Some people with Type 2 diabetes can put their medicine aside.
Of the types of weight-loss surgery, gastric bypass typically has the most powerful effect.
By Lisa Esposito
For Arnoldo Gutierrez, 59, the priority for weight-loss surgery was getting his “horrendous” diabetes under control. The Aspermont, Texas, veterinarian took pills three times a day and an insulin injection each evening – but his blood sugar levels remained high. At 5 feet 9 inches and a peak weight of 267 pounds, he was at the low end of the scale for severe obesity.
In September, Gutierrez had a vertical sleeve gastrectomy, in which a large portion of the stomach is removed, leaving the rest as a tube or sleeve-shaped section, and his weight has since dropped to 187 pounds. He calls his results “fantastic” – especially in terms of his diabetes. “I have no medication,” he says. “Zero. Nada.”
Shedding Diabetes and Pounds
The U.S. is in the midst of twin epidemics – obesity and diabetes – according to the American Society for Metabolic and Bariatric Surgery. Obesity is a major risk factor for developing diabetes, and more than 90 percent of Type 2 diabetics are overweight or obese, according to the ASMBS.
Some obese people who have weight-loss (or bariatric) surgery see their diabetes disappear. Their blood sugar normalizes, and they no longer need medication to control it. Whether the diabetes-free benefit lasts forever, though, remains to be seen.
Weight-loss surgery performed today is safe, effective – and underused, says Stacy Brethauer, a bariatric surgeon at the Cleveland Clinic Bariatric and Metabolic Institute. “Only 1 percent of patients who are currently eligible to receive bariatric surgery based on their weight are receiving the therapy,” he says.
“Weight loss and particularly massive weight loss has a really powerful effect on diabetes improvement,” Brethauer says. But, he adds, there’s something about the surgery in itself that undermines diabetes, independent of the effect of reducing pounds.
Of weight-loss procedures, he says, gastric bypass has the most powerful effect. As the flow of nutrients is rerouted in the body, changes occur in the gut hormones that stimulate the pancreas, with shifts in hunger and satiety control. “We see improvement in the diabetes earlier than the weight loss in many of these patients,” he says.
Benefits Beyond Weight Loss
Bharati Desai, 66, a retired anesthesiologist in Richfield, Ohio, had gastric bypass surgery six years ago. Her health was “not good,” she says, with high blood pressure, high cholesterol, sleep apnea and thyroid trouble. But it was the diabetes that swayed her. “I decided I didn’t want to be on insulin and the weight loss would be good for me,” she says.
Her diabetes “went away on the fourth day after surgery,” Desai says. Her previously high hemoglobin A1C – a measure of blood glucose control – normalized, and she went completely off her diabetes medications. Overall, her health gradually improved as she lost 70 pounds, with dosages of her blood pressure and cholesterol medicine sharply reduced. And her sleep apnea went away.
Remission or Cure?
In the diabetes arena, partial remission means the patient’s blood sugar stays at "pre-diabetes" level, without medication, for at least a year. Complete remission mean blood sugar stays normal under those conditions. Prolonged remission – the closest thing to a cure – involves complete remission for at least five years.
Last year, Brethauer led a study on the long-term effects of weight-loss surgery on patients with Type 2 diabetes. Of the 217 patients followed for at least five years, nearly one-quarter had complete remission of their diabetes and another quarter had partial remission. A Swedish study of 343 patients published in June found a 72 percent remission rate after two years – which dropped to 30 percent at 15 years after surgery.
Similar studies also suggest weight-loss surgery can help treat hard-to-control diabetes in some obese patients. But experts say more long-term, randomized controlled studies are needed. Brethauer would like to see research on surgery for diabetic patients who are only moderately overweight, or even normal weight.
His latest research, released at a recent conference, shows risks for gastric bypass surgery among patients with diabetes are similar to those for common procedures such as gallbladder surgery and knee replacement.
Lifestyle and Medicine First
Diabetes expert Jeffrey Mechanick, immediate past president of the American Association of Clinical Endocrinologists, agrees there’s a role for weight-loss surgery in moderate obesity, with “a bona fide obesity-related complication” like diabetes. “You would consider surgery – there’s never a ‘must,'" he says. That consideration is in order "for a patient that’s failing lifestyle management and pharmacotherapy.”
If intensive treatment isn’t working, or if a patient’s behavior is an issue and the A1C level is “sky high,” it might be time to discuss surgery, says Mechanick, who is also director of metabolic support in the division of endocrinology at the Icahn School of Medicine at Mount Sinai. “You’re just not making a dent" in such cases. "You’re giving more and more insulin; [patients are] more and more insulin resistant. They’re not adherent [to treatment].” When doctors sees other risk factors such as high blood pressure, cholesterol problems and vascular disease worsening, he says, they don’t need to wait forever.
But first, Mechanick says, doctors should approach obesity more holistically, including addressing behavioral issues and diet, understanding the risks and benefits of surgery and other treatments, and being well-versed in medications such as the recently approved obesity drugs Qsymia, Belviq and Contrave.
“You can see a lot of patients are falling through the cracks and a lot of physicians are saying, ‘Ah, the only thing I’ve got left is bariatric surgery,’” he says. But in the view of endocrinologists, Mechanick says, "there’s short shrift being dealt to lifestyle and pharmacotherapy that can be used more intensely and more appropriately.”
Gutierrez is a repeat customer. In 2007, he had a lap band placement that shows some of the downsides of weight-loss surgery. “My life was a wreck,” he says. Eating became a nightmare. “I didn’t know if I was going to choke or if I was going to vomit, or something else.”
This time around, Gutierrez did a lot more research. He went to Lubbock, Texas, bariatric surgeon David Syn, who removed the lap band while performing the sleeve gastrectomy. Now, Gutierrez is “ecstatic” with the results. He eats what he wants, just less than he used to. “Being so heavy, it’s not easy to get around the corrals and work with large animals, with cattle,” he says. That’s much easier these days, along with indulging his passion for riding horses. And as long as his blood sugar holds steady, he’s happy to be diabetes free.