Location: Obesity and Metabolism Research Unit
Title: Prevalence of undiagnosed and inadequately treated type 2 diabetes mellitus, hyperension, and dyslipidemia in morbidly obese patients who present for bariatric surgery Authors
|Mostaedi Md, Rouzbeh -|
|Dada, Stephen -|
|Hoda, Zahid -|
|Ali Md, Mohamed -|
Submitted to: Obesity Surgery
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: January 23, 2014
Publication Date: February 13, 2014
Citation: Mostaedi Md, R., Lackey, D.E., Adams, S.H., Dada, S.A., Hoda, Z.A., Ali Md, M. 2014. Limited efficacy of pharmacotherapy to treat obesity-related comorbidities in bariatric patients. Obesity Surgery. 24:927-935. doi: 10.1007/S11695-014-1196-Z.. Interpretive Summary: Obesity, especially morbid obesity, is associated with much greater risk for developing metabolic disorders such as diabetes mellitus (DM), hypertension (HTN), and high blood lipids and cholesterol (dyslipidemia, DYS). Recent studies have shown that bariatric surgery in which a portion of the stomach and intestine are manipulated to promote smaller meals and quicker passage of food to the gut have rapid and remarkable positive effects on metabolism, even in the absence of major weight loss. Yet, surgery is considered an extreme treatment option and most standard of care messages emphasize non-surgical interventions as a primary approach (e.g., weight loss, pharmacotherapy, etc.). This study determined the success of this standard of care approach in a large (>1500 patient) cross sectional cohort of obese subjects entering the bariatric surgery clinic over almost 4 yr. Astonishingly, ca. 16%, 14%, and 42% of subjects were previously undiagnosed for DM, HTN, or DYS, respectively. Furthermore, non-pharmacotherapy approaches yielded significantly lower success at metabolic disease control vs. pharmacotherapy, and only ca. 50-60% of treated patients achieved metabolic control while on pharmacotherapy. Our study suggests that, in the setting of morbid obesity, treatment strategies for DM, HTN, and DYS have limited efficacy, even with best-practice pharmacotherapy, and that many obese persons remain undiagnosed for existing major metabolic pathology. However, bariatric/metabolic surgery shows promise as a primary treatment for these comorbidities in morbidly obese patients. Further refinement in treatment recommendations to combine pharmacotherapy and surgery may improve control of these metabolic derangements and reduce associated end-organ consequences. This study also highlights the need for better diagnostic and preventative strategies for the obese in terms of achieving improved metabolic health.
Technical Abstract: Context: Pharmacotherapy is considered the primary treatment modality for metabolic diseases, such as diabetes mellitus (DM), hypertension (HTN), and dyslipidemia (DYS). Objective: We hypothesize that these metabolic diseases become exceedingly difficult to treat with pharmacotherapy in morbidly obese patients referred for bariatric surgery. Design, Setting, and Patients: Demographic and comorbidity history were prospectively collected on 1508 patients who were referred for bariatric consultation at a single institution from February 1, 2008 to March 30, 2012. Patients with prior bariatric surgery (n=35) and those younger than 18 years (n=3) were excluded. To avoid non-uniform laboratory results, we only included patients whose blood biochemistry was performed at a single laboratory. These criteria were met by 881 patients. We utilized published consensus guidelines (GL) for the diagnosis and treatment of DM, HTN, DYS, and metabolic syndrome. These GL were also used to benchmark the efficacy of standard pharmacotherapy. Results: Most patients exhibited at least one form of metabolic dysregulation (pre-DM and DM,75.8%; pre-HTN and HTN, 91.1%; pre-DYS and DYS, 84.0%; metabolic syndrome, 76.0%). The majority of patients with DM, HTN, or DYS either did not meet GL treatment goals (DM, 45.7%; HTN, 39.5%; DYS, 22.3%) or were previously undiagnosed (DM, 15.8%; HTN, 13.7%; DYS, 41.7%). Non-GL pharmacotherapy was significantly less effective than GL pharmacotherapy at achieving treatment goals for DM (31.8% vs 53.2%, P<.001) and HTN (43.6% vs 63.2%, P=.007). Patients with concurrent DM, HTN, and DYS (35.5%) were less likely than patients with only one or two of these metabolic diseases to achieve GL treatment goals for HTN (38.1% vs 72.6%, P<.001) and DYS (55.7% vs 73.8%, P=.002). Only a small minority of these patients (8.0%) achieved treatment goals for all three obesity-related metabolic comorbidities. Conclusion: Our study suggests that, in the setting of morbid obesity, treatment strategies for DM, HTN, and DYS have limited efficacy, even with best-practice GL pharmacotherapy. However, bariatric/metabolic surgery shows promise as a primary treatment for these comorbidities in morbidly obese patients. Further refinement in treatment recommendations to combine pharmacotherapy and surgery may improve control of these metabolic derangements and reduce associated end-organ consequences.