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Weight Loss Surgery: A Cure for Diabetes?

Obesity often occurs with Type 2 diabetes mellitus. At least 8 out of 10 people with Type 2 diabetes are overweight or frankly obese. In fact, the rising number of people with diabetes in the last 20-30 years has been attributed to the rising number of people who are overweight or obese. This is observed worldwide, alerting health experts to the continuing twin epidemics of diabetes and obesity.

Occurring together, diabetes and obesity share common grounds going back to how they start, how they develop and how they cause health problems. With this close association, it is easy to see the possibility that treating one will help treat the other. Clearly, effective diabetes treatment targets good to normal blood sugar readings, normal blood pressure levels, normal cholesterol values and of course, healthy weight. On the other hand, healthy weight loss can help treat diabetes and even prevent diabetes. Thus, managing diabetes and obesity together is really a must.

Lifestyle intervention through healthy eating and adequate physical activity can effectively help treat diabetes and can lead to significant weight loss. Since lifestyle changes require behavioral changes, the results are often limited by problems of patient compliance and commitment on a long term basis. Losing weight and keeping it down for good are difficult, just ask anyone who has battled weight problems. Drugs to treat obesity, with the few ones available, have some limited effectiveness and have known potential side effects. Lifestyle intervention and drug therapy both only result in modest weight loss, average of as little as 3 to 5% and up to 5 to 10% of initial body weight.

Weight loss surgery then comes into the picture as part of effective options for treating obesity. The commonly used surgical procedures today for weight loss started in the 1960s and have been called bariatric surgery. The earlier focus of these procedures is to bypass the person’s stomach so that food taken in is delivered to the distal or lower parts of the small intestines. Delaying food emptying from the stomach to the small intestines is also part of these procedures. As such, the absorption of food will then be minimized, contributing to weight loss due to less food absorbed by the body. Thus, these bypass procedures are also called malabsorptive.

Newer surgical procedures,focus on limiting the capacity of the stomach to take in food. These are thus called restrictive procedures because they effectively limit the available stomach area for food intake. They may be in the form of cutting part of the stomach (gastric resection or gastrectomy) or by narrowing the passage to the stomach (gastric inlet, gastric banding). More recently, gastric banding procedures done laparoscopically, meaning with guidance from endoscopic machines and with minimal and small incisions in the abdomen, have become popular with surgeons and patients alike because of their minimally invasive nature, ease in doing the procedure, less complications and shorter hospital stay. Combination effects of malaborption/bypass and restriction are also seen in the commonly done bypass procedure called Roux-en-Y gastric bypass.

In the past, these weight loss surgical procedures were performed on patients considered morbidly obese, with body mass index (BMI) of 40 and above or those patients, not as heavy-BMI of 35 and above but with significant weight-related health problems (diabetes, heart disease, sleep disorder and others). The classification of overweight and obesity used internationally is based on the BMI, a measure of an individual’s body weight in kilograms divided by his height in meters squared. Table 1 summarizes the criteria for each degree of overweight or obesity and the attendant health risk. A different classification is recommended for Asians because it has been noted that Asians have more weight-related health problem at lower BMI levels (lower weight/lesser degree of obesity) compared to Caucasians.

Results of weight loss surgery are quite dramatic, causing weight loss of more than 20 to 50 kilograms. This degree of weight loss (30-50% of initial weight) can be maintained for many years as seen in many long term studies lasting more than 10 years. Again, the earlier data were on patients who have more severe degree of obesity.

More recently, convincing data have shown that weight loss surgery has many beneficial effects, aside from the significant weight loss. Normalization of blood sugars, blood pressure and cholesterol levels have been observed in many of these patients who underwent these procedures. In at least half (50%) and maybe more (up to 80% and higher) of these patients had resolution of diabetes, hypertension, hypercfiolesterolemia and obstructive sleep apnea. Risk of death has also been shown to be cut by 30% in patients who had the gastric bypass compared to those who did not. Clearly, effective weight management leads to important disease resolution as well as disease prevention.

Solid evidence now points out that weight loss surgery can not only treat but also cure diabetes. The long term follow up of many patients post bariatric surgery in several medical centers in the US, Sweden, Brazil and other countries have shown that the weight loss surgery can prevent the development of diabetes in patients who are at high risk of developing diabetes (93%, compared to 25% with lifestyle changes and 19% with weight loss drugs). Moreover, among patients already with diabetes and who had weight loss surgery, normalization of blood sugars and discontinuation of antidiabetes medications have been noted in up to 80% of them. These positive effects were maintained up to a period of more than 10 years in many of these patients. It was also observed that even before the significant weight loss has occurred, normalization of blood sugars already started to occur. Many mechanisms, aside from weight loss, appear to contribute to this remarkable resolution of diabetes. Truly, weight loss surgery, does treat and cure diabetes.

Weight loss surgery leads not only to weight loss and diabetes remission but also to important metabolic and cardiovascular benefits that range from normalization of blood pressure and cholesterol levels, resolution of sleep apnea to reduction in death rates. Because many of these changes may also benefit those who are less obese (BMI of less than 35 or even 30), not a few experts in the field of weight loss surgery have proposed lowering the threshold for performing weight loss surgery. They have even started calling these procedures metabolic surgery, instead of bariatric or weight loss surgery. These experts strongly believe that beyond causing weight loss, metabolic surgery can treat and prevent many diseases, foremost among them is diabetes.

Efficacy of weight loss surgery is clearly well-demonstrated and the next important question is its safety. As a surgical procedure, weight loss surgery carries a very low risk of 0.2% mortality from the procedure itself. Mechanical problems from banding procedures and dumping problem due to the rapid transit of food from the stomach to the intestines can be seen in some patients. The improvement in surgical techniques and the use of laparoscopic procedures have contributed to the better outcomes.

However, since weight loss surgery involves restructuring the normal anatomy of the stomach and intestines, there are known potential problems. Nutritional deficiencies are common because of the resultant malabsorption as well as low intake of nutrients. This can lead to vitamin deficiencies, anemia, increased risk of gallstones, some kidney stones and osteoporosis. Behavioral problems, particularly depression, may be seen even though significant improvement in psychosocial functioning is usually noted. Long-term multidisciplinary management before and after the procedure will help address these potential problems. Metabolic monitoring, nutritional supplementation and psychological counseling are part of the total management plan. The other drawbacks include the costs of the procedure. The procedures are already being done in several centers in the Philippines and costs can run up to PhP 300,000 to 500,000.

Clearly, weight loss surgery is a welcome addition to our options for the comprehensive treatment not only of obesity but also of diabetes. Selection of the right patient who will benefit most from the procedure is crucial. Heavier and older patients, with significant associated conditions and without psychiatric history nor eating disorder or substance abuse problem may be the best candidates but several factors, such as unrealistic expectations, socioeconomic status and health care access, can be limiting. Being well informed, motivated and committed to lifelong lifestyle changes and good family support are likewise prerequisites to the ideal potential candidate for weight loss programs.

Special considerations for the young patients, women in the child bearing age, elderly patients and super obese individuals (BMI above 60) must also be emphasized in the selection of potential candidates for the procedure. Multidisciplinary team approach to the twin problem of diabetes and obesity will ensure the best outcome of whatever treatment plan, medical versus surgical, is chosen for the patients with diabetes. Finally, it can not be overemphasized that the best treatment for many diseases, including diabetes, is PREVENTION. Your doctor can help you do it!

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