The results of recent research studies illustrate the importance of prioritizing obese people with type 2 diabetes mellitus when it comes to selecting patients for bariatric surgery. For example, the number of people eligible for bariatric surgery in England far exceeds the bariatric surgery capacity of its National Health Service. If the aim of bariatric surgery is to reduce mortality and morbidity among obese patients, then the focus should be on selecting patients for surgery based on the presence of the conditions that have the greatest detrimental effect on health status. It may therefore be appropriate to reconsider the importance of body mass index alone as a predictor of mortality and put more emphasis on the presence of comorbidities when assessing eligibility for bariatric surgery. Given the significant benefits for people with type 2 diabetes that bariatric surgery offers and the resulting major improvements in their health status, there is a strong case that type 2 diabetes should be considered as the preferred comorbidity when selecting patients for surgery.
The full letter can be read in JAMA Surgery.
In a study published in the journal BMJ Open, we reviewed the clinical outcomes of combined diet and physical activity interventions for people at high risk of type 2 diabetes. We looked at combined diet and physical activity interventions including ≥2 interactions with a healthcare professional, and ≥12 months follow-up. Our primary outcome measures included glycaemia, diabetes incidence. Secondary outcomes included behaviour change, measures of adiposity, vascular disease and mortality.
We identified 19 recent reviews for inclusion in our study. Most reviews reported that interventions were associated with net reductions in diabetes incidence, measures of glycaemia and adiposity. Small effect sizes and potentially transient effect were reported in some studies, and some reviewers noted that durability of intervention impact was potentially sensitive to duration of intervention and adherence to behaviour change. Behaviour change, vascular disease and mortality outcome data were infrequently reported, and evidence of the impact of intervention on these outcomes was minimal. Evidence for age effect was mixed, and sex and ethnicity effect were little considered.
We concluded that relatively long-duration lifestyle interventions can limit or delay progression to diabetes under trial conditions. However, outcomes from more time-limited interventions, and those applied in routine clinical settings, are more variable, in keeping with the findings of recent pragmatic trials. There is little evidence of intervention impact on vascular outcomes or mortality end points in any context. Hence, ‘real-world’ implementation of lifestyle interventions for diabetes prevention may be expected to lead to modest outcomes.
An article published in the journal Cardiovascular Diabetology examines gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes.
Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past few decades but controversies persist about the cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.
We found that diabetes-related admission rates remained unchanged for AMI, increased for stroke by 2% and for PCI by 3%; and declined for CABG by 3% annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI and stroke compared with men with diabetes. However, gender differences in admission rates for AMI attenuated in diabetes compared with the non-diabetic group.
While diabetes tripled admission rates for AMI in men, it increased it by over four-fold among women. Furthermore, while the presence of diabetes was associated with a three-fold increase in rates for PCI and a five-fold increase in rates for CABG in men; among women, diabetes was associated with a 4.4-fold increased admission rates for PCI and 6.2-fold increased rates for CABG. Proportional changes in rates were similar in men and women for all study outcomes, leaving the relative risk of admissions largely unchanged.
We concluded that diabetes still confers a greater increase in risk of hospital admission for AMI in women relative to men. However, the absolute risk remains higher in men. These results call for intensified CVD risk factor management among people with diabetes, consideration of gender-specific treatment targets, and treatment intensity to be aligned with levels of CVD risk.