Diabetes under control without insulin seven years after surgery
9 November 2017
This is good news for diabetes sufferers! We know that Weight Loss Surgery is able to do good things for diabetics but putting some figures around how good the benefit is has been the difficulty. This study is useful because it looks at what has happened to diabetic patients following Bariatric surgery (both Gastric Bypass and Gastric Sleeve) in the longer term. It is well known that the improvement in diabetic control is related very strongly to how long the patient has had diabetes ie the shorter their history of diabetes the more likely they will get complete remission from their diabetes. The cohort of patients in this trial had been diabetic for an average of 11 years, so to see such good results at the 7 year post-surgery mark is impressive. Who would have thought that surgery is in fact the best treatment for obesity related diabetes! If you have any questions regarding this issue, do drop me an email and we can talk that way. Alternatively, make an appointment to see me! Looking forward to it.
Seven years after bariatric surgery, 44 percent of patients with severe obesity had their diabetes under control and were able to stop taking insulin, and 15 percent achieved diabetes remission, according to researchers from the Cleveland Clinic in Ohio who presented their findings at ObesityWeek 2017 - the largest international event focused on the basic science, clinical application and prevention and treatment of obesity hosted by the American Society for Metabolic and Bariatric Surgery and The Ob
“This study shows bariatric surgery can induce a significant and sustainable improvement in metabolic profile of patients with obesity and insulin-treated type 2 diabetes, typically a much more difficult group to achieve glycemic control or remission,” said Dr Ali Aminian, study co-author and associate professor of surgery at the Cleveland Clinic in Ohio. “Anytime a patient can come off insulin and still have their diabetes be under control, it’s a big deal, in terms of quality of life, decreased healthcare costs and preventing weight gain.”
In their study, ‘Long-term effects of bariatric surgery in patients with insulin-treated type 2 diabetes: 44% at glycemic target without insulin use’, the Cleveland Clinic researchers examined the long-term effect of bariatric surgery in patients who were on insulin before surgery. They reviewed the outcomes of 252 patients who had either Roux-en-Y gastric bypass (194 patients) or sleeve gastrectomy (58 patients) between January 2004 and June 2012. Prior to surgery, patients had type 2 diabetes for an average of 11 years, were taking insulin, and had an average BMI of nearly 46. The average age of the patients was 52.
The two primary outcomes were the percentage long-term diabetes remission and the percentage long-term glycemic control without insulin use. Long-term diabetes remission was characterised by glycated hemoglobin (HbA1c) <6.5%, fasting blood glucose (FBG) <126mg/dL, and off diabetes medications at five years or more after surgery. Glycemic control without insulin use was considered as HbA1c <7% without insulin use at five years or more after surgery.
Out of 252 patients, 161 (57%) patients were female. Patients had a mean age of 51.9±10.5 years, a mean baseline BMI45.9±8.3, a mean HbA1c of 8.5±1.7%, and a median duration of T2DM of 11 (interquartile range, 7-15) years. At a median postoperative follow up of seven years (range, 5-12), a mean BMI reduction of 11.2±5.8 was associated with a significant mean reduction in HbA1c (1.5±1.9%, <0.001), FBG (52.5±76.5 mg/dL, p<0.001), and diabetes medication requirement (1±1.2, p<0.001).
The proportion of patients met the American Diabetes Association glycemic target (HbA1c <7%) at baseline and last follow-up were 18% vs. 59%, respectively (p<0.001). Long-term glycemic control without insulin use and long-term diabetes remission were achieved in 44% and 15%, respectively.
Preoperative duration of T2DM was an independent predictor of both primary outcomes of study (p<0.001 for both analyses). Compared to SG, RYGB was associated with a greater reduction in BMI (12.2±5.7 vs. 7.8±4.7, p<0.001) and number of diabetes medications (1.1±1.2 vs. 0.6±1.1, p=0.01). A significant improvement in blood pressure and lipid profile was observed.
“The findings of this study, which is the largest series with the longest follow-up time to date, indicate that bariatric surgery can induce a significant and sustainable improvement in the metabolic profile and glycemic status in patients with insulin-treated T2DM,” the authors concluded.
“Certainly, we’d like to see patients sooner, but this study demonstrates bariatric and metabolic surgery can still have a significant impact, even after a person has had diabetes for years and years,” said Dr Samer Mattar, president-elect, ASMBS and a bariatric surgeon at Swedish Weight Loss Services in Seattle Washington, who was not involved in the study.
The study co-authors were Drs Zubaidah Nor Hanipah, Suriya Punchai, Jennifer Mackey, Stacy Brethauer and Phillip R Schauer.
Bariatric Surgery Improves Metabolic Syndrome for PCOS
3 January 2017
Happy New Year to you all! I hope you find the below article interesting. Polycystic Ovary Syndrome (PCOS) is a silent disease that affects young women significantly. The main things they notice are the masculinizing features such as body hair growth, menstrual irregularity with infertility and acne, but there are more significant medical consequences of PCOS that are not fully realised by those affected. PCOS accelerates the changes associated with metabolic syndrome ie hypertension, hypercholesterolemia with consequent Cardiovascular consequences. This does mean that treatment of PCOS becomes more of a priority and it seems that bariatric surgery does have significant positive effects on PCOS when there is very little other treatments on offer. An interesting read with indications for more in depth research into the area in the future.
Bariatric Surgery Improves Metabolic Syndrome for PCOS
Small cohort with obesity and PCOS saw improvement
ORLANDO -- Women who were overweight or obese and had polycystic ovarian syndrome (PCOS) saw significant improvements in all major metabolic syndrome components 8 months after undergoing bariatric surgery, researchers reported here.
The retrospective analysis of baseline factors and outcomes in 19 women, most of them black, showed significant improvements from pre-surgery values in body weight (P<0.0001), body mass index (P<0.0001), systolic blood pressure (P=0.0002), diastolic blood pressure (P=0.007), triglycerides (P=0.04), HbA1c (P=0.03), and HDL cholesterol (P=0.04).
Before surgery, about half (47%) of the women met the criteria for metabolic syndrome; only 21% after the surgery did, according to authors Mc Anto Antony, MBBS, and Shannon Sullivan, MD, PhD, at MedStar Washington Hospital in the District of Columbia.
Antony presented the findings at a poster session here at the annual meeting of the American Association of Clinical Endocrinologists.
"The reason we conducted this study is because PCOS is a very commonly seen disorder in reproductive-aged women, and most of these women are either overweight or obese, and obesity exacerbates the metabolic phenotype in these women; and, in the long run, because of the metabolic syndrome they are at risk for developing cardiovascular problems," said Antony in an interview with MedPage Today. "So we wanted to see if bariatric surgery could provide a solution in this population."
He added that for women who find it hard to achieve weight loss through diet and exercise, bariatric surgery could be a good option that might reduce cardiovascular risk.
All of the patients had visited MedStar at some point, and all were at least 18 years old. All values were taken at least 6 months after surgery (mean 7.9 ±3.4 months). Fifty-three percent of the women were black, 41% were white, and 6% were Asian. Prior to surgery, the mean number of metabolic syndrome factors per patient was 2.7 (±1.1) versus 1.9 (±1.2) after surgery (P<0.01).
Antony said that most of the time the first-line intervention among this populations is weight loss through diet and exercise. "But it's very hard for most of them to achieve that, and even if they achieve that, it's hard for them to sustain it," he said. "Hence we thought of bariatric surgery as an option."
Antony said that a significant limitation of the study was that there were not enough data to determine how the surgery affected the patients' PCOS. "We tried to look up whether the surgery had any effect on the PCOS itself, but there were not enough data in the patients' notes," he said.
But he added that other studies have showed an improvement after bariatric surgery for some PCOS symptoms, "like an improvement of menstrual irregularities and hormone markers." Participants in one study were more likely to conceive after surgery, he said.
He added that the topic needs more research, however. "It would be really interesting to follow a larger population to see if they are able to sustain the weight loss after surgery," he said.
Patients who attend follow-up have better outcomes
8 November 2016
This study proves what I have anecdotally noticed about my own patient group. The patients who are more reliable at attending follow up appointments, either to see me, my Nutritionist (Nicola Page) or my Bariatric Nurse Specialist (Kate Berridge) are more likely to stay on track with their weight loss in the long term. It is interesting to see that this also translates into improvements in their medical conditions associated with being overweight ie Hypertension, Hypercholesterolemia and Type 2 diabetes. It probably follows that if you are more conscientious about attending appointments you are probably going to be more strictly adhering to nutritional and eating habit guidelines that we suggest for post-bariatric surgery life. It is true that everything changes around eating and drinking immediately after having Bariatric surgery and these new habits should become a 'new normal' from then on to ensure the long term outcomes are good. The better patients are at practicing their new habits, the better the outcomes they will achieve. Anyway, plenty more to talk about when we meet in person. An appointment to see me for a chat is the first step to take and we can take it from there!
Bariatric patients who stick to a schedule of three-, six- and 12-month follow-up visits with their doctors see greater improvements or remission of their diabetes, high blood pressure and high cholesterol than patients who skip their visits, according to research presented at ObesityWeek 2016. The paper, “The effect of close postoperative follow-up on comorbidity improvement after bariatric surgery,” was presented by researchers from the Brody School of Medicine at East Carolina University in Greenville, NC.
The study assessed the relationship between complete follow-up and improvement or remission of comorbid conditions at 12-months after surgery. The investigators obtained data from the Bariatric Outcomes Longitudinal Database (BOLD) from 2007 to 2012 and reviewed the results of 38,613 patients who had the three follow-up visits (complete follow-up) and compared them to the results of 12,468 patients who only had one or two follow-ups (incomplete follow-up). Improvement and remission of comorbid conditions were compared between the two cohorts. Specifically, changes in diabetes (T2D), hypertension, and dyslipidemia were evaluated at 12-month postoperatively.
After one year, 62.3 percent of patients with complete follow-up saw their type 2 diabetes go into remission, while those who missed a visit or two had a remission rate of 57.5 percent. The rate of improvement in diabetes was also better for those who made all three visits (74.6% vs. 68.9%). The differences between the two groups also held for high blood pressure and lipid abnormalities including high cholesterol.
“This study shows there is great value in seeing patients at routine intervals after surgery in terms of health outcomes,” said Dr Andrea Schwoerer, study co-author, currently at Carolinas Medical Center. “Unfortunately, many patients, reportedly as many as 50 percent, are lost to follow-up and therefore may not benefit as much as they can from weight-loss surgery, no matter how well it was performed.”
Hypertension improved in 63.2 percent of the patients in the complete follow-up group and 58.1 percent in the incomplete follow-up group. The difference in resolution rates in the groups was less, but still statistically significant (46.1% vs. 42%). The trend also held for lipid abnormalities, with these improving for 55 percent of patients completing follow up versus 51.1 percent for those who did not. Remission rates were,42.8% vs. 41.1% respectively, a small, but still statistically significant difference. After adjusting for baseline characteristics, complete postoperative follow-up in the first year after surgery was independently associated with a higher rate of improvement or remission of comorbid conditions.
“We cannot stress enough the importance of follow-up visits and post-operative care,” said Dr Stacy Brethauer, President-elect, ASMBS and bariatric surgeon at the Cleveland Clinic in Ohio, who was not involved in the study. “It could mean the difference between a good and a great result. The most committed patients do best, and we need to find ways to keep all patients engaged for the long-term.”
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