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Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2018:11 459–467
Diabetes, Metabolic Syndrome and Obesity: Targets and erapy Dovepress
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ORIGINAL RESEARCH
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/DMSO.S176761
Efcacy of bariatric surgery in improving
metabolic outcomes in patients with diabetes.
A 24-month follow-up study from a single center
in the UAE
Hanadi Alnageeb1
Elamin Abdelgadir2
Azza Khalifa2
Mohamed Suliman3
Subash Chander Gautam4
Laurent Layani4
Sriganesh Subramaniam4
Alaaeldin Bashier2
1Medical Department, Fujairah
Hospital, Fujairah, UAE; 2Endocrine
Department, Dubai Hospital, Dubai
Health Authority, Dubai, UAE;
3Endocrinology, Imperial College
London Diabetes Centre, Al Ain,
UAE; 4Surgical Department, Fujairah
Hospital, Fujairah, UAE
Background: Owing to its impact on weight loss, remission of diabetes mellitus and metabolic
syndrome, bariatric surgery has offered hope for grossly obese individuals. In recent years,
obesity has increased in the UAE and the use of bariatric surgery has increased in-line with this
trend. However, data regarding bariatric surgery outcomes in diabetic Emirati people is scarce.
Objective: To evaluate the effect of bariatric surgery in patients with diabetes mellitus.
Methods: This is a retrospective analysis of diabetic patients treated with bariatric surgery with
a minimal follow-up of 1 year and extended for some patients (21) to 2 years follow up. A total of
80 patients underwent bariatric surgery. Two surgical procedures were used; laparoscopic sleeve
gastrectomy (n=53) or mini-gastric bypass between January 1, 2015, and July 20, 2017.
Results: Mean baseline weight was 119.2±31.2 kg, this has significantly dropped to 100.1±23.1,
91.2±22.3, 82.3±17.5, and 81.3±15.3 kg at 3, 6, 12, and 24 months respectively, and this change
was statistically significant P<0.001 at each time point. Mean baseline HbA1c was 8.6% ± 2.3%
and this dropped significantly to 6.5±1.7, 5.9±1.2, 5.6±0.8, and 5.4±0.7 at 3, 6, 12, and 24 months
respectively (P<0.000). In 49 (61.3%) we considered fatty liver based on ultrasound features
either with or without elevation in alanine aminotransferase (ALT). We noticed a significant
decrease in ALT at 3, 6, and 12 months after surgery. Furthermore, 11 patients (22.4%) showed
sonographic features of improvement in fatty liver in addition to normalization of ALT.
Conclusions: Bariatric surgery was effective over a follow-up period of 2 years in achieving
significant weight loss as well as resulting in improvements in glycemic control, blood pres-
sure, and fatty liver.
Keywords: sleeve gastrectomy, type 2 diabetes, type 1 diabetes, excess weight loss, HbA1c,
weight, bariatric surgery, Middle East, UAE
Introduction
Obesity is gradually becoming a global health concern. According to the World Health
Organization (WHO), worldwide prevalence of obesity has tripled since 1975.1 As of
2016, around 39% of adults aged 18 years or older were overweight, and 13% were
obese.1 The estimated prevalence in the Middle East does not differ remarkably from
international records, as the WHO has reported over 74% and 69% overweight women
and men, respectively. The United Arab Emirates (UAE), in particular, is one of six
Middle Eastern countries with the highest rates of overweight and obesity.2
Sheikh-Ismail et al3 demonstrated that the prevalence of obesity along with over-
weight in the seven emirates of UAE was 27% and 16%, respectively. Adult females
Correspondence: Alaaeldin Bashier
Dubai Hospital, Dubai Health Authority,
PO Box 94132, Dubai, UAE
Tel +971 55 415 4445
Email alaaeldin11@gmail.com
Journal name: Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy
Article Designation: Original Research
Year: 2018
Volume: 11
Running head verso: Alnageeb et al
Running head recto: Efficacy of bariatric surgery in patients with diabetes mellitus
DOI: http://dx.doi.org/10.2147/DMSO.S176761
This article was published in the following Dove Press journal:
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy
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Alnageeb et al
were prone to be more obese in the UAE than their male
counterparts. Similarly, Mahboub et al4 reported the rate of
obesity prevalence to be 20.9%. This would make the UAE one
of the highest countries in the Middle East in terms of obesity.5
The alarming rise in the prevalence of obesity in UAE has
been noted in both adults and children. In a population-based
study evaluating the prevalence of overweight and obesity in
children, using the CDC method, revealed that 37.2% of the
Emiratis between 15 and 18 years were overweight, 22.2%
were obese and 8.8% were extremely obese. The highest
percentages of overweight adolescents were living in Dubai
(52.6%).6
Despite the globally rising prevalence of obesity, few
pharmacologic treatment options are currently available
for clinical prescription, and even fewer are available
in the UAE. This, in addition to patients and physician’s
inertia toward medical treatment of obesity, have probably
contributed in increasing the demand for weight reduc-
tion surgeries in the UAE, and the gulf region in general.
Bariatric surgeries are currently being done in many centers
across the UAE; however, few outcome reports have been
published.7
In this study, we aimed at assessing bariatric surgery
outcomes in patients with diabetes mellitus in the UAE. We
looked at weight loss and changes in metabolic parameters
over a 2-year period. To our knowledge, this is the second
study from the UAE to evaluate bariatric surgery outcomes,
and the first to assess outcomes specifically in patients with
diabetes.
Methodology
Patients and procedures
Subjects
This is a retrospective analysis of outcome data of patients
with diabetes (type 1 or type 2) treated by bariatric surgery
between January 1, 2015, and July 1, 2017, from a single
center in the city of Fujairah, UAE. All included patients were
at least 18 years old, non-pregnant and had complete data
on demographics, and pre- and post-surgery biometric and
biochemical parameters. To be included in the study patients
should have completed follow up for at least 6 months after
surgery. We excluded patients without diabetes, those who
had post-operative follow-up for <6 months, and patients
with incomplete data records.
Ethical approvals
The study was part of an MSc thesis that has been approved
by the ethical committees of the Ministry of Health (UAE)
and by Queen Mary, University of London. Owing to the
retrospective nature of the study and in accordance to the
ethical committees rules for such study designs, a waiver of
informed consent was granted. Patient identity and confiden-
tiality of information have been protected.
Aim of the study
The aim of the study was to assess the efficacy and consis-
tency of metabolic benefits of bariatric surgery in patients
with diabetes mellitus.
Outcome measures
Primary outcome
To assess the trend of percentage of excess body weight
(EBW) reduction at 3, 6, 12, and 24 months after the bar-
iatric surgery
Secondary outcomes
We aimed to assess the bariatric surgery outcomes in diabetic
patients including morbidity, and mortality. We also looked
at changes in HbA1c, lipid profile, blood pressure, TSH,
and serum transaminases (as indicator for fatty liver status).
Furthermore, we aimed at assessing the rates of diabetes,
hypertension and dyslipidemia remission following surgery.
Moreover, we wished to assess whether there was improve-
ment in osteoarthritis or obstructive sleep apnoea symptoms
after surgery using questionnaires.
Data collection
We collected the data from surgical records and selected
patients based on pre-determined inclusion and exclusion
criteria. We then reviewed medical files as well as an elec-
tronic database for completion of data records. Data collected
included demographic data of age, sex, and nationality as
well as information about patients’ co-morbidities. We also
collected anthropometric data that included weight, height,
and blood pressure at 3, 6, 12, and 24 months. Laboratory
data included HbA1c, lipid profile, creatinine, liver function
tests, and thyroid function tests. We also collected data on
ultrasound imaging of the liver for evaluation of fatty liver
disease. To assess regression of diabetes and hypertension
we assessed the use of medications at baseline and then at
3, 6, 12, and 24 months.
As part of hospital protocol direct questions were
addressed to all patients in each visit to monitor the status
of their osteoarthritis and obstructive sleep apnea if they had
these conditions at baseline. This included severity of joints
pain, requirement for painkillers, quality of nocturnal sleep,
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Efcacy of bariatric surgery in patients with diabetes mellitus
reduction in daytime sleepiness, and discontinuation of long-
term oxygen therapy. These questions have been analyzed to
get an insight on the degree of improvement in symptoms.
Statistical analysis
All data was then entered in an excel sheet and was prepared
for analysis. Paired Student’s t-tests were used to test the
significance of differences between values for continuous
variables measured at baseline and those at various time
points. Independent t-tests, one-way analysis of variance
(ANOVA) and Chi squared tests were used to assess the
significance of differences between the groups. Continuous
data are presented as the mean ± SD, and categorical data are
presented as frequencies and percentages. Differences with
P-values ≤0.05 were considered to be statistically significant.
Analyses were performed using Statistical Package for the
Social Sciences (SPSS) version 23 (IBM Corp, New York,
NY, USA).
Denitions
Percentage of excess weight loss (%EWL) was calculated
by dividing the weight loss in kilograms after surgery by
the pre-surgery excess body weight (calculated as the excess
weight in kilograms to yield a BMI of 25 kg/m2) and mul-
tiplied by 100.
Type 2 diabetes was defined using the American Diabetes
Association definition of type 2 diabetes (HbA1c>6.5%) or
fasting blood glucose 7 mmol/L (126 mg/dL). Type 1 diabetes
was diagnosed based on the same criteria, in addition, the
patient should either have positive antibodies or documented
on hospital records as type 1 diabetes. Complete remission
of type 2 diabetes was defined using SOARD-ASMBS (Sur-
gery for Obesity and Related Diseases-American Society
for Metabolic Surgery and Obesity) standardized reporting
outcomes 2015 as: “HbA1c<6% range and fasting blood
glucose <100 mg/dL in the absence of active pharmacologi-
cal agent.” Partial response was defined based on the same
criteria as: Sub-diabetic hyperglycaemia (HbA1c 6%–6.4%,
FBG 100–125 mg/dL) in the absence of antidiabetic medica-
tions.8 Fat free mass (kg) was calculated by subtracting fat
mass (kg) from total weight (kg)
Patients’ pathway
Preoperative care
All patients received detailed information and extensive
counseling regarding the surgical procedures and expected
complications. Screening for potential candidates was
based on the American Society for Metabolic and Bariatric
Surgery (ASMBS) guidelines, which recommend surgery
if the BMI is >40 kgm2 in patients with no comorbidities,
and in patients with a BMI of >35 kgm2 if they had obesity
associated comorbidities, including diabetes, hypertension,
hyperlipidaemia, obstructive sleep apnoea, and non-alcoholic
fatty liver disease.9
Surgical procedures
A range of bariatric surgical procedures were provided,
however, laparoscopic mini gastric bypass (MGB) and
laparoscopic sleeve gastrectomy were the most commonly
chosen procedures. All procedures were done by a single
bariatric surgeon.
Postoperative care
The bariatric nurse contacted patients usually on day 5
after surgery and appointed them to visit the clinic on the
10th post-operative day for a suture removal. Patients were
given free access to nutrition services in the center to receive
personalized dietary advice, however, the general rule was
gradual re-introduction of solid foods, avoidance of high gly-
cemic index foods, and more consumption of high fiber diets.
Patients were also given follow-up appointments with the
clinician, and psychologist at 1, 3, 6, 12, 18, and 24 months.
Results
Baseline characteristics
A total of 80 patients fulfilled the inclusion criteria and were
included in the study, 51% (n=41) were females and the mean
age was 37.4±10.2 years. The Emirati nationals contributed
92.5% (74) of the cohort, while 2.5% (n=2) were other Arab
nationalities and 5% (n=4) were non-Arabs. All patients were
known to have diabetes with type 2 diabetes constituting 86%
(n=69) of patients while 14% (n=11) had type 1 diabetes. A
total of 56.3% (n=45) had hypertension, 22.5% (n=18) were
diagnosed with dyslipidemia and 65% (n=52) were diagnosed
with non-alcoholic fatty liver (Table 1). Most patients under-
went sleeve gastrectomy 66.2% (n=53), while 25% (n=20)
underwent bypass surgery, the rest underwent other forms of
surgery (laparoscopic gastric banding) 8.8% (n=7).
As per our inclusion criteria, all the 80 patients have
been followed up for at least 6 months, 69 patients (86%)
were followed up for at least 1 year while 20 patients (25%)
were followed up for at least 2 years. Figure 1 shows the
flow chart for the patients at the various time points of the
follow-up.
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Alnageeb et al
Weight changes
The obesity measures assessed were weight, BMI and per-
centage loss of excess weight. The mean baseline weight was
119.2±31.2 kg, this had significantly dropped to 100.1±23.1,
91.2±22.3, 82.3±17.5, and 81.3±15.3 kgs at 3, 6, 12 and 24
months respectively, this change was statistically significant
P<0.001 at each time point. Patients had lost an average of
their excess body weight (EBW) of 34.5%, 55.4%, 71% and
71.7% at 3, 6, 12 and 24 months respectively, P<0.001, Table 2.
The BMI had dropped significantly from 46.5±13.1 kg/m2 at
the baseline to 38.3±8.6, 34.5±8.0, 31.3±7.1, 30.9±5.5 kg/
m2 at 3, 6, 12 and 24 months respectively, P<0.001 (Table 2).
Males’ weights were statistically significantly higher than
females’ weights at the baseline and each of the follow-up
time points, with P-values of 0.017, 0.003, 0.006, 0.016,
and 0.04 at 3, 6, 12, and 24 months respectively. There were
no statistically significant differences by gender in terms of
EBW% loss and BMI (Table 3). Furthermore, we did not find
any significant differences between age groups nor between
type 1 and type 2 diabetes patients in obesity measures at
the baseline and follow-up periods.
Metabolic parameters
Baseline HbA1c was 8.6% ± 2.3% and this dropped signifi-
cantly to 6.5±1.7, 5.9±1.2, 5.6±0.8, and 5.4±0.7 at 3, 6, 12 and
24 months respectively (P<0.000), Table 4. Similar improve-
ments were seen with blood pressure, the systolic blood
pressure at baseline was 135.8±18.0 mmHg and dropped
significantly to 124.8±15.1, 121.6±19.3, 120.6±12.6, and
120.1+10.2 at 3, 6, 12, and 24 months respectively (Table 4).
Total cholesterol and low-density lipoprotein (LDL)
were significantly reduced by bariatric surgery, The LDL
was reduced from 2.8±1.5 at baseline to 2.3±1.0 and 1.6±1.0
mmol/L at 12 and 24 months, respectively (P<0.05). Similar
changes were seen with total cholesterol as it dropped from
a baseline of 4.6±1.3 mmol/L to reach 4.05±0.8 mmol/L at
follow-up visits (Table 4). There were no significant changes
in serum creatinine throughout the follow-up period.
Medications
At baseline 51.3% (n=41) were using one drug to treat their
diabetes, 26.3% (n=21) were using two drugs, 17.5 (n=14)
were on three drugs, and 5% (n=4) were on four drugs. At
24 months 80% (n=16) stopped all medications while 15%
(n=3) were using a single medicine to control their diabetes
and only 5% (n=1) were using two medications (P<0.05). A
larger percentage (72.5%) of patients have stopped using any
kind of anti-diabetes medication after 3 months of the surgery
and the percentage increased to 80% (16 out of 20 patients
who completed 2 years of follow up), Figure 2. According
to these results, diabetes had regressed in 72.5% at 3 months
and in 80% of patients followed at 2 years. Patients using
insulin at 12 and 24 were mostly type 1 diabetes, while only
two patients with type 2 diabetes were using insulin at 12
months and a single patient at 24 months.
The use of statins and calcium channel blockers was
decreased from 21.3% and 12.5% before surgery to 10%
and 0%, respectively, after surgery, P≤0.05.
Other parameters
Despite being prescribed multivitamins postoperatively, few
of our patients developed vitamin D deficiency after bariatric
surgery (31.6% [n=6] patients), and 15.8% (n=3) patients
Table 1 Characteristics of patients at baseline
Variable
Age (years)
Mean (SD) 37.4 (10.2)
<30 years, n (%) 19 (23.8)
30–40 years, n (%) 32 (40)
>40 years, n (%) 29 (36.2)
Gender, n (%)
Male 39 (48.8)
Female 41 (51.2)
Nationality, n (%)
UAE 74 (92.5)
Other Arabs 2 (2.5)
Non-Arabs 4 (5)
Type of surgery, n (%)
Sleeve 53 (66.2)
Bypass 7 (8.8)
Others 20 (25)
Diabetes, n (%)
Type 2 69 (86.3)
Type 1 11 (13.8)
Comorbidities, n (%)
Hypertension 45 (56.3)
Dyslipidemia 18 (22.5)
Fatty liver 52 (65)
Figure 1 Participants (patients) follow-up ow chart for both sleeve gastrectomy
and gastric bypass, showing the numbers who participated in each procedure at
Fujairah Hospital and participants who completed the follow ups for up to 24 months.
Abbreviation: LPG, laparoscopic gastric banding.
3
months
N=53
24
months
N=6
12
months
N=21
6
months
N=18
3
months
N=27
12
months
N=48
6
months
N=53
24
months
N=14
Total
number
of
surgeries =80
Gastric
bypass
and LGP
N=27
Sleeve
gastrec-
tomy
N=53
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Efcacy of bariatric surgery in patients with diabetes mellitus
developed vitamin B12 deficiency, 10.5% (n=2) patients
developed iron deficiency anemia, and one patient developed
folate deficiency. These vitamin deficiencies might reflect
lack of compliance to prescribed treatment.
Comorbidities
Almost 61.3% (n=49) patients were considered to have fatty
liver based on ultrasound features ± elevated alanine amino-
transferase (ALT). We noticed a significant decrease in ALT
at 3, 6 and 12 months after surgery. Furthermore, 11 (22.4%)
Table 2 Changes in obesity measures
Variable Baseline
(n=80)
3 months
(n=80)
6 months
(n=80)
12 months
(n=69)
24 months
(n=20)
Weight (kg) 119.2±31.2 100.1±23.1* 91.2±22.3* 82.3±17.5* 81.3±15.3*
Excess weight loss (%) 34.5±28.4* 55.4±32.5* 71.0±31.5* 71.7±20.4*
BMI (kg/m2)46.5±13.1 38.3±8.6* 34.5±8.0* 31.3±7.1* 30.9±5.5*
Note: *Highly signicant P-value <0.001.
Table 3 Changes in obesity measures after surgery by gender
Variable Baseline (n=80) 3 months (n=80) 6 months (n=80) 12 months (n=69) 24 months (n=20)
Male Female Male Female Male Female Male Female Male Female
Weight (kg) 127.7±27.9* 111.2±32.3* 107.7±23.2* 92.8±20.7* 98.2±23.6* 84.5±19.1* 87.6±19.5* 77.5±14.1* 86.5±17.8* 76.0±10.7*
P-value 0.017 0.003 0.006 0.016 0.041
Excess weight
loss (%)
33.7±33.4 35.3±22.9 56.9±38.7 53.9±25.6 74.0±39.0 68.2±22.0 70.5±19.9 72.9±21.9
P-value 0.790 0.681 0.467 0.800
BMI (kg/m2)46.1±10.6 46.9±15.2 39.2±9.2 37.4±8.0 34.8±8.8 34.2±7.3 31.4±7.9 31.3±6.4 31.0±6.7 30.8±4.3
P-value 0.807 0.341 0.656 0.914 0.938
Note: *Signicantly different (P≤0.05).
Abbreviation: BMI, body mass index.
Table 4 Changes in parameters after surgery
Parameter Baseline
(n=80)
3 months
(n=80)
6 months
(n=80)
12 months
(n=69)
24 months
(n=20)
HbA1C (%) 8.6±2.3 6.5±1.7* (<0.001) 5.9±1.2* (<0.001) 5.6±0.8* (<0.001) 5.4±0.7* (<0.001)
Blood pressure (mmHg)
Systolic 135.8±18.0 124.8±15.1* (0.007) 121.6±19.3* (<0.001) 120.6±12.6* (<0.001) 120.1±10.2* (<0.001)
Diastolic 82.9±12.4 77.2±10.5* (<0.001) 73.9±11.2* (<0.001) 70.3±7.8* (<0.001) 68.5±8.4* (<0.001)
Lipid prole (mmol/L)
LDL 2.8±1.5 2.2±0.9* (0.001) 2.1±0.8* (0.001) 2.3±1.0* (0.001) 1.6±1.0* (<0.001)
HDL 1.1±1.0 1.0±0.2 (0.788) 1.1±0.3 (0.788) 1.1±0.2 (0.605) 1.0±0.2 (0.605)
Triglycerides 2.0±1.7 1.6±0.8 (0.063) 1.7±0.8 (0.110) 1.4±0.7* (0.021) 1.7±0.6 (0.717)
Total cholesterol 4.6±1.3 4.3±0.8* (0.015) 4.1±0.9* (0.003) 4.3±0.8* (0.015) 4.05±0.8* (0.040)
ALT (IU/L) 51.5±38.8 41.6±23.8* (0.015) 43.7±24.1* (0.050) 38.6±21.2* (0.029) 55.0±15.2 (0.512)
Creatinine (mmol/L) 63.2±15.8 60.4±15.5 (0.141) 60.6±17.8 (0.177) 63.2±16.0 (0.842) 71.9±9.2 (0.318)
TSH (mIU/L) 2.0±1.5 1.4±0.91* (<0.001) 1.2±0.5* (<0.001) 1.31±0.5* (0.001) 1.5±0.7(0.193)
ACR 0.9±0.8 1.3±0.8 (0.294) 1.6±1.7 (0.728) 0.8±0.6 (0.567)
Note: *Signicantly different from baseline (P≤0.05).
Abbreviations: LDL, low-density lipoprotein; HDL, high-density lipoprotein; ALT, alanine aminotransferase; TSH, thyroid-stimulating hormone; ACR, albumin to creatinine
ratio.
showed sonographic features of improvement in fatty liver
in addition to normalization of ALT.
Thyroid-stimulating hormone (TSH) levels decreased
significantly from baseline at 3, 6 and 12 months after surgery,
P≤0.05, but increased again after 24 months of follow-up,
P>0.05. This was reflected as well in a reduction in thyroxine
dose in the hypothyroid cohort (Table 4).
At baseline, 31.3% (n=25) patients gave a history of
osteoarthritis and other joint problems; 14 of them reported
significant improvement in their symptoms. Another 15%
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Alnageeb et al
(n=12) patients were diagnosed preoperatively with obstruc-
tive sleep apnea, 11 of them (91.7%) reported improvement
in the quality of their sleep, reduced daytime sleepiness, and
discontinuation of long-term oxygen therapy.
Males had significantly higher levels of triglycerides,
ALT and creatinine than females before surgery, P≤0.05.
However, those differences disappeared at the subsequent
follow-up periods as shown in Table 4.
Outcomes per type of surgery
Laparoscopic sleeve gastrectomy (LSG) outcome
measures
Of all 53 patients who underwent LSG, only 19 (35.8%) had
complete profiles at 24 months. Table 5 shows weight changes
in those who underwent LSG. Forty-eight patients (97.9%) of
type 2 diabetes mellitus patients who underwent sleeve gas-
trectomy stopped using both insulin and oral hypoglycemic
agents. Four patients with type 1 diabetes mellitus continued
on insulin at lower doses. Figure 3 shows changes in body
composition after LSG. All patients (n=31) with hypertension
Figure 2 The use of medications over the study period.
3 months (n=80)
Baseline (n=80) 6 months (n=80) 12 months (n=69) 24 months (n=20)
80
15
5
0
0
78.3
17.4
1.4
1.4
1.4
77.5
20
1.3
0
1.3
72.5
18.8
5
2.5
1.3
0
51.3
26.3
17.5
5
0
1
2
3
4
0
10
20
30
40
50
60
70
80
90
Percentage of patientsNumber of drugs
used
stopped their antihypertensive treatment, except for one
patient who continued using two antihypertensive drugs.
No major complications (leakages, bleeding) were
observed after surgery. The average length of stay in the
hospital was 2–3 days. No deaths occurred postoperatively
or even in the period of follow up.
Outcomes following mini-gastric bypass (MGB)
At 24 months after surgery, fat, muscle, and water mass
decreased by 49.36% and 9.8%, respectively. Twenty patients
out of 27 who underwent MGB were diagnosed with type 2
diabetes and were on antidiabetic medications. Sixteen out of
the 20 patients stopped their antihyperglycemic medications
at 12 months. Seven out of the 27 patients had type 1 diabetes
and continued on their insulin at a lower dose.
Discussion
In the UAE, the prevalence of obesity in patients with diabe-
tes is >30% and overweight is 43%.2 While type 2 diabetes
affects nearly a fifth of the population according to the latest
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Efcacy of bariatric surgery in patients with diabetes mellitus
estimate of the IDF.10 Bariatric surgery is widely performed in
the UAE and the Middle East in general, however, very few
studies have assessed the outcomes of those procedures.7,11
Our study looked specifically at the outcomes of surgery in
patients with diabetes.
Weight changes
Weight reduction after bariatric surgery is attributed to
different mechanisms including the minimization of the
absorption surface area, modulation of eating behavior either
due to limited gastric space or due to higher brain centers
Table 5 Weight outcomes for LSG presented as mean data
Month Start weight Average weight Weight loss BMI BMI change Number of patients
0 125.4 115.5 9.9 46.5 0 53
3 123.8 109.6 14.2 38.4 5.3 53
6 122.4 101.6 20.8 35.9 7.9 53
12 123.7 95.8 27.9 33.3 10.3 48
24 123.2 88.6 34.6 30.8 12.8 19
Abbreviation: LSG, laparoscopic sleeve gastrectomy.
Figure 3 Changes in body composition post LSG.
Abbreviation: LSG, laparoscopic sleeve gastrectomy.
Fat mass Water loss Muscle mass
Baseline 6 months 12 months 24 months
Mean weight (kg)
0
14
28
42
56
70
remodeling after surgery leading to healthier meals prefer-
ences, and the satiety set point.7,12 Moreover, alterations of
the systemic neuro-hormones (eg, ghrelin, glucose-dependent
insulin-tropic peptide, GLP-1, and peptide YY) may also
contribute to the weight loss.13,14 Glycemic improvement in
patients with diabetes is widely considered to be attributable
to weight reduction but the neurohormonal changes are also
an important factor.15–17
At the time of writing of this paper, there have been
only a handful of studies in the UAE that looked into the
bariatric surgery outcomes. In a study by Abusnana et al,7
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Alnageeb et al
an assessment was made of the outcomes in 95 bariatric sur-
geries in Emirati patients, only a third of these patients had
diabetes while our cohort was solely patients with diabetes.
Another difference between the two studies is that sleeve
gastrectomy was performed in 66.2% (n=53) of our cohort
compared to 90% (n=86) in Abusnana’s cohort. Moreover,
our study analyzed the observed the outcome until 24 months
after surgery, while in the other study it was only 12 months.7
Despite these differences, we observed comparable
weight reduction between our cohort and that of Abus-
nana et al7 at 12 months (119.2±31.2– 82.3±17.5, and
123.67±18.03– 74.3±15.18, respectively). Similarly, the
EBWL was 71.0±31.5 and 67.88, respectively.7 There was
no statistically significant difference between patients with
or without diabetes in Abusnana’s study from a weight point
of view. The weight and BMI reduction were maintained in
our cohort for up to 24 months, this is the trend of many of
the previous bariatric surgery outcome studies.18–20
In the systemic review by Gill et al21 in which they
analyzed 28 studies, the mean percentage of excess weight
loss was 47.3% (range 6.3%–74.6%) after a mean follow-up
period of 13 months (range 3–36).
Metabolic parameters
Achieving remission of type 2 diabetes is a difficult target
to achieve except by bariatric surgery. In our cohort, all
patients with type 2 diabetes who were on hypoglycaemic
medications, managed to stop all diabetes treatments after
surgery with the exception of two patients who needed to be
re-started on metformin because of a marginal increase in
HbA1c. We report in our patients an overall remission rate
of 78.3% at 12 months, which remained stable at 80% of the
patients followed up to 24 months. The rates of emission of
type 2 diabetes varied from one study to another. Gill et al21
reviewed the remission rate in the studies between 2000 and
2010 and reported a remission rate of 66.2% in these patients,
improvement in glycemic control in 26.9%, and stabilization
in 13.1%. The mean decreases in FBG and HbA1c levels
after LSG were 88.2 mg/dL and 1.7%, respectively.21 All
patients with type 1 diabetes continued their insulin but even
in these patients we noticed significant reductions in total
daily insulin doses.
Blood pressure changes
Weight loss is well-known to result in reduction in blood
pressure in many studies.18–21 In our study we found a very
significant reduction in both systolic and diastolic blood
pressure at the end of the study, which was maintained up
to 24 months. These findings indicate that the benefit from
LSG regarding blood pressure is more significant for those
with clinically diagnosed hypertension. Another study was
conducted retrospectively on 100 patients who underwent
LSG, reported a complete resolution of 60% of the total
number of those labelled as hypertensives before surgery.
This was attained at 1 year postoperatively.22
Other effects
The effect of metabolic surgery on thyroid function tests has
been evaluated in a few studies. Zendel et al23 have shown
that metabolic surgery resulted in favorable effects in hypo-
thyroid patients, as it is associated with improvements in
thyroid function tests, and a reduction in thyroxine dose.23
Interestingly, Neves et al24 concluded that metabolic surgery
results in significant reductions in TSH levels independent
of EBWL in patients with normal thyroid function tests. Our
patients showed similar results with significant reductions in
TSH levels over a 12-month period.
Strengths and limitations
One of the major limitations of the trial is the retrospective
nature of the trial, however, it is considered to be the first trial
in the region that evaluated the effects of metabolic surgery
in patients with diabetes exclusively. Unlike many other trials
we have also looked at the effects of metabolic surgery in both
type 1 and type 2 diabetes. Furthermore, we evaluated many
other parameters including effect on TSH levels.
Conclusions
Bariatric surgery in obese patients with diabetes is effec-
tive in producing significant weight loss, HbA1c blood
pressure, and LDL reduction. More importantly, bariatric
surgery results in a very high rate of diabetes and hyperten-
sion remission rates. We recommend bariatric surgery as an
integral part of diabetes management in obese patients with
diabetes. Further studies are required to evaluate the effects
of metabolic surgery in patients with diabetes, and specifi-
cally type 1 diabetes.
Disclosure
The authors report no conflicts of interest in this work.
References
1. WHO. Obesity and overweight. Available from: http://www.who.int/
news-room/fact-sheets/detail/obesity-and-overweight. Accessed May
26, 2018.
2. Sulaiman N, Elbadawi S, Hussein A, et al. Prevalence of overweight
and obesity in United Arab Emirates expatriates: the UAE National
Diabetes and Lifestyle Study. Diabetol Metab Syndr. 2017;9:88.
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467
Efcacy of bariatric surgery in patients with diabetes mellitus
3. Sheikh-Ismail LI, Henry CJK, Lightowler HJ, Aldhaheri AS, Masuadi
E, Al Hourani HM. Prevalence of overweight and obesity among adult
females in the United Arab Emirates. Int J Food Sci Nutr. 2009;60(Suppl 3):
26–33.
4. Mahboub B, Afzal S, Alhariri H, Alzaabi A, Vats M, Soans A. Prevalence
of symptoms and risk of sleep apnea in Dubai, UAE. Int J Gen Med.
2013;6:109–114.
5. EMRO WHO Int [Internet]. Obesity. Cairo, Egypt: World Health
Organization Regional Office for the Eastern Mediterranean; 2014.
6. Alblooshi A, Shaban S, Altunaiji M, et al. Increasing obesity
rates in school children in United Arab Emirates. Obes Sci Pract.
2016;2(2):196–202.
7. Abusnana S, Abdi S, Tagure B, Elbagir M, Maleckas A. Bariatric surgery
outcomes: a single-center study in the United Arab Emirates. Diabetes
Metab Syndr Obes. 2015;8:461–471.
8. Brethauer SA, Kim J, El Chaar M, et al. Standardized outcomes
reporting in metabolic and bariatric surgery. Surg Obes Relat Dis.
2015;11(3):489–506.
9. AACE/TOS/ASMBS Guidelines. Perioperative bariatric guidelines.
Available from: http://www.sunut.org.uy/wp-content/uploads/2012/11/
guias-AACE-TOS-ASMBS-BARIATRICA.pdf. Accessed May 26,
2018.
10. International Diabetes Federation (IDF). Diabetes Atlas, 8th edition.
Available from: http://www.diabetesatlas.org/across-the-globe.html.
Accessed May 27, 2018.
11. Nimeri A, Mohamed A, El Hassan E, et al. Are results of bariatric sur-
gery different in the Middle East? Early experience of an international
bariatric surgery program and an ACS NSQIP outcomes comparison.
J Am Coll Surg. 2013;216(6):1082–1088.
12. Quercia I, Dutia R, Kotler DP, Belsley S, Laferrère B. Gastrointestinal
changes after bariatric surgery. Diabetes Metab. 2014;40(2):87–94.
13. Beckman LM, Beckman TR, Earthman CP. Changes in gastrointestinal
hormones and leptin after Roux-en-Y gastric bypass procedure: a review.
J Am Diet Assoc. 2010;110(4):571–584.
14. Sala PC, Torrinhas RS, Giannella-Neto D, Waitzberg DL. Relationship
between gut hormones and glucose homeostasis after bariatric surgery.
Diabetol Metab Syndr. 2014;6(1):87.
15. Elder KA, Wolfe BM. Bariatric surgery: a review of procedures and
outcomes. Gastroenterology. 2007;132(6):2253–2271.
16. Rubino F. Is type 2 diabetes an operable intestinal disease? A pro-
vocative yet reasonable hypothesis. Diabetes Care. 2008;31(Suppl
2):S290–S296.
17. Rubino F, R’bibo SL, del Genio F, Mazumdar M, McGraw TE. Metabolic
surgery: the role of the gastrointestinal tract in diabetes mellitus. Nat
Rev Endocrinol. 2010;6(2):102–109.
18. Zhang F, Strain GW, Lei W, et al. Changes in lipid profiles in morbidly
obese patients after laparoscopic sleeve gastrectomy (LSG). Obes Surg.
2011;21(3):305–309.
19. Sampalis JS, Liberman M, Auger S, Christou NV. The impact of weight
reduction surgery on health-care costs in morbidly obese patients. Obes
Surg. 2004;14(7):939–947.
20. Berry M, Fajardo M, Villagran R, Lamoza P, Urrutia L. P-113: Lapa-
roscopic sleeve gastrectomy (LSG) impact in diabetic (T2DM) obese
patients. Surg Obes Relat Dis. 2010;6(3):S64–S65.
21. Gill RS, Birch DW, Shi X, Shar ma AM, Karmali S. Sleeve gastrectomy
and type 2 diabetes mellitus: a systematic review. Surg Obes Relat Dis.
2010;6(6):707–713.
22. Sammour T, Hill A, Singh P, Ranasingghe S, Babor R. Rahman H.
Laparoscopic sleeve gastrectomy as a single stage bariatric procedure.
Obes Surg. 2009;20:1442–1450.
23. Zendel A, Abu-Ghanem Y, Dux J, Mor E, Zippel D, Goitein D. The
impact of bariatric surgery on thyroid function and medication use in
patients with hypothyroidism. Obes Surg. 2017;27(8):2000–2004.
24. Neves JS, Castro Oliveira S, Souteiro P, et al. Effect of weight loss
after bariatric surgery on thyroid-stimulating hormone levels in
patients with morbid obesity and normal thyroid function. Obes Surg.
2018;28(1):97–103.
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