Lifestyle intervention and medical management with vs without roux-en-y gastric bypass and control of hemoglobin a1c, ldl cholesterol, and systolic blood pressure at 5 years in the diabetes surgery study
Journal
JAMA - Journal of the American Medical Association
Journal Volume
319
Journal Issue
3
Pages
266-278
Date Issued
2018
Author(s)
Ikramuddin S.
Korner J.
Lee W.-J.
Thomas A.J.
Connett J.E.
Bantle J.P.
Leslie D.B.
Wang Q.
Inabnet Iii W.B.
Jeffery R.W.
Chong K.
Jensen M.D.
Vella A.
Ahmed L.
Belani K.
Billington C.J.
Abstract
IMPORTANCE The Roux-en-Y gastric bypass is effective in achieving established diabetes treatment targets, but durability is unknown. OBJECTIVE To compare durability of Roux-en-Y gastric bypass added to intensive lifestyle and medical management in achieving diabetes control targets. DESIGN, SETTING, AND PARTICIPANTS Observational follow-up of a randomized clinical trial at 4 sites in the United States and Taiwan, involving 120participantswhohad a hemoglobinA1c (HbA1c) level of 8.0%or higher and a body mass index between 30.0and 39.9 (enrolled between April 2008and December 2011)were followed up for 5 years, ending inNovember 2016. INTERVENTIONS Lifestyle-intensive medical management intervention based on the Diabetes Prevention Program and LookAHEAD trials for 2 years, with and without (60 participants each) Roux-en-Y gastric bypass surgery followed by observation to year 5. MAIN OUTCOMES AND MEASURES The American Diabetes Association composite triple end point of hemoglobin A1c less than 7.0%, low-density lipoprotein cholesterol less than 100mg/dL, and systolic blood pressure less than 130mmHg at 5 years. RESULTS Of 120 participants whowere initially randomized (mean age, 49 years [SD, 8 years], 72women [60%]), 98 (82%) completed 5 years of follow-up. Baseline characteristicswere similar between groups: Mean (SD) body mass index 34.4 (3.2) for the lifestyle-medical management group and 34.9 (3.0) for the gastric bypass group and had hemoglobin A1c levels of 9.6%(1.2) and 9.6%(1.0), respectively. At 5 years, 13 participants (23%) in the gastric bypass group and 2 (4%) in the lifestyle-intensive medical management group had achieved the composite triple end point (difference, 19%; 95%CI, 4%-34%; P = .01). In the fifth year, 31 patients (55%) in the gastric bypass group vs 8 (14%) in the lifestyle-medical management group achieved an HbA1c level of less than 7.0%(difference, 41%; 95%CI, 19%-63%; P = .002). Gastric bypass had more serious adverse events than did the lifestyle-medical management intervention, 66 events vs 38 events, most frequently gastrointestinal events and surgical complications such as strictures, small bowel obstructions, and leaks. Gastric bypass had more parathyroid hormone elevation but no difference in B12 deficiency. CONCLUSIONS AND RELEVANCE In extended follow-up of obese adults with type 2 diabetes randomized to adding gastric bypass compared with lifestyle and intensive medical management alone, there remained a significantly better composite triple end point in the surgical group at 5 years. However, because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement. ? 2018 American Medical Association.
SDGs
Other Subjects
hemoglobin A1c; low density lipoprotein cholesterol; parathyroid hormone; antidiabetic agent; glycosylated hemoglobin; low density lipoprotein cholesterol; adult; anastomosis leakage; anastomosis stenosis; Article; B12 deficiency; body mass; body weight loss; body weight management; clinical outcome; controlled study; diabetes control; diet supplementation; exercise; female; follow up; human; hyperparathyroidism; lifestyle modification; major clinical study; male; middle aged; non insulin dependent diabetes mellitus; obesity; observational study; outcome assessment; physical activity; priority journal; randomized controlled trial; Roux-en-Y gastric bypass; small intestine obstruction; systolic blood pressure; Taiwan; United States; blood; gastric bypass surgery; lifestyle; non insulin dependent diabetes mellitus; treatment outcome; Cholesterol, LDL; Diabetes Mellitus, Type 2; Female; Gastric Bypass; Glycated Hemoglobin A; Humans; Hypoglycemic Agents; Life Style; Middle Aged; Taiwan; Treatment Outcome
Publisher
American Medical Association
Type
journal article