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Original Investigation
March 12, 2018

Comparison of Surgical and Medical Therapy for Type 2 Diabetes in Severely Obese Adolescents

Thomas H. Inge, MD, PhD1; Lori M. Laffel, MD2; Todd M. Jenkins, PhD3; et al Marsha D. Marcus, PhD4; Natasha I. Leibel, MD5; Mary L. Brandt, MD6,7; Morey Haymond, MD6,7; Elaine M. Urbina, MD3; Lawrence M. Dolan, MD3; Philip S. Zeitler, MD, PhD8; for the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) Consortia
Author Affiliations
  • 1Department of Pediatric Surgery, Children’s Hospital Colorado, University of Colorado, Denver, Aurora
  • 2Department of Pediatrics, Joslin Diabetes Center, Boston, Massachusetts
  • 3Department of Pediatrics and Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
  • 4Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 5Department of Pediatrics, Columbia University, New York, New York
  • 6Michael E. Debakey Department of Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston
  • 7Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston
  • 8Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Denver, Aurora
JAMA Pediatr. Published online March 12, 2018. doi:10.1001/jamapediatrics.2017.5763
Key Points

Question  How does bariatric surgery compare with medical therapy to treat type 2 diabetes in adolescents with severe obesity?

Findings  In this study of 93 severely obese adolescents with type 2 diabetes, hemoglobin A1c concentration and mean body mass index decreased in 30 patients who underwent surgical treatment and increased in 63 patients who received medical treatment at 2-year follow-up. Significant improvements in blood pressure, dyslipidemia, and abnormal kidney function were also observed in the patients treated surgically but not in those treated medically.

Meaning  Surgical treatment of severely obese adolescents with type 2 diabetes was associated with better glycemic control, reduced cardiovascular risk markers, and improved kidney function; these findings support the need for a well-designed, prospective controlled study to define the role of surgery for adolescents with type 2 diabetes.

Abstract

Importance  Because of the substantial increase in the occurrence of type 2 diabetes in the pediatric population and the medical complications of this condition, therapies are urgently needed that will achieve better glycemic control than standard medical management.

Objective  To compare glycemic control in cohorts of severely obese adolescents with type 2 diabetes undergoing medical and surgical interventions.

Design, Setting, and Participants  A secondary analysis of data collected by the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) consortia was performed. Teen-LABS enrolled 242 adolescents (≤19 years of age) from March 1, 2007, through December 31, 2011. TODAY randomized 699 participants (aged 10-17 years) from July 24, 2004, through February 25, 2009. Data analysis was performed from July 6, 2015, to June 24, 2017. Anthropometric, clinical, and laboratory data from adolescents with severe obesity and type 2 diabetes who underwent treatment with metabolic or bariatric surgery in the Teen-LABS study or medical therapy in the TODAY study were compared.

Interventions  Teen-LABS participants underwent a primary bariatric surgical procedure; TODAY participants were randomized to receive metformin therapy alone or in combination with rosiglitazone or an intensive lifestyle intervention; insulin therapy was given in cases of progression of disease.

Main Outcomes and Measures  Glycemic control, body mass index, prevalence of elevated blood pressure, dyslipidemia, abnormal kidney function, and clinical adverse events were measured.

Results  Data from 30 participants from Teen-LABS (mean [SD] age at baseline, 16.9 [1.3] years; 21 [70%] female; 18 [66%] white) and 63 from TODAY (mean [SD] age at baseline, 15.3 [1.3] years; 28 [44%] female; 45 [71%] white) were analyzed. During 2 years, mean hemoglobin A1c concentration decreased from 6.8% (95% CI, 6.4%-7.3%) to 5.5% (95% CI, 4.7% -6.3%) in Teen-LABS and increased from 6.4% (95% CI, 6.1%-6.7%) to 7.8% (95% CI, 7.2%-8.3%) in TODAY. Compared with baseline, the body mass index decreased by 29% (95% CI, 24%-34%) in Teen-LABS and increased by 3.7% (95% CI, 0.8%-6.7%) in TODAY. Twenty-three percent of Teen-LABS participants required a subsequent operation during the 2-year follow-up.

Conclusions and Relevance  Compared with medical therapy, surgical treatment of severely obese adolescents with type 2 diabetes was associated with better glycemic control, reduced weight, and improvement of other comorbidities. These data support the need for a well-designed, prospective controlled study to define the role of surgery for adolescents with type 2 diabetes, including health and surgical outcomes.

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