For kids with severe obesity and type 2 diabetes, metabolic surgery may provide the best outcomes, such as better glycemic control and weight loss, versus medical therapy, researchers reported.
Comparing participants from the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) versus Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY), adolescents who underwent bariatric surgery had several improved health outcomes compared to those who received either stand-alone metformin, combination therapy or lifestyle intervention, according to Thomas H. Inge, MD, PhD, of Children’s Hospital Colorado in Aurora, and colleagues.
After 2 years, mean HbA1c significantly dropped from 6.8% to 5.5% (95% CI 6.4%-7.3%) in those who had surgery compared with an increase from 6.4% to 7.8% in nonsurgical patients (6.1%-6.7%), they wrote in JAMA Pediatrics.
BMI had similar outcomes, with an average drop of 29% (24%-34%) from baseline BMI for surgical patients versus a 3.7% (0.8%-6.7%) increase in those involved in the TODAY trial.
“There is a need to identify management approaches, including metabolic surgery, that may yield clinically significant and durable glycemic control,” the researchers wrote, citing that “neither metformin nor insulin, the only drugs approved by the US Food and Drug Administration to treat type 2 diabetes in youths, addresses the underlying pathophysiologic properties of obesity-related comorbidities.”
They also raised the point that type 2 diabetes diagnosed in youth tends to be a more aggressive disease compared with adult-onset diabetes, with the TODAY trial finding almost half of participants progressing to insulin therapy after only 11 months.
A group of 30 youth (mean age at baseline 16.9 years) with type 2 diabetes from the Teen-LABS trial were included in this analysis, all of whom had a BMI of ≥35 plus a comorbid condition or a BMI ≥40. A total of 24 of these participants underwent Roux-en-Y gastric bypass, while six underwent the vertical sleeve gastrectomy.
In comparison, 63 adolescents (mean age 15.3 years) with type 2 diabetes in the TODAY trial, all with a BMI >35, were prescribed metformin therapy alone or in conjunction with rosiglitazone, or intensive lifestyle intervention.
In addition to the aforementioned 2-year benefits seen following metabolic surgery, several cardiovascular outcomes also showed significant improvement. After surgery, the number of kids with elevated blood pressure dropped from 45% to 20%, while the nonsurgical treatment group saw a stark rise from 22% to 41% with high blood pressure. Similar findings were reported in the number of with dyslipidemia, decreasing from 72% to 24% in the surgery group, while the nonsurgical group saw no major changes during this time.
Kidney functioning also improved in the surgery group, marked by a complete elimination in kids with low eGFR and a 21% drop in the number with elevated urinary albumin-creatinine ratio.
However, the rate of adverse events were markedly higher following surgery, with 23% of the patients having experienced complications necessitating a reoperation or readmission versus two adverse events seen in the nonsurgical group.
Such complications and reoperations can be a major source of costs associated with surgery, with a prior cost-effective analysis of the Teen-LABS study pegging the initial costs and complications. But in the long run (≥5 years after the surgery), there was a 78% probably of cost-effectiveness, according to that analysis.
Limits to this current study included the design combining and comparing two separate cohorts, despite the similar methods of the analyses. Also, very few cases of the sleeve gastrectomy were included in the surgical group, a procedure that has since gained greatly in popularity.
The findings, “combined with the effects of type 2 diabetes on mortality being greatest for those who received diagnoses at a young age, suggest that surgical therapy should be considered earlier rather than later for those who are diagnosed with youth-onset type 2 diabetes,” the authors stated.
The study was supported with grants from the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institutes of Health Office of the Director, the National Center for Research Resources General Clinical Research Centers Program, and from the National Centre for Advancing Translational Science Awards.
Inge dislcosed a relevant relationship with Standard Bariatrics. Co-authors disclosed multiple relevant relationships with industry.