Factors determining chance of type 2 diabetes remission after Roux-en-Y gastric bypass surgery: a nationwide cohort study in 8057 Swedish patients

Abstract

IntroductionBariatric and metabolic surgery is an effective treatment option for type 2 diabetes (T2D). Increased knowledge regarding factors associated with diabetes remission is essential in individual decision making and could guide postoperative care. Therefore, we aimed to explore factors known to affect the chance of achieving diabetes remission after bariatric and metabolic surgery and to further investigate the impact of socioeconomic factors.Research design and methodsIn this nationwide study, we assessed all patients with T2D who underwent Roux-en-Y gastric bypass (RYGB) surgery between 2007 and 2015 in the Scandinavian Obesity Surgery Registry. Remission was defined as absence of antidiabetic medication for T2D 2 years after surgery. Multivariable logistic regression was used to evaluate factors associated with diabetes remission, with missing data handled by multiple imputations.ResultsA total of 8057 patients were included. Mean age±SD was 47.4±10.1 years, mean body mass index 42.2±5.7 kg/m2, mean hemoglobin A1c 59.0±17.33, and 61.7% (n=4970) were women. Two years after surgery, 6211 (77.1%) patients achieved T2D remission. Preoperative insulin treatment (OR 0.26, 95% CI 0.22 to 0.30), first-generation immigrant (OR 0.66, 95% CI 0.57 to 0.77), duration of T2D (OR 0.89, 95% CI 0.88 to 0.90), dyslipidemia (OR 0.71, 95% CI 0.62 to 0.81), age (OR 0.97, 95% CI 0.96 to 0.97), and high glycosylated hemoglobin A1c (HbA1c) (OR 0.99, 95% CI 0.98 to 0.99) were all associated with lower T2D remission rate. In contrast, residence in a medium-sized (OR 1.39, 95% CI 1.20 to 1.61) or small (OR 1.46, 95% CI 1.25 to 1.71) town and percentage of total weight loss (OR 1.04, 95% CI 1.03 to 1.04) were associated with higher remission rates.ConclusionAmong patients with T2D undergoing RYGB surgery, increasing age, HbA1c, and diabetes duration decreased the chance of reaching diabetes remission without cut-offs, while postoperative weight loss demonstrated a positive linear association. In addition, being a first-generation immigrant and living in a large city were socioeconomic factors having a negative association.

Results from the Scandinavian Obesity Surgery Registry: A narrative review

“…In the several cohort studies based on SOReg data, only immigration status (less improvement for first-generation immigrants) and living in larger cities were factors associated with reduced postoperative weight loss 48 and lower chance of diabetes remission. 49 These findings are supported by a recent meta-analysis reporting ethnicity as the only socioeconomic factor associated with differences in weight outcomes. 50 While it is important to clarify that all socioeconomic groups have acceptable outcomes in terms of safety and efficacy after bariatric surgery, further studies and interventions may be necessary to ensure a more equal care delivered to all patients seeking treatment for obesity.…”

“…Despite a connection between postoperative weight loss and improvement of health‐related quality of life, 47 associations to postoperative weight loss appear to be weak for most socioeconomic factors. In the several cohort studies based on SOReg data, only immigration status (less improvement for first‐generation immigrants) and living in larger cities were factors associated with reduced postoperative weight loss 48 and lower chance of diabetes remission 49 . These findings are supported by a recent meta‐analysis reporting ethnicity as the only socioeconomic factor associated with differences in weight outcomes 50 .…”

“…In an expanded study, longer duration of diabetes, higher patient age, and higher HbA1c decreased the chance of remission of diabetes, while increased weight loss increased the chance of remission. 49 Bariatric surgery in patients with type 1 diabetes has been somewhat controversial. We have demonstrated that patients with type 1 diabetes have similar benefits (reduced mortality and lower risk for cardiovascular disease and stroke) after surgery as patients with type 2 diabetes, but at a greater risk of hypoglycemia.…”

Bariatric‐metabolic surgery for NHS patients with type 2 diabetes in the United Kingdom National Bariatric Surgery Registry

“…This indicates that in the NHS people undergo bariatric‐metabolic surgery with more advanced and established diseases than patients in Sweden, which has a similarly structured health service. Multiple studies including RCTs indicate that people on insulin or who have a longer duration of T2DM diagnosis at the time of surgery, such as seen in this study of NHS practice, have a reduced likelihood of achieving remission 10–12,26,27 . The use of bariatric‐metabolic surgery with shorter T2DM disease duration would likely lead to reduced patient treatment burden and higher rates of T2DM remission.…”

“…Multiple studies including RCTs indicate that people on insulin or who have a longer duration of T2DM diagnosis at the time of surgery, such as seen in this study of NHS practice, have a reduced likelihood of achieving remission. [10][11][12]26,27 The use of bariatric-metabolic surgery with shorter T2DM disease duration would likely lead to reduced patient treatment burden and higher rates of T2DM remission. From the health system perspective, bariatricmetabolic surgery for people with T2DM and severe obesity has been reported as cost-effective and may even be cost-saving over longer time horizons.…”