Determinants of Diabetes Remission and Glycemic Control After Bariatric Surgery

Abstract

OBJECTIVEEligibility criteria for bariatric surgery in diabetes include BMI ‡35 kg/m 2 and poorly controlled glycemia. However, BMI does not predict diabetes remission, and thus, predictors need to be identified. RESEARCH DESIGN AND METHODSSeven hundred twenty-seven patients were included in a database merged from the Swedish Obese Subjects (SOS) study and two randomized controlled studies, with 415 surgical and 312 medical patients in total. Bariatric operations were divided into gastric only (GO) and gastric plus diversion (GD). RESULTSSixty-four percent of patients in the surgical arm and 15.0% in the medical arm experienced diabetes remission (P < 0.001). GO yielded 60% remission, and GD yielded 76% remission. The best predictors of diabetes remission were lower baseline glycemia and shorter diabetes duration. However, when operation type was considered, GD predicted a higher likelihood of remission and greater weight loss. Patients in remission (responders) lost more weight (25% vs. 17%) and waist circumference (18% vs. 13%) and experienced better insulin sensitivity than nonresponders. CONCLUSIONSSurgery is more effective than medical treatment in achieving diabetes remission and tighter glycemic control. Shorter diabetes duration, lower fasting glycemia before surgery, and GD versus GO procedures independently predict higher rates of remission, whereas baseline HbA 1c and waist circumference predict improved glycemic control. The results show the advantage of an early operation together with better controlled glycemia on diabetes remission independently of BMI.The prospective, controlled Swedish Obese Subjects (SOS) study showed that the shortterm rate of remission of diabetes after bariatric surgery is 72% compared with 21% in subjects treated with conventional weight loss methods (1). Randomized controlled studies have revealed diabetes remission rates between 37% and 42% (2) to 73% (3), 24% and 38% (4), and 75% and 95% (5), depending on the criteria used to define diabetes remission and baseline patient characteristics, choice of surgical therapy, and duration of follow-up (1-3 years). Unfortunately, such differences in diabetes remission criteria obscure important questions regarding the determinants of diabetes remission, which in turn affect eligibility criteria for patient selection for bariatric surgery.Historically, only subjects with BMI $35 kg/m 2 in the presence of uncontrolled diabetes were considered as potential candidates for bariatric and metabolic

An Untargeted Metabolomics Approach to Characterize Short-Term and Long-Term Metabolic Changes after Bariatric Surgery

“…Our in-depth analyses of patients with established diabetes mellitus confirm previously described predictors of diabetes remission after bariatric surgery such as age and diabetes duration at the time of the surgery [74]. Furthermore, our metabolomics analysis demonstrates that patients having a diabetes remission after one year showed larger declines in amino acids levels of alanine, proline and leucine as well as in the glycine metabolite sarcosine and the glutaminic acid derivate pyroglutamic acid.…”

Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations

“…There are no data showing that baseline BMI predicts metabolic surgery success. Instead, strong evidence indicates that preoperative BMI, at least within the obese range, does not predict the benefits of GI surgery with regard to diabetes prevention (51,57), remission (11,20,52,53,56,98,99), relapse after initial remission (20), or the magnitude of its effects on CVD events (62,100), cancer (61), or death (LoE IIA) (51, 53,56,[61][62][63]98). Of note, a recent meta-analysis of all studies reporting diabetes remission rates following bariatric surgerydincluding 94,579 surgical patients with T2Ddshowed that the rate of remission was equivalent among the 60 studies in which mean preoperative BMI was $35 kg/m 2 compared with the 34 studies with mean preoperative BMI ,35 kg/m 2 (71% versus 72%, respectively) (98).…”

Neuronal Food Reward Activity in Patients With Type 2 Diabetes With Improved Glycemic Control After Bariatric Surgery

“…Furthermore, a remission of T2DM after Roux-en-Y gastric bypass (RYGB) surgery has been reported in the majority of patients (20)(21)(22). Several independent factors, including weight loss and diabetes duration, predict T2DM improvement (23). The effectiveness of successful longterm weight loss and diabetes remission thus depends on various factors that might also include neuronal food reward processes.…”