Is Weight Loss Surgery the Best Currently Available Treatment for Type 2 Diabetes?

Today almost 26 million Americans have Type 2 Diabetes and the Center for Disease Control (CDC) estimates that as many as 1 in 3 U.S. adults could have diabetes by 2050 if current trends continue.

The risk for death among people with diabetes is about twice that of people of similar age without diabetes and is projected to rise by more than 50% in the next 10 years.

Diabetes is the Leading Cause for:

• Kidney failure
• Nontraumatic lower limb amputations
• New cases of blindness
• A major cause of heart disease and stroke

What is Type 2 Diabetes?

Type 2 Diabetes results from the body’s ineffective use of insulin, which helps glucose enter the body’s cells to provide energy, and accounts for 90% to 95% of cases. Risk factors for Type 2 Diabetes include older age, obesity, family history, having diabetes while pregnant, a sedentary lifestyle and race/ethnicity. While not everyone who has the disease is overweight, the emerging global epidemic of diabetes can be traced back to rapid increases in overweight, obesity, and physical inactivity.

Lifestyle changes, such as losing 5 to 10 percent of body weight and exercising regularly, are often the first treatments suggested but many people find it difficult to make permanent lifestyle changes on their own. Oral medications are commonly used for treatment, but these often fail to control Type 2 Diabetes adequately, necessitating the use of injected insulin.

Surgeons noted that weight loss surgery had an effect on blood sugar control decades ago but it wasn’t until more recently that compelling evidence documenting this effect accumulated.

Several recent systematic reviews of the published literature on patient outcomes have demonstrated that the resolution of Type 2 Diabetes after weight loss surgery reaches 80- 90%!

This means that the majority of diabetic patients do not have to take medications after surgery to control their disease and their blood sugars normalize. This profound effect of weight loss surgery on diabetes has brought significant enthusiasm among physicians and has led to the renaming of the American Society of Bariatric Surgery to the American Society of Metabolic and Bariatric Surgery and the introduction of the term metabolic surgery.

Weight Loss Surgery and Diabetes

While the mechanism of diabetes resolution after weight loss surgery is associated with the ensuing profound and long lasting weight loss, hormonal factors not fully elucidated at the present time are also at play. This has become clear based on basic science research but also on clinical experience. The type of bariatric procedure appears to be one of the main factors that affect diabetes resolution. Laparoscopic Roux-en-Y Gastric Bypass leads to diabetes resolution early after surgery in many patients before significant weight loss has set in. The procedure effectively bypasses the first part of the small intestine (duodenum) which does not “see” food any longer, leading to hormonal changes that affect insulin secretion and sensitivity. Other common bariatric procedures such as the sleeve gastrectomy or adjustable gastric band also lead to improvement of diabetes but have been shown to be less effective than the gastric bypass.

Besides the type of bariatric procedure, however, other determinants of diabetes resolution after surgery include the length of time the disease has been present and the amount of treatment it requires. In other words, the longer diabetes has been manifest and the more medications are required to control it the less likely its resolution becomes after surgery. Still, the majority of patients benefit from metabolic surgery which represents the only currently available cure for diabetes.

It should be noted that metabolic surgery is associated with some risks which need to be taken into account by diabetic patients and need to be balanced with the anticipated benefits. Nevertheless, recent data demonstrated that the risks of laparoscopic bariatric surgery are no different than other commonly performed low-risk procedures such as laparoscopic cholecystectomy which makes metabolic surgery by experienced surgeons a very attractive option. It is also important to mention that while the benefits of metabolic surgery on diabetes appear to extend beyond the obese patient, the vast majority of eligible patients currently have a BMI>35. Finally, appropriate lifestyle modifications that include exercise and healthy diet on the part of the patient are an essential companion to surgery for the long term success of patients.

In conclusion, bariatric / metabolic surgery provides the only reliable chance for cure of Type 2 Diabetes and should be considered in the treatment algorithm of the diabetic patient especially if obese.

Feature image credit: Jill Brown cc

ABOUT THE AUTHOR Dr. Dimitrios Stefanidis, MD, PhD FACS, FASMBS, is fellowship trained in minimally invasive, advanced laparoscopic and bariatric surgery. He specializes in laparoscopic weight loss surgery and laparoscopic general surgery. Dr. Stefanidis has a special interest in simulation and teaching of advanced laparoscopic techniques and is the medical director of the Carolinas Simulation Center. He is a member of the American College of Surgeons, American Society for Metabolic and Bariatric Surgery and the Society of American Gastrointestinal and Endoscopic Surgeons.