Potential Benefits and Harms of Gastric Bypass Surgery in Obese Individuals With Type 1 Diabetes: A Nationwide, Matched, Observational Cohort Study

Abstract

OBJECTIVE To study the potential long-term benefits and possible complications of bariatric surgery in patients with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS In this register-based nationwide cohort study, we compared individuals with T1D and obesity who underwent Roux-en-Y gastric bypass (RYGB) surgery with patients with T1D and obesity matched for age, sex, BMI, and calendar time that did not undergo surgery. By linking the Swedish National Diabetes Register and Scandinavian Obesity Surgery Registry study individuals were included between 2007 and 2013. Outcomes examined included all-cause mortality, cardiovascular disease, stroke, heart failure, and hospitalization for serious hypo- or hyperglycemic events, amputation, psychiatric disorders, changes in kidney function, and substance abuse. RESULTS We identified 387 individuals who had undergone RYGB and 387 control patients. Follow-up for hospitalization was up to 9 years. Analysis showed lower risk for cardiovascular disease (hazard ratio [HR] 0.43; 95% CI 0.20–0.9), cardiovascular death (HR 0.15; 95% CI 0.03–0.68), hospitalization for heart failure (HR 0.32; 95% CI 0.15–0.67), and stroke (HR 0.18; 95% CI 0.04–0.82) for the RYGB group. There was a higher risk for serious hyperglycemic events (HR 1.99; 95% CI 1.07–3.72) and substance abuse (HR 3.71; 95% CI 1.03–3.29) after surgery. CONCLUSIONS This observational study suggests bariatric surgery may yield similar benefits on risk for cardiovascular outcomes and mortality in patients with T1D and obesity as for patients with type 2 diabetes. However, some potential serious adverse effects suggest need for careful monitoring of such patients after surgery.

Bariatric surgery in the treatment of patients with obesity and type 1 diabetes: A retrospective study of clinical data

“…29 The recent Swedish study showed that bariatric surgery in obese individuals with type 1 diabetes reduced the incidence of cardiovascular mortality. 21 In our cohort, bariatric surgery had beneficial effects on blood pressure, lipid profile, and total daily insulin dose per kilogram of body weight. Although we did not estimate it directly, it seems likely that these changes would be associated with a reduction in insulin resistance.…”

“…21 Previous studies have tested the use of adjunctive therapies to help with weight loss in patients with type 1 diabetes, including metformin, glucagon-like peptide-1 receptor agonists and sodiumglucose cotransporter-2 inhibitors, all with limited and temporary success. [22][23][24] The improvement in glycaemic control in the study cohort was modest and comparable to that previously reported, 12,13,21 albeit in the context of a marked and significant reduction in daily insulin requirement. Possible mechanisms for the improvement in glycaemic control include reduced caloric intake, reduction in obesity-associated insulin resistance and reduction in lipotoxicity.…”

“…Glomerular hyperfiltration is considered to be an early manifestation of diabetic kidney disease and has been shown to be predictive of a more rapid decline in measured GFR in individuals with type 1 diabetes 30,31 as well as in individuals with type 2 diabetes or normoglycaemia. 32 Cohen et al 33 12,21,36 DKA can also be precipitated by nausea and vomiting, the stress of surgery as well as abrupt discontinuation of insulin in the context of reduced oral intake in the immediate postoperative period. 36 In our series, all three patients who developed DKA were treated by sleeve gastrectomy.…”

“…to lead to reduction in cardiovascular events, including cardiovascular mortality. 21 Effects on quality of life have not been established.…”

“…A systematic review and meta‐analysis of all available case series and reports of patients with obesity and type 1 diabetes treated by bariatric surgery published in 2016 identified a total of 107 cases worldwide 12 . A recent large cohort study from Sweden also looked at the long‐term benefits and harms of bypass surgery in these patients 21 . Previous studies have tested the use of adjunctive therapies to help with weight loss in patients with type 1 diabetes, including metformin, glucagon‐like peptide‐1 receptor agonists and sodium‐glucose cotransporter‐2 inhibitors, all with limited and temporary success 22–24 …”