Long-Term Health Outcomes After Bariatric Surgery
Another series of articles in the 2018 JAMA special issue on obesity, deals with the impact of bariatric surgery on health outcomes and overall mortality. The first article by Sayeed Ikramuddin and colleagues is an 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 BMI between 30.0 and 39.9. The study compared intensive lifestyle and 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. 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 (HbA1c less than 7.0%, LDL cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg). 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%. As is to be expected, surgical treatment resulted in more serious adverse events (66 vs 38 events), most frequently involving gastrointestinal and surgical complications such as strictures, small bowel obstructions, and leaks. A second study by Gunn Signe Jakobsen and colleagues from Norway, reports on changes in obesity related comorbidities in patients with severe obesity (BMI ≥40 or ≥35 and at least 1 comorbidity) undergoing bariatric surgery (n=932, 92 gastric bypass) or specialized medical (“lifestyle”) treatment (n=956) at a tertiary care outpatient center. Based on drugs dispensed according to the Norwegian Prescription Database and data from the Norwegian Patient Registry and a local laboratory database, surgically treated patients had a greater likelihood of remission (RR, 2.1) and lesser likelihood for new onset of hypertension (RR, 0.4), a greater likelihood of diabetes remission (RR, 3.9) but also a greater risk of new-onset depression (RR, 1.5) and treatment with opioids (RR, 1.3. Again, as expected, surgical patients had a greater risk for undergoing at least 1 additional gastrointestinal surgical procedure (RR, 2.0). From these findings the researchers conclude that adding gastric bypass to lifestyle and intensive medical management alone in patients with severe obesity and type 2 diabetes, there remained a significantly better composite triple end point in the surgical group at 5 years. The third study by Orna Reges and colleagues from… Read More »
Gastric Bypass Vs. Sleeve Gastrectomy For Severe Obesity
In the 2018 special issue of JAMA on obesity, two research articles compare long-term outcomes (5 years) after laparoscopic roux-en-Y gastric bypass (RYG) to sleeve gastrectomy (SG). In the first study by Ralph Peterli and colleagues from Switzerland, the authors report on the findings from the Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, that included 217 patients at 4 bariatric centres, who were enrolled and randomly assigned to SG or RYG. At 5 years, weight loss was slightly greater in the RYG group but this difference was not statistically significantly. Gastric reflux improved more after RYG and was more likely to worsen with SG. Reoperation rates were marginally higher in the RYG group (seven reoperations after sleeve gastrectomy were for severe GERD, and 17 reoperations after bypass were for internal hernias) . In the second study Paulina Salminen and colleagues from Finland report on the Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial which randomly assigned patients with severe obesity to SG (n=121) or RYG (n=119) with a 5-year follow-up period. At 5 years, weight loss, remission of diabetes, as well as improvements in dyslipidemia and hypertension were slightly higher in the RYG group than in the SG group. Overall, there was no difference in improvement in quality of life or in morbidity rates between the two groups. There was no treatment-related mortality in either group. In an accompanying editorial, David Arterburn and Arniban Gupta from the University of Washington, Seattle, note that, “Collectively, these studies provide reassuring data to suggest that the rapid switch from Roux-en-Y gastric bypass to sleeve gastrectomy in the last decade has not been a therapeutic misadventure similar to the rise and fall of the adjustable gastric band,5 which has been all but abandoned.” They also point to five important learnings from these studies: Patients should be informed that deciding between sleeve gastrectomy and bypass is complex and requires patients to simultaneously consider information about many factors, including weight loss, control of different comorbidities, and short- and long-term risks. Weight loss between the two procedures are more or less on par. GS may be a reasonable choice even for patients with diabetes. Patients with GERD deserve careful consideration, because their outcomes are differentially affected by sleeve gastrectomy and gastric bypass. Given the relative parity between these procedures in weight loss and comorbidity resolution, shared decision making conversations should prioritize… Read More »
Obesity Reimagined: 2018 JAMA Theme Issue On Obesity
This week, JAMA revisits obesity with a dedicated theme issue, which includes a range of articles on obesity prevention and management (including several on the impact of taxing sugar-sweetened beverages and five original long-term studies on bariatric surgery). In an accompanying editorial, Edward Livingston notes that, “The approach to the prevention and treatment of obesity needs to be reimagined. The relentless increase in the rate of obesity suggests that the strategies used to date for prevention are simply not working.” Also, “From a population perspective, the increase in obesity over the past 4 decades has coincided with reductions in home cooking, greater reliance on preparing meals from packaged foods, the rise of fast foods and eating in restaurants, and a reduction in physical activity. There are excess calories in almost everything people eat in the modern era. Because of this, selecting one particular food type, like SSBs, for targeted reductions is not likely to influence obesity at the population level. Rather, there is a need to consider the entire food supply and gradually encourage people to be more aware of how many calories they ingest from all sources and encourage them to select foods resulting in fewer calories eaten on a daily basis. Perhaps tax policy could be used to encourage these behaviors, with taxes based on the calorie content of foods. Revenue generated from these taxes could be used to subsidize healthy foods to make them more affordable.” Over the next few days, I will be reviewing about the individual articles and viewpoints included in this special issue. In the meantime, the entire issue is available here. @DrSharma Edmonton, AB
The OPQRST Of Body Weight
The assessment of weight history is no doubt a key feature of obesity assessment. Not only can weight history and trajectories provide important insights into obesity related risk but, perhaps more importantly, provide key information on precipitating factors and drivers of excessive weight gain. Now, in a short article published in MedEdPublish, Robert Kushner discusses how the well-known OPQRST mnemonic for assessing a “chief complaint” can be applied to assess body weight. In short, OPQRST is a mnemonic for Onset, Precipitating, Quality of Life, Remedy, Setting, and Temporal pattern. Applied to obesity, Kushner provides the following sample questions for each item: Onset: “When did you first begin to gain weight?” “What did you weight in high school, college, early 20s, 30s, 40s?” “What was your heaviest weight?” Precipitating: “What life events led to your weight gain, e.g., college, long commute, marriage, divorce, financial loss?” “How much weight did you gain with pregnancy?” “How much weight did you gain when you stopped smoking?” “How much weight did you gain when you started insulin?” Quality of life: “At what weight did you feel your best?” “What is hard to do at your current weight?” Remedy: “What have you done or tried in the past to control your weight?” “What is the most successful approach you tried to lose weight?” “What do you attribute the weight loss to?” “What caused you to gain your weight back?” Setting: “What was going on in your life when you last felt in control of your weight?” “What was going on when you gained your weight?” “What role has stress played in your weight gain?” “How important is social support or having a buddy to help you?” Temporal pattern: “What is the pattern of your weight gain?” “Did you gradually gain your weight over time, or is it more cyclic (yo-yo)?” “Are there large swings in your weight, and if so, what is the weight change?” As Kushner notes, “These features provide a contextual understanding of how and when patients gained weight, what efforts were employed to take control, and the impact of body weight on their health. Furthermore, by using a narrative or autobiographical approach to obtaining the weight history, patients are able to express, in their own words, a life course perspective of the underlying burden, frustration, struggle, stigma or shame associated with trying to manage body weight. Listening should be unconditional and nonjudgmental. By letting patients tell their story, the… Read More »
DIRECT Remission of Type 2 Diabetes in Primary Care?
There is no reasonable argument against the fact that excess weight gain is one of the key drivers of diabetes risk, and it should come as no surprise to anyone, that losing weight (though bariatric surgery or otherwise) dramatically improves glycemic control in people living with type 2 diabetes. So what exactly can we learn from the DIRECT study published by Michael Lean and colleagues in The Lancet? For one, this is a large cluster-randomised trial of obesity intervention conducted entirely in a non-specialist primary care setting with significant weight loss (at least 15 Kg) and diabetes remission (defined as glycated haemoglobin (HbA1c) of less than 6·5% after at least 2 months off all antidiabetic medications) as the pre-defined primary outcome at 12 months. In the intervention centres, a nurse or dietitian (as available locally) was given a total of 8 h structured training by the study research dietitians experienced in the Counterweight-Plus program. Initial weight loss was induced with a total diet replacement phase using a low energy formula diet (825–853 kcal/day) for 3 months (extendable up to 5 months if wished by participant), followed by structured food reintroduction of 2–8 weeks (about 50% carbohydrate, 35% total fat, and 15% protein), and an ongoing structured programme with monthly visits for long-term weight loss maintenance. Given the primary care non-specialist setting of this trial, the key findings (as summarized by the authors), were perhaps surprising: “Just less than a quarter of participants in the intervention group achieved weight loss of 15 kg or more at 12 months, half maintained more than 10 kg loss, and almost half had remission of diabetes, off antidiabetic medication….Remission was closely related to the degree of weight loss maintained at 12 months, with achievement in 86% of participants with at least 15 kg weight loss, and 73% of those with weight loss of 10 kg or more. 28% of all eligible individuals volunteered to participate,17 and 79% completed the intensive total diet replacement phase…” In general, the intervention was well tolerated with 117 out of 150 participants (78%) in the intervention group completing the intervention. So here are the key learning from DIRECT: For one, there should no longer be any doubt that “remission” of Type 2 diabetes is possible in a substantial number of patients, if we can help them achieve and sustain significant weight loss – the odds of experiencing remission are directly proportional… Read More »
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