Type 2 diabetes

Diabetes remission better with earlier bariatric surgery

Bariatric surgery should probably be available at an earlier stage for people with diabetes, according to a study of long-term surgical outcomes in the US.

Many organisations such as the ADS currently recommend bariatric surgery as a treatment option for people with obesity and type 2 diabetes “where lifestyle interventions and medical treatments for obesity or diabetes have not been successful.”

But new research finds that it is more successful the sooner it is done.

The LABS-2 study, published in the Journal of Clinical Endocrinology & Metabolism, provided seven-year outcomes in 827 patients with known diabetes at the time of their bariatric surgery.

Overall diabetes remission occurred in about 57% of patients (46% complete, 11% partial) following Roux-en-Y gastric bypass (RYGB) procedures.

Of the patients who underwent laparoscopic gastric banding (LAGB) about 22.5% achieved remission (16.9% complete, 5.6% partial).

The study found diabetes remission peaked two to three years after the procedures, before declining slightly during the remaining follow-up period

The decline in remission following RYGB was mostly in the complete remission group whereas the decline in remission following LAGB was in both complete and particle remissions.

Importantly, the study found younger age, shorter duration of diabetes, fewer diabetes medications and lower insulin use at baseline were factors predicting remission.

“Participants who achieved diabetes remission after both surgeries also had greater baseline estimated beta-cell function by both C-peptide levels and HOMA %B without any difference in HOMA IR, had higher hs-CPR levels, and were much less likely to use anti-hyperlipidemia medications compared to those that did not achieve diabetes remission,” the study said.

The study also found that the probability of diabetes remission was greater for RYGB than LAGB at all follow-up time points – increasing from an adjusted relative risk (aRR) of 1.86 in the first postoperative year to 3.96 after seven years of follow-up.

“These findings extend our previous findings from three years to seven years and are in alignment with our hypothesis that weight-independent processes are occurring after RYGB that disproportionately lead to improvements in insulin secretory capacity and disposition index,” the investigators said.

“We not only show that the weight-loss independent likelihood of achieving diabetes remission remains greater after RYGB than after LAGB during extended follow-up, but it continues to increase overtime, from nearly 2-fold more likely three years after surgery to nearly 4-fold more likely seven years after their surgery.”

They said their data also suggested that delaying bariatric surgery until patients have “failed” medical therapy was not optimal for patient care and should be reconsidered in current treatment guidelines and algorithms.

“However, this does not mean that a patient with poorly controlled diabetes or who is insulin-requiring will not benefit from bariatric surgery. Rather the benefit they might experience would come in the form of better glucose control while requiring fewer diabetes medications (including a lower insulin dose) as opposed to complete or partial diabetes remission.”

Commenting on the study, Professor Ian Caterson told the limbic that the findings were expected – that younger patients with less duration of diabetes were far more likely to have a less damaged pancreas and to achieve remission with weight loss.

However there were good practical reasons why bariatric surgery should not be first line treatment.

Professor Caterson, Boden Professor of Human Nutrition at the University of Sydney, said there were now many more good diabetes drugs, and less costly, non-surgical ways of inducing diabetes remission.

For example, meal replacements work very well for two years at least and are less costly than surgery.

“There are some interesting drugs in the pipeline for diabetes which are capable of getting the same results as bariatric surgery. One of them achieved more than 15% weight loss which is bariatric surgery level,” he said.

And Australia didn’t yet have the capacity for the numbers of procedures that would be required.

“In Australia we do about 25,000 operations a year. If you look at the number of people who, according to the current guidelines are eligible for operations, we have 60 years of operating to do.”

“It’s not at the moment the treatment that should be available first up,” he said.

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