Patients Continue to Experience Benefits 3 Years After Weight-Loss Surgery for Severe Obesity

Anita P. Courcoulas, MD, MPH, director of Minimally Invasive Bariatric and General Surgery at the University of Pittsburgh Medical Center, and colleagues found that 3 years after undergoing bariatric surgery for severe obesity, patients had, on average, lost a substantial amount of weight and improved on several health measures. (Image: University of Pittsburgh Medical Center)

Anita P. Courcoulas, MD, MPH, director of Minimally Invasive Bariatric and General Surgery at the University of Pittsburgh Medical Center, and colleagues found that 3 years after undergoing bariatric surgery for severe obesity, patients had, on average, lost a substantial amount of weight and improved on several health measures. (Image: University of Pittsburgh Medical Center)

More encouraging data are emerging on the benefits of bariatric surgery in reducing substantial amounts of weight and improving health in severely obese patients, according to a study published by JAMA.

Researchers with the Longitudinal Assessment of Bariatric Surgery Consortium, a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse regions of the country looked at health measures for severely obese patients 3 years after weight-loss surgery. Patients who had undergone Roux-en-Y gastric bypass surgery had lost about 90 pounds, or about 30% of their original weight; those who had undergone laparoscopic adjustable gastric banding lost about 44 pounds, or about 16% of their original weight. The median presurgical weight for both groups was about 284 pounds.

The researchers also found among study participants who had diabetes at the time of surgery, partial remission of the disease occurred in about two-thirds of those undergoing Roux-en-Y bypass and just over a quarter of those undergoing gastric banding. Abnormal blood lipid levels were eliminated in about 62% of patients after Roux-en-Y bypass and in about 27% after gastric banding. Hypertension resolved in almost 40% of patients with Roux-en-Y bypass and in almost 20% of patients with gastric banding.

Lead author Anita P. Courcoulas, MD, MPH, director of Minimally Invasive Bariatric and General Surgery at the University of Pittsburgh Medical Center, discusses her team’s findings.

news@JAMA: Why did you do the study?

Dr Courcoulas: Our focus was to look at the durability of weight and health changes after bariatric surgery in a carefully studied, heterogeneous population with a high degree of follow-up.

news@JAMA: These patient populations had different results based on the procedure performed. Why is that?

Dr Courcoulas: Our study didn’t specifically address the potential mechanisms of weight change, nor was it designed to make head-to-head procedure comparisons. In our study, both bypass and banding did lead to substantial weight loss at 3 years that compares favorably to the modest weight loss resulting from lifestyle intervention alone. The weight loss after banding was less than reported in previous studies and not as large as the weight loss after bypass. This may be a function of patient, provider, and/or many other factors and deserves further attention.

news@JAMA: Given that Roux-en-Y bypass appears to outperform gastric banding, why not have everyone who needs bariatric surgery receive the bypass?

Dr Courcoulas: There are patients who come to see a bariatric surgeon who are not comfortable with bypass because of the anatomical changes they will undergo, so banding is appealing for those still wanting help to lose weight.

news@JAMA: So is bariatric surgery the best option for severely obese individuals looking to lose weight and improve health measures?

Dr Courcoulas: The extreme heterogeneity in outcomes we found highlights the need to better understand factors contributing to individual differences in weight loss results. It would make sense if one of the important variables in determining how much weight one will lose and how well that weight loss is maintained is lifestyle modification—how do you make the most of an operation to help enhance those results? Even so, longer-term follow-up is needed to determine the durability of the weight and health improvements we observed.

Bariatric Surgery Achieves Long-term Diabetes Remission in Some Patients, Study Shows

Roux-en-Y gastric bypass surgery is more likely than other bariatric surgical procedures to reverse diabetes in obese patients who have the condition, according to a new study. (Image: JAMA, ©AMA)

Roux-en-Y gastric bypass surgery is more likely than other bariatric surgical procedures to reverse diabetes in obese patients who have the condition, according to a new study. (Image: JAMA, ©AMA)

Bariatric surgery can reverse type 2 diabetes for more than 5 years in some obese patients who have the condition, according to new research.

The study, published online today in the Annals of Surgery, followed up 217 obese patients with type 2 diabetes for a median of 6 years after they had bariatric surgery. Patients had 1 of 3 bariatric procedures: 162 had Roux-en-Y gastric bypass surgery, in which the size of the stomach is permanently reduced; 32 had gastric banding, which uses an adjustable band to narrow the opening from the esophagus to the stomach; and 23 had sleeve gastrectomy, in which much of the stomach is removed.

Overall, patients lost 55% of their excess weight and half of the patients had a complete or partial remission of their diabetes after the median 6-year follow-up period. Specifically, 24% of patients had a complete remission of their diabetes with a blood sugar level of less than 6% without diabetes medications. The American Diabetes Association (ADA) recommends a blood sugar level no higher than 7%.

An additional 26% of patients had a partial remission of their diabetes, and 34% had improved glycemic control. Cardiovascular risk factors decreased by 25%. Diabetic neuropathy improved in 53% of patients and stabilized in 47%.

The investigators also found that patients who had long-term weight loss, were diagnosed with diabetes less than 5 years before their surgery, and had gastric bypass surgery rather than the other 2 procedures were most likely to have sustained diabetes remission.

However, 19% of patients who achieved full or partial remission had a recurrence of their diabetes. Even so, those patients had improved glycemic control and cardiovascular risk factors compared with their status before surgery. The investigators noted that 75% of patients who had a recurrence still met the ADA goal of blood sugar levels less than 7%.

“Only about half of diabetics in the United States currently have acceptable control of their blood glucose level,” lead investigator Stacy Brethauer, MD, a bariatric surgeon at the Cleveland Clinic Bariatric and Metabolic Institute, said in a statement. “This study confirms that [Roux-en-Y gastric bypass surgery] can offer durable remission of diabetes in some patients and should be considered as an earlier treatment option for patients with uncontrolled diabetes.”

Author Insights: Gastric Bypass Surgery Plus Lifestyle-Intensive Medical Management May Improve Type 2 Diabetes Control

Sayeed Ikramuddin, MD, of the University of Minnesota in Minneapolis, and colleagues found gastric bypass surgery and adherence to intensive-lifestyle medical management (taking diabetes medication plus supervised dieting and exercise) helped patients in controlling their type 2 diabetes. (Image: University of Minnesota)

Sayeed Ikramuddin, MD, of the University of Minnesota in Minneapolis, and colleagues found gastric bypass surgery combined with medication and lifestyle modifications helped patients control their type 2 diabetes. (Image: University of Minnesota)

Shedding pounds is a key element to treating type 2 diabetes, but even with this motivation, many people who want to lose weight have difficulty doing so. Weight loss through Roux-en-Y gastric bypass surgery along with lifestyle-intensive medical management—diabetes medication plus supervised dieting and exercise—may help patients achieve lower blood pressure; lower glucose levels; and lower levels of “bad cholesterol,” low-density lipoprotein cholesterol (LDL-C). The findings appear today in JAMA.

The research involved 120 patients treated at 4 teaching hospitals in Minnesota and Taiwan who were randomly assigned to lifestyle-intensive medical management alone or coupled with Roux-en-Y gastric bypass surgery. All patients had type 2 diabetes for at least 6 months, a hemoglobin A1c (HbA1c) level of 8.0% or higher, and a body mass index (BMI) between 30.0 and 39.9. At 12 months, 49% of patients undergoing both interventions and 19% of those receiving only lifestyle-intensive medical management achieved the designated goals of an HbA1c of less than 7.0%, systolic blood pressure less than 130 mm Hg, and an LDL-C less than 100 mg/dL.

Achieving these goals was attributed to weight loss, with those who had surgery experiencing an average loss of about 26% compared with about 8% of those receiving only intensive-lifestyle medical management.

Lead author Sayeed Ikramuddin, MD, of the University of Minnesota in Minneapolis, discusses his team’s findings:

news@JAMA: Why did you do the study?

Dr Ikramuddin: Type 2 diabetes is an epidemic and difficult to treat. The first step to treatment is weight loss—and however it’s achieved is good. The question is whether weight loss surgery helps people achieve their goals. The other key component to our study was to look at bariatric surgery in patients who are generally not considered appropriate for it. Traditionally bariatric surgery is reserved for patients with morbid obesity (BMIs greater than 40), but type 2 diabetes begins at BMI levels of 31, so we looked at patients with BMIs of 30 to 40.

news@JAMA: Other studies have also hinted at the benefits of bariatric surgery for the treatment of type 2 diabetes. How does your study add to the discussion?

Dr Ikramuddin: A criticism of the other studies is that they are from single centers of excellence and it’s hard to interpret the results to other settings. Our study involved 2 hospitals in the United States and 2 in Taiwan to study surgery’s effect on Asians, and we found similar results.

news@JAMA: Should bariatric surgery be a first-line therapy for treatment of type 2 diabetes?

Dr Ikramuddin: We have to balance our results against the risk for surgical complications. Surgery is good for people who are psychologically prepared for it. And there are complications—leaks, bleeding—and not everybody should have it. What we’re looking for are patients who can make the lifestyle changes to complement the surgery, to justify the risk-benefit ratio.

Author Insights: Lifestyle Modification May Lead to Partial Remission of Diabetes but Only in Very Few Patients

Edward W. Gregg, PhD, of the US Centers for Disease Control and Prevention (CDC), and colleagues found that the vast majority of patients with diabetes could not achieve complete or partial remission by following an intensive program of  weight loss and physical activity. (Image: CDC)

Edward W. Gregg, PhD, of the US Centers for Disease Control and Prevention (CDC), and colleagues found that the vast majority of patients with diabetes could not achieve complete or partial remission by following an intensive program of weight loss and physical activity. (Image: CDC)

Overweight patients with type 2 diabetes are usually told by physicians to modify their diets and increase physical activity in the hope of causing the condition to go into remission. But a study appearing today in JAMA suggests that even intensive lifestyle interventions will likely help only a small percentage of patients achieve acceptable blood glucose levels without medication.

Researchers monitored 4503 US adults with type 2 diabetes and a body mass index of 25 or higher for 4 years; participants were randomly assigned to receive long-term intensive weight loss interventions (including group and individual counseling) or traditional diabetes support only. Enrollees in the intensive program lost almost 8% more weight at 1 year and almost 4% more weight at 4 years compared with those receiving traditional support. Nearly 12% of the intensive program enrollees had partial or complete remission at 1 year and 7.3% at 4 years compared with 2% of those receiving traditional support at either year. Only 3.5% of enrollees receiving intensive interventions experienced continuous remission at 4 years, although it was better than the 0.5% receiving traditional support. Continue reading

Author Insights: Bariatric Surgery May Lead to Increases in Substance Use

Alexis Conason, PsyD, of New York Obesity Nutrition Research Center in New York City, and colleagues found patients may be at increased risk of substance use (drugs, alcohol, and cigarette smoking) after bariatric surgery. (Image: Jeffrey Truitt)

Although bariatric weight loss surgery is often an effective treatment for severe obesity and may reduce the risk for diabetes and heart disease, the procedure may also increase a patient’s risk for substance use. A study appearing today in the Archives of Surgery found participants reported a significant increase in the frequency of substance use—calculated as a composite of drug use, alcohol use, and cigarette smoking—after bariatric surgery.

The study enrolled 155 participants (132 women) who underwent either Roux-en-Y gastric bypass surgery or adjustable gastric band surgery. Each participant completed questionnaires assessing eating behaviors and substance use prior to the operation and periodically up to 24 months afterward.

The researchers found increased alcohol use was particularly associated with participants who underwent Roux-en-Y bypass surgery. The researchers noted prior studies suggesting patients become intoxicated more quickly and take longer to return to sobriety with less alcohol following Roux-en-Y bypass surgery. They speculated these patients may experience the rewarding emotional aspects of alcohol use sooner and more frequently, which may contribute to increased alcohol use. Continue reading

Author Insight: After Bariatric Surgery, Patients Have a Greater Risk of Alcohol Problems

Wendy C. King, PhD, of the University of Pittsburgh School of Public Health, and her colleagues found that bariatric surgery may be associated with increased risk of alcohol problems in the years after surgery. (Image: University of Pittsburgh)

Patients who undergo bariatric surgery for severe obesity may be at increased risk of developing alcohol use problems in the years following the surgery, according to an article published today in JAMA.

Some surgeons and patients have expressed concern that bariatric surgery may increase a patient’s risk of developing an alcohol use disorder, based on anecdotal reports. To test whether such a relationship exists, Wendy C. King, PhD, of the University of Pittsburgh School of Public Health, and her colleagues conducted a prospective cohort study of 2458 bariatric surgery patients who completed both preoperative and postoperative assessments between 2006 and 2011. They found no difference in the level of problematic alcohol use among patients 1 year before and 1 year after surgery; however, by the second year after surgery, a significantly higher number of patients reported symptoms of an alcohol use disorder—9.6%, compared with 7.6% reporting such symptoms during the year before surgery. In particular, having undergone the Roux-en-Y gastric bypass procedure was associated with an elevated risk of alcohol problems compared with other types of bariatric surgery. Continue reading

Author Insights: Bariatric Surgery May Help Patients’ Families, Too

John Morton, MD, MPH, and colleagues at Stanford University found the family members of patients undergoing bariatric surgery also experienced weight loss and improved their diets and lifestyle choices. (Image: Norbert von der Groeben/Stanford School of Medicine)

In addition to being an effective treatment for morbid obesity, bariatric surgery may also create a halo effect helping a patient’s family members lose weight. The finding appears today in the Archives of Surgery.

Researchers at Stanford University School of Medicine in Stanford, Calif. found that 1 year after a patient underwent Roux-en-Y gastric bypass surgery and dietary and lifestyle counseling, adult family members who were also obese had significant weight loss. Children in the family who were obese trended to have a lower body mass index (BMI) than expected for their growth curve in the year after a family member’s surgery. Family members also increased their daily activity levels and improved eating habits. The study involved 35 patients undergoing the procedure, 35 adult family members, and 15 children. Before the procedure, 60% of the adult family members and 73% of the children were obese. Continue reading