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Bariatric Surgery Beats Regular Therapy in Obese Diabetes Patients, Independent of Weight Loss

Posted: Monday, April 09, 2012

Bariatric surgery performed considerably better than traditional medical therapy in obese patients with type 2 diabetes, independent of weight loss according to findings from two randomized trials published online.
Dr. Paul Zimmet (Heart and Diabetes Institute, Melbourne, Australia) and Dr. George MM Alberti (King's College Hospital, London, UK) said in an accompanying editorial, "In both studies, bariatric surgery induced remission and was associated with a significant improvement in metabolic control over and above medical therapy, both conventional and intensive." "The studies . . . are likely to have a major effect on future diabetes treatment," they add. Such procedures should no longer be considered as a last resort in diabetes and "might well be considered earlier in the treatment of obese people with type 2 diabetes."

However, Zimmet and Alberti caution, that surgery is not yet "the universal panacea for obese patients with type 2 diabetes." Both studies had relatively small sample sizes and short duration, which are important limitations, they note. And bariatric surgery is associated with perioperative risks and potential long-term problems due to micronutrient deficiencies, both of which need to be considered. More studies are needed, "particularly those that may provide better prediction of success and the expected duration of remission and long-term complications," they conclude.

Schauer and colleagues enrolled 150 obese patients (BMI 27-43 kg/m2) with uncontrolled type 2 diabetes and randomly assigned them to medical therapy, Roux-en-Y gastric bypass (RYGB), or sleeve gastrectomy. Mean age was 49 years, and mean HbA1c was 9.2%.

The main study outcome of HbA1c <6.0% after 12 months of treatment was met by 12% of the medical-therapy group, 42% of the RYGB group (p=0.002 vs medical therapy), and 37% of the sleeve-gastrectomy group (p=0.008 vs medical therapy). Although glycemic control improved in all three groups, improvements were significantly greater in the surgical groups, as was weight loss and improvement in insulin resistance.

The second study, by Dr. Geltrude Mingrone (Catholic University, Rome, Italy) and colleagues, involved 60 severely obese patients (BMI more than 35 kg/m2) aged 30 to 60 years with advanced type 2 diabetes randomly assigned to RYGB, biliopancreatic diversion (BPD), or conventional treatment (individualized medication therapy and strictly monitored diet and lifestyle interventions).

The main study outcome was remission, defined as fasting glucose <100 mg and HbA1c <6.5% for one year or longer, without the use of diabetes medication.

At two years, 95% of patients in the BPD group and 75% of those in the RYGB group had entered and maintained remission and were able to discontinue all diabetes medications. In contrast, none of the patients in the medical group had entered remission. Age, sex, baseline BMI, duration of diabetes, and weight loss after surgery, did not predict diabetes remission or improvement in glycemia at one and three months.

"These findings confirm that the effects of bariatric surgery on type 2 diabetes may be attributed to the mechanisms of surgery rather than the consequences of weight loss," Mingrone says in a statement. "Studying the actual mechanisms by which surgery improves diabetes may help understand the disease better."

Source:, March 26, 2012 in the New England Journal of Medicine. The larger of the two trials was also simultaneously presented at the American College of Cardiology (ACC) 2012 Scientific Sessions.

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