of weight loss and their impact on cardiovascular risk factors, especially the resolution of type 2 diabetes mellitus, and the implications for cardiovascular event reduction in patients with morbid obesity.
BACKGROUND: Control of hyperglycemia in diabetes mellitus through diet, exercise, oral hypoglycemics and insulin has underlined the medical treatment for that disease. Morbidly obese diabetics can be more successfully rendered euglycemic if their excess body weight is reduced and their diets are carefully controlled. METHODS: Roux-en-Y Gastric Bypass has been used as a weight control measure for 205 morbidly obese diabetics over an 8-year period, 1988-1995. Early follow-up has been possible in all patients up to 3 months, and late follow-up has been achieved by phone contact and office visits in 133 patients. RESULTS: Operative mortality occurred in 1/205 patients (0.49%). Major operative morbidity occurred in 14/205 (6.8%). While 46/133 (35%) patients were on insulin preoperatively, only 11/133 (8%) have remained on insulin and 9/11 at lower doses. 64/133 (48%) were on oral hypoglycemics, but only 8/133 (6%) continue their use. 23/133 (17%) were on diet alone or no treatment before surgery, and 91/133 (68%) claimed diet alone or no treatment after surgery. The long-term mean % Excess Body Weight Loss is 55%. CONCLUSIONS: Morbidly obese diabetics undergoing Roux-en-Y Gastric Bypass can experience markedly diminished need for insulin and oral hypoglycemics to control hyperglycemia.
We sought to examine the relationship of body mass index (BMI) at age 18 years with the degree and rate of rise in body weight during adulthood among the morbidly obese. We evaluated 196 patients with a standard medical history form and a structured interview with questions regarding weight at age 18 years. The study included 40 (20.4%) men and 156 (79.6%) women. The mean BMI was 50.2+/-8.0 kg/m2, range 37.0-80.0 kg/m2. Based on self-reported weight, 133 (67.9%) were overweight/obese (BMI >25 kg/m2) and 68 (34.7%) were obese (BMI > or =30 kg/m2) at age 18 years. The distribution of cumulative weight gain was normal with a mean of 60.8+/-23.7 kg. There was a positive relationship (r=0.36, p<0.0001) between BMI at age 18 years and BMI in adulthood at a mean of 44+/-10.6 years. Independent predictors for cumulative adult weight gain were BMI at age 18 years (p<0.0001); women (p<0.0001); African Americans (p=0.05). These data suggest that modestly overweight young adults can have excessive weight gains during adult life, resulting in morbid obesity and high rates of obesity-related comorbidities.