Diabetes and Bariatric Surgery
When bariatric surgeons first identified weight loss surgery as a cure for type 2 diabetes, many argued the claims were “too good to be true.” We now have evidence from prospective randomized clinical trials demonstrating significantly greater improvement and even resolution of type 2 diabetes with surgery compared to medical therapies. The realization that bariatric surgery treats not only obesity, but also type 2 diabetes and other metabolic conditions, was so significant that the American Society of Bariatric Surgery (ASBS) changed their name to the American Society of Metabolic and Bariatric surgery (ASMBS) in 2007.
Despite the medical evidence that obesity is a disease, many medical professionals and laypeople alike continue to harbor negative stereotypes and implicit bias that prevent patients with obesity from receiving evidence-based care for their disease. Recognizing that diabetes and other medical conditions are directly related to obesity has led to the understanding that bariatric surgery is not a cosmetic procedure; rather, it is medically indicated.
Evidence supporting bariatric surgery for patients with diabetes
Today we know that Type 2 diabetes resolves or is improved in the majority of patients who undergo bariatric surgery. There are hormonal changes that occur on the day of surgery, before any weight loss has occurred, that can immediately improve glycemic control. Thus, it seems the stomach does more than just signal hunger. It also modulates the balance between insulin and glucagon and their role in blood sugar control through a complex pathway that involves other hormones such as GLP-1, Ghrelin, and peptide YY. While the exact mechanism is not known, scientists suspect a hormonal pathway modified by bariatric surgery promotes resolution of diabetes independent of weight loss.
Bariatric surgeons and patients celebrate not only weight loss, but also the resolution of obesity-associated medical problems after surgery. Measurement of blood sugar and laboratory testing of hemoglobin A1c and glucose tolerance testing provide evidence of some of these benefits. Multiple studies have confirmed these findings; two of these are described here:
The Swedish Obese Subject study followed more than 2000 severely obese patients electing to have bariatric surgery and compared them with well-matched controls at 2 and 10 years after surgery. These data established the effectiveness of bariatric surgery in prevention and remission of Type 2 diabetes.
Another notable study, performed by Philip Schauer et al, is the STAMPEDE trial. Researchers randomized patients with uncontrolled Type 2 diabetes into one of two groups: intensive medical therapy alone or intensive medical therapy plus bariatric surgery. Those who had bariatric surgery were much more likely to experience resolution of diabetes than those who did not have surgery.
Based on data such as these, the American Diabetes Association now recommends consideration of bariatric surgery for patients with BMI<35 who have diabetes. However, insurance policies do not routinely cover bariatric surgery for these patients.
In our next #obsm chat, we look forward to discussing these and other facts about bariatric surgery and diabetes. While there is a lot of informations on this topic, there remains much more to learn. We will discuss scientific data on the efficacy of bariatric surgery for patients with diabetes as well as strategies to increase the number of patients with diabetes we can help. The chat will take place June 11 at 9 pm EST, and we will discuss the following topics:
What are some of the misconceptions about #BariatricSurgery and diabetes?
What is the mechanism of improvement or resolution of diabetes after #BariatricSurgery?
Which surgical option affords the highest likelihood of resolution of diabetes? Why? What are the negative consequences? In what ways can we help more patients with diabetes get #BariatricSurgery? What are the barriers?
What is the best care for patients with diabetes whose BMI is between 30 and 35?
What other topics would you like to see discussed in the #obsm forum? What comments/feedback do you have about how the chats are run?
#OBSM Tweetchat Group
Neil Floch, MD
Amir Ghaferi, MD, MS
Heather Logghe, MD
Babak Moein, MD
Arghavan Salles, MD, PhD