Elsevier

Surgery for Obesity and Related Diseases

Volume 8, Issue 5, September–October 2012, Pages 548-555
Surgery for Obesity and Related Diseases

Original article
Type 2 diabetes after gastric bypass: remission in five models using HbA1c, fasting blood glucose, and medication status

https://doi.org/10.1016/j.soard.2012.05.005Get rights and content

Background

The remission rates of type 2 diabetes mellitus (T2DM) after Roux-en-Y gastric bypass (RYGB) vary according to the glycosylated hemoglobin A1c (HbA1c), fasting blood glucose (FG), and medication status. Our objectives were to describe remission using the American Diabetes Association standards for defining normoglycemia and to identify the factors related to the preoperative severity of T2DM that predict remission to normoglycemia, independent of weight loss, after RYGB. The setting was an urban not-for-profit community hospital.

Methods

We performed a retrospective analysis of prospectively collected data from a cohort of 2275 patients who qualified for bariatric surgery (2001–2008). Five different models for defining remission (no diabetes medication and a FG <100 mg/dL; no diabetes medication and HbA1c <6.0; no diabetes medication and HbA1c <5.7%; no diabetes medication, FG <100 mg/dL, and HbA1c <6.0%; and no diabetes medication, FG <100 mg/dL, and HbA1c <5.7%) were compared in 505 obese patients with T2DM 14 months after RYGB. The secondary aims were to determine the effects of preoperative insulin therapy and the duration of known T2DM on remission.

Results

Of the 505 patients, 43.2% achieved remission using the most stringent criteria (no diabetes medication, HbA1c <5.7%, and FG <100 mg/dL) compared with 59.4% using the most liberal definition (no diabetes medication and FG <100 mg/dL; P < .001). The remission rates were greater for patients not taking insulin preoperatively (53.8% versus 13.5%, P < .001) and for patients with a more recent preoperative T2DM diagnosis (8.9 versus 3.7 yr, P < .001).

Conclusion

Remission, defined at a threshold less than what would be expected to result in microvascular damage, was achieved in 43.2% of diabetic patients by 14 months after RYGB. A more recent diagnosis of T2DM and the absence of preoperative insulin therapy were significant predictors, regardless of how remission was defined, independent of the percentage of excess weight loss.

Section snippets

Study design

We performed a retrospective analysis of data prospectively collected from a cohort of 2275 patients who qualified for bariatric surgery under the standards defined by the 1991 National Institutes of Health Consensus Conference [26] and underwent RYGB in a community hospital from 2001 to 2008. For patients diagnosed preoperatively with T2DM, remission was defined using a composite of FG and HbA1c values combined with diabetes medication status by 14 months after surgery. The institutional

Preoperative demographics

The characteristics of the total population are listed in Table 1. Of the 2275 patients (79.8% women, 86.7% white) who underwent RYGB, 1312 (57.7%) had normoglycemia, 296 (13%) had impaired fasting glucose (at risk of T2DM), and 667 (29.3%) had T2DM before surgery. The patients who were at risk of T2DM and those who had T2DM weighed more (P = .008), were older, and had a greater number of co-morbidities (P < .001) than the patients with normoglycemia. The patients with T2DM had greater FG and

Discussion

Using the current criteria (a composite of FG <100 mg/dL, HbA1c <5.7%, and no diabetes medication), our data revealed T2DM remission to normoglycemia by 14 months after RYGB in 218 (43.2%) of the 505 patients or 200 (53.8%) of 372 noninsulin-requiring patients and 18 (13.5%) of 133 insulin-requiring patients. Both the preoperative absence of insulin therapy and a shorter duration with a known diagnosis of T2DM independently predicted remission by 14 months. Even among those patients not

Conclusion

We propose defining T2DM remission after bariatric surgery as a return to normoglycemia and the discontinuation of diabetes medications using current ADA criteria for both FG and HbA1c. Even with these more stringent criteria, a number of patients achieved remission and discontinued all diabetes medications within 14 months. Also, the estimates of preoperative disease severity (shorter known T2DM duration and not requiring insulin therapy) were robust and independent predictors for the

Acknowledgment

We acknowledge the nursing and clinical staff at Scottsdale Bariatric Center and Scottsdale Healthcare for their kind and compassionate care of patients.

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    Supported in part (contribution of J.C.B.) by the Intramural Research Program of the National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases.

    Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.

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