The research shows that giving patients support to keep weight off after surgery is key to maintaining diabetes remission.
Payers may soon have a simpler solution to a question in diabetes care: how to tell which patients will experience remission from the disease after weight loss surgery.
Bariatric surgery is now recognized as a potential treatment for type 2 diabetes (T2D), and in June 2016 the American Diabetes Association issued a statement on the topic, referring to the various methods as “metabolic surgery.” But while many patients who have gastric bypass or other forms of surgery experience diabetes remission following weight loss, not all do. A 2012 study found that up to 68% of patients with T2D initially experience remission, but for 35% of these patients, the disease returned.
This week, researchers led by a team at University College of London report in the journal Diabetic Medicine they have developed a simplified test to determine when surgery will be successful. While various studies have attempted to pin down whether certain surgical methods are preferred for reversing diabetes, this study reports that the method surgeons use matters less than keeping weight off afterward.
Research pioneered at the Cleveland Clinic speculates that weight loss surgery promotes the reversal of diabetes through 1 of 3 mechanisms: (1) the weight loss promotes insulin sensitivity, (2) reduced insulin resistance leads to less “lipotoxicity,” which means there is less dysregulated fatty acid reflux and inflammation, and (3) reaction of the hormones in the gut in response to the surgical procedure change the body’s response to carbohydrate and fat absorption.
The work done at University College of London was a retrospective cohort study of patients with type 2 diabetes (T2D) who were followed for 2 years after having either Roux-en-Y gastric bypass surgery (107 patients) or sleeve gastrectomy (103 patients), alongside a separate study of 173 patients whose records were used to validate the scoring system. Researchers tested both an established method, known as DiaRem, and a newer method developed for the study, known as DiaBetter.
The DiaRem algorithm has been shown to be predictive by the Geisinger Health System, but involved more than 250 separate clinical variables. Three factors went into the DiaBetter score: the patient’s medication, the glycated hemoglobin level, and their disease duration—the number of years they had had T2D. In this new research, patients with low DiaRem scores were much more likely to achieve T2D than those with higher scores. In the DiaBetter scoring, remission rates for patients in the lowest quintile were 98%, compared with 19% in the highest quintile.
The study also found that the percentage of weight loss was a better predictor of long-term remission than either surgical method—there wasn’t a difference between the methods after adjusting for weight loss. For every 5% of body weight a patient lost, the chances of T2D remission increased by 54%.
The study showed that while access to surgery is important, these resources are wasted if patients don’t get support afterward to keep the weight off. “Access to bariatric surgery is very carefully controlled, yet post-surgery support is often lacking. We've added to the evidence that it's vital to support people in maintaining their weight loss long-term, to make sure that the surgery is effective,” said Andrea Pucci, MD, PhD, of the UCL Centre for Obesity Research and the study’s first author, in a statement.
Pucci A, Tymoszuk U, Cheung WH, et al. Type 2 diabetes remission 2 years post Roux-en-Y gastric bypass and sleeve gastrectomy: the role of the weight loss and comparison of DiaRem and DiaBetter scores [published online November 21, 2017]. Diab Med. 2017; doi: 10.1111/dme.13532.