Obesity Surgery

, Volume 25, Issue 10, pp 1772–1778 | Cite as

The Effect and Predictive Score of Gastric Bypass and Sleeve Gastrectomy on Type 2 Diabetes Mellitus Patients with BMI < 30 kg/m2

  • Wei-Jei Lee
  • Abdullah Almulaifi
  • Keong Chong
  • Shu-Chun Chen
  • Jun Juin Tsou
  • Kong-Han Ser
  • Yi-Chih Lee
  • Jung-Chien Chen
Original Contributions



Metabolic surgery is a novel therapy for mild obesity (BMI 30–35 Kg/m2) in type 2 diabetes mellitus (T2DM) patients. The ABCD score, which comprise age, BMI, C-peptide level, and duration of T2DM (years), was reported as useful in predicting the success of T2DM treatment using metabolic surgery. This study examines gastric bypass and sleeve gastrectomy as a salvage treatment for non-obese (BMI < 30 kg/m2) T2DM patients and evaluates the role of ABCD scores.


From January 2007 to July 2013, 512 (71.2 %) of 711 T2DM patients enrolled in a metabolic surgical program had at least 1-year follow-up were recruited. Clinical data and outcomes of 80 (15.6 %) patients with BMI < 30 Kg/m2 were compared with those of the other 432 (84.4 %) patients with BMI ≥ 30 Kg/m2. Complete remission was defined as HbA1c ≤ 6 %, and partial remission was defined as HbA1c < 6.5 %. A binary logistic regression was used to identify predictors of T2DM remission.


Mean age of the 80 non-obese T2DM patients was 47.7 ± 9.1 years, and mean HbA1c and disease duration were 9.1 ± 1.8 % and 6.5 ± 5.1 years, respectively. Mean total body weight loss was 17.1 ± 7.4 % at 1 year, and mean BMI decreased from 26.9 ± 2.2 to 22.7 ± 2.5 kg/m2 at 1 year. Complete remission of T2DM was achieved in 25.0 % of patients, and partial remission was achieved in 23.8 %. The complete remission rate was significantly lower than the 49.5 % found in patients with BMI 30–35 and 79.0 % of patients with BMI > 35 Kg/m2. In univariate analysis, non-obese patients who had T2DM remission after surgery were heavier and had a wider waist, higher C-peptide levels, shorter disease duration, more weight loss, and higher ABCD score than those without remission. The ABCD score remained the only independent predictor of success after multivariate logistical regression analyses (P = 0.003).


Metabolic surgery may be useful in achieving glycemic control of selected non-obese T2DM patients. The ABCD score is a simple multidimensional grading system that can predict the success of T2DM treatment.


Type 2 diabetes mellitus Metabolic surgery BMI < 30 Predictor 




Conflict of Interest

The authors declare that they have no conflict of interest


  1. 1.
    Whiting DR, Guariguata L, Weil C, et al. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract. 2011;94:311–2.CrossRefPubMedGoogle Scholar
  2. 2.
    Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA. 2009;301(20):2129–40.CrossRefPubMedGoogle Scholar
  3. 3.
    Stark Casagrande S, Fradkin JE, Saydah SH, et al. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1998–2010. Diabetes Care. 2013;36(8):2271–9.PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.CrossRefPubMedGoogle Scholar
  5. 5.
    Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. NEJM. 2004;351:2683–93.CrossRefPubMedGoogle Scholar
  6. 6.
    Dixon JB, O’Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299:316–23.PubMedGoogle Scholar
  7. 7.
    Lee WJ, Chong K, Ser KH, et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Arch Surg. 2011;146:143–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567–76.PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the diabetes surgery study randomized clinical trial. JAMA. 2013;309(21):2240–9.PubMedCentralCrossRefPubMedGoogle Scholar
  10. 10.
    Liang Z, Wu Q, Chen B, et al. Effect of laparoscopic Roux-en-Y gastric bypass for type 2 diabetes mellitus with hypertension: a randomized controlled trial. Diabetes Res Clin Pract. 2013;101(1):50–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Wentworth J, Playfair J, Lavrie C, et al. Multidisciplinary diabetes care with and without bariatric surgery in overweight people: a randomized controlled trial. Lancet Diabetes Endocrinol. 2014;2(7):545–52.CrossRefPubMedGoogle Scholar
  12. 12.
    Diagnosis and classification of diabetes mellitus. Diabetes Care 2010; 33(Suppl 1):S62–9.Google Scholar
  13. 13.
    Buse JB, Laughlin S, Caprio S, et al. How do we define cure of diabetes? Diabetes Care. 2009;32:2133–5.PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Lee WJ, Hur KY, Lakadawala M, et al. Predicting success of metabolic surgery: age, body mass index, C-peptide, and duration score. Surg Obes Relat Dis. 2013;9:379–84.CrossRefPubMedGoogle Scholar
  15. 15.
    Dixon J, Chung LM, Chong K, et al. Predicting the glycemic response to gastric bypass surgery in patients with type 2 diabetes. Diabetes Care. 2013;36:20–6.PubMedCentralCrossRefPubMedGoogle Scholar
  16. 16.
    Dixon J, Hur KJ, Lee WJ, et al. Gastric bypass in Type 2 diabetes with BMI < 30: weight and weight loss have a major influence on outcomes. Diabet Med. 2013;30:e127–34.CrossRefPubMedGoogle Scholar
  17. 17.
    Matthews DR, Hosker JP, Rudensky AS, et al. Homeostasis model assessment: insulin resistance and B-cell function from fasting plasma glucose and insulin concentration in man. Diabetologia. 1985;28:412–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Lee WJ, Yu PJ, Wang W, et al. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity. Ann Surg. 2005;242:20–8.PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Ser KH, Lee WJ, Lee YC, et al. Experience in laparoscopic sleeve gastrectomy for morbid obese Taiwanese: staple-line reinforcement is important for preventing leakage. Surg Endosc. 2010;16:2253–9.CrossRefGoogle Scholar
  20. 20.
    Carcia-Caballero M, Valle M, Martinez-Moreno JM, et al. Resolution of diabetes mellitus and metabolic syndrome in normal weight 24–29 BMI patients with one anastomosis gastric bypass. Nutr Hops. 2012;27:623–31.Google Scholar
  21. 21.
    Geloneze B, Gelonee SR, Chaim E, et al. Metabolic surgery for non-obese type 2 diabetes: incretin, adipocytokines, and insulin secretion/resistance changes in a 1-year interventional clinical controlled study. Ann Surg. 2012;256:72–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Lee WJ, Ser KH, Chong K, et al. Laparoscopic sleeve gastrectomy for diabetes treatment in non-morbidly obese patients: efficacy and change of insulin secretion. Surgery. 2010;147:664–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Scopinaro N, Adami GF, Papadia FS, et al. Effects of biliopancreatic diversion on type 2 diabetes in patients with BMI 25–35. Ann Surg. 2011;253:699–703.CrossRefPubMedGoogle Scholar
  24. 24.
    Kim MJ, Hur KY. Short-term outcomes of laparoscopic single anastomosis gastric bypass (LSAGB) for the treatment of type 2 diabetes in lower BMI (<30 Kg/m2) patients. Obes Surg. 2014;24:1044–51.CrossRefPubMedGoogle Scholar
  25. 25.
    Cummings D, Cohen RV. Beyond BMI: the need for new guidelines governing the use of bariatric and metabolic surgery. Lancet Diabetes Eendocrinol. 2014;2:175–81.CrossRefGoogle Scholar
  26. 26.
    Dixon JB, Zimmet P, Alberti KG, et al. Bariatric surgery: an IDF statement for obese type 2 diabetes. Diabet Med. 2011;28:628–42.PubMedCentralCrossRefPubMedGoogle Scholar
  27. 27.
    DeFronzo RA. Diab Care 1998; Am J Med 2009;122(6)j.Google Scholar
  28. 28.
    Muscelli E, Mari A, Casolaro A, et al. Separate impact of obesity and glucose tolerance on the incretin effect in normal subjects and type 2 diabetic patients. Diabetes. 2008;57:1340–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Lee WJ, Chong K, Chen RC, et al. Predictors of diabetes remission after bariatric surgery in Asian. Asian J Surg. 2012;35:67–73.CrossRefPubMedGoogle Scholar
  30. 30.
    Blackstone R, Bunt JC, Cortes MC, et al. Type 2 diabetes after gastric bypass: remission in five models using HbA1c, fasting blood glucose, and medication status. Surg Obes Relat Dis. 2012;8:548–55.CrossRefPubMedGoogle Scholar
  31. 31.
    Still CD, Wood GC, Benotti P, et al. A probability score for preoperative prediction of type 2 diabetes remission following RYGB surgery. Lancet Diabetes Endocrinol. 2014;2:38–45.PubMedCentralCrossRefPubMedGoogle Scholar
  32. 32.
    Carrison LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Sweden obese subjects. NEJM. 2012;367:2683–93.Google Scholar
  33. 33.
    Lee WJ, Chong K, Ser KH, et al. C-peptide predicts the remission of type 2 diabetes after bariatric surgery. Obes Surg. 2012;22:293–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Arts EOI, Janssen J, Jassen IM, et al. Preoperative fasting plasma C-peptide level may help to predict diabetes outcome after gastric bypass surgery. Obes Surg. 2013;23:867–73.CrossRefGoogle Scholar
  35. 35.
    Cohen RV, Petry TZ, Caravatto PP. Low levels of C-peptide may not be a sign of pancreatic B-cell death or apoptosis: new insight into pancreatic endocrine function and indications for metabolic surgery. Surg Obes Relat Dis. 2013;9:1022–4.CrossRefPubMedGoogle Scholar
  36. 36.
    Thaler JP, Cummings DE. Minireview: hormonal and metabolic mechanisms of diabetes remission after gastrointestinal surgery. Endocrinology. 2009;150(6):2518–25.CrossRefPubMedGoogle Scholar
  37. 37.
    DePaula AL, Macedo AL, Rassi N, et al. Laparoscopic treatment of metabolic syndrome in patients with type 2 diabetes mellitus. Surg Endosc. 2008;22(12):2670–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Ramos AC, Galvao N, de Souza YM, et al. Laparoscopic duodenal-jejunal exclusion in the treatment of type 2 diabetes mellitus in patients with BMI < 30 Kg/m2 (LBMI). Obes Surg. 2009;19:307–11.CrossRefPubMedGoogle Scholar
  39. 39.
    Cohen R, Caravatto PP, Correa JL, et al. Glycemic control after stomach-sparing duodenal-jejunal bypass surgery in diabetic patients with low body mass index. Surg Obes Relat Dis. 2012;8:375–80.CrossRefPubMedGoogle Scholar
  40. 40.
    Kim JW, Cheong JH, Hyung WJ, et al. Outcome after gastrectomy in gastric cancer patients with type 2 diabetes. World J Gastroenterol. 2012;18(1):49–54.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Wei-Jei Lee
    • 1
  • Abdullah Almulaifi
    • 1
  • Keong Chong
    • 2
  • Shu-Chun Chen
    • 1
  • Jun Juin Tsou
    • 1
  • Kong-Han Ser
    • 1
  • Yi-Chih Lee
    • 3
  • Jung-Chien Chen
    • 1
  1. 1.Department of SurgeryMin-Sheng General HospitalTaoyuan CityTaiwan
  2. 2.Division of Endocrinology, Department of Internal MedicineMin-Sheng General HospitalTaoyuan CityTaiwan
  3. 3.Department of International BusinessChien Hsin University of Science and TechnologyTaoyuan CityTaiwan

Personalised recommendations