Research

JAMA Dermatology | Original Investigation

Association of Bariatric Surgery With Skin Cancer Incidence

in Adults With Obesity
A Nonrandomized Controlled Trial
Magdalena Taube, PhD; Markku Peltonen, PhD; Kajsa Sjöholm, PhD; Åsa Anveden, MD, PhD;
Johanna C. Andersson-Assarsson, PhD; Peter Jacobson, MD, PhD; Per-Arne Svensson, PhD; Martin O. Bergo, PhD;
Lena M. S. Carlsson, MD, PhD

Supplemental content
IMPORTANCE Obesity is a cancer risk factor, and bariatric surgery in patients with obesity is
associated with reduced cancer risk. However, evidence of an association among obesity,
bariatric surgery, and skin cancer, including melanoma, is limited.

OBJECTIVE To investigate the association of bariatric surgery with skin cancer (squamous cell
carcinoma and melanoma) and melanoma incidence.

DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled trial, the Swedish Obese
Subjects (SOS) study, is ongoing at 25 surgical departments and 480 primary health care
centers in Sweden and was designed to examine outcomes after bariatric surgery. The study
included 2007 patients with obesity who underwent bariatric surgery and 2040
contemporaneously matched controls who received conventional obesity treatment.
Patients were enrolled between September 1, 1987, and January 31, 2001. Data analysis was
performed from June 29, 2018, to November 22, 2018.

INTERVENTIONS Patients in the surgery group underwent gastric bypass (n = 266), banding
(n = 376), or vertical banded gastroplasty (n = 1365). The control group (n = 2040) received
the customary treatment for obesity at their primary health care centers.

MAIN OUTCOMES AND MEASURES The SOS study was cross-linked to the Swedish National
Cancer Registry, the Cause of Death Registry, and the Registry of the Total Population for data
on cancer incidence, death, and emigration.

RESULTS The study included 4047 participants (mean [SD] age, 47.9 [6.1] years; 2867
[70.8%] female). Information on cancer events was available for 4042 patients. The study
found that bariatric surgery was associated with a markedly reduced risk of melanoma
(adjusted subhazard ratio, 0.43; 95% CI, 0.21-0.87; P = .02; median follow-up, 18.1 years) and
risk of skin cancer in general (adjusted subhazard ratio, 0.59; 95% CI, 0.35-0.99; P = .047).
The skin cancer risk reduction was not associated with baseline body mass index or weight;
insulin, glucose, lipid, and creatinine levels; diabetes; blood pressure; alcohol intake; or
smoking.

CONCLUSIONS AND RELEVANCE The results of this study suggest that bariatric surgery in
individuals with obesity is associated with a reduced risk of skin cancer, including melanoma.

TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01479452

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Magdalena
Taube, PhD, Department of Molecular
and Clinical Medicine, Institute of
Medicine, Sahlgrenska Academy,
University of Gothenburg,
JAMA Dermatol. doi:10.1001/jamadermatol.2019.3240 Vita Stråket 15, S-413 45 Gothenburg,
Published online October 30, 2019. Sweden (magdalena.taube@gu.se).

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 Research Original Investigation Association of Bariatric Surgery With Skin Cancer Incidence in Adults With Obesity

T
he incidence of malignant melanoma in fair-skinned
populations has increased steadily for decades, faster Key Points
than for any other cancer.1,2 Although the 5-year sur-
Question Is bariatric surgery associated with skin cancer
vival rate has improved during the same period partly incidence in patients with obesity?
because of the introduction of immunotherapy, in the United
Findings In this nonrandomized controlled trial of 4047
States only, the number of deaths from melanoma increased
participants in the Swedish Obese Subjects study, bariatric surgery
from 8650 in 2009 to an estimated 10 130 in 2016.3,4 Despite
was associated with reduced incidence of skin cancer, including
extensive research, a need still exists for increased under- melanoma.
standing of mechanisms and risk factors underlying
Meaning The findings suggest that bariatric surgery is associated
melanoma.
with a reduction in the incidence of skin cancer, including
Obesity is an established risk factor for several cancer
melanoma, in patients with obesity and that there may be an
types,5,6 but the association between obesity and melanoma is association between obesity and this cancer form.
inconclusive.7 Increasing evidence from human and murine
models suggests that obesity is a risk factor for squamous cell
carcinoma (SCC) and melanoma, the 2 most common skin can- sis. We identified participants who switched groups by using the
cer types.8,9 High consumption of fat may be associated with National Patient Register and SOS questionnaires (at baseline and
increased risk of SCC tumor, particularly in people with a his- follow-up visits). In the surgery per-protocol group (n = 2007),
tory of skin cancer.10 Obesity and skin pigmentation are geneti- participants underwent gastric bypass (n = 266), banding (n =
cally associated and share common susceptibility genes.8 Obese 376), or vertical banded gastroplasty (n = 1365). The control group
mice and mice with diet-induced obesity display larger mela-
noma tumors and higher rates of melanoma metastasis com- Figure 1. Trial Flow Diagram
pared with mice with normal body weights.8 Furthermore, fat
11 453 Standardized applications from potential
cells in deep skin layers secrete hormones, cytokines, chemo- participants sent to SOS
kines, free fatty acids, and other lipids, and these factors have
been suggested to be associated with skin tumor growth.9 2487 Not eligible
Bariatric surgery is the most effective treatment for sus-
tainable weight loss in patients with obesity, and it reduces the 8966 Fulfilled criteria
risk of morbidity and mortality.11-14 In addition, bariatric sur-
gery has been shown to reduce cancer risk in patients with 1373 Did not return questionnaire

obesity.15-17 In 2009, bariatric surgery was reported to be as-

sociated with reduced cancer incidence in the Swedish Obese 7593 Offered matching examination

Subjects (SOS) study.18 However, the low incidence of spe-

688 Did not attend matching
cific cancer diagnoses at that time made it impossible to draw examination
firm conclusions on skin cancer risk. With a median fol-
low-up time of 18.1 years, there are now sufficient numbers of 6905 Completed matching examination
skin cancer events. The aim of this study was to investigate the
association between bariatric surgery and skin cancer, includ- 1570 Not eligible or interested
ing melanoma.
5335 Selected from matching examination

1288 Not selected for matching

Methods
4047 Matched
Study Design and Treatment
This nonrandomized controlled trial, the SOS study, is an ongo-
ing, prospective, and matched intervention trial that compares
2010 Chose surgerya 2037 Chose nonsurgical treatmenta
bariatric surgery with conventional obesity treatment.13,19 The
trial flow diagram is presented in Figure 1, and details on study
2007 With vital status and cancer 2040 With vital status and cancer
design and recruitment are given in the eAppendix in the Supple- information information
ment. Patients were recruited to the SOS study between Septem- 2 Social Security number deleted 1 Died of myocardial infarction
on request
ber 1, 1987, and January 31, 2001. Data analysis was performed 1 Obtained secret Social Security
from June 29, 2018, to November 22, 2018. Seven regional eth- number
1 Health status unknown
ics review boards approved the SOS study protocol, and informed
consent (oral and written) was obtained from all participants.
2003 Included in final analysis 2039 Included in final analysis
A per-protocol approach was used in all analyses; thus, all
participants were included in their original study group until any
bariatric surgery was performed in the control group or there was SOS indicates Swedish Obese Subjects study.
a
a change in or removal of the bariatric surgical procedure in the Three patients switched from the surgery group to the nonsurgical treatment
group before surgery.
surgery group, after which they were censored from the analy-

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 Association of Bariatric Surgery With Skin Cancer Incidence in Adults With Obesity Original Investigation Research

(n = 2040) received the customary treatment for obesity at their

Figure 2. Cumulative Incidence of Skin Cancer in the Bariatric Surgery
primary health care centers. Inclusion criteria were age of 37 to and Control Groups
60 years and a body mass index (BMI) (calculated as weight in
kilograms divided by height in meters squared) greater than 38 0.020
Unadjusted SHR, 0.54; 95% CI, 0.33-0.90; P = .02
for women and greater than 34 for men. Exclusion criteria were 0.018
Adjusted SHR, 0.59; 95% CI, 0.35-0.99; P = .047
identical in the surgery and control groups and were minimal, 0.016

Cumulative Incidence
aimed at obtaining an operable surgical group. The intervention 0.014
Control (41 events)
began on the day of surgery for the surgically treated individual 0.012

and the matched control. Surgery and control participants un- 0.010

derwent a baseline examination approximately 4 weeks before 0.008

the start of the intervention. Thereafter, clinical examinations 0.006

Surgery (23 events)
were performed after 0.5, 1, 2, 3, 4, 6, 8, 10, 15, and 20 years. Cen- 0.004

tralized biochemical examinations were performed at matching 0.002

and baseline examinations and after 2, 10, 15, and 20 years. Ques- 0
0 2 4 6 8 10 12 14 16 18 20
tionnaires were completed at every clinical examination.
Follow-up Time, y
The primary end point of the study was overall mortality,13
and the secondary end points were diabetes,19 gallbladder Cumulative incidence function plots based on competing risk regression,
disease,20 and cardiovascular disease.14 The outcomes of the subhazard ratio (SHR), and adjusted SHR. Adjustments were made for sex, age,
current study, skin cancer incidence and melanoma inci- body mass index, smoking, and alcohol intake. The x-axis is truncated at 20
years, but observations after 20 years were included in the analyses.
dence, were not predefined end points.

Data Collection Figure 3. Cumulative Incidence of Malignant Melanoma

Baseline characteristics were obtained from the clinical exami- in the Bariatric Surgery and Control Groups
nation, questionnaires, and centralized blood chemical analy-
0.020
ses. Baseline alcohol intake was calculated from dietary ques- Unadjusted SHR, 0.40; 95% CI, 0.20-0.78; P = .007
0.018
tionnaires, as previously described.21 Smoking was defined as Adjusted SHR, 0.43; 95% CI, 0.21-0.87; P = .02
0.016
a positive answer to the question, “Do you smoke daily?” Data
Cumulative Incidence

on cancer incidence, death, and emigration were obtained by
cross-checking Social Security numbers from the SOS database
with the Swedish National Cancer Registry, the Cause of Death
Registry, and the Registry of the Total Population, respectively.
The Swedish National Cancer Registry has more than 95% cov-
erage for all tumors of which 99% are morphologically verified.22
To capture all skin tumor events in the cohort, codes 190 and 191
according to the International Classification of Diseases, Seventh
Revision (ICD-7) or codes 172 and 173 according to the Interna-
tional Classification of Diseases, Ninth Revision (ICD-9) were in-
cluded. No basal cell carcinomas were included in the study.
When melanoma skin tumors were analyzed separately, codes
190 (ICD-7) and 172 (ICD-9) were used. The cutoff date for the cur-
rent report was December 31, 2013.
Statistical Analysis
Data for all baseline characteristics are reported as mean (SD).
A 2-sided P≤.05 was considered to be statistically significant.
Statistical analyses were performed using Stata, version 12.1
(StataCorp). Cumulative incidence of skin cancer and inci-
dence of malignant melanoma were estimated with compet-
ing risk regression models in which deaths from causes other
than skin cancer or melanoma were treated as competing
events. The cumulative incidence functions are presented as
Figure 2 and Figure 3. The relative treatment effect in the bar-
iatric surgery group compared with the control group was
evaluated in a primary unadjusted analysis with a single co-
variate for the treatment group (surgery or control) and is ex-
pressed as a subhazard ratio from the competing risk regres-
sion. Calculation of the 95% CI for the number needed to treat
was based on the bootstrap method with 5000 replications of
0.014
Control (29 events)
0.012
0.010
0.008
0.006
0.004
Surgery (12 events)
0.002
0
0 2 4 6 8 10 12 14 16 18 20
Follow-up Time, y
Cumulative incidence function plots based on competing risk regression,
subhazard ratio (SHR), and adjusted SHR. Adjustments were made for sex, age,
body mass index, smoking, and alcohol intake. The x-axis is truncated at 20
years, but observations after 20 years were included in the analyses.
individuals sampled with replication. To assess the baseline
differences between the surgery and control groups, analy-
ses were adjusted for the following baseline confounders: sex,
age, BMI, alcohol, and smoking status. No adjustments were
made for multiple comparisons. In addition, sensitivity analy-
ses based on propensity score methods were conducted to
evaluate the effects of potential confounders.
In the interaction analysis, the incidence rates were cal-
culated in subgroups defined by risk factors at baseline. The
subgroups were based on insulin levels, blood glucose levels,
presence of diabetes, body weight, BMI, systolic and diastolic
blood pressure, serum triglyceride levels, serum high-
density lipoprotein cholesterol level, serum cholesterol level,
serum creatinine level, alcohol intake, and smoking status at
baseline. The association of bariatric surgery with the inci-
dence of cancer events was tested by including the correspond-
ing interaction term (ie, product of type of treatment [sur-

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 Research Original Investigation Association of Bariatric Surgery With Skin Cancer Incidence in Adults With Obesity

Table. Baseline Characteristics of the Swedish Obese Subjects Study Participantsa

Characteristic Control Group (n = 2040) Surgery Group (n = 2007) P Value

Female, No. (%) 1447 (70.9) 1420 (70.8) .92
Age, y 48.7 (6.3) 47.2 (5.9) <.001
Weight, kg 114.7 (16.5) 120.9 (16.6) <.001
BMI 40.1 (4.7) 42.4 (4.5) <.001
Sagittal diameter, cm 27.4 (3.7) 28.9 (3.7) <.001 Abbreviations: BMI, body mass index
(calculated as weight in kilograms
Blood glucose level, mg/dL 88 (32) 94 (36) <.001
divided by height in meters squared);
Serum insulin level, μIU/L 18.0 (11.4) 21.5 (13.7) <.001 HDL-C, high-density lipoprotein
Blood pressure, mm Hg cholesterol.
Systolic 137.9 (18.0) 145.0 (18.8) <.001 SI conversion factors: to convert
Diastolic 85.2 (10.7) 89.9 (11.1) <.001 glucose to millimoles per liter,
multiply by 0.0555; to convert insulin
Lipid levels, mg/dL
to picomoles per liter, multiply by
Total cholesterol 216 (42) 228 (42) <.001 6.945; to convert total cholesterol
HDL-C 50 (12) 54 (12) .84 and HDL-C to millimoles per liter,
Triglycerides 177 (124) 195 (133) <.001 multiply by 0.0259; and to convert
Alcohol consumption, g/d 5.3 (8.1) 5.2 (7.2) .63 triglycerides to millimoles per liter,
multiply by 0.0113.
Daily smoking, No. (%) 422 (20.8) 518 (25.8) <.001
a
Data are presented as mean (SD)
Diabetes at baseline, No. (%) 263 (12.9) 344 (17.2) <.001
unless otherwise indicated.

gery or control] and the corresponding continuous variable)
in the competing risk regression model.
Results
The study included 4047 participants (mean [SD] age, 47.9 [6.1]
years; 2867 [70.8%] female). The surgery group underwent gas-
tric bypass (265 [13.2%]), banding (376 [18.7%]), or vertical banded
gastroplasty (1369 [68.1%]). The control group received conven-
tional treatment for obesity at their primary health care center,
ranging from advanced lifestyle advice to no professional
treatment.23 The Table gives the baseline characteristics of the
2 groups. Patients in the surgery group were a mean of 1 year
younger than the patients in the control group, but the surgery
group had greater amounts of most other metabolic risk factors.
After bariatric surgery, the mean (SD) weight loss was 28.7 (14.3)
kg at the 2-year follow-up visit, 21.1 (15.1) kg at the 10-year follow-
up visit, and 21.6 (16.6) kg at the 15-year follow-up visit. The mean
(SD) weight changes in the control group were small and never
exceeded 3 kg in gain or loss (eFigure 1 in the Supplement). The
relative weight loss between the surgery and control group groups
was 23.7% (95% CI, 23.1%-24.3%) at year 2, 19.5% (95% CI, 18.5%-
20.4%) at year 10, and 18.9% (95% CI, 17.6%-20.2%) at year 15.
Information on cancer incidence was available for 4042 of the
4047 participants in the cohort. Median follow-up time was 18.1
years (interquartile range, 14.8-20.9 years; maximum, 26 years).
During the follow-up period, 16 SCC events and 29 mela-
noma events occurred in the control group and 11 SCC and
12 melanoma events in the surgery group. In a pooled analy-
sis, the first-time skin cancer events (SCC and melanoma com-
bined) in the 2 groups were analyzed. The incidence rates for
skin cancer were 1.2 per 1000 person-years (95% CI, 0.9-1.6 per
1000 person-years) in the control group and 0.7 per 1000 per-
son-years (95% CI, 0.4-1.0 per 1000 person-years) in the sur-
gery group (Figure 2). The subhazard ratio with surgery was
0.59 (95% CI, 0.35-0.99; P = .047) compared with the control
group after adjusting for sex, age, BMI, smoking, and alcohol
intake. The unadjusted hazard ratio for SCC with surgery was
0.65 (95% CI, 0.30-1.39), but this finding was not statistically
significant (eFigure 2 in the Supplement). On the basis of 29
malignant melanoma events in the control group and 12 in the
surgery group, the incidence rates were 0.8 per 1000 person-
years (95% CI, 0.6-1.2 per 1000 person-years) in the control
group and 0.3 per 1000 person-years (95% CI, 0.2-0.6 per 1000
person-years) in the surgery group (Figure 3). The adjusted sub-
hazard ratio between the surgery and control groups was 0.43
(95% CI, 0.21-0.87; P = .02). The number needed to treat to pre-
vent 1 malignant melanoma event during 20 years with bar-
iatric surgery was 106 (95% CI, 54-440). A total of 655 deaths
(16.2%) among the 4047 study participants were treated as
competing events in the analyses of skin cancer and mela-
noma. Results remained essentially unchanged after analy-
ses based on different propensity score adjustments and match-
ing (eTable 1 in the Supplement). In patients with melanoma,
the number of deaths attributed to melanoma was 7 in the con-
trol group and 2 in the surgery group.
When we stratified the analysis by sex, 22 women with mela-
noma were in the control group and 9 women with melanoma
were in the surgery group (hazard ratio, 0.38; 95% CI, 0.18-0.83;
P = .02). In addition, 7 men with melanoma were in the control
group and 3 men with melanoma were in the surgery group (haz-
ard ratio, 0.41; 95% CI, 0.10-1.60; P = .20). No differences were
found in the surgical treatment benefit between the subgroups
by baseline BMI, body weight, insulin level, blood glucose level,
presence of diabetes, systolic or diastolic blood pressure, serum
triglyceride levels, serum high-density lipoprotein cholesterol
level, serum cholesterol level, serum creatinine level, alcohol in-
take, or smoking (eTable 2 in the Supplement).
Discussion
These findings suggest that bariatric surgery is associated with
reduced incidence of skin cancer (SCC and melanoma com-
bined) and melanoma in individuals with obesity. However,

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 Association of Bariatric Surgery With Skin Cancer Incidence in Adults With Obesity Original Investigation Research

bariatric surgery should not be viewed as a public health in-
tervention specific to skin cancer. Instead, these findings give
additional support for an association between obesity and skin
cancer and for an association between weight loss and re-
duced cancer incidence.
Of importance, baseline BMI was not associated with the
preventive effect of bariatric surgery on skin cancer inci-
dence. It is possible that the reduced skin cancer risk after sur-
gery is associated with altered metabolic or endocrine pro-
cesses after bariatric surgery. In line with this possibility, a
previous study24 found that baseline insulin levels are asso-
ciated with reduced cancer incidence in women after bariat-
ric surgery. Moreover, bariatric surgery may reduce circulat-
ing cancer-associated biomarkers related to inflammation, cell
proliferation, and angiogenesis.25
Well-described risk factors for melanoma include fair skin,
hair, and eye color; UV exposure; and family history of skin
cancer.26-28 Melanoma is more common in white people than
in African American people because of the fair skin risk factor.29
The sun-protective effect of melanin in dark skin likely medi-
ates the lower incidence in African American people. How-
ever, the relative risk of melanoma is greater in obese vs non-
obese African American men (relative risk, 2.39) compared with
the relative risk in obese vs nonobese white men (relative risk,
1.29) according to data from a large cohort of US military
veterans.30 Thus, the relative melanoma risk in African Ameri-
can veterans with regard to obesity is similar in magnitude to
the risk associated with a family history of melanoma.26,31 Rel-
evant to our study, these results suggest that mechanisms be-
sides sun exposure mediate the increased risk of melanoma
in people with obesity.
There are several potential factors that could explain the
association among obesity, weight loss, and melanoma.32 For
example, the metabolic hormone leptin is upregulated in obe-
sity and is associated with lymph node metastasis in patients
with melanoma,33 and melanoma cells, but not melanocytes,
express the leptin receptor.34 Obesity leads to chronic sys-
temic inflammation, which could provide a permissive envi-
ronment for tumor growth.35 In addition, α-melanocyte–
stimulating hormone, which is involved in energy homeostasis
and skin pigmentation, reduces the expression of adhesion
molecules on melanoma cells that normally stimulates im-
mune cell interactions and thereby reduces the ability of the
immune system to detect tumor cells.36 Other factors that may
be associated with melanoma incidence are changes in life-
style, such as increased physical activity, or changes in diet af-
ter surgery. Obesity is associated with sedentary lifestyle, and
prolonged sedentary time has been associated with in-
creased cancer incidence and mortality.37 Bariatric surgery al-
ters gastrointestinal anatomic features and leads to neuro-
logic and physiologic changes associated with hypothalamic
signaling, gut hormones, bile acids, and gut microbiota. These
changes lead to modifications in eating behavior and food pref-
erence, and patients reportedly prefer lower-calorie foods af-
ter gastric bypass surgery.38 Further research should focus on
distinguishing among the aforementioned factors.
Strengths and Limitations
The strengths of the SOS study include its prospective de-
sign, matched control group, long follow-up time, and the pos-
sibility of obtaining information from comprehensive na-
tional registers. However, the study also has limitations. For
example, the high mortality after bariatric surgery in the 1980s
made randomization unethical. However, the performed sen-
sitivity analyses (ie, the propensity score–adjusted analysis and
the quantification of the possibility of unmeasured confound-
ing) confirm the robustness of the results. In addition, be-
cause skin cancer and melanoma incidences were not pre-
defined end points, the study was not specifically designed to
address the current research question. A large randomized clini-
cal trial with long-term follow-up that is designed to examine
melanoma incidence as a primary end point would be opti-
mal. However, it is questionable whether such a study would
be ethical because bariatric surgery is associated with re-
duced risk of several other serious outcomes, including car-
diovascular events and type 2 diabetes.12,14
Conclusions
The global obesity epidemic has been accompanied by in-
creased incidences of many serious diseases, including can-
cer. These findings suggest that melanoma incidence is sig-
nificantly reduced in patients with obesity after bariatric
surgery and may lead to a better understanding of melanoma
and preventable risk factors.

ARTICLE INFORMATION
Accepted for Publication: August 26, 2019.
Published Online: October 30, 2019.
doi:10.1001/jamadermatol.2019.3240
Author Affiliations: Department of Molecular and
Clinical Medicine, Institute of Medicine, Sahlgrenska
Academy, University of Gothenburg, Gothenburg,
Sweden (Taube, Sjöholm, Anveden,
Andersson-Assarsson, Jacobson, Svensson,
Carlsson); Department of Chronic Disease
Prevention, National Institute of Health and
Welfare, Helsinki, Finland (Peltonen); Department
of Surgery, Hallands Hospital, Halmstad, Sweden
(Anveden); Institute of Health and Care Sciences,
Sahlgrenska Academy, University of Gothenburg,
Gothenburg, Sweden (Svensson); Department of
Biosciences and nutrition, Karolinska Institutet,
Huddinge, Sweden (Bergo); Institute of Medicine,
Sahlgrenska Cancer Center, Department of
Molecular and Clinical Medicine, Sahlgrenska
Academy, University of Gothenburg, Gothenburg,
Sweden (Bergo).
Author Contributions: Dr Taube 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.
Concept and design: Taube, Peltonen, Anveden,
Carlsson.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Taube.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Peltonen.
Obtained funding: Sjöholm, Carlsson.
Administrative, technical, or material support:
Taube, Sjöholm, Andersson-Assarsson, Jacobson,
Svensson, Bergo, Carlsson.
Supervision: Taube, Svensson, Carlsson.
Conflict of Interest Disclosures: Dr Bergo reported
receiving personal fees from Baxter Medical and
LEO Pharma outside the submitted work.
Dr Carlsson reported receiving personal fees from
AstraZeneca, Johnson & Johnson, and Merck Sharp
& Dohme during the conduct of the study. No other
disclosures were reported.
Funding/Support: This work was supported by
grant R01DK105948 (Dr Carlsson) from the US

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 Research Original Investigation
National Institute of Diabetes and Digestive and
Kidney Diseases of the National Institutes of Health,
grant 2017-01707 (Dr Carlsson) from the Swedish
Research Council, grants from the Swedish state
under the agreement between the Swedish
government and the county councils, ALF
agreement ALFGBG-717881, and the Swedish
Diabetes Foundation.
Role of the Funder/Sponsor: The funding source
had no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and the decision to
submit the manuscript for publication.
Disclaimer: The content is solely the responsibility
of the authors and does not necessarily represent
the official views of the National Institutes of
Health.
Additional Contributions: Christina Torefalk and
Björn Henning provided administrative support. We
thank the Swedish Obese Subjects (SOS) study
patients and staff members at 480 primary health
care centers and 25 surgical departments in
Sweden at which the SOS study was conducted.
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