Is Early Bariatric Surgery the Answer for Diabetes in Obesity?

Abstract

The article by Aung et al1 in this issue of JAMA Surgery continues the excellent clinical research from the group in Taiwan.Multiple randomized studies havedemonstrated the efficacy of bariatric surgery in treatingtype2diabetes (T2D), and the term metabolic surgery is being increasingly used, although it is not alwayswell defined. In their introduction, Aung and colleagues define this surgery as “the application of bariatric surgical procedures to patients with a body mass index (BMI) (calculated as weight in kilograms divided by height inmeters squared) of less than 35who also have severe comorbidities.”1 We feel defining it as the manipulation of the gastrointestinal tractwith the goal of treatingT2D isnot only more appropriate but also more representative of what the authors have evaluated in their study. In this article, the authors compare the outcomes of bariatric surgery in those with early-onset T2D (age <40 years) and late-onset T2D (age ≥40 years) and conclude that early intervention leads to better ratesofcompletediabetes remission (hemoglobinA1c<6.0% [toconvert toproportionof totalhemoglobin,multiplyby0.01] without antidiabetic medication).1 Previous studies have shown that the duration of diabetes,useof insulin,degreeofpostoperativeweight loss, andtype of surgeryperformed can influence the remission rates of diabetes following bariatric surgery.2 The studybyAung and colleagues shows that age at diabetes onset canbeused as an additionalpredictorof success,whichsuggestseitheradifference in the pathophysiology of early-onset diabetes or preserved pancreatic reserve in young patients, as inferred by higher C-peptide levels. These data are in keepingwith a 2016 study by Inge et al3 showing a 95%diabetes remission rate at 3 years in their adolescent cohort (aged 13-19 years). Taken together, there appears to be an amassing body of data in support of early consideration of bariatric surgery for obese individualswithT2D. This not only has thepotential to reduce their long-termneed for multiple medications but also has the potential to significantly mitigate their risks of health complications compounded over their lifetime. Thestudy’s5-yearoutcomesareamajor strengthof this article. Although the follow-up ratewas around 50%, these data pointsarerareandvaluabletothefield.Theauthorsaretobecongratulatedforcollectingthesedata,whichreveal thatT2Drecurrence,anAchillesheelofbariatricsurgery,occurseveninthemost idealofpatients—onewithearlyonsetandshortdurationofT2D. Thus, identifyingmarkersof long-termT2Dremissionis,andwill continue to be, an area of heavy interest in the field.