Which Obese type 2 diabetes should be considered for Bariatric Surgery ?
- Surgery should also be considered as an option in persons with BMI 30 to 35 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors
- In Asian, and some other ethnicities of increased risk, BMI action points may be lower e.g. BMI 27.5 to 32.5
Bariatric surgery for Obese Adolescents with type 2 diabetes
- Bariatric surgery be considered if adolescents have BMI >40 , or >35 with severe co-morbidities, are 15 years or over & can provide informed consent
Obesity and Type 2 diabetes are serious chronic diseases associated with complex metabolic dysfunctions that increase the risk for morbidity and mortality
1- The dramatic rise in the prevalence of obesity and diabetes has become a major global public health issue and demands urgent attention.
2- Faced with the escalating global diabetes crisis, healthcare providers require as potent an armamentarium of therapeutic interventions as possible.
3- In addition to behavioural and medical approaches, various types of surgery on the gastrointestinal tract, originally developed to treat morbid obesity (‘bariatric surgery’), constitute powerful options to ameliorate diabetes in severely obese patients, often normalizing blood glucose levels, reducing or avoiding the need for medications and providing a potentially cost-effective approach to treating the disease.
* How is Metabolic / Bariatric Surgery defined:
Alteration of the gastrointestinal tract that affects cellular and molecular signaling leading to a physiologic improvement in energy balance, nutrient utilization and metabolic disorders.
* Why consider bariatric surgery?
Both insulin resistance and insulin secretory reserve are important in the pathogenesis of Type 2 diabetes , but to different extents in different people. It is very important to recognize that not all Type 2 diabetes is the same and it is currently difficult to match the different therapies available to different phenotypes often resulting to suboptimal responses to therapy.
Type 2 diabetes is a progressive disease and the usual natural history is of progressive loss of insulin secretory capacity over time and the need for intensification of therapy and polypharmacy. Arresting this progression is a formidable therapeutic challenge. Treatment for Type 2 diabetes must also include active management of all cardiovascular risk factors (hypertension, dyslipidaemia, smoking and inactivity) but glycaemic control is very important—and not just for prevention of microvascular disease. Years of improved glycaemic control continue to deliver reduced risk of macrovascular disease and mortality over subsequent years.
* Bariatric surgery and Type 2 diabetes
Bariatric procedures aim to reduce weight and maintain weight loss through altering energy balance, primarily by reducing food intake and modifying the physiological changes that drive weight regain. There also appear to be independent metabolic benefits, associated with effects of incretins and possibly other hormonal or neural changes after some surgical procedures , in addition to weight loss. For example, rapid and sustained improvements in glycaemic control can be achieved within days of gastric bypass surgery, before any significant weight loss is eviden.
Various Studies to Support-
Results: Significantly More Diabetic Patients at Glycemic Control with Bariatric / Metabolic Surgery,
- "In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone."
Results: Average levels of HbA1c were also significantly lower after Bariatric / Metabolic Surgery
- ""Mean levels of glycated hemoglobin and fasting plasma glucose were significantly lower in each of the two surgical groups than in the medical therapy group"(p<0.001)
Results: Significant Decreases in Diabetic Medication Usage with Bariatric / Metabolic Surgery
- "The average number of diabetic medications per patient per day tended to increase in the medical therapy group but decreased significantly in each surgical group"(p<0.001)
* 50% of patients in each surgical group used
* NO diabetes medications at 12 months.
A growing consensus favors bariatric surgery
"The Endocrine Society recommends that practitioners consider several factors in recommending surgery for their obese patients with type 2 diabetes, including patient's BMI and age, the number of years of diabetes and the assessment of the (patient's) ability to comply with the long-term lifestyle changes that are required to maximize success of surgery and minimize complications."
"… remission of diabetes, even if temporary, will still lead to a reduction in the progression to secondary complications of diabetes (such as retinopathy, neuropathy and nephropathy), which would be an important outcome of … surgery."