Islamabad: Bariatric or metabolic surgery remains significantly more effective than medicines and lifestyle changes in controlling type 2 diabetes and achieving sustained weight loss, even among people living in socially deprived areas, according to a major long term analysis published in Annals of Internal Medicine.
The study, led by researchers from four US academic centres, analysed data from the ARMMS T2D consortium, which pooled results from randomised trials comparing bariatric surgery with intensive medical and lifestyle treatment in people with long standing type 2 diabetes. Importantly, the researchers examined whether social vulnerability such as poverty, neighbourhood deprivation and limited resources reduced the benefits of surgery.
Using the Area Deprivation Index, a widely used measure of social disadvantage based on residential ZIP codes, the researchers followed 258 participants with type 2 diabetes for seven to twelve years after treatment. They found that surgery consistently delivered better blood sugar control and greater weight loss than medical therapy alone, regardless of whether participants came from high or low deprivation areas.
Among people living in highly deprived areas, bariatric surgery lowered HbA1c, a key marker of long term glucose control, by an additional 1.29 percentage points compared with medicines and lifestyle intervention. In less deprived groups, the additional reduction was 0.95 percentage points.
Weight loss results were also striking, with surgery leading to around 10 to 13 percent more weight loss than medical therapy across both social groups. Crucially, the study found no statistically significant interaction between social deprivation and treatment effect, meaning social vulnerability did not blunt the benefits of surgery.
For Pakistan, where type 2 diabetes and obesity are rising rapidly across all income groups, the findings carry important implications. Pakistan is among the top ten countries globally for diabetes burden, with an estimated 30 million adults affected.
While diabetes is often associated with urban lifestyles and higher incomes, recent surveys show growing prevalence in low income and underserved populations, driven by cheap calorie dense foods, physical inactivity and limited access to preventive healthcare.
Experts say one of the persistent concerns around bariatric surgery has been whether patients from poorer or socially disadvantaged backgrounds can achieve the same outcomes as wealthier patients, given challenges such as follow up care, dietary adherence and access to specialist services. This new evidence suggests that, when provided, metabolic surgery can deliver durable benefits irrespective of social disadvantage.
In Pakistan, bariatric surgery is still largely confined to the private sector and major urban centres, making it inaccessible for most low and middle income patients. Public sector hospitals offer limited metabolic surgery services, and the procedure is not routinely covered under government health protection schemes. As a result, diabetes management for poorer patients relies heavily on medicines, often with suboptimal control and high out of pocket costs.
The study’s findings strengthen the argument that metabolic surgery should be seen not as a luxury intervention but as an effective treatment option for selected patients with uncontrolled diabetes, including those from deprived backgrounds. Pakistani endocrinologists and surgeons have long argued that early surgical intervention in appropriate patients can reduce long term complications such as kidney failure, heart disease, blindness and amputations, which impose enormous costs on families and the health system.
The authors caution that their analysis had limitations, including a relatively small sample size and the fact that the original trials were not specifically designed to study social vulnerability. However, the long follow up period and consistent results across deprivation levels add weight to the conclusions.
For policymakers in Pakistan, the study highlights the need to rethink diabetes care models. Expanding access to metabolic surgery through public hospitals, regulated centres and national insurance schemes could offer long term savings by reducing complications, especially among patients who struggle to achieve control with medicines alone. It also underscores the importance of not excluding disadvantaged populations from advanced treatments on the assumption that they will benefit less.
As Pakistan struggles with a growing diabetes crisis cutting across class lines, evidence that effective interventions work equally well in socially vulnerable groups could help shape more equitable and impactful health policies.