Metabolic Surgery Improves Diabetes-Related Quality of Life

Patients with type 2 diabetes who underwent metabolic surgery reported improved general health, mobility, and energy, along with less pain and diabetes-related concerns compared with similar patients who only received intensive medical therapy, during a 5-year study.

That is, among 104 patients in the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial, those randomized to surgery versus medical therapy reported better quality of life, especially diabetes-related aspects of life, in annual questionnaire replies.

Notably, “about one third of surgical patients had long-term remission of their [type 2 diabetes] (A1c < 6.5% off diabetes medications) and over half of them had good glycemic control (A1c < 7%),” the researchers report in an article published online in Annals of Surgery by Ali Aminian, MD, director of the Cleveland Clinic’s Bariatric & Metabolic Institute, and colleagues.

“Significant weight loss and insulin independence following metabolic surgery drive the improvement in general health measures and quality of life for patients with type 2 diabetes” found in this study, Sangeeta Kashyap, MD, a co-investigator and endocrinologist at the Cleveland Clinic’s Endocrinology & Metabolism Institute, explained in a statement from the clinic.

But notably, metabolic surgery was not associated with long-term improvements in psychological, emotional, or social aspects of quality of life, which suggests “that psychological well‐being needs may require more attention in metabolic surgical patients,” Aminian pointed out.

“As part of our multidisciplinary approach to weight management at Cleveland Clinic, our patients have appointments with psychologists before and after surgery,” he continued.

However, “the study results highlight that we may need greater emphasis on that aspect of the treatment, such as identification of psychosocial and emotional factors before surgery that can predict outcomes of surgery, as well as continuous psychosocial support after surgery.”

Quality of Life Outcomes in STAMPEDE

STAMPEDE randomized 150 patients at the Cleveland Clinic with diabetes and obesity — an A1c > 7% and body mass index (BMI) 27-43 kg/m2 — to either intensive medical therapy alone (lifestyle counseling and guideline-recommended therapies for diabetes, hypertension, dyslipidemia, and cardiovascular disease) or metabolic surgery, between March 2007 and January 2011.

A total of 104 patients who had intensive medical therapy alone (26 patients), gastric bypass (41), or sleeve gastrectomy (37) had complete results from three self-reported quality-of-life questionnaires — the RAND 36-Item Health Survey (RAND-36), the European Quality of Life 5-Dimensions (EQ-5D), and a two-question diabetic-specific questionnaire — at baseline and annually out to 5 years.

At baseline, patients in the three groups were a mean age of 50 years, a mean weight of 104 kg (229 lb), and a mean BMI of 36.5 kg/m2, and 55% were taking insulin. Two thirds were women and about three quarters were White.

Five years after they were randomized, patients in the surgery group had lost more weight, roughly 20 kg (44 lb) vs 7 kg (15.4 lb), and were more likely to have an A1c < 6%, with or without diabetes medication, as previously reported.

In this new analysis, over the course of the 5 years, patients in the metabolic surgery group had significantly better scores on the RAND-36 questionnaire for physical functioning, energy/fatigue, and general health compared with patients in the medical therapy group (all P ≤ .01).

The favorable changes were similar after both types of metabolic surgery and were more pronounced at 3 years versus 5 years — possibly due to late weight regain, diabetes relapse, or long-term surgical adverse events such as gastroesophageal reflux disease after sleeve gastrectomy, the researchers speculate.

“We found that substantial weight loss (achieved with both gastric bypass and sleeve gastrectomy) and no requirement for insulin were independent predictors of change in perceived general health.

“Large weight loss can decrease pressure on joints, may reduce musculoskeletal pain, and improve mobility. Improved diabetes control and requirement for less medications (particularly injectables) may also contribute to patients’ satisfaction following metabolic surgery,” they write.

The aggregate EQ-5D scores (for mobility, self-care, usual activities, pain/discomfort, and anxiety depression) were not significantly different in the three groups.  

However, the diabetes-specific questionnaire revealed that patients who had surgery had fewer problems with 12 diabetes-related activities (such as maintaining a diet, going on vacation, planning meals, eating out with others, and family life) and with living a normal life and taking care of their diabetes up to 5 years later.

STAMPEDE was supported by Ethicon, with additional support from LifeScan, Cleveland Clinic, and the National Institutes of Health. The authors have reported no relevant financial relationships.

Ann Surg. Published online June 16, 2021. Abstract

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