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Cleveland Clinic study compares bariatric surgery to weight loss drugs to manage diabetes

Kimberly Elliott poses for a photo.
Kimberly Elliott
Kimberly Elliott, of Independence, Ohio, struggled with diabetes after the birth of her second child. She tried weight loss drugs but eventually had gastric bypass surgery to manage her diabetes.

Independence native Kimberly Elliott, 64, developed gestational diabetes when she was pregnant with her firstborn, almost 31 years ago. Her diabetes went away after her daughter was born, but it returned with her second pregnancy.

“Only this time it stuck," she said. "And I had been struggling with diabetes after I delivered my second one and I started to look into options of what I could do."

That's when Elliott discovered the Cleveland Clinic study which examined whether bariatric surgery provides better long-term outcomes for some patients with type 2 diabetes.

The study analyzed the results of randomized trials conducted at four U.S. centers, including Cleveland Clinic. The study involved 262 participants who enrolled between 2007 and 2013, and were tracked until 2022.

Although weight loss medications are in high demand, the study found bariatric surgery provides better long-term outcomes for some patients with type 2 diabetes.

Today’s popular semaglutide and tirzepatide medications, like Ozempic and Zepbound, were not tracked in the study since they didn’t exist at its inception. Data on their effectiveness for long-term weight loss remains under research.

Researchers followed two groups of patients with type 2 diabetes — 166 underwent bariatric surgery, and 96 were treated through weight loss medications known as GLP-1 agonists which lower blood sugar levels.

Elliott joined the study in 2007, and was initially assigned to the medical treatment group that received the weight loss drug.

"I was very disappointed because I really wanted the surgery," she recalled.

Surgery patients received gastric bypass, gastric sleeve or adjustable gastric banding. The average body mass index across all participants was 36.

The drugs didn't work for Elliott. She struggled to get her blood sugar levels under control with medication.

“I just felt my numbers were OK during the day, but when I’d get up in the morning, my numbers would be elevated after a full night's sleep," Elliott explained.

An endocrinologist decided surgery would be her best option. She eventually had gastric bypass in 2013.

Dr. Ali Aminian, director of Cleveland Clinic's Bariatric and Metabolic Institute and a co-investigator of the study, said surgery patients maintained 20% weight loss after 12 years compared to 8% weight loss in those who took medication.

Surgery patients also had less need for medications to maintain their glucose levels after surgery.

“A significant number of them came off diabetes medication, including insulin," he said.

Results showed that 40% of patients in the bariatric surgery group were off diabetes medications seven years into the study, compared to 4% of patients in the medical group.

About half of the participants who received surgery also achieved the criteria for remission, meaning they didn't need any diabetes medication, one year after surgery. About 20% of them remained in remission long-term, 10-12 years after surgery, Dr. Aminian said.

That wasn't the case for Elliott, though.

"My diabetes went away for about three months and then it came right back," she said.

She learned that the longer you have diabetes, the more difficult it is to achieve remission. At that point, she had been diabetic for at least 20 years, she said.

Kimberly Elliott
Kimberly Elliott said she was able to eliminate the need for insulin to treat her type 2 diabetes after having gastric bypass surgery in 2013. She lost 70 pounds from the surgery, which she’s kept off with diet and exercise.

Aminian noted that he doesn't view the drop from short-term to long-term remission rate as a failure because surgery still made a difference in the patients' lives.

"Obesity, diabetes are chronic conditions, so it usually gets worse over time," Aminian said. "The point is that, even if they started to have diabetes again, their diabetes, after surgery, when it came back, it was a mild form of diabetes and it was not severe."

Weighing the costs

But bariatric surgery can be costly for patients without health insurance, costing upwards of $15,000 and as high as $30,000.

Weight loss surgeries are often covered by most Medicaid, Medicare, CareSource and Buckeye health plans in Ohio, according to Dr. Anant Jeet, an endocrinologist at Mercy Health in Lorain. People with private insurers are the ones paying the most, he said.

“So there are people who want to have surgery, but if the benefit’s excluded, they don't want to pay out of pocket," he explained.

But Jeet said he's seen an increase in patients who are more interested in Ozempic than surgery. Cost is still a barrier though, as some insurers remain hesitant to cover weight loss drugs. Aminian agreed.

“With the current cost of medication, bariatric surgery is currently the most cost effective treatment for obesity," he said.

Though surgery didn't eliminate her diabetes, Elliott said it was the start she needed for a healthier lifestyle. Now she just takes metformin, a daily oral medication, to manage her blood sugar.

"It lowered my numbers. I didn't have to take insulin. I was, and I still am, taking medication to keep it under control," she explained.

Elliott also lost 70 pounds from the surgery, which she’s kept off with diet and exercise. A healthy lifestyle is the biggest step one can take to manage their weight and diabetes, she said, adding that bariatric surgery is not a quick fix.

"I know many people that have had gastric bypass and gained all the weight back. I've made a conscious effort to continue to eat the right foods and exercise," she noted. "It's a tool. Gastric bypass was a tool to help me get my life in check."

The other study sites were: Joslin Diabetes Center/Brigham and Women’s Hospital (Massachusetts), University of Pittsburgh (Pennsylvania), and University of Washington/Kaiser Permanente Washington (Washington).

The study’s findings were released in February.

Stephanie Metzger-Lawrence is a digital producer for the engaged journalism team at Ideastream Public Media.