Does Gastric Bypass Surgery Save Lives Only In People With Diabetes?

While we know that weight loss of just 5-10% is associated with an improvement in many parameters of health, the only treatment for obesity that has been suggested to reduce mortality is bariatric surgery.  A new study suggests that if gastric bypass surgery reduces mortality, it may be people with diabetes in particular who enjoy this benefit.

The study, published in Diabetes Care, matched 2,428 people in their database who had gastric bypass surgery by age, BMI, gender, and diabetes status to a control group in the database who had not had surgery.

They found that for the 625 people who had diabetes before gastric bypass surgery, their risk of death from any cause was reduced by 56% at 5.8 years after surgery, compared to people who had diabetes but hadn't had surgery.  In particulary, death from cardiovascular disease, lung disease, and diabetes were lower in the group who had surgery.  The reduction in mortality was the greatest for people whose diabetes went into remission after surgery.

For the 1,803 people who didn't have diabetes before gastric bypass surgery, the risk of death at 6.7 years after surgery was not significantly different than those who didn't have diabetes and didn't have surgery.  When they boiled it down, the risk of death from cancer and lung diseases was lower in the people who had had gastric bypass surgery, but the risk of death from external causes (including injuries, overdose, and suicide) was higher, especially for younger people.

This study is the first to suggest that a reduction in all-cause mortality after gastric bypass surgery may be limited to people who have diabetes before surgery.  However, even if people without diabetes don't enjoy enhanced life expectancy overall, remember that there are still many health benefits to be enjoyed from bariatric surgery.   It's also important to emphasize that this study is retrospective, meaning that researchers looked back in time and analyzed pre existing data.  This type of data can be muddied by other factors that can't be controlled for (called 'confounding factors'), so we have to take them with a grain of salt.

The increased death risk from injuries, overdose, and suicide for people without diabetes who had surgery needs attention. It is known that there is a higher risk of self harm after surgery, pointing towards the need for psychological counselling and support both pre and post surgery.  There is still very little known about how bariatric surgery changes the absorption of medications and other substances, increasing the risk of potential overdose; further studies are desperately needed in this area.

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How Successful is Gastric Bypass Surgery 12 Years Later?

We know that gastric bypass surgery is a powerful tool in the management of obesity and metabolic syndrome.  However, there is not a lot of data available following patients out over the very long term.  A recent study is the first prospective study looking only at Roux-en-Y gastric bypass surgery, to give us data out as far as 12 years.

The study, published by Adams and colleagues in the New England Journal of Medicine, enrolled 418 patients in Utah, USA who underwent gastric bypass surgery, and compared them over the long term to 417 patients who wanted surgery but did not have surgery (primarily because of lack of financial insurance coverage), and a third group of 321 patients with obesity who were not interested in surgery. They had an excellent rate of follow up of over 90% of patients at 12 years.

Here are some of the key findings: (skip to take home messages below for the short version)

1.  Weight loss:

• Two years after gastric bypass surgery, the mean weight loss was 45 kg. 
• At 6 years postop, the mean weight loss was 36.3kg (so there was about 20% weight regain, which is very consistent across studies).
• At 12 years postop, the mean weight loss was 35kg – so weight was overall stable from 6 years to 12 years after surgery.

 [At 12 years, people who wanted surgery but didn’t have it had lost 2.9 kg (probably because they were part of this study), and people with obesity who did not want surgery had lost 0 kg (also notable for no weight gain over the long term).]

2.  Type 2 diabetes:

Among patients in the surgery group who had type 2 diabetes before surgery:

• At 2 years postop, 75% of diabetes had gone into remission.
• At 6 years postop, 62% of diabetes cases were in remission
• At 12 years postop, 51% of diabetes cases were in remission.
• The likelihood of diabetes being in diabetes remission at 12 years was 8.9 times higher for those who had had surgery compared to those who wanted but did not get surgery, and 14.8 times higher than those who did not want surgery in the first place.
• At 12 years, the likelihood of being in diabetes remission was highest in people who had diet controlled diabetes before surgery (remission rate 73%), less for people who needed pills to treat their diabetes before surgery (remission rate 56%), and lowest for people who required insulin to treat their diabetes before surgery (remission rate 16%). 
• At 12 years, there was a 91-92% lower risk of having new type 2 diabetes develop in patients who had had bariatric surgery, compared to the non surgery groups.

3.  Mortality rates:

At 12 years, mortality in people who had gastric bypass surgery was lower than those who wanted surgery but didn’t get it, but there no different between those who had gastric bypass surgery than those who didn’t want surgery in the first place, likely because the group not wanting surgery was healthier at baseline. There were 5 suicides in the group that had bariatric surgery, compared to 2 suicides in the non surgical group.  (see here and here and here for discussion of suicide risk after bariatric surgery ) 

Take home messages from this study:

• On average, weight loss is stable over the long term after gastric bypass surgery – though the results can be different for different people, and certainly lifelong dedication to permanent lifestyle changes are essential for continued success.

• Gastric bypass surgery can be a powerful tool to not only put diabetes into remission, but also to decrease the risk of developing diabetes later on.  Earlier intervention is better, because the longer a person has diabetes, the more tired their pancreas gets (ie decreased beta cell function, which are the cells that produce insulin), and a tired pancreas may be too tired to control blood sugars after bariatric surgery without help from medication.  Thus, considering bariatric surgery early in the course of diabetes, or even in the prediabetes phase, may have the most powerful impact.

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Mental Health and Bariatric Surgery - Canadian Data

We know that there is a relationship between mental health and obesity, with mental health issues such as depression being associated with an increased risk of obesity, and with the risk of mental health issues developing increasing as weight increases. In people with more pronounced obesity who are considering bariatric surgery as a treatment option, it is important to consider how mental illness may impact the efficacy and safety of surgical treatment for obesity.

These issues were beautifully summarized in a recent review by Val Taylor and colleagues, published in the Canadian Journal of Diabetes, with a focus on Canadian data.

Here are a few of the highlights:

1. How common are mental health issues in Canadian bariatric surgery patients? 

Over half of patients presenting in Ontario for bariatric surgery had a history of mental illness (most commonly depression). Neither a history of depression nor bipolar disorder seem to be associated with success of weight loss with bariatric surgery, but stability and control of mental health issues preoperatively is important to optimize success.  The prevalence and severity of depression in the bariatric population are consistently decreased after surgery – but there is a risk of development of depression for some people as well, which may be related to some of the psychological challenges that can present after surgery.  Many people with mental health issues are taking medications to treat these conditions, and absorption of these meds may be affected after surgery, so close monitoring to ensure good control of the mental health issue after surgery is important.

2. Eating disorders:

Binge eating disorder (BED) has a prevalence of up to 30% in people presenting for bariatric surgery, with the data conflicting on whether BED reduces the success of weight loss with bariatric surgery. Management of the feeling of loss of control and regulation of emotions in these individuals are important factors to help reducing binge eating in this group.

Active bulimia is a contraindication to bariatric surgery.

3. Suicide risk:

While depression usually improves after surgery, the risk of suicide is increased after bariatric surgery, with a multitude of possible reasons/contributors behind this fact.  The risk of self harm seems to be increased at least 3 years after surgery, so long term psychological follow up and support of bariatric patients is essential.

4. What if there is a past history of sexual abuse?

A history of sexual abuse is present in 21.5% of people in the Ontario Bariatric Surgery Registry.  While this does not appear to influence the success of surgery, these individuals are at a higher risk of mental health issues such as depression, speaking to the need for proper assessment and follow up.

5.  Substance use/abuse:

A history of substance use (alcohol, tobacco, or recreational/illicit drugs) seems to be correlated with a risk of substance use after surgery, particularly if the substance use history is near to the time of surgery.  Alcohol abuse is a particular risk, as alcohol hits harder and fasterafter surgery.  A ‘transfer’ of addictions from one thing to another (eg, from food to gambling) after surgery has been described, and should be discussed and managed ahead of time.

Most often, mental health issues can generally be well managed to optimize success of the individual undergoing bariatric surgery.  Identifying and managing these issues before surgery is essential, and long term support after surgery is key as well.

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Obesity, Addiction, Alcohol and Bariatric Surgery Part II

We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors.  We are also learning increasingly that there are many areas of neurophysiologic (brain), psychological and behavioral overlap in the realms of obesity and addiction.

In part I of this two-part blog post, we discussed some of the changes that happen after bariatric surgery, as discussed in a recent review.

Now, some threads that weave a connection for some people between obesity and addiction: 

1.  For some people, food is an addictive substance.  People who have high scores on food addiction questionnaires have similar patterns of brain activation as in people with other addictions.  Also, overconsumption of certain nutrients (eg sugar) elicits chemical responses in our brains, similar to those that result from consumption of drugs or alcohol.

Some people think that combatting a food addiction is no different than trying to quit smoking.  But remember, a person who quits smoking can (and ideally will) lead their life without ever touching another cigarette.  But the person battling a food addiction can't stop eating - they have to continue to eat for the rest of their lives, while controlling the addictive component that leads to overeating: a very, very difficult thing to do. 

2.  Some people with obesity have more 'turbo-charged' food reward circuits in their brains, which results in a powerful drive to seek high calorie food.  Obesity can also be accompanied by a reduced brain-driven ability to resist temptation and control impulses to eat, with data suggesting that there is a genetic component to these differences.  After gastric bypass surgery, research has identified some changes in this brain activity, and these changes may be associated with the amount of weight lost after surgery.

Know that feeling of: I am so hungry I don't care what it is it just has to happen RIGHT NOW...?
For some people, this feeling may come only if meals are skipped for many hours, or after a fierce workout.  For others, they may feel like this until their body is at a higher body weight 'set point'.  The level of energy reserves, or time from last meal that contributes to the threshold for this feeling to set in, is very different from person to person.

So for people who have a food addiction, as well as for people who have a more powerful reward circuitry, weight management will be difficult, but not impossible - having a psychologist with professional training in obesity management is an important part of the team to help manage their weight struggles.

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Obesity, Addiction, Alcohol and Bariatric Surgery Part I

We know that the factors behind each individual's struggle with obesity are unique, with a long list of physiologic, psychological, and environmental factors as potential contributors.  We are also learning increasingly that there are many areas of neurophysiologic, psychological and behavioural overlap in the realms of obesity and addiction.  A recent review draws on our knowledge of alcohol use after bariatric surgery to help us understand these connections.

After gastric bypass surgery:

• 9.4% of patients who have had gastric bypass surgery report a period of excessive alcohol intake at some point after surgery
• 7% of patients with no preoperative history of excessive alcohol intake develop a problem after surgery
• middle aged females seem to be at higher risk
• post bariatric surgery addiction problems seem to be fairly specific to alcohol (though addictions to other substances, or activities such as gambling are also seen - see 'addiction transference' below)
• when a person who has had gastric bypass surgery drinks alcohol, there is a faster rise, higher peak, and longer duration of blood alcohol levels 

Interestingly, some people who were frequent alcohol consumers before surgery actually have a decreased enjoyment of alcohol after surgery, which may be mediated by an increase in the gut hormone GLP-1, and a decrease in the hunger hormone ghrelin.

Psychological and social factors can also have a big influence on alcohol consumption after surgery.  As blogged previously, food addiction seeking a new outlet (called 'addiction transference') may be a factor for some people.  A need for a coping mechanism as a person watches their body change after surgery may be involved.   Some may reach for alcohol as a way to manage the complex psychological issues that can arise after surgery. 

Stay tuned for the next blog post, where I'll discuss some of the parallels between obesity and addiction discussed in this review. 

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After Bariatric Surgery - Pateints' Perspectives

There is no doubt that bariatric surgery is a hot topic of research these days.  Most of this research focuses on the medical benefits that can be enjoyed after bariatric surgery, such as improvements in diabetes control, high blood pressure, sleep apnea, and so forth.  Much less qualitative research has been done - the kind of research that looks at things that are hard to measure with numbers, such as psychological effects and changes in quality of life. Most of the qualitative information that has been published is on small groups of individuals, and it is challenging for patients or clinicians to synthesize this smattering of data as a whole.

Coulman and colleagues recently collected information on this topic in the first systematic review of qualitative research in the bariatric surgery field.  Published in Obesity Reviews (and free to download!), they included 33 studies reporting on the patient perspective on living with the outcomes of bariatric surgery.

Three themes were identified:

1.  Control.  Patients reported making the decision to undergo bariatric surgery to gain control over eating, weight, and health.  In general, a feeling of improved control was experienced in the first year after surgery, but after a year, there was less of a sense of physical control (described as 'stomach control'), and it became more about relying on their own 'head control' to manage food intake.

2. Normality.  A sense of 'normality' was something that many patients were striving for after bariatric surgery - lives less burdened by physical and psychological ill health, ability to participate in normal everyday activities, and what patients described as a more 'socially acceptable' appearance.  While many people felt more 'normal' after surgery, there were also several issues identified that challenged patients' desire to feel 'normal'.  This included a change in their own or others' perceptions of their bodies, unpleasant gastrointestinal side effects (eg vomiting or diarrhoea), not being able to eat like others, and loose hanging skin.

3.  Ambivalence. Patients reported that while some things changed for the better, other changes were difficult to cope with or adapt to. This included physical pros (improvement in metabolic health) and cons (gastrointestinal and nutritional side effects of surgery).  This also included psychological pros (improvement in depression, self esteem, control) and cons (eg continued depression and self esteem issues with a realization by some that bariatric surgery was not going to fix these issues; challenges of finding ways other than food to cope with emotions; feeling a loss of protection from the outside world and a feeling of vulnerability with weight loss).

This review is a treasure trove of information, including quotes from patients, and is a great read in its entirety.   These findings highlight that while bariatric surgery is an excellent treatment strategy for some people, for others it may not be the best choice.  These findings certainly speak to the need for long term follow up for patients who have had bariatric surgery, including long term psychological and nutritional support.

As the authors write: Surgery was not the end of their journey with obesity, but rather the beginning of a new and sometimes challenging path.

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Will Bariatric Surgery Help Me Control My Diabetes?

One of the major reasons why we might suggest bariatric (obesity) surgery to our patients with obesity and type 2 diabetes, is that studies have shown bariatric surgery to be very effective in improving diabetes control, or even putting diabetes into remission.  However, it has been slow to grow the body of research data in this area, as it is difficult to conduct high quality, long term studies in this field.

Now, just published, we have 5 year data showing that bariatric surgery (gastric bypass surgery and sleeve gastrectomy) are superior to medical therapy to treat type 2 diabetes in people with obesity.

I blogged on the 3 year data in this trial, called the STAMPEDE trial, when it came out in 2014 - where you can read about the structure, goals of the study and the results at that time.

Now, published in the New England Journal of Medicine, the extended results of the STAMPEDE study show that 5 years after bariatric surgery, 29% of patients who had gastric bypass surgery had tight control of their diabetes, vs 23% of those who had sleeve gastrectomy, vs only 5% of those who had intensive medical treatment alone.  A duration of diabetes of less than 8 years before surgery was the main predictor of achieving tight control of diabetes, suggesting that earlier intervention with bariatric surgery may give the maximum benefit in glycemic control.

There were also greater improvements in body weight, several measures of cholesterol, need for insulin, and quality of life in the surgical groups.  No late major surgical complications were reported except for one person in the sleeve gastrectomy group who underwent gastric bypass at year 4 to treat a gastric fistula.  Follow up at the 5 year mark was 90%, which is excellent.

While I still take issue to the target for diabetes control being too tight in this study at an A1C of 6.0%, this study does now give us good 5 year data to support that bariatric surgery can be an effective tool to help treat type 2 diabetes in people with obesity.

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Bariatric Surgery - Can We Predict Remission Of Diabetes?

One of the most important benefits of bariatric surgery (especially gastric bypass and sleeve gastrectomy) is its ability to improve the control of type 2 diabetes, often to the point where type 2 diabetes actually goes into remission after surgery.  Not everyone with type 2 diabetes who has bariatric surgery will experience remission - about 70-80% of patients having gastric bypass and about 50-60% of patients having sleeve gastrectomy will experience remission.  Ideally, we would be able to predict the likelihood of diabetes remission before the surgery is done, as this is arguably one of the most important potential benefits of bariatric surgery.

A recent study tried to answer this question using a scoring system called the DiaRem Score, which looked at at 4 preoperative variables amongst a group of 407 patients who underwent gastric bypass surgery:

• age
• need for insulin 
• diabetes medication use (points assigned varied by type of medication)
• hemoglobin A1C (a blood test which is a 3 month report card of diabetes control)

They found that this score, which is based on the above 4 variables, was highly predictive of who went into remission from their type 2 diabetes and who did not.

Other scoring systems and variables have been looked at as well.  Other variables that stands out in the literature are a shorter duration of diabetes, and preoperative serum C peptide level, which is a marker of a person's ability to produce insulin.

It is exciting to know that as we learn more about bariatric surgery, that we can become better at predicting who may benefit from a diabetes standpoint.  However, a word of caution - longer term studies suggest that for people who do enjoy diabetes remission after bariatric surgery, the diabetes recurs in about 50% of these people by 5 years post op.  While there is still certainly a health benefit to being free of diabetes for a number of years, it is important to remember that the diabetes can return and must be screened for regularly and lifelong.

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