What you need to know about bariatric surgery for type 2 diabetes

TThe term bariatric is derived from the Greek words for “weight” and “heal.” Originally, as its name suggests, this form of surgery was intended to help people deal with obesity. But as medical science’s understanding of bariatric surgery has improved, experts have recognized that these procedures can also help people with obesity-related health conditions, including type 2 diabetes.

“In 1999, when I was a junior resident in general surgery, I was struck by the observation that patients who underwent this type of surgery very quickly saw an improvement in their diabetes,” says Dr. Francesco Rubino, who is now chairman of the Metabolic and bariatric surgery at King’s College London. “Even patients who had very severe diabetes would reach normal blood sugar levels and be able to stop taking medication.” He was not the only one to notice these effects, which were supported by formal research.

An early study by researchers at East Carolina University found that 83 percent of patients with Type 2 diabetes who have experienced gastric bypass surgery long-term remission of their disease. Despite these kinds of dramatic clinical observations, surgery at the time was not considered a primary treatment option for type 2 diabetes. It was also assumed, Rubino says, that any improvements in diabetes were caused solely by weight loss. “But I’ve always felt that the degree of improvement was too great simply to be a byproduct of weight loss,” he says. In some cases, improvements in a person’s diabetes will occur even before they have lost significant weight.

Fast forward more than 20 years, and experts continue to debate exactly how bariatric procedures benefit people with type 2 diabetes. But today, there’s no doubt that these procedures are beneficial. Recent studies have found that bariatric surgery is associated with better patient outcomes than nonsurgical treatments alone. In 2017, the results of a long-term trial published in New England Journal of Medicine, found that adding bariatric surgery to nonsurgical management of diabetes led to large improvements in patient outcomes. People who had surgery were more than three times more likely to achieve normal blood sugar results one year after treatment. They were also less likely to take glucose-lowering medications and reported greater improvements in quality of life.

“Surgery can actually put diabetes into remission and is safe and cost-effective compared to standard non-surgical care,” said Dr Karel Le Roux, a professor at University College Dublin who studies bariatric surgery in people with diabetes. “Right now, it’s the best treatment we have for type 2 diabetes, and I’m an internal medicine doctor, not a surgeon, so I have no interest in talking about surgery.” Le Roux says there’s no doubt that bariatric procedures should now be considered the primary treatment for type 2 diabetes, and that too few people who are eligible for these surgeries receive them. However, he adds that surgery is “not a silver bullet” and not everyone with type 2 diabetes is a candidate.

Here, Le Roux and other experts discuss the latest in bariatric surgery for type 2 diabetes, including the benefits and risks, the procedures themselves, and how combining surgery with medication may ultimately provide the best long-term results.

How does bariatric surgery benefit people with diabetes?

That’s the million dollar question. And there is more than one right answer.

“My view is that weight loss is the dominant mechanism, but there are obviously other mechanisms at work,” says Le Roux. Type 2 diabetes is a disease of too little insulin and too much blood sugar. Excess body weight increases the amount of insulin needed to manage blood sugar levels, thus exacerbating the imbalances that give rise to diabetes. There is also evidence that fat (fat) cells release byproducts that can damage the pancreas, where insulin is produced. These are just a few of the reasons why weight loss is associated with improvements in diabetes.

But something else—something beyond these weight-loss benefits—is clearly going on. “We’re seeing some people who are on hundreds of units of insulin leave the hospital after surgery that doesn’t require insulin, and that precedes weight loss,” said Dr. Andrew Craftson, clinical associate professor and director of the post-bariatric program at the University of Michigan . “This is a somewhat controversial area, but some evidence suggests that there are unique properties of the surgery itself that produce metabolic benefits.”

The most common bariatric procedures for people with type 2 diabetes are Roux-en-Y gastric bypass and sleeve gastrectomy. Both procedures involve shrinking the size of the stomach, either by removing part of it (sleeve gastrectomy) or by dividing it into two sections and connecting the smaller of the two sections to the small intestine (gastric bypass). “Clearly, the stomach and intestines are not only a digestive organ, but also an endocrine organ,” says Rubino. “The gastrointestinal tract produces a huge number of hormones, and they are all involved in sugar metabolism and insulin production.” In addition, he says, bariatric surgeries affect populations of microbes in the stomach and intestines, which themselves produce metabolites that play a role in sugar metabolism. “These are just some of the mechanisms that may explain why bowel surgery can have such a huge impact on diabetes even in the absence of weight loss,” he says.

In fact, Rubino and other healthcare professionals who treat people with diabetes have started calling bariatric surgery “metabolic surgery” to emphasize that it’s not all about weight loss.

Read more: The relationship between type 2 diabetes and mental disorders

Who Should Consider Bariatric Surgery?

At the moment, the criteria are pretty clear. National Institutes of Health guidelines say anyone with type 2 diabetes and a BMI of 35 or higher is a candidate. If your BMI is between 30 and 35 and your diabetes is not responding well enough to medication and lifestyle changes, surgery may also make sense. However, in this lower BMI group, insurance may not pay for the procedure. “Insurance coverage remains a barrier for people with a lower BMI,” says Craftson. But even for people who meet all the insurance criteria, only a small percentage undergo surgery. “We know that bariatric surgery is underutilized,” he says. “Only 1-2% of eligible patients actually have it, so it’s something we need to promote more.”

Le Roux echoes his sentiments. He says this anyone with type 2 diabetes who has been on medication and has failed to control his blood sugar, surgery should be considered regardless of BMI. “I think surgery should be on the table and discussed for many more patients,” he adds.

Aside from hurdles around insurance coverage, Craftson says other factors may prevent metabolic surgery from really taking off as a diabetes treatment. Obesity is a stigmatized disease, he says, and some people may be averse to undergoing a surgical procedure traditionally only performed on the severely obese. “Also, people focus on the one person they know who had it [the surgery] and gained all the weight back,” he says.

Although this is not the experience of most patients, it can happen. “The effectiveness of the surgery diminishes over time, and some people regain weight or have a reactivation of their diabetes,” says Craftson. A 2020 study found that three to six years after a sleeve gastrectomy or Roux-en-Y gastric bypass, about a quarter of patients had regained their weight. “Most people just need surgery and then the job is done,” says Le Roux. “But there’s a subset of people who either don’t have a good response or have a relapse later.” Among people who have the procedure at a younger age — something that’s increasingly common as the incidence of type 2 diabetes increases in people under 40 – weight regain or diabetes relapse may be more likely.

The operation is associated with additional risks and costs. “About 1 in 20 people will have a significant complication,” says Le Roux. These include gastrointestinal bleeding, infections or leakage. Embolism or thrombosis are also possible, which can be life-threatening. “All of this usually happens early on, which is why we keep people in the hospital for a night or two,” he says.

Finally, metabolic surgery requires major lifestyle adjustments. After surgery, people must adopt a specialized diet and exercise regimen to maintain their health and facilitate weight loss. Eating too much or too quickly can cause symptoms such as intestinal cramps, pain and diarrhea. Also, things a person once enjoyed eating—even healthy foods—may not taste the same or provide the same pleasure. Alcohol was initially banned. Even after a full recovery, people should be very careful about how they drink. Finally, to avoid nutrient deficiencies, it is necessary to take several daily supplements. “Typically you have to take a multivitamin twice a day and calcium three times a day, so it’s a lot of work to prevent these deficiencies,” says Craftson.

Even in people who do everything right, surgery is not always successful. Understanding why some people don’t respond well — and figuring out how to prevent a poor response — is “the cutting edge” of type 2 diabetes surgery research today, Le Roux says.

Read more: The truth about fasting and type 2 diabetes

The future: A mix of surgery and drugs?

One of the big stories in both obesity and diabetes care is the arrival of new injectable drugs that, at least in clinical trials, have been shown to help people with obesity lose significant weight— in some cases 20% or more. “A lot of people think these drugs are going to be the death of bariatric surgery,” says Le Roux. “I disagree, and I think a large number of patients will have surgery plus drugs, but at a lower dose.”

The vast majority of people who undergo the surgery — roughly 70 percent of patients, he says — enjoy long-term weight loss and diabetes remission without the help of drugs. But for the subset of people who either don’t have a good response or who eventually relapse, some of these new drugs may prove helpful. “The answer may not be surgery instead of medicine, but medicine with surgery,” he says.

Others share his opinion. “We’re finding that some of these weight management drugs work synergistically with surgery, so they improve portion control and satiety,” says Craftson. It remains to be seen whether the latest drugs improve patient outcomes when combined with metabolic surgery. But it’s a different possibility, and it could become the standard of care for people with both obesity and difficult-to-control diabetes.

Rubino says the big message for people with type 2 diabetes is that surgery may provide the best hope for permanent remission. “We’re taught that type 2 diabetes is a chronic, progressive, irreversible disease,” he says. “But complete remission is possible with surgery, and this is possible in most patients.”

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