CONTACT: Amber Hamilton TYPE 2 DIABETES AND OBESITY: TWIN EPIDEMICS OVERVIEW

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1 FACT SHEET CONTACT: Amber Hamiltn TYPE 2 DIABETES AND OBESITY: TWIN EPIDEMICS OVERVIEW Type 2 diabetes accunts fr 90-95% f the 29.1 millin diabetes cases in the U.S. 1 Obesity is a majr independent risk factr fr develping the disease, and mre than 90% f type 2 diabetics are verweight r have besity 2 Mdest weight lss, as little as 5% f ttal bdy weight, can help t imprve type 2 diabetes in patients wh are verweight r have besity 3 Metablic and bariatric surgery may result in reslutin r imprvement f type 2 diabetes independent f weight lss 4 PREVALENCE 86 millin Americans, r 37% f American adults 20 r lder have prediabetes % f peple with prediabetes will develp type 2 diabetes within 5 years Peple with pre-diabetes are als at risk fr heart disease and strke 5 Diabetes affects 9.3% f the ttal U.S. ppulatin (29.1 millin peple) millin peple have been diagnsed 8.1 millin peple are unaware they suffer frm the disease Abut 90-95% f the diabetes ppulatin has type 2 diabetes Increases in type 2 diabetes cases acrss the cuntry are assciated with high besity rates and rising age f ppulatin 6 Mre than ne-third (35.7%) f adults have besity 7 African-Americans and the elderly are disprprtinately affected by diabetes % f all African-Americans ver 20 years ld have diabetes, cmpared t 7.6% f whites 25.9% f Americans age 65 and lder have diabetes, cmpared t 12.3% f adults ver 20 HEALTH RISKS OF TYPE 2 DIABETES Peple with diabetes have duble the mrtality risk f similar-aged peple withut diabetes, and the disease is the seventh leading cause f death in the U.S. 8 Diabetes is the leading cause f kidney failure, nn-traumatic lwer-limb amputatins, new cases f blindness amng adults, and it is assciated with increased risk f: Heart disease and strke High bld pressure Nervus system disease Kidney disease -mre- Blindness Amputatins Dental disease Pregnancy cmplicatins

2 -2- IMPACT OF METABOLIC & BARIATRIC SURGERY ON TYPE 2 DIABETES Meta-analysis f 22,000 bariatric surgery patients in 136 studies ( ) fund 86% f patients saw imprvement r reslutin f type 2 diabetes and the mean excess weight lss was 61.2% 13 Gastric bypass may result in reslutin r imprvement f type 2 diabetes independent f weight lss by decreasing levels f ghrelin appetite stimulating hrmne secreted by the stmach 14 Peple with severe besity wh had gastric bypass surgery significantly reduced lng-term mrtality frm diabetes by 92% and frm any cause by 40% 15 Surgical Treatment vs. Medical Therapy Cmparative Studies Five-year fllw-up data shwed 50% f bariatric surgery patients maintain diabetes remissin, cmpared t nne f the patients treated with medical therapy alne 16 Meta-analysis f 796 participants in 11 studies cmparing bariatric surgery t nnsurgical treatment fr besity fund surgery results in greater weight lss and higher type 2 diabetes remissin rates 17 (BMJ, 2013) Studies with mre than six mnths fllw up shwed surgical patients lst an average f 57 mre punds than participants in nnsurgical weight lss prgrams, and were 22 times mre likely t see their type 2 diabetes abate Head-t-head studies cmparing bariatric surgery t medical therapy fund bariatric surgery superir t medical treatment in prducing type 2 diabetes remissin, even befre weight lss Cleveland Clinic study shwed within ne year, diabetes remissin rates with bariatric surgery were abut 40% (42% gastric bypass, 37% gastric sleeve) cmpared t abut 12% fr patients treated with the best pharmactherapy available; patients had BMI between 27 and (NEJM, 2012) Cathlic University/New Yrk-Presbyterian/Weill Crnell Medical Center shwed remissin rates were abut 85% fr bariatric surgery (75% gastric bypass, 95% bilipancreatic diversin) and zer fr medical therapy in patients with BMI greater than 35, after tw years 19 (NEJM, 2012) In surgical grups, bth weight lss and preperative BMI were nt predictrs f diabetes cntrl, suggesting such surgical prcedures may be independent f weight lss Cleveland Clinic study shwed bariatric surgery is a highly effective and durable treatment fr type 2 diabetes in patients with mderate and severe besity up t three years after surgery 20 Of patients wh had gastric bypass, 37.5% maintained bld sugar cntrl withut the use f diabetic medicatins, cmpared t 24.5% f thse wh had sleeve gastrectmy and 5% f patients treated with medical therapy alne Lng-Term Results f Surgical Treatment 24% f patients wh have bariatric surgery experience cmplete, lng-term five years r mre remissin f their type 2 diabetes; 26% experience partial remissin and 34% imprve frm baseline 21 (Annals f Surgery, 2013) Six years after surgery, 62% f gastric bypass patients with severe besity BMI 35 r higher experienced type 2 diabetes remissin, cmpared t 6-8% in cntrl grups 22 (JAMA, 2012) Ten years after interventin, 7% f surgery patients have type 2 diabetes, cmpared t 24% f nnsurgically treated patients 23 Fifteen years after bariatric surgery 30.4% f bariatric surgery patients maintained remissin f their diabetes, cmpared 6.5% f a cntrl grup 24 -mre-

3 -3- Surgery in Patients with Lwer BMIs and Type 2 Diabetes Cmpared t nnsurgical treatments, bariatric surgery fr patients with mild-t-mderate besity (BMI 30-35) and type 2 diabetes prduces better intermediate glucse utcmes ne-t-tw years fllwing treatment 25 (JAMA, 2013) Imprvements in glycemic cntrl are maintain fr up t five years after bariatric surgery 26 (JAMA Surgery, 2015) 36% f patients maintained cmplete remissin 28% f patients maintained partial remissin Cmpared t patient treated with medical therapy alne - 1.2% achieved cmplete remissin - 1.6% achieved partial remissin Laparscpic gastric band surgery is a mre effective treatment than nnsurgical therapy 27 (Annals f Internal Medicine, 2006) After tw years, nly 3% f surgical patients cntinued t have metablic syndrme, cmpared t 24% f nn-surgical patients, wh were treated with very-lw-calrie diets, pharmactherapy and lifestyle change COSTS ASSOCIATED WITH TYPE 2 DIABETES Ttal csts f diagnsed diabetes rse 41% in five years, frm $174 billin in 2007 t $245 billin in Mre than 1-in-5 health care dllars in the U.S. are spent n diabetes care with half directly attributable t treatment 29 Indirect csts, including absenteeism, reduced wrk prductivity, inability t wrk and lst wrkers due t premature death, accunt fr $68.6 billin Diabetes patients incur average medical csts f $7,900 fr treatment; ttal medical expenses are 2.3 times higher than fr peple withut diabetes 30 Metablic surgery has been shwn t be assciated with reductins in verall health care csts in patients with type 2 diabetes 31 Annual health care csts decreased 34.2% after tw years and by 70.5% after three years Assciated with eliminatin f diabetes medicatin in nearly 85% f patients tw years after surgery GUIDELINES & RECOMMENDATIONS Jint statement frm 45 internatinal prfessinal rganizatins, including the American Diabetes Assciatin (ADA), the Internatinal Diabetes Federatin (IDF) and the ASMBS, endrses evidence-based guidelines recmmending metablic surgery as a standard treatment ptin fr peple with diabetes, including peple wh have mild besity and fail t respnd t cnventinal treatment 32 (Diabetes Care, 2016) Jint statement by the ADA and the American Heart Assciatin recmmends bariatric surgery be cnsidered fr adults wh have a BMI greater than 35 and an besity-related c-mrbidity, in particular if a patient s diabetes is difficult t cntrl with lifestyle and pharmaclgic therapy 33 (Diabetes Care 2015) 2011 statement frm Internatinal Diabetes Federatin said surgery was effective, safe and cst-effective therapy fr patients with besity and type 2 diabetes, nting it significantly imprves glycemic cntrl in severely bese patients with the disease 34 (Diabetes Medicine, 2011) ###

4 REFERENCES 1 Centers fr Disease Cntrl and Preventin (2014). Diabetes Reprt Card. p. 9 Accessed Octber 2015 frm 2 Wrld Health Organizatin. Obesity and Overweight Fact Sheet. (2015) Accessed Octber 2015 frm 3 Office f the Surgen General U.S. Department f Health and Human Services. Overweight and besity: health cnsequences. Accessed March 2012 frm 4 Schauer, P. R., et al. (2003). Effect f laparscpic rux-en y gastric bypass n type 2 diabetes mellitus. Annals f Surgery. 238(4) p Accessed frm Octber Centers fr Disease Cntrl and Preventin (2011). Natinal Diabetes Fact Sheet, p. 1. Accessed frm Octber, Centers fr Disease Cntrl and Preventin (2012). Diabetes Reprt Card. p. 2. Accessed frm Octber, Centers fr Disease Cntrl and Preventin (2013). Adult Obesity Facts: Obesity is Cmmn, Serius and Cstly. Accessed frm Octber, Natinal Institute f Diabetes and Digestive and Kidney Diseases (2011). Accessed frm Octber, Buchwald, H., et al. (2004). Bariatric surgery: a systematic review and meta-analysis. Jurnal f the American Medical Assciatin. 292(12) Accessed frm Octber, Schauer, P. R., et al. (2003). Effect f laparscpic rux-en y gastric bypass n type 2 diabetes mellitus. Annals f Surgery. 238(4) p. 480 Accessed frm Octber, Adams, T. D., et al. (2007). Lng-term mrtality after gastric bypass surgery. New England Jurnal f Medicine. 357 pp Accessed frm Octber, Mingrne, G., et al. (2015). Bariatric metablic surgery versus cnventinal medical treatment in bese patients with type 2 diabetes: 5 year fllw-up f an pen-label, single-centre, randmised cntrlled trial. The Lancet. Accessed Octber 2015 frm 17 Gly, V.L., et. al. (2013.) Bariatric surgery versus nn-surgical treatment fr besity: a systematic review and meta-analysis f randmised cntrlled trials. British Medical Jurnal. Accessed frm Nvember, Schauer, P. R., et al. (2012). Bariatric surgery vs. intensive medical therapy in bese patients with diabetes. New England Jurnal f Medicine. DOI: /NEJMa Mingrne, G., et al. (2012). Bariatric surgery vs. cnventinal medical therapy fr type 2 diabetes. New England Jurnal f Medicine.DOI: /NEJMa Schauer, P.R., et al. (2014) Bariatric Surgery versus Intensive Medical Therapy fr Diabetes 3-Year Outcmes. New England Jurnal f Medicine. Accessed Octber 2015 frm 21 Brethauer, S.A., et. al. (2013). Can Diabetes Be Surgically Cured? Lng-Term Metablic Effects f Bariatric Surgery in Obese Patients with Type 2 Diabetes Mellitus. Annals f Surgery. Accessed frm Lng_Term aspx Octber Adams T.D., et. al. (2012). Health Benefits f Gastric Bypass Surgery After 6 Years. Jurnal f the American Medical Assciatin. Accessed frm Octber, Sjöström L., et. al. (2004). Lifestyle, Diabetes, and Cardivascular Risk Factrs 10 Years after Bariatric Surgery. New England Jurnal f Medicine. Accessed frm Octber, Sjstrm L., et al. (2014). Assciatin f bariatric surgery with lng-term remissin f type 2 diabetes and with micrvascular and macrvascular cmplicatins. Jurnal f the American Medical Assciatin. Accessed Octber 2015 frm 25 Maggard-Gibbns M., et. al. Bariatric Surgery fr Weight Lss and Glycemic Cntrl in Nn Obese Adults With Diabetes: A Systematic Review. Jurnal f the American Medical Assciatin. Accessed frm Octber, Chih-Cheng H., et al. (2015). Effect f Bariatric Surgery vs Medical Treatment n Type 2 Diabetes in Patients With Bdy Mass Index Lwer Than 35. JAMA Surgery. Accessed Octber 2015 frm 27 O Brien P.E., et. al. (2006). Treatment f Mild t Mderate Obesity with Laparscpic Adjustable Gastric Banding r an Intensive Medical Prgram. Annals f Internal Medicine. p Accessed frm Octber, American Diabetes Assciatin (2013). Ecnmic Csts f Diabetes in the U.S. in 2012 Diabetes Care. p. 1. Accessed frm Octber, American Diabetes Assciatin. (2012). The Cst f Diabetes. Advcate. Accessed frm Octber, American Diabetes Assciatin. (2012). The Cst f Diabetes. Advcate. Accessed frm Octber, Makary M., et al. (2010). Medicatin Utilizatin and Annual Health Care Csts in Patients with Type 2 Diabetes Mellitus Befre and After Bariatric Surgery. Archives f Surgery. 145(8) pp American Diabetes Assciatin. (2016). Metablic Surgery in the Treatment Algrithm fr Type 2 Diabetes: A Jint Statement by Internatinal Diabetes Organizatins. Accessed Octber 2016 frm

5 33 American Diabetes Assciatin. (2013). Update n Preventin f Cardivascular Disease in Adults With Type 2 Diabetes Mellitus in Light f Recent Evidence: A Scientific Statement Frm the American Heart Assciatin and the American Diabetes Assciatin. Accessed Octber 2015 frm 34 Dixn J.B., et. al. (2011). Bariatric Surgery: An IDF Statement fr Obese Type 2 Diabetes. Diabetes Medicine. Accessed frm Octber, Updated Octber 2016