Bariatric surgery is an Effective Tool for Managing Diabetes

Bariatric surgery is more beneficial than medicine and lifestyle changes in achieving long-term Type 2 diabetes management and remission, according to new research headed by a surgeon-scientist at the University of Pittsburgh School of Medicine and published today in JAMA.

In the largest and most extensive randomized follow-up study to date, the researchers discovered that bariatric surgery lowered cholesterol and triglyceride levels more effectively than medicinal and lifestyle changes. Diabetes and cholesterol are key risk factors for heart disease; therefore, managing both may result in fewer heart attacks, strokes, and other consequences.

“This analysis is the strongest evidence we have to date that bariatric surgery is a safe and effective tool for achieving diabetes control and remission,” said lead author Anita Courcoulas, M.D., M.P.H., professor in Pitt’s Department of Surgery and chief of UPMC’s Minimally Invasive Bariatric Surgery Program.

Researchers examined participants’ outcomes—measures of blood sugar control (HbA1c), weight loss, and insulin and other diabetic medication use—in four distinct, randomized clinical trials conducted between May 2007 and August 2013. All four trials included individuals with Type 2 diabetes and obesity who either had bariatric surgery or participated in a medical and lifestyle program based on well-established therapies that have been shown to lower diabetes risk. The researchers then combined the data into a single study, which was completed in 2022. Long-term results were assessed at seven and, if practicable, twelve years after randomization.

At each follow-up point, patients in the bariatric surgery group had consistently lower HbA1c levels—indicating better blood sugar control—than those in the medical/lifestyle group, despite starting the research with higher baseline values. At the seven-year mark, 18.2% of individuals in the surgical group had achieved diabetic remission, compared to 6.2% in the medical and lifestyle groups. At year 12, the difference was even more pronounced: no patients in the medical/lifestyle group had diabetic remission, compared to 12.7% in the surgical group. Even in those who did not achieve remission, bariatric surgery resulted in better blood sugar control and required fewer diabetic medications than medical/lifestyle care.

The findings were consistent across weight class groups, indicating that surgery is equally effective for patients with BMIs below and beyond 35 kg/m2—the traditional cutoff for bariatric surgery therapy.

“This indicates that people with Type 2 diabetes—even those below the BMI threshold for bariatric surgery for weight loss alone—should be offered bariatric surgery as a treatment for inadequately controlled diabetes,” Courcoulas said. “These results further support the need for flexible and patient-centered care, based on an individual’s health problems and goals.”

Although the study’s purpose was to examine diabetes management and remission rates, the researchers discovered that bariatric surgery outperformed medical/lifestyle therapies in terms of long-term weight loss. At year 12, surgical patients had lost an average of 19.3% of their body weight, compared to 10.8% for patients receiving medical/lifestyle interventions.

The researchers found no differences in mortality or major cardiovascular events between the two groups. However, bariatric surgery participants were more likely to experience anemia, fractures, and severe gastrointestinal symptoms such as nausea and abdominal pain.

The analysis relied on data from randomized clinical studies conducted at Pitt, Cleveland Clinic, Joslin Diabetes Center, Brigham and Women’s Hospital, the University of Washington, and Kaiser Permanente Washington. The trials involved 355 people with type 2 diabetes. The studies were conducted prior to the widespread availability of GLP-1 agonist medicines for diabetes control and weight loss.

Medical and lifestyle interventions at all four sites were based on national standards for intensive diabetes management and included physical activity and nutrition tracking, increased engagement with the health care team, stress management, support groups, and medications available at the time of study enrollment. Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding were among the bariatric surgery methods performed.

More information: Anita P. Courcoulas et al, Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes, JAMA (2024). DOI: 10.1001/jama.2024.0318 , jamanetwork.com/journals/jama/ … .1001/jama.2024.0318

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