Hypoglycemia is prevalent among patients postbariatric surgery, but its clinical implications remain unclear. The purpose of this study was to examine the longitudinal associations of hypoglycemia (i.e., occurrence in the past 3 months, frequency in the past 7 days, number of severe episodes in the past 3 months, and symptoms) with depressive symptoms, quality of life (QoL), work productivity, and weight loss over an 84-month follow-up period after bariatric surgery.
Methods:
This secondary analysis used data from the Longitudinal Assessment of Bariatric Surgery-2 study. Hypoglycemia, depressive symptoms, QoL, and work productivity were self-reported. Weight was primarily based on objective measures. Linear mixed modeling with time-lagged techniques was used for analysis, adjusting for potential covariates such as age and gender.
Results:
Across the 84-month follow-up, 20%–30% of participants (N = 552) reported experiencing hypoglycemia in the past 3 months. Hypoglycemia occurrence was positively associated with depressive symptoms [β = 2.4; 95% confidence interval (CI): 1.7, 3.0] and negatively associated with physical (β = −4.2; 95% CI: −5.1, −3.3) and mental QoL (β = −3.4; 95% CI: −4.4, −2.4). These associations became stronger with increased frequency of hypoglycemia, a higher number of severe episodes, and the presence of symptoms. Additionally, hypoglycemia occurrence was associated with several domains of work productivity, including presenteeism (β = 5.8; 95% CI: 3.4, 8.2), work productivity loss (β = 5.6; 95% CI: 2.6, 8.6), and activity impairment (β = 8.8; 95% CI: 6.0, 11.6), with the strength of these associations increasing with greater hypoglycemic frequency.
Conclusions:
This study highlights the critical role of hypoglycemia in patients’ physical and psychosocial well-being postbariatric surgery. Future studies employing more rigorous measures of hypoglycemia and expanded outcomes (e.g. cognitive function) are needed to fully understand its clinical relevance.
Get full access to this article
View all access options for this article.
References
1.
LazarLO, SapojnikovS, PinesG, et al.Symptomatic and asymptomatic hypoglycemia post three different bariatric procedures: A common and severe complication. Endocr Pract, 2019; 68(Suppl 1).
2.
RoslinMS, OrenJH, PolanBN, et al.Abnormal glucose tolerance testing after gastric bypass. Surg Obes Relat Dis, 2013; 9(1):26–31.
3.
BienvenotR, SirveauxMA, Nguyen-ThiPL, et al.Symptomatic hypoglycemia after gastric bypass: Incidence and predictive factors in a cohort of 1,138 consecutive patients. Obesity (Silver Spring), 2021; 29(4):681–688.
4.
LupoliR, LemboE, RainoneC, et al.Rate of post-bariatric hypoglycemia using continuous glucose monitoring: A meta-analysis of literature studies. Nutr Metab Cardiovasc Dis, 2022; 32(1):32–39.
5.
YuY, GrothSW. Use of continuous glucose monitoring in patients following bariatric surgery: A scoping review. Obes Surg, 2023; 33(8):2573–2582.
6.
HalperinF, PattiME, SkowM, et al.Continuous glucose monitoring for evaluation of glycemic excursions after gastric bypass. J Obes, 2011; 2011:869536.
7.
LaferrèreB, PattouF. Weight-independent mechanisms of glucose control after Roux-en-Y gastric bypass. Front Endocrinol (Lausanne), 2018; 9:530.
8.
HolstJJ, MadsbadS, Bojsen-MøllerKN, et al.Mechanisms in bariatric surgery: Gut hormones, diabetes resolution, and weight loss. Surg Obes Relat Dis, 2018; 14(5):708–714.
BumbuA, MoutairouA, MatarO, et al.Non-severe hypoglycaemia is associated with weight gain in patients with type 1 diabetes: Results from the Diabetes Control and Complication Trial. Diabetes Obes Metab, 2018; 20(5):1289–1292.
11.
The DCCT Research Group. Weight gain associated with intensive therapy in the diabetes control and complications trial. Diabetes Care, 1988; 11(7):567–573.
12.
GreenAJ, FoxKM, GrandyS, SHIELD Study Group. Self-reported hypoglycemia and impact on quality of life and depression among adults with type 2 diabetes mellitus. Diabetes Res Clin Pract, 2012; 96(3):313–318.
13.
JungA, DuY, NübelJ, et al.Are depressive symptoms associated with quality of care in diabetes? Findings from a nationwide population-based study. BMJ Open Diabetes Res Care, 2021; 9(1).
14.
YafeiS, HummadiA, BadediM, et al.Disordered eating behaviors and insulin restriction in Saudi adolescents and young adults with type 1 diabetes. Medicina (Kaunas), 2023; 59(2).
15.
BiggersA, SharpLK, NimitphongH, et al.Relationship between depression, sleep quality, and hypoglycemia among persons with type 2 diabetes. J Clin Transl Endocrinol, 2019; 15:62–64.
16.
HayashinoY, TsujiiS, IshiiH, Diabetes Distress and Care Registry at Tenri Study Group *. High frequency of non-nocturnal hypoglycemia was associated with poor sleep quality measure by Pittsburg Sleep Quality Index in patients with diabetes receiving insulin therapy: Diabetes Distress and Care Registry at Tenri (DDCRT 4). Exp Clin Endocrinol Diabetes, 2013; 121(10):628–634.
17.
LopezJM, AnnunziataK, BaileyRA, et al.Impact of hypoglycemia on patients with type 2 diabetes mellitus and their quality of life, work productivity, and medication adherence. Patient Prefer Adherence, 2014; 8:683–692.
18.
FulcherG, SingerJ, CastañedaR, et al.The psychosocial and financial impact of non-severe hypoglycemic events on people with diabetes: Two international surveys. J Med Econ, 2014; 17(10):751–761.
19.
DaviesMJ, DerezinskiT, PedersenCB, et al.Reduced weight gain with insulin detemir compared to NPH insulin is not explained by a reduction in hypoglycemia. Diabetes Technol Ther, 2008; 10(4):273–277.
20.
GilsanzP, KarterAJ, BeeriMS, et al.The bidirectional association between depression and severe hypoglycemic and hyperglycemic events in type 1 diabetes. Diabetes Care, 2018; 41(3):446–452.
21.
PrinzN, EbnerS, GrünerbelA, et al.Female sex, young age, northern German residence, hypoglycemia and disabling diabetes complications are associated with depressed mood in the WHO-5 questionnaire – A multicenter DPV study among 17,563 adult patients with type 2 diabetes. J Affect Disord, 2017; 208:384–391.
22.
PathakRD, SchroederEB, SeaquistER, et al.; SUPREME-DM Study Group. Severe hypoglycemia requiring medical intervention in a large cohort of adults with diabetes receiving care in U.S. integrated health care delivery systems: 2005-2011. Diabetes Care, 2016; 39(3):363–370.
23.
WilliamsSA, PollackMF, DibonaventuraM. Effects of hypoglycemia on health-related quality of life, treatment satisfaction and healthcare resource utilization in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract, 2011; 91(3):363–370.
24.
RossiMC, NicolucciA, OzzelloA, et al.; HYPOS-1 Study Group of AMD. Impact of severe and symptomatic hypoglycemia on quality of life and fear of hypoglycemia in type 1 and type 2 diabetes. Results of the Hypos-1 observational study. Nutr Metab Cardiovasc Dis, 2019; 29(7):736–743.
25.
HaluzikM, KretowskiA, StrojekK, et al.Perspectives of patients with insulin-treated type 1 and type 2 diabetes on hypoglycemia: Results of the HAT observational study in central and eastern European countries. Diabetes Ther, 2018; 9(2):727–741.
26.
WillisWD, Diago-CabezudoJI, Madec-HilyA, et al.Medical resource use, disturbance of daily life and burden of hypoglycemia in insulin-treated patients with diabetes: Results from a European online survey. Expert Rev Pharmacoecon Outcomes Res, 2013; 13(1):123–130.
27.
RebelosE, MoriconiD, ScaleseM, et al.Impact of postprandial hypoglycemia on weight loss after bariatric surgery. Obes Surg, 2020; 30(6):2266–2273.
28.
VarmaS, ClarkJM, SchweitzerM, et al.Weight regain in patients with symptoms of post–bariatric surgery hypoglycemia. Surg Obes Relat Dis, 2017; 13(10):1728–1734.
29.
BauraitėK, MikuckytėD, GudaitytėR, et al.Factors associated with quality of life and weight regain 12 years after Roux-en-Y gastric bypass. Surg Endosc, 2022; 36(6):4333–4341.
30.
FischerLE, WolfeBM, FinoN, et al.; LABS Investigators. Postbariatric hypoglycemia: Symptom patterns and associated risk factors in the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis, 2021; 17(10):1787–1798.
31.
BelleSH, BerkPD, ChapmanWH, et al.; LABS Consortium. Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. Surg Obes Relat Dis, 2013; 9(6):926–935.
32.
SmithKE, MasonTB, CaoL, et al.Trajectories of depressive symptoms and relationships with weight loss in the seven years after bariatric surgery. Obes Res Clin Pract, 2020; 14(5):456–461.
33.
WareJEJr, SherbourneCD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care, 1992; 30(6):473–483.
34.
FarivarSS, CunninghamWE, HaysRD. Correlated physical and mental health summary scores for the SF-36 and SF-12 Health Survey, V.I. Health Qual Life Outcomes, 2007; 5:54.
35.
ReillyMC, ZbrozekAS, DukesEM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics, 1993; 4(5):353–365.
36.
AlyahyaRA, AlnujaidiMA. Prevalence and outcomes of depression after bariatric surgery: A systematic review and meta-analysis. Cureus, 2022; 14(6):e25651.
37.
RaaijmakersLCH, PouwelsS, ThomassenSEM, et al.Quality of life and bariatric surgery: A systematic review of short- and long-term results and comparison with community norms. Eur J Clin Nutr, 2017; 71(4):441–449.
38.
Orozco-BeltránD, Mezquita-RayaP, Ramírez de ArellanoA, et al.Self-reported frequency and impact of hypoglycemic events in Spain. Diabetes Ther, 2014; 5(1):155–168.
39.
PuleioA, SheehanA, MusenG, et al.Cognition in patients with post-bariatric hypoglycemia. Obesity (Silver Spring), 2024; 32(3):466–471.
40.
EisenbergD, ShikoraSA, AartsE, et al.2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for metabolic and bariatric surgery. Surg Obes Relat Dis, 2022; 18(12):1345–1356.
