Long-term Microvascular Disease Outcomes in Patients With Type 2 Diabetes After Bariatric Surgery: Evidence for the Legacy Effect of Surgery

Abstract

OBJECTIVETo identify and quantify any legacy effect of bariatric surgery on risk of incident microvascular disease in patients with type 2 diabetes.RESEARCH DESIGN AND METHODSWe conducted a retrospective observational cohort study (n = 4,683; 40% racial/ethnic minority) of patients with type 2 diabetes who underwent bariatric surgery from 2001 through 2011. The primary outcome measure was incident microvascular disease defined as a composite indicator of the first occurrence of retinopathy, neuropathy, and/or nephropathy. The Cox proportional hazards framework was used to investigate the associations between type 2 diabetes remission/relapse status and time to microvascular disease.RESULTSCovariate-adjusted analyses showed that patients who experienced type 2 diabetes remission had 29% lower risk of incident microvascular disease compared with patients who never remitted (hazard ratio [HR] 0.71 [95% CI 0.60, 0.85]). Among patients who experienced a relapse after remission, the length of time spent in remission was inversely related to the risk of incident microvascular disease; for every additional year of time spent in remission prior to relapse, the risk of microvascular disease was reduced by 19% (HR 0.81 [95% CI 0.67, 0.99]) compared with patients who never remitted.CONCLUSIONSOur results indicate that remission of type 2 diabetes after bariatric surgery confers benefits for risk of incident microvascular disease even if patients eventually experience a relapse of their type 2 diabetes. This provides support for a legacy effect of bariatric surgery, where even a transient period of surgically induced type 2 diabetes remission is associated with lower long-term microvascular disease risk.

Diabetic retinopathy in people with Type 2 diabetes and obesity treated by Roux‐en‐Y gastric bypass compared with non‐operated controls: with focus on the role of diabetes remission in a cross‐sectional and a 6‐year follow‐up study

“…This aligns the theory of ‘metabolic memory’, introduced into a RYGB setting by Coleman et al . suggesting that even though a RYGB‐operated individual with Type 2 diabetes relapses into hyperglycaemia after a period of remission, the time spent in remission is a positive predictor for fewer microvascular complications. Finally, by using a less strict definition of diabetes remission there is a chance that our two subgroups of RYGB‐operated individuals are so similar that it has masked a true difference.…”

Reconciliation of Type 2 Diabetes Remission Rates in Studies of Roux-en-Y Gastric Bypass

“…Simulation models have suggested that delaying the onset of diabetes delays the onset of complications and comorbidities and reduces their cumulative incidence, partly because of competing mortality (24,25). A recent study indicates that even temporary partial remission reduces the risk of incident microvascular disease (26). However, further research is needed to measure the magnitude of the effect on other outcomes such as complications, comorbidities, and survival.…”

Diabetes after Bariatric Surgery

“…Further, those with type 2 diabetes who underwent BS experienced the benefit of reduced microvascular outcomes, although long-term data on large number of patients are limited (37). Long-term outcome studies of up to 6.9 years have shown BS to be associated not only with improved glucose control but also with reduced rates of hypertension, hyperlipidemia and cardiovascular mortality (38,39).…”