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Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes
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This pooled analysis of four randomized clinical trials examined the long-term glycemic control and safety of bariatric surgery compared with that of medical/lifestyle management of type 2 diabetes. The primary outcome was change in HbA1c measurement from baseline to 7 years. Participants who underwent bariatric surgery had a greater change in HbA1c measurement from baseline to 7 years. Remission of diabetes was more likely in participants who underwent bariatric surgery compared with those who received medical management.
- Clinicians should consider referring patients with diabetes and overweight or obesity to bariatric surgeons to discuss surgical options and risks given the potential benefit associated with treating diabetes or having diabetes in remission.
abstract
This abstract is available on the publisher's site.
Access this abstract nowIMPORTANCE
Randomized clinical trials of bariatric surgery have been limited in size, type of surgical procedure, and follow-up duration.
OBJECTIVE
To determine long-term glycemic control and safety of bariatric surgery compared with medical/lifestyle management of type 2 diabetes.
DESIGN, SETTING, AND PARTICIPANTS
ARMMS-T2D (Alliance of Randomized Trials of Medicine vs Metabolic Surgery in Type 2 Diabetes) is a pooled analysis from 4 US single-center randomized trials conducted between May 2007 and August 2013, with observational follow-up through July 2022.
INTERVENTION
Participants were originally randomized to undergo either medical/lifestyle management or 1 of the following 3 bariatric surgical procedures: Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding.
MAIN OUTCOME AND MEASURES
The primary outcome was change in hemoglobin A1c (HbA1c) from baseline to 7 years for all participants. Data are reported for up to 12 years.
RESULTS
A total of 262 of 305 eligible participants (86%) enrolled in long-term follow-up for this pooled analysis. The mean (SD) age of participants was 49.9 (8.3) years, mean (SD) body mass index was 36.4 (3.5), 68.3% were women, 31% were Black, and 67.2% were White. During follow-up, 25% of participants randomized to undergo medical/lifestyle management underwent bariatric surgery. The median follow-up was 11 years. At 7 years, HbA1c decreased by 0.2% (95% CI, -0.5% to 0.2%), from a baseline of 8.2%, in the medical/lifestyle group and by 1.6% (95% CI, -1.8% to -1.3%), from a baseline of 8.7%, in the bariatric surgery group. The between-group difference was -1.4% (95% CI, -1.8% to -1.0%; P < .001) at 7 years and -1.1% (95% CI, -1.7% to -0.5%; P = .002) at 12 years. Fewer antidiabetes medications were used in the bariatric surgery group. Diabetes remission was greater after bariatric surgery (6.2% in the medical/lifestyle group vs 18.2% in the bariatric surgery group; P = .02) at 7 years and at 12 years (0.0% in the medical/lifestyle group vs 12.7% in the bariatric surgery group; P < .001). There were 4 deaths (2.2%), 2 in each group, and no differences in major cardiovascular adverse events. Anemia, fractures, and gastrointestinal adverse events were more common after bariatric surgery.
CONCLUSION AND RELEVANCE
After 7 to 12 years of follow-up, individuals originally randomized to undergo bariatric surgery compared with medical/lifestyle intervention had superior glycemic control with less diabetes medication use and higher rates of diabetes remission.
Additional Info
Disclosure statements are available on the authors' profiles:
Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes
JAMA 2024 Feb 27;331(8)654-664, AP Courcoulas, ME Patti, B Hu, DE Arterburn, DC Simonson, WF Gourash, JM Jakicic, AH Vernon, GJ Beck, PR Schauer, SR Kashyap, A Aminian, DE Cummings, JP KirwanFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Much literature has been published on the superiority of bariatric surgery over the medical management of diabetes, but it is unclear if longer-term follow-up shows surgery to continue to have the edge in the face of improved medical therapies. The ARMMS-T2D (Alliance of Randomized Trials of Medicine versus Metabolic Surgery in Type 2 Diabetes) is a pooled analysis of 262 participants from four US single-center randomized trials. The trials had different designs with slightly different medical interventions, but the pooled data allowed analysis of 7- and 12-year data from randomization. The results showed that, at the end of year 7, the HbA1c mean went from 8.2 to 8.0 in the medical/lifestyle group versus 8.7 to 7.2 in the bariatric surgery group. Similarly, remission of diabetes was 6.2% in the medical/lifestyle group versus 18.2% in the bariatric surgery group at 7 years.
Weight loss in the bariatric surgery group at 7 years was 19.9% versus 8.3% in the medical management group. Interestingly, weight loss in the medical group at 12 years was higher than it was at 7 years but still lower than in the bariatric surgery group, at 10.8% and 19.3%, respectively.
The increasing weight loss in the medical groups with time appears to be due to the use of newer GLP-1 agonists, but it is surprising to see that, despite this increased weight loss, the mean HbA1c reduction in the medical/lifestyle group was very small compared with the bariatric surgery group. These analyses show that, despite improvements in medical therapy for diabetes, bariatric surgery remains the most effective solution for the long-term management of glycemic control in persons with diabetes.