OBES SURG DOI 10.1007/s11695-014-1187-0
ORIGINAL CONTRIBUTIONS
Resolution of Diabetes After Bariatric Surgery Among Predominantly African-American Patients Race has no Effect in Remission of Diabetes After Bariatric Surgery Mereb Araia & Michael Wood & Joshua Kroll & Abdul Abou-Samra & Berhane Seyoum
# Springer Science+Business Media New York 2014
Abstract Background The aim of this study was to assess the relative efficacy in diabetes remission among predominantly AfricanAmerican patients who have undergone one of the three different types of bariatric surgical procedures. Methods A total of 597 morbidly obese patients underwent one of the three bariatric surgical procedures at Harper University Hospital, Detroit, Michigan from 2008 to 2011. Of the three procedures, 203 (34 %) patients had laparoscopic sleeve gastrectomy, 264 (44.2 %) patients had laparoscopic gastric bypass, and 130 (21.8 %) had laparoscopic adjustable gastric banding. The prevalence of diabetes prior to surgery was 20.7, 17.4, and 24 %, respectively. There was no statistical difference in the prevalence of diabetes among the three surgical groups. Results Of the 119 patients with diabetes, 46 (38.7 %) were males and 73 (61.3 %) were females. The majority of patients were African-Americans (65 %). The average age of patients was 42.2±8.3 years for sleeve gastrectomy, 44.8±7.9 years for gastric banding, and 41.5±7.7 years for gastric bypass surgery. Of all the study patients with a preoperative diagnosis of type 2 diabetes, 86 patients (72.3 %) had resolution of diabetes 1 year after surgery. The resolution of diabetes was reported in 89.1, 66.7, and 54.8 % of patients who underwent
M. Araia : M. Wood : J. Kroll Harper Bariatric Medicine Institute, Harper University Hospital, Wayne State University School of Medicine, 4201 St. Antoine, UHC-4H, Detroit, MI 48201, USA A. Abou-Samra Hamad Medical Corporation, Doha, Qatar B. Seyoum (*) Division of Endocrinology, Wayne State University School of Medicine, 4201 St. Antoine, UHC-4H, Detroit, MI 48201, USA e-mail:
[email protected]
laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding, respectively. Conclusions This study, which was conducted among predominantly African-Americans, showed consistent results with other studies. Patients who underwent laparoscopic gastric bypass appeared to benefit the most in terms of achieving better remission of diabetes. Keywords Diabetes . African-Americans . Bariatric surgery
Introduction Obesity is a major risk factor in the development of type 2 diabetes mellitus (T2DM). The risk is proportional to the degree of body mass index (BMI) and the duration of obesity. Because of the strong link with obesity, the term “diabesity” has been coined to describe these two disease processes [1]. Several studies report that obesity and T2DM are highly associated [2]. Over 80 % of the patients with T2DM in the USA are overweight or obese [3]. Effective lifestyle changes that result in significant weight loss is essential to the long-term treatment of T2DM. It has been shown that weight loss as little as 5–10 % improves glycemic control and reduces the requirements for antidiabetic medication. In addition to hyperglycemia, diabetes is characterized by specific (microvascular) or nonspecific (cardiovascular) complications. To prevent such complications, blood sugar control alone is not enough. It needs an extensive management plan that includes treating the other components of metabolic syndrome such as hypertension and dyslipidemia to having more stringent goals than those without diabetes [4]. Besides the remission and improvement of diabetes, weight loss has other numerous benefits. Modest weight loss lowers blood pressure, improves dyslipidemia, and is associated with reduced T2DM-related morbidity and
OBES SURG
mortality. The most significant challenge however is how to achieve and maintain weight loss in obese patients with diabetes. Compliance and maintenance of lifestyle modifications have been disappointing [1]. Bariatric surgery, or as some people call it metabolic surgery, has emerged as one of the most effective treatment for obesity. This surgery not only reduces body weight but also produces sustained weight loss and improvement in many obesity-related conditions, including diabetes and other components of metabolic syndrome. Bariatric surgery has been shown to produce a loss of 48–70 % excess body weight in most patients [5]. This surgery has become a beacon of hope among morbidly obese patents in achieving and maintaining weight loss. Diabetes remission observed among patients who had bariatric surgery does not directly correlate with the amount of weight loss. While weight loss is the recommended first-line management of metabolic syndrome, it cannot account fully for the rapid results seen after bariatric surgery. In some patients, glucose levels have been seen to drop to normal levels in the first 2–3 days post surgery, which clearly suggest the presence of other factors that play a major role in changing the metabolic milieu [6, 7]. The rate of remission of T2DM is higher after gastric bypass than after banding or other procedures. Many consider it as the gold standard bariatric procedure for achieving diabetes remission. The remission rate after this type of bariatric surgery ranges from 67 to 90 % [8–10]. Remission rates in purely restrictive procedures are directly proportional to the degree of weight loss. However, in procedures with an additional malabsorptive component such as the bypass of the duodenum and jejunum, the reduction of blood sugar levels and the improvement in glucose tolerance and insulin action are remarkable. As a result of this concept, some authors suggest that the proximal gut might play a major role in the pathogenesis of T2DM [11]. The most common surgical procedure for treating obesity in the USA is the laparoscopic Roux-en-Y gastric bypass (RYGB) with an estimated 180,000 operations performed each year. As with any surgical procedure, gastric surgery involves risks such as bleeding, infection, and reactions to anesthesia. The reported risk of death from bariatric surgery is 0.1 to 2 % [12]. According to the 2009 consensus document, partial remission of diabetes is defined as a subdiabetic hyperglycemia (HbA1c not diagnostic of diabetes (16 years, BMI>35 kg/m2 with ≥1 existing comorbidity or BMI ≥40 kg/m2 and a history of prolonged previous attempts of weight loss by other means [13]). A total of 597 patients who fulfilled the inclusion criteria were included in this analysis. Of these, 119 patients had diabetes prior to surgery. Patients were followed for 2–3 weeks postoperatively, then every 3 months for the first year. In order to reduce potential variations in surgical methods, we only included all surgical procedures that were performed by a single surgeon (MW). A thorough assessment was performed on each patient’s general condition and mental status, complications of diabetes, risk factors, and motivations for surgery. The surgeon clinically evaluated all patients, and a medical practitioner conducted a preoperative assessment. A team that included a nutritionist, a psychologist, and an exercise consultant followed all patients before and after surgery. Baseline demographic data were collected on each patient included in the study. Those patients who failed to present for follow-up appointments following surgery were considered dropouts and were removed from the study. There were a total of eight patients who were excluded because they did not have follow-up after surgery. The study was approved by the Wayne State University School of Medicine institutional review board. Types of Bariatric Surgery Roux-en-Y Gastric Bypass The Roux-en-Y gastric bypass (RYGBP) is a combined bariatric procedure, already being accepted as a standard in the USA and seeing expanded use in Europe as well [14, 15]. The first step in the procedure uses staples to divide the stomach into a small pouch with an approximate volume of 20–30 ml. The second step is the bypass where the jejunum is connected to the pouch. Bowel continuity is restored by an entero-entero anastomosis, between the excluded biliary limb and the
OBES SURG
alimentary limb, performed at about 100 cm from the gastrojejunostomy.
*P0.05 >0.05 >0.05
OBES SURG
There are two prevailing theories that could possibly explain the dramatic remission of diabetes after surgery. These are the foregut and hindgut theories. The foregut theory states that it is the overstimulation of the foregut (stomach, duodenum, and jejunum) that is the important causative factor in T2DM. Therefore, operations that bypass this area will result in decreased stimulation of the foregut, resulting in improved glycemic control. The current study of diabetes remission rates secondary to various bariatric surgeries provides an additional impetus to the prevailing understanding of the mechanisms that the various surgical procedures exert their beneficial effects separately. The hindgut theory postulates that the increased stimulation of the distal small bowel is the responsible factor. By facilitating the presentation of intestinal contents to the ileum, incretin release, including GLP-1 and other peptide mediators, is enhanced, resulting in T2DM improvement [13, 28]. Several studies attribute the early metabolic effects of RYGB to alterations that resulted from bypass of the foregut and greater improvement in glucose tolerance and insulin responses as compared to the effects of gastric banding [6, 29]. In the sleeve gastrectomy procedure, a similar rapid improvement in insulin resistance and diabetes remission by partial stomach resection occurs with the absence of foregut bypass, leaning towards the hindgut theory [29]. Studies have shown that with improved glycemic control, each 1 % decrease in HbA1c decreases T2DM-related deaths by 21 % [26]. Furthermore, the improvement in glycemic control results in an overall reduction of dollar amount spent on diabetes-related complications. Other reports have suggested that individuals with obesity-related complications have medical costs that are 42 % greater than normal-weight individuals. Extreme obesity (BMI>40 kg/m2) engenders even greater costs [30]. The overall cost of diabetes is also substantially high. The estimated total economic cost of diabetes in the USA in 2012 was US$245 billion, of which US$176 billion represents direct health care expenditure and US$69 billion represents loss of productivity [31]. Cost effectiveness of bariatric surgery tends to increase over the years because the direct costs related to the procedure will be diluted over time, whereas the cost savings related to reduction of antidiabetic medications tend to accumulate [32]. Other studies have shown that bariatric surgery provides cost-effective methods of reducing mortality and diabetes complications in severely obese adults with diabetes [1, 33]. Such understanding is important because it will allow the identification of the persons who are the most appropriate candidates for surgery. Our study has significant limitations. We were not able to include socioeconomic impacts in the overall remission of diabetes after bariatric surgery. Moreover, as this is mainly retrospective data, it has its own inherent limitations. However, the study has shown consistent results, in line with the reports in the literature. The causes of T2DM are multifactorial, and
the mechanisms by which it can be treated or prevented are as well complex. Bariatric surgery has the potential to be an effective treatment option in all populations including African-Americans. In conclusion, in this study, we showed that bariatric surgery is effective in reversing diabetes. Moreover, it looks that race has no effect in the remission of diabetes after bariatric surgery. However, this has to be confirmed in a larger prospective study. We recognize that the number of subjects included in this study is very low, which is a substantial shortcoming by itself.
Conflict of Interest All authors have no conflict of interest, and there was no external funding for the study.
References 1. Arroyo K, Kini SU, Harvey JE, et al. Surgical therapy for diabesity. Mt Sinai J Med. 2010;77(5):418–30. 2. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289(1):76–9. 3. Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the U.S.: 1990-1998. Diabetes Care. 2000;23(9):1278–83. 4. Buse JB, Caprio S, Cefalu WT, et al. How do we define cure of diabetes? Diabetes Care. 2009;32(11):2133–5. 5. Gumbs AA, Modlin IM, Ballantyne GH. Changes in insulin resistance following bariatric surgery: role of caloric restriction and weight loss. Obes Surg. 2005;15(4):462–73. 6. Lee WJ, Huang MT, Wang W, et al. Effects of obesity surgery on the metabolic syndrome. Arch Surg. 2004;139(10):1088–92. 7. Pournaras DJ, Aasheim ET, Sovik TT, et al. Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders. Br J Surg. 2012;99(1):100–3. 8. Milone M, Di Minno MN, Leongito M, et al. Bariatric surgery and diabetes remission: sleeve gastrectomy or mini-gastric bypass? World J Gastroenterol. 2013;19(39):6590–7. 9. Albeladi B, Bourbao-Tournois C, Huten N. Short- and midterm results between laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy for the treatment of morbid obesity. J Obes. 2013;2013:934653. 10. Yip S, Plank LD, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a systematic review and meta-analysis of outcomes. Obes Surg. 2013;23(12):1994–2003. 11. Mingrone G. Role of the incretin system in the remission of type 2 diabetes following bariatric surgery. Nutr Metab Cardiovasc Dis. 2008;18(8):574–9. 12. Franco JV, Ruiz PA, Palermo M, et al. A review of studies comparing three laparoscopic procedures in bariatric surgery: sleeve gastrectomy, Roux-en-Y gastric bypass and adjustable gastric banding. Obes Surg. 2011;21(9):1458–68. 13. Mingrone G, Castagneto-Gissey L. Mechanisms of early improvement/resolution of type 2 diabetes after bariatric surgery. Diabetes Metab. 2009;35(6 Pt 2):518–23. 14. Campos GM, Rabl C, Roll GR, et al. Better weight loss, resolution of diabetes, and quality of life for laparoscopic gastric bypass vs banding: results of a 2-cohort pair-matched study. Arch Surg. 2011;146(2):149–55. 15. Suter M, Giusti V, Heraief E, et al. Laparoscopic Roux-en-Y gastric bypass: initial 2-year experience. Surg Endosc. 2003;17(4):603–9.
OBES SURG 16. Ponce J, Haynes B, Paynter S, et al. Effect of lap-band-induced weight loss on type 2 diabetes mellitus and hypertension. Obes Surg. 2004;14(10):1335–42. 17. Dixon JB, O'Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299(3):316–23. 18. Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238(4):467–84. discussion 484-465. 19. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122(3):248–56. e245. 20. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222(3):339–50. discussion 350-332. 21. Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus nonsurgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934. 22. DeMaria EJ, Sugerman HJ, Kellum JM, et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg. 2002;235(5):640–5. discussion 645-647. 23. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515–29. 24. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.
25. Bradley D, Conte C, Mittendorfer B, et al. Gastric bypass and banding equally improve insulin sensitivity and beta cell function. J Clin Invest. 2012;122(12):4667–74. 26. de la Cruz-Munoz N, Messiah SE, Arheart KL, et al. Bariatric surgery significantly decreases the prevalence of type 2 diabetes mellitus and pre-diabetes among morbidly obese multiethnic adults: long-term results. J Am Coll Surg. 2011;212(4): 505–11. discussion 512-503. 27. Smith Jr SC. Multiple risk factors for cardiovascular disease and diabetes mellitus. Am J Med. 2007;120(3 Suppl 1):S3–11. 28. Gu YC, Yu JC. Mechanisms of gastrointestinal surgery in treatment of type 2 diabetes. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2011;33(3):262–4. 29. Rizzello M, Abbatini F, Casella G, et al. Early postoperative insulinresistance changes after sleeve gastrectomy. Obes Surg. 2010;20(1): 50–5. 30. Myers VH, McVay MA, Adams CE, et al. Actual medical and pharmacy costs for bariatric surgery: 6-year follow-up. South Med J. 2012;105(10):530–7. 31. Herman WH. The economic costs of diabetes: is it time for a new treatment paradigm? Diabetes Care. 2013;36(4):775–6. 32. Terranova L, Busetto L, Vestri A, et al. Bariatric surgery: cost-effectiveness and budget impact. Obes Surg. 2012;22(4): 646–53. 33. Hoerger TJ, Zhang P, Segel JE, et al. Cost-effectiveness of bariatric surgery for severely obese adults with diabetes. Diabetes Care. 2010;33(9):1933–9.
