Bariatric Surgery More Effective Than Medical Therapy for Obese, T2D Teens

JAMA Pediatrics Study Calls for More Comparative Research into Treatment Effectiveness

Thursday, March 15, 2018

Researchers at Cincinnati Children’s are part of a multi-institutional scientific team reporting in JAMA Pediatrics that bariatric surgery is associated with more effective glycemic control, weight loss and better overall health than medical management for severely obese adolescents with type 2 diabetes.

The new study consisted of a secondary analysis of clinical data from two previous longitudinal studies: Treatment Options for Type 2 Diabetes in Adolescents in Youth (TODAY) and Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS).

The TODAY trial ran between 2004 and 2009. It included 699 adolescents with type 2 diabetes from 15 U.S. centers who were treated with medication or lifestyle (either metformin alone or in combination rosiglitazone or lifestyle). The Teen-LABS study was established in 2007. It is the only multicenter, NIH-sponsored research on adolescent bariatric surgery.

Teen-LABS is an ongoing NIH-funded study comprised of six U.S. clinical centers: Cincinnati Children’s, Children’s Hospital Colorado, Nationwide Children’s Hospital, Texas Children's Hospital, the University of Alabama at Birmingham and the University of Pittsburgh Medical Center. That study examined 242 adolescents who underwent bariatric surgery at five of the six centers between 2007 and 2012.

In the current JAMA Pediatrics study, clinical data from 30 participants with type 2 diabetes from the Teen-Labs study were compared to that from 63 age-similar participants in the TODAY study.

The researchers found that adolescents with severe obesity and type 2 diabetes who received medical management experienced modest weight gain, progression of their type 2 diabetes, and no improvement in cardiovascular risk factors after two years.

In comparison, most adolescents who underwent surgical procedures in the Teen-LABS study experienced significant weight loss, normalization of blood glucose, and improvements in markers of cardiovascular health and kidney function over the same period.

“Our comparative assessment of adolescents highlighted significant improvements in glycemic control, cardiovascular risk marks and kidney function in patients who were treated surgically. In contrast, such improvements were not observed in teens who were medically treated,” said Todd Jenkins, PhD, a study co-author and scientist in the Division of Pediatric General and Thoracic Surgery at Cincinnati Children’s.

Elaine Urbina, MD, a physician in the Cincinnati Children’s Heart Institute, also co-authored. The study’s lead investigator is Thomas Inge, MD, former head of the Bariatric Surgery Program at Cincinnati Children’s who now works at Colorado Children’s Hospital.

The authors stress that more research is needed to strengthen clinical evidence about bariatric surgery’s comparative effectiveness in severely obese teens with type 2 diabetes. The use of bariatric surgery to treat these teens has so far been largely based on evidence from studies of bariatric surgery in adults.

The authors propose conducting an extensive prospective study of severely obese teens with type 2 diabetes to more accurately compare outcomes between teens getting medical therapy and those treated with surgery.

Shifting Clinical Focus

Publication of the study comes as Cincinnati Children’s establishes a joint clinic for patients with type 2 diabetes, according to Michael Helmrath, MD, surgical director of Surgical Weight Loss Program for Teens. The clinic is a collaboration between the medical center’s Bariatric Surgery Program and Division of Endocrinology, which also cares for patients fighting abnormal weight gain and diabetes.

“The current study shows severely obese teens with type 2 diabetes come off their diabetes medications after the surgery along with the beneficial impact of weight loss,” Helmrath says. “Having a combined clinic can offer surgery as another option to medication for these patients.”

Formation of the joint clinic comes with the growing evidence of bariatric surgery’s enhanced effectiveness for severely obese diabetic teens. Medical center care teams want all treatment options available to the patients in a single, multidisciplinary clinic with access to everything from lifestyle changes to medications and, if warranted, bariatric surgery.

“These patients are seen by doctors, nurse practitioners, dieticians, social workers and diabetes educators,” said Amy Sanghavi Shah, MD, an endocrinologist at Cincinnati Children’s. “All patients hear about lifestyle changes, medications and the potential for surgery.”

The new joint clinic is also part of a broader initiative at Cincinnati Children’s to build multidisciplinary teams at the medical center that focus on specific diseases.