Better Diabetes Outcomes — For Everyone
Joslin Research Shows Bariatric Surgery Benefits Extend Across Socioeconomic Lines
BOSTON — Nonmedical factors drive up to 60 percent of health outcomes, and for people with type 2 diabetes (T2D), social determinants of health factors like poverty, food insecurity, and unstable housing can derail even the best treatment plans. Now, a long-term study led by investigators at Joslin Diabetes Center finds that bariatric metabolic surgery is more effective at glycemic and weight control than medical and lifestyle interventions for people with T2D, even in the setting of social vulnerability.
“Our randomized study allowed us to explore the influence of social deprivation on the comparative efficacy of surgical versus medical therapy,” said Mary Elizabeth Patti, MD, a senior investigator at Joslin and a professor of medicine at Harvard Medical School. “The marked advantage of surgery over medical therapy was seen in populations with both high and low social vulnerability over the long term.”
The findings come from analysis of the ARMMS-T2D study (Alliance of Randomized Trials of Medicine vs. Metabolic Surgery in Type 2 Diabetes), a landmark collaboration that pooled data from four independent U.S. clinical trials to compare the long-term effectiveness of bariatric metabolic surgery against medical and lifestyle interventions for people with type 2 diabetes and obesity. (Notably, while the medical interventions did include GLP-1 receptor medications, the study was conducted before the more potent versions were available.) With up to 12 years of follow-up on 262 participants, ARMMS-T2D represents the largest and longest analysis of its kind.
Social determinants of health are increasingly recognized as powerful drivers of chronic disease outcomes. Previous reports from the consortium established that bariatric metabolic surgery produces superior long-term blood sugar control compared to medical management for patients with type 2 diabetes, with higher rates of diabetes remission and reduced need for diabetes medications. The current study extends that work by examining whether social vulnerability — measured using factors like income, education, and housing — affects patients’ response to each treatment approach.
Patti and colleagues stratified participants by social vulnerability using the Area Deprivation Index, a measure that accounts for factors like income, education, housing, and employment at the neighborhood level. They found that bariatric metabolic surgery produced greater improvements in blood sugar control and weight loss than medical and lifestyle interventions in both high- and low-vulnerability groups.
The findings could have implications for how clinicians counsel patients about treatment options and how health systems allocate resources. While bariatric surgery improved outcomes across all socioeconomic groups, more vulnerable patients still had worse glycemic control and less weight loss than their more advantaged peers. The researchers note that future studies will need to explore why, and whether factors like food insecurity, limited health literacy, or reduced access to medications and physical activity help explain the gap.
Co-authors included Hannah J. Wang, Kathleen Foster, BS, RN, Yael Sarig, BA, Danielle Wolfs, MS, Lori Laffel, MD, MPH, Sando Ojukwu, MD, MPH, of Joslin Diabetes Center and Harvard Medical School; Bo Hu, PhD, Sarah Kirschling, MS, of the Cleveland Clinic; Donald C Simonson, MD, MPH, ScD, and Ashley H Vernon, MD, of Brigham and Women’s Hospital and Harvard Medical School; David Arterburn, MD, MPH of Kaiser Permanente Washington Health Research Institute; Matthew J O’Brien, MD, MSc, of Northwestern University Feinberg School of Medicine; John M Jakicic, PhD, of the University of Kansas Medical Center; Sangeeta R Kashyap, MD, of Weill Cornell Medicine-New York Presbyterian; Ali Aminian, MD, of the Cleveland Clinic; David E Cummings, MD, of University of Washington, and VA Puget Sound Health Care System; William F Gourash, PhD, CRNP, RN, and Anita Courcoulas, MD, MPH, of University of Pittsburgh; and Philip R Schauer, MD, and John P Kirwan , PhD, of Metamor Institute, Pennington Biomedical Research Center.
Grant Support: ARMMS-T2D was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (U01 DK114156). This study was additionally supported by the Diabetes Research Center at Joslin Diabetes Center (P30-DK036836); the Chicago Center for Diabetes Translation Research (P30-DK092949); the Louisiana Clinical and Translational Science Center (U54 -GM104940). Disclosure forms are available with the article online.
About Joslin Diabetes Center
Joslin Diabetes Center is world-renowned for its deep expertise in diabetes treatment and research. Part of Beth Israel Lahey Health, Joslin is dedicated to finding a cure for diabetes and ensuring that people with diabetes live long, healthy lives. We develop and disseminate innovative patient therapies and scientific discoveries throughout the world. Joslin is affiliated with Harvard Medical School and one of only 18 NIH-designated Diabetes Research Centers in the United States.
