Association of bariatric surgery with cardiovascular outcomes in adults with severe obesity and nonalcoholic fatty liver disease
Open accessAbstract
Importance: There are no approved treatments for nonalcoholic fatty liver disease (NAFLD) despite its association with obesity and increased risk of cardiovascular disease (CVD). Objective: To examine the association between bariatric surgery and CVD risk in individuals with severe obesity and NAFLD. Design, Setting, and Participants: This large, population-based retrospective cohort study obtained data from the MarketScan Commercial Claims and Encounters database from January 1, 2007, to December 31, 2017. Participants included insured adults aged 18 to 64 years with NAFLD and severe obesity (body mass index ≥40) without a history of bariatric surgery or CVD before NAFLD diagnosis. Baseline characteristics were balanced between individuals who underwent surgery (surgical group) and those who did not (nonsurgical group) using inverse probability of treatment weighting. Data were analyzed from March 2020 to April 2021. Exposures: Bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy, and other bariatric procedures) vs nonsurgical care. Main Outcomes and Measures: The main outcome was the incidence of cardiovascular events (primary or secondary composite CVD outcomes). The primary composite outcome included myocardial infarction, heart failure, or ischemic stroke, and the secondary composite outcome included secondary ischemic heart events, transient ischemic attack, secondary cerebrovascular events, arterial embolism and thrombosis, or atherosclerosis. Cox proportional hazards regression models with inverse probability treatment weighting were used to examine the associations between bariatric surgery, modeled as time varying, and all outcomes. Results: The study included 86 964 adults (mean [SD] age, 44.3 [10.9] years; 59 773 women [68.7%]). Of these individuals, 30 300 (34.8%) underwent bariatric surgery and 56 664 (65.2%) received nonsurgical care. All baseline covariates were balanced after applying inverse probability treatment weighting. In the surgical group, 1568 individuals experienced incident cardiovascular events compared with 7215 individuals in the nonsurgical group (incidence rate difference, 4.8 [95% CI, 4.5-5.0] per 100 person-years). At the end of the study, bariatric surgery was associated with a 49% lower risk of CVD (adjusted hazard ratio [aHR], 0.51; 95% CI, 0.48-0.54) compared with nonsurgical care. The risk of primary composite CVD outcomes was reduced by 47% (aHR, 0.53 [95% CI, 0.48-0.59), and the risk of secondary composite CVD outcomes decreased by 50% (aHR, 0.50; 95% CI, 0.46-0.53) in individuals with vs without surgery. Conclusions and Relevance: Results of this study suggest that, compared with nonsurgical care, bariatric surgery was associated with significant reduction in CVD risk in individuals with severe obesity and NAFLD.
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Many prospective studies have shown that bariatric surgery induces stable weight loss, remission of T2D, improvement in cardiovascular risk, and a reduction in cancer (including liver cancer) risk.
“Many prospective studies have shown that bariatric surgery induces stable weight loss, remission of T2D, 436 improvement in cardiovascular risk, 437 and a reduction in cancer (including liver cancer) risk.”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [437]
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“These cardiovascular benefits are attributed to substantial weight loss and the resolution of comorbidities such as diabetes and hypertension [20].”
BackgroundNonalcoholic Fatty Liver Disease and Cardiovascular Disease: Causation or Association
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“Bariatric surgery has been shown to lead to improvement in steatohepatitis and fibrosis 106 and a significant reduction of cardiovascular events 107 and may be considered per the AASLD, but has not been recommended.”
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“While pharmaceutical intervention for MASLD must provide substantial clinical benefits at a modest annual price to be cost-effective [57], bariatric surgery has been shown to reduce the risk of cancer and cardio-vascular disease in MASLD patients with morbid obesity [58, 59].”
BackgroundNon-Alcoholic Fatty Liver Disease, Atherosclerosis, and Cardiovascular Disease in Asia
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“Recently, bariatric surgery showed a 49% risk-reduction of CVD compared with nonsurgical care [84].”
BackgroundCaffeine: a potential mechanism for anti-obesity
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“Bariatric surgery induces a substantial long-term weight loss with significant improvements in obesity-related comorbidities such as non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus [1–3].”
BackgroundLi, X., Liang, X., Li, Z., Liang, J., Qi, Z., Zhong, L., Geng, Z., Liang, W., Quan, X., Liang, C., et al. (2024) · International Journal of Surgery · doi:10.1097/js9.0000000000001191 · Cited by 8 · see citing works
“…the interactions between clinical data, imaging features, pathological indicators, and PA-TACE bene fi t associated with recurrence-free survival (RFS) and overall survival (OS) were analyzed using inverse probability of treatment weighting-adjusted Cox proportional hazard regression analysis [27] .”
MethodPathogenesis and Clinical Management of Metabolic Dysfunction-Associated Steatotic Liver Disease
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“It is essential to highlight that bariatric surgery in MASLD patients is associated with a decreased risk of major liver outcomes and of cardiovascular events [204].”
MASLD in childhood as a multisystem health challenge beyond the liver
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Clinical Outcomes of Metabolic Surgery on Diuretic Use in Patients With Heart Failure
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Antihypertensive Medication Use Trajectories After Bariatric Surgery: A Matched Cohort Study
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MASLD and the cardiovascular-kidney-liver-metabolic syndrome
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“Compared to nonsurgical care, bariatric surgery had a 49% lower risk of CVD (aHR, 0.51; 95% CI, 0.48–0.54) [32].”
InfluentialCardiorenal outcomes of weight loss interventions in people with CKD and type 2 diabetes
Wilkinson, T. J., Goldney, J., Yates, T. E., Henson, J. J., Zaccardi, F., Khunti, K., Webb, D. R., Papamargaritis, D., & Davies, M. J. (2025) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfaf258 · Cited by 2 · see citing works
“The effects of BS on cardiovascular outcomes are well-described in previous studies, with BS associated with large reductions in the risk of CVD and cardiovascular events such as atherosclerosis and ischaemic heart disease [46 ].”
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Surgical treatment of obesity for NAFLD
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Approach to Weight Loss Patient's Post Bariatric Surgery
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Metabolic Surgery and Chronic Traumatic Encephalopathy: Perceptions of Former NFL Players
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“For example, 60.0% reported being more likely to undergo MBS if it could also cure diabetes and significantly reduce risk of heart disease, as research indicates [35, 36, 87].”
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“In contrast, BAE offers a long-term, less invasive alternative with the potential to reduce surgical risks and offer patients an adjuvant to their treatment, though larger, long-term studies are required to define its role in clinical practice [20].”
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“Furthermore, Elsaid et al. (2022) report that this surgical procedure decreases the likelihood of cardiovascular events in obese patients with Non-Alcoholic Fatty Liver Disease.”
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“Beyond well-documented improvements in Type 2 diabetes, hypertension, and other systemic risk factors, bariatric surgery has been associated with significant reductions in cardio-metabolic disease burden and improved long-term health outcomes [10 ].”
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“Metabolic bariatric surgery is recommended for adults with non-cirrhotic MASLD who meet surgical criteria, as it can achieve sustained weight loss of up to 30% and improve diabetes, hepatic fibrosis, cardiovascular risk, and overall morbidity and mortality [75–77].”
- Authors
- Elsaid, M. I., Li, Y., Bridges, J. F. P., Brock, G., Minacapelli, C. D., & Rustgi, V. K.
- Affiliations
- The Ohio State University (US)
- Rutgers, The State University of New Jersey (US)
- Corresponding author
- Rustgi, Vinod K.
- Venue
- JAMA Network Open
- Publisher
- American Medical Association (AMA)
- Published
- 2022-10-07
- Volume
- 5
- Issue
- 10
- Pages
- e2235003
- ISSN
- 2574-3805 (ISSN-L)
- PMC
- PMC9547320
- OpenAlex
- W4303437732
- Cited by
- 63
- References
- 74
- Citations by year
- 2026: 12 · 2025: 14 · 2024: 26 · 2023: 10
- FWCI
- 11.93
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JAMA Network Open (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
- Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- bariatric surgery, non-alcoholic fatty liver disease, morbid obesity, cardiovascular disease, cardiovascular events, Roux-en-Y gastric bypass, sleeve gastrectomy, myocardial infarction, heart failure, ischemic stroke, transient ischemic attack, atherosclerosis, cardiovascular risk reduction, inverse probability of treatment weighting, commercial claims data
- MeSH terms
- Adult, Female, Humans, Myocardial Infarction, Obesity, Morbid, Retrospective Studies, Bariatric Surgery, Non-alcoholic Fatty Liver Disease
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