Comparing Surgery, Medication for Type 2 Diabetes in Overweight Patients

Patients with type 2 diabetes (T2D) who were overweight but not obese lost more weight, had better glycemic control, and reported better quality of life 5 years after gastric band surgery than those treated with medication only, according to researchers from a small study in Australia.

However, the better outcomes came at a cost—medical costs for those who had gastric band surgery were $8861 higher than those in the medication-only group. And, the authors note, government rules barred them from using sodium glucose co-transporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists, which could have brought greater weight loss for the medication group.

The findings, reported Sunday in Diabetes Care, add to the debate over the use of surgery—now called “metabolic surgery” by those who treat diabetes. The American Diabetes Association last year issued guidelines for when surgery is appropriate for the sole purpose of treating diabetes, separate from its weight loss benefits.

The CDC defines obesity as having a body mass index (BMI) of 30 kg/m² or higher; those who have a BMI of 25 to 29.9 kg/m² are considered overweight. Results from STAMPEDE, reported 3 years ago by the Cleveland Clinic, showed that diabetes remission was possible in surgical patients with a BMI as low as 27 kg/m², and more studies of diabetes remission in lower-weight patients have appeared since then.

A study from the University of Washington found that rates of diabetes remission were not lower among less-obese patients, even though they lost fewer pounds.

The Australian authors note their study’s small size, which they say was not powered to detect “small differences in rates of diabetes remission.” The 51 patients were randomized to have either gastric band surgery or medication therapy; at the 5-year mark, 5 surgery patients (23%) had achieved remission compared with 2 patients (9%) on medication therapy. Other results at the 5-year mark were:

· Weight loss. Average weight loss over 5 years was 12.2% in the surgery group and 1.8% in the medication therapy group.

· Glycemic control. Despite using fewer diabetes medications, the surgery group had an average glycated hemoglobin level that was 10.4 mmol/mol lower than the medication group.

· Blood pressure. This was not significantly different between the 2 groups.

· Quality of life. This was unchanged in the medication therapy group, but both physical and mental health scores in the surgery group showed sustained improvement.

· Cholesterol. High-density lipoprotein cholesterol was higher (0.24 mmol/L) for the surgery group and triglycerides were lower (0.7 mmol/L), while low-density lipoprotein cholesterol was 0.5 mmol/L higher, although authors noted these patients were taking fewer medications.

The authors concluded that sustained weight loss of 10% of body weight is a “powerful therapy” because it delivers “clinically meaningful improvements” in health indicators while improving quality of life.

Reference

Wentworth JM, Burton P, Laurie C, Brown WA, O’Brien PE. Five-Year outcomes of a randomized trial of gastric band surgery in overweight but not obese people with type 2 diabetes [published online February 20, 2017]. Diabetes Care. 2017; dc162149. https://doi.org/10.2337/dc16-2149