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Definitions of comorbidity remission after bariatric surgery
Posted in Lectures on 13 June 2019

Roser Termes
General Surgery Resident

Obesity, which is defined by an increase of the body adipose index with a BMI > 30 Kg/m2, is currently one of the major health problems of our society. The high incidence of this disease in first world countries makes it the main global epidemic of the 21st century, with more than 1 billion overweight or obese people worldwide.

Obesity has well-documented links to decreased life expectancy and quality of life. According to the most recent data from the World Health Organization, most of the world’s population lives in countries where overweight and obesity result in more deaths than being underweight. These negative consequences of obesity are also due to its strong association with type 2 diabetes mellitus (T2DM), hypercholesterolemia (HCLT), hypertension (HT), gastroesophageal reflux disease (GERD), obstructive sleep apnea, etc. This constellation of metabolic disorders can be included in the concept of Metabolic Syndrome (MS), which is a cluster of conditions that occur together, increasing cardiovascular risk.

Regarding obesity treatment, behavioral and pharmacological therapies usually lead to modest weight loss and improvement in obesity-related comorbidities. Therefore these methods are frequently ineffective in the long term.

By contrast, bariatric surgery leads to greater sustained weight loss, particularly in cases of severe obesity. In addition to the weight loss benefits of bariatric surgery (BS), it has been proved in multiple studies that bariatric surgery results in remarkable improvements in obesity-related comorbidities, far beyond what has been reported with nonsurgical therapies. Improvement rates have been shown to vary by procedure type, with Roux-en-Y gastric bypass (RYGB) generally resulting in greater improvement in metabolic comorbidities than other techniques.
To standardize the outcomes of BS in different studies, the American Society for Metabolic and Bariatric Surgery has proposed a uniform method of defining the results on comorbidity remission after BS. In this video we focus on the definitions of T2DM, HT and HCLT remission after BS.

Type 2 Diabetes Mellitus

  • Complete remission: Normal measures of glucose metabolism (HbA1c < 6%, FBG (fasting blood glucose) < 100 mg/dL) in the absence of antidiabetic medication.
  • Partial remission: Subdiabetic hyperglycemia (HbA1c 6% – 6.4%, FBG 100 – 125 mg/dL) in the absence of antidiabetic medication.
  • Improvement: Statistically significant reduction in HbA1c and FBG not meeting criteria for remission or decrease in antidiabetic medication requirement (by discontinuing insulin or one oral agent, or ½ reduction in dose)
  • Unchanged: The absence of remission or improvement as described earlier.
  • Recurrence: FBG or HbA1c in the diabetic range (≥ 126 mg/dL and ≥ 6.5%, respectively) or need for antidiabetic medication after any period of complete or partial remission.

Hypertension

  • Improvement: Defined as a decrease in dosage or number of antihypertensive medication or decrease in systolic or diastolic blood pressure (BP) on the same medication (better control).
  • Partial remission: Defined as prehypertension values (120 – 140 / 80 – 89) when off medication.
  • Complete remission: Defined as being normotensive (BP < 120/80) off antihypertensive medication. If medication such as beta-blockade is used for another indication (atrial fibrillation), this needs to be clearly described but cannot be included as complete remission because of the dual therapeutic effect of some medications.

Hypercholesterolemia

    • Improvement: Decrease in number or dose of lipid-lowering agents with equivalent control of dyslipidemia or improved control of lipids on equivalent medication.
      Which components of the lipid profile are being studied must specified.
    • Remission: Normal lipid panel (or specific component being studied) off medication.