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

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 120 participants who had a hemoglobin A1c (HbA1c) level of 8.0% or higher and a body mass index between 30.0 and 39.9 (enrolled between April 2008 and December 2011) were followed up for 5 years, ending in November 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 100 mg/dL, and systolic blood pressure less than 130 mm Hg at 5 years.

Results: Of 120 participants who were initially randomized (mean age, 49 years [SD, 8 years], 72 women [60%]), 98 (82%) completed 5 years of follow-up. Baseline characteristics were 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.

Trial registration: clinicaltrials.gov Identifier: NCT00641251.

Figure 1.. Flow Diagram of Patients Through the Diabetes Surgery Study

BMI indicates body mass index, calculated as weight in kilograms divided by height in meters squared.

Figure 2.. Outcomes Over Time

Point estimates represent fitted values from longitudinal mixed models. The 0 time point represents randomization. Error bars indicate 95% CI; LDL-C, low-density lipoprotein cholesterol (to convert from mg/dL to mmol/L, multiply by 0.0259). The P value for difference is .01.

Figure 3.. Weight Loss Over Time

For Roux-en-Y gastric bypass, the 0 time point represents randomization. For both groups, blue indicates that the participant did not have bariatric surgery. Two patients were randomized to the Roux-en-Y gastric bypass group and are represented in blue based on their decision to decline surgery. Orange indicates that the participant did have bariatric surgery (as-treated basis). Some patients randomized to the intensive medical management group later obtained gastric bypass surgery outside of the study. They are reported on the intensive medical management graph (based on their randomization assignment), but their line turns from blue to orange at their approximate surgery date.