Long Term Outcomes of Bariatric Surgery in Type 2 Diabetes

Long-term outcomes of Bariatric surgery in Type 2 diabetes vs Medical Weight Loss interventions were evaluated in a study published in JAMA.

Key points of the study: Long Term Outcomes of Bariatric Surgery vs Medical Management in Type 2 Diabetes

• Among People with type 2 diabetes, bariatric surgery produced noticeably better long-term glycemic control than medication/lifestyle changes.
• Among intervention groups, bariatric surgery participants needed fewer anti-diabetic drugs, indicating better diabetes control after surgery.
• When compared to medical/lifestyle care, bariatric surgery resulted in greater rates of diabetic remission, with notable differences seen at 7 and 12 years of follow-up.
• Along with the benefits, there were also increased risks of developing anemia, fractures, and GIT issues.
• The benefits of bariatric surgery were not associated with the risks of mortality or CVD, as there were no significant differences between the medical/lifestyle management and bariatric surgery groups during the follow-up period.

Long-Term Outcomes of Bariatric Surgery in Type 2 Diabetes:

Type 2 diabetes is a problem for worldwide public health. The prevalence of diabetes among adults aged 20-79 years was 8.3% worldwide, affecting 366 million people.

It was projected that by 2030, the number would rise to 9.9%. Recent treatments for type 2 diabetes now concentrate on preventing and managing complications, rather than offering a drastic cure.

More than 90% of patients with higher body mass index BMI may completely resolve their diabetes after bariatric surgery, and risk factors for heart disease, hypertension, and lipid abnormalities decrease as a result [ref].

The recent study also concluded, that the individuals who undergo bariatric surgery compared with medical/lifestyle modification had better glycemic control and required fewer diabetic medications.

Findings of the Study:

Comparing medical weight loss and lifestyle interventions vs bariatric surgery, those who underwent bariatric surgery had better glycemic control, used fewer diabetic medications, and had greater rates of diabetic remission at 7 to 12 years of follow-up [ref].

Methodology and Analysis:

According to the study, data from four US studies that were conducted in previous years with follow-up through recent studies were pooled for the ARMMS-T2D analysis.

Randomization was used to assign participants with type 2 diabetes and BMIs between 27 and 45 to either intensive medical or lifestyle care or bariatric surgery.

The percentage change in HbA1c after seven years was the main result. Adverse events and diabetes remission were secondary outcomes.

When compared to medication and lifestyle care, bariatric surgery demonstrated better glucose control and higher rates of diabetes remission.

Anemia, fractures, and GIT issues were among the adverse effects. Intention-to-treat and per-protocol methods were used in statistical analysis, along with modifications for site variability and missing data.

Multiple testing did not affect the results. Subgroup analysis was carried out for those whose BMI was less than 35.

Which bariatric surgery is best for type 2 diabetes?

The risk of morbidity and death related to bariatric surgery is a significant worry when treating type 2 diabetes.

Few bariatric studies that were conducted previously concluded that with biliopancreatic diversions the operative death rate was 1.1%, with Roux-en-Y gastric bypass surgery, it was 0.5%, and with restrictive treatments like laparoscopic adjustable gastric banding, it was 0.1%.

So laparoscopic adjustable gastric banding is thought to be the safest bariatric technique available.[ref]

Short-term risks after bariatric surgery:

According to studies the risks that usually appear after bariatric surgeries shortly are band erosion and band slippage or prolapse in laparoscopic adjustable gastric banding that need to be surgically resolved.

In a Roux-en-Y gastric bypass, the risk of major complications increases. Pulmonary embolism, aseptic leak, and hemorrhage can be fatal if proper care is not given to the patient.

Problems such as ulcer or stricture formation at the gastrojejunostomy site arise and are managed non-operatively.[ref]

Mechanisms to control Type 2 Diabetes among diabetics:

If you are looking for how to deal with type 2 diabetes, here are some mechanisms by working on them we can control the progression of diabetes among diabetics.

1. Restriction of calories.
2. Increased meal-induced thermogenesis.
3. Physiological changes in energy balance.
4. Alteration in neural circuits and hormones.

e.g.: control of appetite, food choices, altered eating patterns.

1. Altered GUT Microbiome.
2. Increased secretion of bile acids
3. Alteration in adipokines – increased circulating adiponectin.
4. Alteration in GUT hormones.

e.g: increased insulin secretion – stimulated by glucagon-like peptide-1, peptide YY, oxyntomodulin, Obestatin, Ghrelin, cholecystokinin.[ref]

These are the few mechanisms by which we can manage the progressing effects of type 2 diabetes and the chances of developing other secondary diseases due to diabetes.

Nutritional deficiencies after bariatric surgery:

Few nutritional deficiencies are reported to be caused after bariatric surgery in type 2 diabetic patients.

• Anaemia:

25-50% of individuals after gastric bypass have been found to have anemia. The most prevalent cause is iron deficiency anemia, which might take years to manifest.

In the studies, it was investigated that by 7-18 months of continuous follow-up or by higher supplementation, anemia can be managed.

• Vitamin D deficiency:

Vitamin D deficiency is common after bariatric surgical procedures. It affects up to 50-80% of patients after bariatric surgery.

But if can be easily treated if adequate supplementation is advised before and after surgery [ref]

• Acrodermatitis enteropathica:

It is a nutritional deficiency that is associated with zinc. When the zinc deficiency occurs after the surgery the eczematous plaques develop over the extremities and around natural orifices.

• Pellagra:

After bariatric surgery, there is another common manifestation, called pellagra. It is caused by niacin deficiency also known as nicotinic acid, a form of vitamin B3.

It results in the formation of symmetrical erythematous plaques that can be accompanied by edema or sometimes blisters. It can be resolved in a few days by regular supplementation.

• Vitamin B12 deficiency:

Researchers concluded that after Bariatric surgery nutritional deficiency such as vitamin B12 deficiency causes the development of leg ulcers, round scars on forearms, impetigo-like lesions on the scalp, localized alopecia, and angular cheilitis.

It resolves in approximately 6 months by regular supplemental intake or through diet.[ref]

• Protein-calorie malnutrition:

Signs including edema, hypoalbuminemia, and hair loss develop in protein-calorie malnutrition.

Following gastric bypass surgery, we advise patients to consume 60-80g of protein and 700-800 kcal per/day to reduce the issue.