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Clinical Research

Weight-loss thresholds after bariatric surgery and cardiovascular outcomes: more is better



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).


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.


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.

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  1. 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.

    Article  Google Scholar 

  2. 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.

    Article  Google Scholar 

  3. 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.

    Article  Google Scholar 

  4. 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.

    Article  Google Scholar 

  5. 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.

    Article  Google Scholar 

  6. 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.

  7. 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.

    Article  Google Scholar 

  8. 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.

    Article  Google Scholar 

  9. 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.

    Article  Google Scholar 

  10. 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.

  11. 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.

    Article  Google Scholar 

  12. 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.

    Article  Google Scholar 

  13. 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.

    Article  CAS  Google Scholar 

  14. 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.

    Article  Google Scholar 

  15. 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.

    Article  Google Scholar 

  16. 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.

    Article  Google Scholar 

  17. 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.

    Article  Google Scholar 

  18. 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

    Article  Google Scholar 

  19. 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

    Article  Google Scholar 

  20. 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.

    Article  Google Scholar 

  21. 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

    Article  Google Scholar 

  22. 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.

    Article  Google Scholar 

  23. 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.

    Article  CAS  Google Scholar 

  24. 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.

    Article  Google Scholar 

  25. 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.

    Article  CAS  Google Scholar 

  26. 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.

    Article  Google Scholar 

  27. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021; 44(Suppl 1): S15–33.

  28. 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

    Article  CAS  Google Scholar 

  29. 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.

    Article  Google Scholar 

  30. 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.

  31. 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.

    Article  Google Scholar 

  32. 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.

    Article  Google Scholar 

  33. 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.

    Article  Google Scholar 

  34. 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.

    Article  CAS  Google Scholar 

  35. 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.

    Article  Google Scholar 

  36. 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.

    Article  Google Scholar 

  37. 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.

    Article  Google Scholar 

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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).

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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.

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Correspondence to Josep Vidal.

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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).

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