Abstract
Background/objectives
Whether the extent of weight loss (WL) modulates bariatric surgery (BS) cardiovascular benefits has scarcely been assessed. Several WL thresholds have been commonly used to classify BS patients as good or poor responders without a proven clinical relevance. We examined the relationship between the magnitude of WL after BS and post-surgery major adverse cardiovascular-event (MACE) incidence. We also compared the performance of three different insufficient weight-loss (IWL) criteria for their association with MACE.
Subjects and methods
All individuals who underwent a primary Roux-en Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in our institution at least six years before data analysis (12/2020) were included in the study. Data on MACE were available in 1638 of 1700 participants (96.4%). Proportional-hazard Cox analyses were performed to ascertain the association between MACE, WL, and the three IWL criteria. IWL was defined as: <50% excess weight loss (<50% EWL), <20% total body-weight loss (<20% TBWL), and −1 standard deviation of alterable weight-loss percentage (<1 SD% AWL).
Results
During a mean follow-up of 10.2 ± 2.8 years, 86 participants experienced a first post-surgery MACE. Higher WL at one year (HR: 0.77 (95% CI: 0.61–0.98)) and 5 years (HR: 0.63 (95% CI: 0.42–0.92)) was related to a lower incidence of MACE. All short-term criteria for defining IWL were similarly associated with MACE, yet <1 SD% AWL identified more at-risk subjects. Five-year TBWL < 20% and 5-year <1 SD-AWL% were significantly associated with a higher risk for CV events. TBWL < 20% identified more subjects at risk.
Conclusions
The extent of WL is closely related to long-term MACE incidence. Patients who lost −1SD% AWL at one year or <20% TBWL at five years may be considered poor responders.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$259.00 per year
only $21.58 per issue
Rent or buy this article
Prices vary by article type
from$1.95
to$39.95
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Cohen RV, Pereira TV, Aboud CM, Petry TBZ, Lopes Correa JL, Schiavon CA, et al. Effect of gastric bypass vs best medical treatment on early-stage chronic kidney disease in patients with type 2 diabetes and obesity: a randomized clinical trial. JAMA Surg. 2020;155:e200420.
Mingrone G, Panunzi S, De GA, Guidone C, Iaconelli A, Capristo E, et al. Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2021;397:293–304.
Schauer DP, Feigelson HS, Koebnick C, Caan B, Weinmann S, Leonard AC, et al. Bariatric surgery and the risk of cancer in a large multisite cohort. Ann Surg. 2019;269:95–101.
Schiavon CA, Bersch-Ferreira AC, Santucci EV, Oliveira JD, Torreglosa CR, Bueno PT, et al. Effects of bariatric surgery in obese patients with hypertension: the GATEWAY randomized trial (gastric bypass to treat obese patients with steady hypertension). Circulation. 2018;137:1132–42.
Aminian A, Zajichek A, Arterburn DE, Wolski KE, Brethauer SA, Schauer PR, et al. Association of metabolic surgery with major adverse cardiovascular outcomes in patients with type 2 diabetes and obesity. JAMA. 2019;322:1271–82.
Benotti PN, Wood GC, Carey DJ, Mehra VC, Mirshahi T, Lent MR et al. Gastric bypass surgery produces a durable reduction in cardiovascular disease risk factors and reduces the long-term risks of congestive heart failure. J Am Heart Assoc 2017; 6: e005126.
Eliasson B, Liakopoulos V, Franzén S, Näslund I, Svensson AM, Ottosson J, et al. Cardiovascular disease and mortality in patients with type 2 diabetes after bariatric surgery in Sweden: a nationwide, matched, observational cohort study. Lancet Diabetes Endocrinol. 2015;3:847–54.
Fisher DP, Johnson E, Haneuse S, Arterburn D, Coleman KJ, O’Connor PJ, et al. Association between bariatric surgery and macrovascular disease outcomes in patients with type 2 diabetes and severe obesity. JAMA. 2018;320:1570–82.
Liakopoulos V, Franzén S, Svensson AM, Sattar N, Miftaraj M, Björck S, et al. Renal and cardiovascular outcomes after weight loss from gastric bypass surgery in type 2 diabetes: cardiorenal risk reductions exceed atherosclerotic benefits. Diabetes Care. 2020;43:1276–84.
Näslund E, Stenberg E, Hofmann R, Ottosson J, Sundbom M, Marsk R et al. Association of metabolic surgery with major adverse cardiovascular outcomes in patients with previous myocardial infarction and severe obesity: a nationwide cohort study. Circulation 2020; 143: 1458–67.
Sjöström L, Peltonen M, Jacobson P, Sjöström CD, Karason K, Wedel H, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307:56–65.
Courcoulas AP, King WC, Belle SH, Berk P, Flum DR, Garcia L, et al. Seven-year weight trajectories and health outcomes in the longitudinal assessment of bariatric surgery (LABS) study. JAMA Surg. 2018;153:427–34.
Kolotkin RL, Andersen JR. A systematic review of reviews: exploring the relationship between obesity, weight loss and health-related quality of life. Clin Obes. 2017;7:273–89.
Monpellier VM, Antoniou EE, Aarts EO, Janssen IMC, Jansen ATM. Improvement of health-related quality of life after Roux-en-Y gastric bypass related to weight loss. Obes Surg. 2017;27:1168–73.
Sundbom M, Hedberg J, Marsk R, Boman L, Bylund A, Hedenbro J, et al. Substantial decrease in comorbidity 5 years after gastric bypass: a population-based study from the Scandinavian obesity surgery registry. Ann Surg. 2017;265:1166–71.
Moussa O, Ardissino M, Heaton T, Tang A, Khan O, Ziprin P, et al. Effect of bariatric surgery on long-term cardiovascular outcomes: a nationwide nested cohort study. Eur Heart J. 2020;41:2660–7.
Bonouvrie DS, Uittenbogaart M, Luijten AAPM, van Dielen FMH, Leclercq WKG. Lack of standard definitions of primary and secondary (non)responders after primary gastric bypass and gastric sleeve: a systematic review. Obes Surg. 2019;29:691–7.
Karmali S, Birch DW, Sharma AM. Is it time to abandon excess weight loss in reporting surgical weight loss? Surg Obes Relat Dis. 2009;5:503–6. Jul-Aug
Kraljević M, Köstler T, Süsstrunk J, Lazaridis II, Taheri A, Zingg U, et al. Revisional surgery for insufficient loss or regain of weight after Roux-en-Y gastric bypass: biliopancreatic limb length matters. Obes Surg. 2020;30:804–11. Mar
Poublon N, Chidi I, Bethlehem M, Kuipers E, Gadiot R, Emous M. et al. One anastomosis gastric bypass vs. Roux-en-Y gastric bypass, remedy for insufficient weight loss and weight regain after failed restrictive bariatric surgery. Obes Surg. 2020;30:3287–94. Sep.
Lunel T, Iceta S, Pasquer A, Pelascini E, Perinel J, Poncet G, et al. Third bariatric procedure for insufficient weight loss or weight regain: how far should we go? Surg Obes Relat Dis. 2021;17:96–103. Jan
van de Laar AW, Nienhuijs SW, Apers JA, van Rijswijk AS, de Zoete JP, Gadiot RP. The Dutch bariatric weight loss chart: a multicenter tool to assess weight outcome up to 7 years after sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2019;15:200–10.
Fried M, Yumuk V, Oppert JM, Scopinaro N, Torres A, Weiner R, et al. Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes Surg. 2014;24:42–55.
Morínigo R, Vidal J, Lacy AM, Delgado S, Casamitjana R, Gomis R. Circulating peptide YY, weight loss, and glucose homeostasis after gastric bypass surgery in morbidly obese subjects. Ann Surg. 2008;247:270–5.
Vidal J, Ibarzabal A, Nicolau J, Vidov M, Delgado S, Martinez G, et al. Short-term effects of sleeve gastrectomy on type 2 diabetes mellitus in severely obese subjects. Obes Surg. 2007;17:1069–74.
Jiménez A, Ibarzabal A, Moizé V, Pané A, Andreu A, Molero J, et al. Ten-year outcomes after Roux-en-Y gastric bypass and sleeve gastrectomy: an observational nonrandomized cohort study. Surg Obes Relat Dis. 2019;15:382–8.
2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021; 44(Suppl 1): S15–33.
Williams B, Mancia G, Spiering W, Agabiti RE, Azizi M, Burnier M, et al. Practice Guidelines for the management of arterial hypertension of the European Society of Hypertension and the European Society of Cardiology: ESH/ESC Task Force for the Management of Arterial Hypertension. J Hypertens. 2018;36:2284–309. 2018
Adams TD, Davidson LE, Litwin SE, Kim J, Kolotkin RL, Nanjee MN, et al. Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med. 2017;377:1143–55.
Arterburn DE, Johnson E, Coleman KJ, Herrinton LJ, Courcoulas AP, Fisher D et al. Weight outcomes of sleeve gastrectomy and gastric bypass compared to nonsurgical treatment. Ann Surg. 2020; 10.1097/SLA.0000000000003826. Online ahead of print.
Peterli R, Wölnerhanssen BK, Peters T, Vetter D, Kröll D, Borbély Y, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial. JAMA. 2018;319:255–65.
Salminen P, Helmiö M, Ovaska J, Juuti A, Leivonen M, Peromaa-Haavisto P, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial. JAMA. 2018;319:241–54.
Carlsson LMS, Sjöholm K, Jacobson P, Andersson-Assarsson JC, Svensson PA, Taube M, et al. Life expectancy after Bariatric surgery in the Swedish obese subjects study. N Engl J Med. 2020;383:1535–43.
Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, Coday M, et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369:145–54.
Aminian A, Zajichek A, Tu C, Wolski KE, Brethauer SA, Schauer PR, et al. How much weight loss is required for cardiovascular benefits? Insights from a metabolic surgery matched-cohort study. Ann Surg. 2020;272:639–45.
Hjorth S, Näslund I, Andersson-Assarsson JC, Svensson PA, Jacobson P, Peltonen M, et al. Reoperations after bariatric surgery in 26 years of follow-up of the Swedish obese subjects study. JAMA Surg. 2019;154:319–26.
de HA, Ruiz T, Jiménez A, Flores L, Lacy A, Vidal J. Patterns of weight loss response following gastric bypass and sleeve gastrectomy. Obes Surg. 2015;25:1177–83.
Acknowledgements
This work was supported by research grants from the Carlos III Institute of Health, Spain, and the Fondo Europeo de Desarrollo Regional (FEDER), Unión Europea, “Una manera de hacer Europa” (PI17/00279 and PI20/0042 to AJ) and by a grant from the Generalitat de Catalunya (SLT008/18/00127) to AJ. It has also been supported by Hospital Clínic de Barcelona (grant “Ajut Josep Font” to AP).
Author information
Authors and Affiliations
Contributions
A.J and J.V. designed the study and contributed to data acquisition, analysis and interpretation, literature search, and paper writing. A.P, E.O and A.H. contributed to the literature search and writing the paper. A.I, A.H,D.T, JM.B, A.A, J.M, S.C, A.O, V.M, L.F and E.O. contributed to data acquisition. A.J. analyzed the data. All authors reviewed the paper and edited it for intellectual content, and gave final approval for this version to be published. J.V. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
Rights and permissions
About this article
Cite this article
Jiménez, A., Pané, A., Ibarzábal, A. et al. Weight-loss thresholds after bariatric surgery and cardiovascular outcomes: more is better. Int J Obes 46, 279–286 (2022). https://doi.org/10.1038/s41366-021-00986-0
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41366-021-00986-0
This article is cited by
-
Perceived Benefits of Bariatric Surgery: Patient Perspectives
Obesity Surgery (2024)
-
Integrated Care Model of Adiposity-Related Chronic Diseases
Current Hypertension Reports (2022)