3
|
Ding SA, Simonson DC, Wewalka M, Halperin F, Foster K, Goebel-Fabbri A, Hamdy O, Clancy K, Lautz D, Vernon A, Goldfine AB. Adjustable Gastric Band Surgery or Medical Management in Patients With Type 2 Diabetes: A Randomized Clinical Trial. J Clin Endocrinol Metab 2015; 100:2546-56. [PMID: 25909333 PMCID: PMC4490302 DOI: 10.1210/jc.2015-1443] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT Recommendations for surgical, compared with lifestyle and pharmacologically based, approaches for type 2 diabetes (T2D) management remain controversial. OBJECTIVE The objective was to compare laparoscopic adjustable gastric band (LAGB) to an intensive medical diabetes and weight management (IMWM) program for T2D. DESIGN This was designed as a prospective, randomized clinical trial. SETTING The setting was two Harvard Medical School-affiliated academic institutions. INTERVENTIONS AND PARTICIPANTS: A 12-month randomized trial comparing LAGB (n = 23) vs IMWM (n = 22) in persons aged 21-65 years with body mass index of 30-45 kg/m(2), T2D diagnosed more than 1 year earlier, and glycated hemoglobin (HbA(1c)) ≥ 6.5% on antihyperglycemic medication(s). MAIN OUTCOME MEASURE The proportion meeting the prespecified primary glycemic endpoint, defined as HbA(1c) < 6.5% and fasting glucose < 7.0 mmol/L at 12 months, on or off medication. RESULTS After randomization, five participants did not undergo the surgical intervention. Of the 40 initiating intervention (22 males/18 females; age, 51 ± 10 y; body mass index, 36.5 ± 3.7 kg/m(2); diabetes duration, 9 ± 5 y; HbA(1c), 8.2 ± 1.2%; 40% on insulin), the proportion meeting the primary glycemic endpoint was achieved in 33% of the LAGB patients and 23% of the IMWM patients (P = .457). HbA(1c) reduction was similar between groups at both 3 and 12 months (-1.2 ± 0.3 vs -1.0 ± 0.3%; P = .496). Weight loss was similar at 3 months but greater 12 months after LAGB (-13.5 ± 1.7 vs -8.5 ± 1.6 kg; P = .027). Systolic blood pressure reduction was greater after IMWM than LAGB, whereas changes in diastolic blood pressure, lipids, fitness, and cardiovascular risk scores were similar between groups. Patient-reported health status, assessed using the Short Form-36, Impact of Weight on Quality of Life, and Problem Areas in Diabetes, all improved similarly between groups. CONCLUSIONS LAGB and a multidisciplinary IMWM program have similar 1-year benefits on diabetes control, cardiometabolic risk, and patient satisfaction, which should be considered in the context of other factors, such as personal preference, when selecting treatment options with obese T2D patients. Longer duration studies are important to understand emergent differences.
Collapse
Affiliation(s)
- Su-Ann Ding
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Donald C Simonson
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Marlene Wewalka
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Florencia Halperin
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Kathleen Foster
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Ann Goebel-Fabbri
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Osama Hamdy
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Kerri Clancy
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - David Lautz
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Ashley Vernon
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| | - Allison B Goldfine
- Harvard Medical School (S.D., D.C.S., M.W., F.H., A.G.-F., O.H., D.L., A.V., A.B.G.), Boston, Massachusetts 02115; Joslin Diabetes Center (S.D., M.W., F.H., K.F., A.G.-F., O.H., A.B.G.), Boston, Massachusetts 02215; and Brigham and Women's Hospital (D.C.S., F.H., K.C., D.L., A.V., A.B.G.), Boston, Massachusetts 02115
| |
Collapse
|
4
|
Halperin F, Ding SA, Simonson DC, Panosian J, Goebel-Fabbri A, Wewalka M, Hamdy O, Abrahamson M, Clancy K, Foster K, Lautz D, Vernon A, Goldfine AB. Roux-en-Y gastric bypass surgery or lifestyle with intensive medical management in patients with type 2 diabetes: feasibility and 1-year results of a randomized clinical trial. JAMA Surg 2014; 149:716-26. [PMID: 24899464 DOI: 10.1001/jamasurg.2014.514] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Emerging data support bariatric surgery as a therapeutic strategy for management of type 2 diabetes mellitus. OBJECTIVE To test the feasibility of methods to conduct a larger multisite trial to determine the long-term effect of Roux-en-Y gastric bypass (RYGB) surgery compared with an intensive diabetes medical and weight management (Weight Achievement and Intensive Treatment [Why WAIT]) program for type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS A 1-year pragmatic randomized clinical trial was conducted in an academic medical institution. Participants included persons aged 21 to 65 years with type 2 diabetes diagnosed more than 1 year before the study; their body mass index was 30 to 42 (calculated as weight in kilograms divided by height in meters squared) and hemoglobin A1c (HbA1c) was greater than or equal to 6.5%. All participants were receiving antihyperglycemic medications. INTERVENTIONS RYGB (n = 19) or Why WAIT (n = 19) including 12 weekly multidisciplinary group lifestyle, medical, and educational sessions with monthly follow-up thereafter. MAIN OUTCOMES AND MEASURES Proportion of patients with fasting plasma glucose levels less than 126 mg/dL and HbA1c less than 6.5%, measures of cardiometabolic health, and patient-reported outcomes. RESULTS At 1 year, the proportion of patients achieving HbA1c below 6.5% and fasting glucose below 126 mg/dL was higher following RYGB than Why WAIT (58% vs 16%, respectively; P = .03). Other outcomes, including HbA1c, weight, waist circumference, fat mass, lean mass, blood pressure, and triglyceride levels, decreased and high-density lipoprotein cholesterol increased more after RYGB compared with Why WAIT. Improvement in cardiovascular risk scores was greater in the surgical group. At baseline the participants exhibited moderately low self-reported quality-of-life scores reflected by Short Form-36 total, physical health, and mental health, as well as high Impact of Weight on Quality of Life-Lite and Problem Areas in Diabetes health status scores. At 1 year, improvements in Short Form-36 physical and mental health scores and Problem Areas in Diabetes scores did not differ significantly between groups. The Impact of Weight on Quality of Life-Lite score improved more with RYGB and correlated with greater weight loss compared with Why WAIT. CONCLUSIONS AND RELEVANCE In obese patients with type 2 diabetes, RYGB produces greater weight loss and sustained improvements in HbA1c and cardiometabolic risk factors compared with medical management, with emergent differences over 1 year. Both treatments improve general quality-of-life measures, but RYGB provides greater improvement in the effect of weight on quality of life. These differences may help inform therapeutic decisions for diabetes and weight loss strategies in obese patients with type 2 diabetes until larger randomized trials are performed. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01073020.
Collapse
Affiliation(s)
- Florencia Halperin
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Su-Ann Ding
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Donald C Simonson
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Panosian
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Ann Goebel-Fabbri
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Marlene Wewalka
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Osama Hamdy
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Martin Abrahamson
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Kerri Clancy
- Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathleen Foster
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - David Lautz
- Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashley Vernon
- Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Allison B Goldfine
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|