Hyperinsulemia

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her hyperinsulemia/insulin resistance is not but her type 2 diabetes is.  hyperinsulemia/insulin resistance both promote weihgt gain and make weight loss very difficult.  the insulin is less  capable of metabolizing glucose, the body produces more insulin in an effort to metabolize the increasing blood sugar, the excess insulin results in hyperinsulinism.  there comes a time when sufficient weight is gained so the combination of ins. resist. exceed the ability of the pancreas to respond w/adequate insulin secretion=type 2 diabetes.  a 50 g/day CHO would help this woman greatly.

a bmi of 40 does not need any co-morbs to qualify for WLS, per NIH  (the specific insurance co. can add to that)  To decide what kind of WLS, there are many factors, age, gender, overall health etc.  but do keep in mind DS, due to the intestinal bypass and when food is presented,  has a very high diabetes CURE rate (in the high 90s% depending on source)  this is something to really think about.  good luck to you and your friend...

I'm not sure if it is considered a co-morbidity. If she has insulin resistance (hyperinsulemia) restriction will not be enough, that is a metabolic problem which is not well understood and at the present time has no "cure". Insulin is also a fat storage hormone, so you can imagine what an excess of it will do. If metformin hasn't brought her insulin levels down, there are a few other drugs to try if she wants to exhaust all options before going under the knife.

I tried metformin and byetta to get my insulin levels down (I have IR, amongst other things but I didn't have the hunger that your friend has), neither did squat for bringing my insulin levels or the weight down. Nor did years of strict dieting and exercise.

Let me tell you, it is not fun injecting yourself with "lizard spit" (the affectionate moniker for Byetta, its synthetic gila monster spit enzyme) twice a day for a year and a half only to see no results beyond nausea so bad you can't eat.

She qualifies for wls based solely on her bmi of 43. However, given that she seems to have a metabolic problem, the sleeve isn't a great choice for her as it won't fix that problem, while the DS will. She needs to think this through some more.
     Also, while Medicare does cover the DS, I don't think it covers the sleeve, unless this has changed in recent months (I might not be up to date on this). But really, the DS would be a better choice for her regardless of coverage.

Larra

The sleeve WILL NOT BE ENOUGH. I cannot stress this too strongly. If she has that package of metabolic problems, she needs the DS.

For Medicare the BMI of 43 qualifies her for any surgery without additional comorbidities.

I started with a BMI of 51, and I have a host of autoimmune and metabolic issues.  I have insulin resistance although my sugars and A1C only put me in the 'pre-diabetic' category rather than full-blown type 2. My A1C was 6.1, fasting sugar 100 before I started my pre-op diet.   I also have Graves' Disease and I have been on a full-replacement dose of Levoxyl (thyroid hormone) for 17 years since having Radioactive Iodine treatments to shut down my thyroid.  I have done long courses of high-dose steroids -- 60-80mg of prednisone a day for periods ranging from 6 months to a year before tapering down to control severe Graves Eye Disease and  Pre-tibial Myxedema (two of the other three Graves's related autoimmune disorders). I have the 'Elephantistic' form of PTM which severely limited my mobility when I was at my highest weight, far less so now.

Despite that,  I have lost 87% of my excess weight post-op with the sleeve in 8 1/2 months in addition to the 32 I lost preop. I am targeting  100% EWL at by 1 year post-op. It can be done, but there's no doubt DS is better suited to significant metabolic disorders than the sleeve alone.  I would advise somone in my same situation  to have DS rather than the sleeve, generally. I had my reasons for going VSG, only, but that doesn't mean my (informed)  personal choice is the right choice for everyone.      
 

Whoa, that's a really tough list of metabolic and health complications. I'm glad to hear that you're doing well and have lost so much weight, it sounds like you've had a much bumpier road than most. Cheers!

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