Bariatric or weight loss surgery should be considered earlier in treatment of eligible patients to stem complications that can result from type 2 diabetes, experts say.
Bariatric (weight loss) surgery should be considered earlier in the treatment of eligible patients to help stem the serious complications that can result from diabetes according to an International Diabetes Federation (IDF) position statement presented by leading experts at the 2nd World Congress on Interventional Therapies for Type 2 Diabetes in New York.
The statement was written by 20 leading experts in diabetes and bariatric surgery who have made a series of recommendations on the use of weight loss surgery as a cost effective treatment option for severely obese people with type 2 diabetes.
The combination of obesity and type 2 diabetes is looming as the biggest epidemic and public health issue in human history. Type 2 diabetes is one of the fastest growing diseases today with close to 300 million people affected worldwide and 450 million people forecast to have diabetes by 2030.
According to the statement there is increasing evidence that the health of obese people with type 2 diabetes, including their glucose control and other obesity related comorbidities (conditions), can benefit substantially from bariatric surgery under certain circumstances.
'Health and cost-effective therapy'
The IDF’s Taskforce on Epidemiology and Prevention of Diabetes convened the expert group with specific goals to:
• Develop practical recommendations for clinicians on patient selection and management
• Identify barriers to surgical access
• Suggest health policies that ensure equitable access to surgery
• Identify priorities for research
Co-chairperson, Professor Sir George Alberti, Senior Research Investigator, Imperial College, London, said: “Bariatric intervention is a health and cost effective therapy for type 2 diabetes and obesity with an acceptable safety profile. Bariatric surgery for severely obese people with type 2 diabetes should be considered much earlier in management rather than held back as a last resort. It should be incorporated into type 2 diabetes treatment protocols.” He also pointed out that the cut-points for action may be lower in Asian populations because of their increased risk of diabetes and heart disease.
Professor Paul Zimmet AO, Director Emeritus, Baker IDI Heart and Diabetes Institute, Melbourne and co-chairperson, said: “Bariatric surgery is a treatment that can be recommended for people with type 2 diabetes and obesity not achieving recommended treatment targets with existing medical therapies, especially when there are other major co-morbidities such as hypertension, high cholesterol or sleep apnoea. Surgery should be an accepted option in people who have type 2 diabetes and a body mass index (BMI) of 35 or more. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment prior to surgery and on-going care as well. ”
'Urgent need for world expert guidance'
Professor Francesco Rubino, Chief of the Gastrointestinal Metabolic Surgery Program at New York-Presbyterian Hospital/Weill Cornell Medical Center and Director of the 2nd World Congress on Interventional Therapies for Type 2 Diabetes said: “This is the first time the International Diabetes Federation or any major international organisation has made recommendations on this rapidly developing area of therapy. It did so because of the urgent need for world-wide expert guidance on the use of bariatric surgery because of the increasing usage. We note the need to establish appropriate measures in education and selection of patients and safe and standardised surgical procedures. Long-term follow up after surgery is essential.”
Professor John Dixon, Head of Obesity Research Unit, Department of General Practice, Monash University, Melbourne, said: “It is very important for health authorities and policy makers to understand that almost all severely obese patients cannot achieve and maintain significant weight loss. They should be treated where appropriate with bariatric surgery which can lead to remission of diabetes in up to 80% of patients. National guidelines and registers for bariatric surgery need to be developed and implemented for people with type 2 diabetes.”
The expert group warns the situation in low and middle income nations presents special problems because severe obesity is increasing at an alarming rate. As health care resources are limited, bariatric surgery should only be performed where the health budget can afford it, and that the expertise is available for both the surgery and the long-term follow up.
Weight loss surgery effective for type 2 diabetes
Several small trials have found greater weight loss and type 2 diabetes remission after bariatric surgeries compared to nonsurgical methods.
More than 20 years of evidence suggests that bariatric surgery produces greater weight loss and more type 2 diabetes remissions than nonsurgical treatments for the obese, according to a review.
Bariatric surgeries more routine
The results, from a National Institutes of Health (NIH) symposium held last year, support the idea that weight loss surgeries are effective and safe, at least within the first two to five years after surgery. But more studies of long term effects are needed, the authors say.
The NIH last held a consensus panel on the issue in 1991. Since then, bariatric surgeries have become much more routine and more small clinical trials and large observational studies on the outcomes of surgery have been done.
In a new clinical review in JAMA Surgery, experts from the National Institute of Diabetes and Digestive and Kidney Diseases and the National Heart, Lung, and Blood Institute at the NIH in Bethesda, Maryland, as well as the Group Health Cooperative in Seattle and the University of Pittsburgh Medical Centre summarise the evidence since 1991.
Several small trials have found greater weight loss and type 2 diabetes remission after bariatric surgeries compared to nonsurgical methods like dieting and behavioural therapies, they write.
Most bariatric surgeries are only approved for patients who have failed to lose significant weight with diet and exercise.
People who get the surgery tend to lose around 20 to 30 percent of their body weight in the following years, compared to little or no weight loss for similar people who do not get the surgery, according to recent long-term studies.
But there are still gaps in bariatric surgery research, the authors point out.
More studies are needed to determine how long type 2 diabetes remission lasts, to assess how often complications occur from surgery and what predicts those complications, and to measure long-term health outcomes, they write.
Common complications include hypoglycaemia, nausea or vomiting and insufficient weight loss, according to the authors.
There should also be more research into optimal dietary and nutritional management following bariatric procedures, as well as how to manage specific complications of bariatric operations. Much more evidence
In 1991, the consensus panel concluded that Roux-en-Y gastric bypass and vertical banded gastroplasty procedures were safe and effective for people with a body mass index (BMI) of 40 or more, or with a BMI of 35 or more in addition to serious medical problems like diabetes, coronary heart disease, sleep apnoea, high blood pressure or severe arthritis.
Whether or not it was meant as such, that consensus became "gospel" for doctors, hospitals and insurers, who to this day rarely agree to cover the surgery for people who do not meet those criteria, said Dr. Justin B. Dimick, chief of minimally invasive surgery at the University of Michigan in Ann Arbor.
"The evidence base then was pretty weak," he said. "Now we have much more evidence, but it's not being brought to bear on decision making."
Studies now suggest that bariatric surgery may be the best option for reversing type 2 diabetes for people with a BMI as low as 30, but the new consensus panel did not revise their 1991 guideline in this regard, he said.
"The relationship between BMI and mortality is not as strong as we thought it was, but between type 2 diabetes and death, it is," Dimick said. "A lot of people with a BMI of 40 are fairly healthy, but others are at a BMI of 33 and have type 2 diabetes and are at greater risk."
Gastric sleeve surgery
Dimick was not involved in the new review, but coauthored an accompanying editorial in JAMA.
Today, lap band surgery, in which an adjustable device is placed over the top portion of the stomach, has dropped off in popularity due to long-term complications, erosion and poor weight-loss results, Dimick said.
The most common option now is gastric sleeve surgery, in which much of the stomach is removed and the remainder is stapled into a small sleeve. The gastric sleeve procedure itself carries more risks but has had fewer long-term complications, Dimick said.
The authors do state that bariatric surgical techniques and their short-term outcomes have improved greatly since 1991.
"In general what we have learned in the last five years is it is very safe and extraordinarily effective when you compare it to nonsurgical options like diet and behavioural therapy," Dimick told Reuters Health.