Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes

Study Questions:

What are the rates of remission for type 2 diabetes mellitus (T2DM) with surgical and nonsurgical treatments?

Methods:

This was a three-arm randomized clinical trial conducted at the University of Pittsburgh Medical Center from October 1, 2009, to June 26, 2014. Outcomes were assessed 3 years after treating 61 obese participants aged 25-55 years with T2DM. Analysis was conducted with an intent-to-treat population. Participants were randomized to either an intensive lifestyle weight loss intervention for 1 year, followed by a low-level lifestyle intervention for 2 years, or surgical treatments (Roux-en-Y gastric bypass [RYGB] or laparoscopic adjustable gastric banding [LAGB], followed by low-level lifestyle intervention in years 2 and 3. Primary endpoints were partial and complete T2DM remission, and secondary endpoints included diabetes medications and weight change.

Results:

Body mass index was <35 kg/m2 for 26 participants (43%): 50 (82%) were women, and 13 (21%) were African American. Mean (standard deviation) values were 100.5 (13.7) kg for weight, 47.3 (6.6) years for age, 7.8% (1.9%) for glycated hemoglobin level, and 171.3 (72.5) mg/dl for fasting plasma glucose level. Partial or complete T2DM remission was achieved by 40% (n = 8) of RYGB, 29% (n = 6) of LAGB, and no intensive lifestyle weight loss intervention participants (p = 0.004). The use of diabetes medications was reduced more in the surgical groups than the lifestyle intervention-alone group, with 65% of RYGB, 33% of LAGB, and none of the intensive lifestyle weight loss intervention participants going from using insulin or oral medication at baseline to no medication at year 3 (p < 0.001). Mean (standard error) reductions in percentage of body weight at 3 years were the greatest after RYGB at 25.0% (2.0%), followed by LAGB at 15.0% (2.0%) and lifestyle treatment at 5.7% (2.4%) (p < 0.01).

Conclusions:

The authors concluded that among obese participants with T2DM, bariatric surgery with 2 years of an adjunctive low-level lifestyle intervention resulted in more disease remission than did lifestyle intervention alone.

Perspective:

This study reports that among obese participants with T2DM, bariatric surgery with 2 years of an adjunctive low-level lifestyle intervention was more effective in disease remission than lifestyle intervention alone. The use of diabetes medications was reduced more in the surgical groups than the lifestyle intervention-alone group, and none of the intensive lifestyle weight loss intervention participants went from using medication at baseline to no medication at year 3. It appears that at longer-term follow-up of 3 years, surgical treatments, including RYGB and LAGB, are superior to lifestyle intervention alone for the remission of T2DM in obese individuals. The impact of these treatments on long-term microvascular and macrovascular complications requires further study, but it seems reasonable to consider bariatric surgery in all severely obese patients with T2DM.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention

Keywords: Bariatric Surgery, Body Mass Index, Body Weight, Diabetes Mellitus, Type 2, Gastric Bypass, Hemoglobin A, Glycosylated, Insulin, Life Style, Metabolic Syndrome X, Obesity, Primary Prevention, Weight Loss, Weight Reduction Programs


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