Tuesday, March 24, 2009

Have Diabetes? Find a Surgeon!

Type 2 diabetes mellitus is one of the most prevalent and expensive “lifestyle” diseases.

Here some numbers from the website of the Canadian Diabetes Association:

- The personal costs of diabetes may include a reduced quality of life and the increased likelihood of complications such as heart disease, stroke, kidney disease, blindness, amputation and erectile dysfunction.

- Approximately 80% of people with diabetes will die as a result of heart disease or stroke.

- Diabetes is a contributing factor in the deaths of approximately 41,500 Canadians each year.

- Life expectancy for people with type 2 diabetes may be shortened by 5 to 10 years.

- People with diabetes incur medical costs that are two to three times higher than those without diabetes. A person with diabetes can face direct costs for medication and supplies ranging from $1,000 to $15,000 a year.

- By 2010, it’s estimated that diabetes will cost the Canadian healthcare system $15.6 billion a year and that number will rise to $19.2 billion by 2020.

So imagine, what if a relatively straightforward laparoscopic operation, which takes 30-90 mins and lets you go home the very next day, cures this condition – in most cases forever?

This may very well be the case if we trust the results of a sytematic review by Henry Buchwald and colleagues from the University of Minnesota, published in this month’s edition of the American Journal of Medicine.

The paper reviews over 600 surgical studies in a total of over 135,000 patients, of whom around 22% had type 2 diabetes.

These are the results:

• Type 2 diabetes was resolved in 78% and resolved or improved in 87% of patients undergoing bariatric surgery.

• Both weight loss and diabetes resolution were greatest for patients undergoing biliopancreatic diversion/duodenal switch, followed by gastric bypass, and least for banding procedures.

• Clinical findings were substantiated by the laboratory parameters of serum insulin, HbA1c, and glucose.

• These findings were maintained for 2 years or more.

To be fair, the authors note several limitations of their study, the most important being the high attrition of patients available for follow-up, the diversity of reporting formats for diabetes outcomes, and the lack of information on specific subpopulations such as different ethnic groups. However, they also note that the the pattern of results for key outcomes in this meta-analysis are so consistent across studies, that they are hard to refute.

Although most of these studies did not study “hard outcomes”, we do know from the SOS Study (with a post-operative follow-up of 15 years and a follow-up rate of 99.9%) that surgery in patients with severe obesity can reduce total mortality by 30% and in a study from Utah, diabetes-related mortality was reduced by around 92%.

In contrast, recent studies of medical diabetes treatment failed to find any significant effect of better glucose control on mortality in patients with poorly-controlled diabetes (e.g. the Veterans Study)

I guess it is fair to ask – should perhaps bariatric surgery now be considered the “Gold Standard” for the treatment of type 2 diabetes, at least in patients with severe obesity? Should conservative diabetes treatments be reserved only for patients who do not meet surgical criteria? Tough questions that challenge much of current diabetes management – after all, why treat a condition for life, when it can be cured?

However, before running aboard with this idea, a word of caution – as I have blogged before – bariatric surgery involves far more than just surgery.

Nevertheless, in the light of these findings it does seem strange to me that a search for the term “bariatric surgery” on the website of the Canadian Diabetes Association comes up empty – I wonder why.

AMS
Edmonton, Alberta

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5 Responses to “Have Diabetes? Find a Surgeon!”

  1. Yoni Freedhoff says:

    A great question Arya.

    Perhaps a quick letter to their Director to ask is in order?

    Regards,
    Yoni

  2. Dr.Barbara Mayr-Belic says:

    Dear Dr.Sharma,
    I personally know of successful dieters who lose their diabetic markers substantiated by normal HBAIC and BS after two years. My family member is one of them.
    So while I think your comments are thought provoking and some form of stopgap minor surgery is perhaps an appropriate consideration at this time for some of those diabetics who fail to lose and maintain weight by current treatments of diet/exercise alone, I don’t think major surgery should be proposed as the ultimate gold standard for treatment. The research into less invasive and reversible surgical procedures for patients who fail dietary interventions is ongoing and looks promising. I think this is where our focus should be for now for those who can’t wait and whose health is deteriorating. We don’t know how much these patients with major gut alterations will fare in their old age when the bowels are usually the first to become problematic (even life threatening) in enjoying a normal life style in their old age.
    You may refer to my now healthy 77 year old energetic family member as an anecdotal case but i am sure there are many family doctors out there with similar success stories that need to be repoted. It is truly remarkable that my family member has kept off 60 pounds for the past five years, keeping the diabetes at bay evidenced by a normal HBAIC ( off previous gluburide needed while obese) and with a high HDL and very low risk cholesterol ratio ongoing since losing weight. This is after ten previous years of horrible chloesterol profiles, despite high doses of statins, and moderately high HBAIC’s despite high doses of glyburide and needing quadruple heart bypass in the year 2000 when she was 220 pounds.
    I am using this personal report as follow-up is easy. Many people get lost in follow-up from specialty clinics but family doctors I am sure will be able to report on similar success stories and I am sure there will be more and more of them as more people in government and medical insurance appreciate the extreme benefits of preventative medicine, weight loss, diet and exercise to diabetes management.
    I refer you also to my previous comments to your August 18, 2008 blog titled “Obesity Needs Treatment Forever”.
    Regards,
    Dr.Barbara Mayr-Belic

  3. wellroundedtype2 says:

    As a person with diabetes and a BMI of around 42, I prefer the treatment to the “cure.” I fully understand the risks of having diabetes, and when I was diagnosed nearly 15 years ago at age 25 and a BMI of around 48, I was terrified of them. But what has happened in those 15 years? So far, no complications, a healthy pregnancy managed with insulin, and I’ve been able to maintain a 30 pound weight difference.
    I believe that my quality of life would not be anywhere near what it is now if I had any of the common effects associated with bariatric surgery. I have a very healthy diet and I’m one of those people who would need to exercise 90 minutes a day and eat no more than 1,200 calories to get my BMI under 30.
    For me, living a healthy life with a chronic condition is preferable to living a compromised life in pursuit of a cure, but that’s a decision that each patient needs to make for her or him self. I’m afraid labeling surgery as a “cure” for type 2 diabetes will deprive people of the option to not have surgery if it isn’t what they truly want.

  4. Aggie says:

    Weight loss surgery “cured” the surrogate measures of diabetes, but that is not to say that it cured the underlying disease process. It remains to be seen if the people who take this drastic step actually live longer, healthier lives, and that is the ony meaningful outcome for any medical treatment.

    The lady who writes the blog junkfoodscience, has some interesting statistics on weight loss and bariatric surgery. http://junkfoodscience.blogspot.com/

  5. J.B. says:

    So, why not specify Type 2 Diabetes in your headline?

    This article has nothing to do with Type 1, and its title is potentially damaging to Type 1’s (especially children). I would call it hyperbolic, but at the very least, the lack of clarity does nothing for your credibility.

    Jan

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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