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Original Investigation |

Association of Bariatric Surgery With Long-term Remission of Type 2 Diabetes and With Microvascular and Macrovascular Complications

Lars Sjöström, MD, PhD1; Markku Peltonen, PhD2; Peter Jacobson, MD, PhD1; Sofie Ahlin, MD, PhD1; Johanna Andersson-Assarsson, PhD1; Åsa Anveden, MD1; Claude Bouchard, PhD3; Björn Carlsson, MD, PhD1; Kristjan Karason, MD, PhD1; Hans Lönroth, MD, PhD4; Ingmar Näslund, MD, PhD5; Elisabeth Sjöström, MD1; Magdalena Taube, PhD1; Hans Wedel, PhD6,7; Per-Arne Svensson, PhD1; Kajsa Sjöholm, PhD1; Lena M. S. Carlsson, MD, PhD1
[+] Author Affiliations
1Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
2Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki, Finland
3Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge
4Institute of Surgery, University of Gothenburg, Gothenburg, Sweden
5Department of Surgery, University Hospital, Örebro, Sweden
6Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
7Nordic School of Public Health, Gothenburg, Sweden
JAMA. 2014;311(22):2297-2304. doi:10.1001/jama.2014.5988.
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Importance  Short-term studies show that bariatric surgery causes remission of diabetes. The long-term outcomes for remission and diabetes-related complications are not known.

Objectives  To determine the long-term diabetes remission rates and the cumulative incidence of microvascular and macrovascular diabetes complications after bariatric surgery.

Design, Setting, and Participants  The Swedish Obese Subjects (SOS) is a prospective matched cohort study conducted at 25 surgical departments and 480 primary health care centers in Sweden. Of patients recruited between September 1, 1987, and January 31, 2001, 260 of 2037 control patients and 343 of 2010 surgery patients had type 2 diabetes at baseline. For the current analysis, diabetes status was determined at SOS health examinations until May 22, 2013. Information on diabetes complications was obtained from national health registers until December 31, 2012. Participation rates at the 2-, 10-, and 15-year examinations were 81%, 58%, and 41% in the control group and 90%, 76%, and 47% in the surgery group. For diabetes assessment, the median follow-up time was 10 years (interquartile range [IQR], 2-15) and 10 years (IQR, 10-15) in the control and surgery groups, respectively. For diabetes complications, the median follow-up time was 17.6 years (IQR, 14.2-19.8) and 18.1 years (IQR, 15.2-21.1) in the control and surgery groups, respectively.

Interventions  Adjustable or nonadjustable banding (n = 61), vertical banded gastroplasty (n = 227), or gastric bypass (n = 55) procedures were performed in the surgery group, and usual obesity and diabetes care was provided to the control group.

Main Outcomes and Measures  Diabetes remission, relapse, and diabetes complications. Remission was defined as blood glucose <110 mg/dL and no diabetes medication.

Results  The diabetes remission rate 2 years after surgery was 16.4% (95% CI, 11.7%-22.2%; 34/207) for control patients and 72.3% (95% CI, 66.9%-77.2%; 219/303) for bariatric surgery patients (odds ratio [OR], 13.3; 95% CI, 8.5-20.7; P < .001). At 15 years, the diabetes remission rates decreased to 6.5% (4/62) for control patients and to 30.4% (35/115) for bariatric surgery patients (OR, 6.3; 95% CI, 2.1-18.9; P < .001). With long-term follow-up, the cumulative incidence of microvascular complications was 41.8 per 1000 person-years (95% CI, 35.3-49.5) for control patients and 20.6 per 1000 person-years (95% CI, 17.0-24.9) in the surgery group (hazard ratio [HR], 0.44; 95% CI, 0.34-0.56; P < .001). Macrovascular complications were observed in 44.2 per 1000 person-years (95% CI, 37.5-52.1) in control patients and 31.7 per 1000 person-years (95% CI, 27.0-37.2) for the surgical group (HR, 0.68; 95% CI, 0.54-0.85; P = .001).

Conclusions and Relevance  In this very long-term follow-up observational study of obese patients with type 2 diabetes, bariatric surgery was associated with more frequent diabetes remission and fewer complications than usual care. These findings require confirmation in randomized trials.

Trial Registration  clinicaltrials.gov Identifier: NCT01479452

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Figure 1.
Prevalence of Diabetes Remission in the Bariatric Surgery and Control Groups

Diabetes remission was defined as fasting blood glucose levels lower than 110 mg/dL and no diabetes medication. Odds ratios (ORs) are unadjusted and calculated using logistic regression analysis. The control group was the reference group. P < .001 for the 2- and 10-year follow-up; P = .001 for the 15-year follow-up. Error bars indicate 95% CIs.

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Figure 2.
Diabetes Remission by Diabetes Duration in the Surgery Group

Diabetes remission was defined as fasting blood glucose levels lower than 110 mg/dL and no diabetes medication. Error bars indicate 95% CIs.

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Figure 3.
Cumulative Incidence of Microvascular and Macrovascular Diabetes Complications in the Surgery and Control Groups

For microvascular complications, there were 134 events in the control group and 106 events in the surgery group; for macrovascular complications, 142 events in the control group and 151 events in the surgery group. Diabetes complications requiring hospital treatment or specialist care or diabetes complications that were associated with death during follow-up were traced by cross-checking against the Swedish National Patient Register and the Cause of Death Registry until December 31, 2012. (eTable 1 of the Supplement lists the International Classification of Diseases codes and surgery procedures used for cross-checking.) The x-axes are truncated at 20 years, but all observations after 20 years were included in the statistical analyses. Shaded areas indicate 95% CIs. The incidence rates of microvascular complications per 1000 person-years were 41.8 (95% CI, 35.3-49.5) in the control group and 20.6 (95% CI, 17.0-24.9) in the surgery group. Incidence rates of macrovascular complications were 44.2 (95% CI, 37.5-52.1) and 31.7 (95% CI, 27.0-37.2), respectively.

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Figure 4.
Cumulative Incidence of All (Microvascular and Macrovascular) Diabetes Complications by Diabetes Duration at Baseline

For a diabetes duration of <1 y, there were 51 events in the control group and 66 events in the surgery group; for 1-3 y, 66 events in control and 54 events in surgery patients; for ≥4 y, 69 events in control and 72 events in surgery patients. Interaction P value for diabetes duration and treatment was .03. The x-axes are truncated, but all observations after 16 y were included in statistical analyses.

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