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International Diabetes Federation Position Statement on Bariatric Surgery



Yesterday, at the 2nd World Congress on Interventional Therapies for Type 2 Diabetes in New York, the International Diabetes Federation (IDF) released a Position Statement calling for bariatric surgery to be considered earlier in the treatment of eligible patients, to help stem the serious complications that can result from diabetes.

The document includes the following statements:

  • 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 normalising blood glucose levels, reducing or avoiding the need for medications and providing a potentially cost-effective approach to treating the disease.
  • Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially when there are other major co-morbidities.
  • Surgery should be an accepted option in people who have type 2 diabetes and a BMI of 35 or more.
  • Surgery should be considered as an alternative treatment option in patients with a BMI between 30 and 35 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors.
  • Strategies to prioritise access to surgery may be required to ensure that the procedures are available to those most likely to benefit.
  • Available evidence indicates that bariatric surgery for obese patients with type 2 diabetes is cost-effective.
  • Bariatric surgery for type 2 diabetes must be performed within accepted international and national guidelines. This requires appropriate assessment for the procedure and comprehensive and ongoing multidisciplinary care, patient education, follow-up and clinical audit, as well as safe and effective surgical procedures. National guidelines for bariatric surgery in people with type 2 diabetes and a BMI of 35 or more need to be developed and promulgated.
  • The morbidity and mortality associated with bariatric surgery is generally low, and similar to that of well-accepted procedures such as elective gall bladder or gall stone surgery.
  • Bariatric surgery in severely obese patients with type 2 diabetes has a range of health benefits, including a reduction in all-cause mortality.
  • In order to optimise the future use of bariatric surgery as a therapeutic modality for type 2 diabetes further research is required.

The entire statement is available here.

This statement comes in the light of the increasing recognition that surgical treatment for obesity leads to an often remarkable remission in diabetes (and some of its complications) as well as other weight-related health problems – this is certainly more than can be expected of any current medical treatments for type 2 diabetes.

Indeed, the strength of this data is such that I recently heard a couple of my colleagues discussing whether or not they could be found liable for not ‘disclosing’ to their diabetes patients that surgery now represents an increasingly accepted ‘alternative’ treatment for type 2 diabetes.

I certainly wonder how many of my readers would consider having surgery themselves if they were diagnosed with type 2 diabetes.

AMS
Edmonton, Alberta

17 Comments

  1. These risks of overweight and obesity should be widely publicized. Prevention of obesity is crucial.

    Every visit to a doctor for a checkup should include either congratulations for maintaining a healthy weight including very explicit information on what risks the person is avoiding, or a warning about the risks of not maintaing healthy weight, with the same explicit information about the risks the overweight/obese patient is facing.

    The more I read in this blog about all the diseases and dangers of overweight and obesity, the more I think bariatric surgery, while necessary for patients already sick, is like locking the barn door after the horses are gone. The point is to prevent people from becoming so overweight/obese that their weight is so damaging.

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  2. “The point is to prevent people from becoming so overweight/obese that their weight is so damaging.”

    Sure, prevention is always best but unfortunately comes too late for the over 1,000,000 Canadians, who are already severely obese and need help. As I said before, if we haven’t managed to keep the horses in the barn let’s at least stop them from galloping off the cliff.

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  3. I have type 2 diabetes, and I was diagnosed at age 25, and I’m now 42. I have no complications. I have an A1C of 6.0, my last lipids lab work (done within the last month) was so good that my doctor considered lowering my already extremely low dose of generic statin medication. I have a BMI of just over 40. I usually get around 200 minutes a week of moderate physical activity a week (or the equivalent mix of moderate and intense activity).
    When we’ve talked about weight management, my doctors have brought up gastric bypass surgery. I’m not convinced that my quality of life would be better — especially if I were to suffer any of the unintended consequences of surgery. I’m sure I would lose weight, at least initially, and that might take me down to a BMI of 30 or so, but I think that eventually, I would be trying to maintain my best health as I age with a crippled gastric system.
    I am not convinced that it’s the best thing for me, and I have to wonder how many other “me”s there are out there. I think that it might be the right thing in certain circumstances, where diabetes control is extremely difficult to achieve by other means, but I think that when the body has fully recovered from the injury to such an essential organ, the endocrine problems will return, and the accompanying complications, too.
    I worry about people like me being pressured into the surgery because it’s deemed cost-effective and reversing of type 2 diabetes, only to end up with a quality or quantity of life that suffers. Guidelines are great, but the risks and downsides of surgery need to be clearly stated, so patients understand what they are in for.

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  4. My dad has had type II diabetes for 30 years, and I also know people who have had weight loss surgery. Judging from their experiences, I would rather have diabetes and manage it than accept the risks and put up with the complications associated with weight loss surgery. I feel confident in saying that I would never consent to that surgery under any circumstances. While my dad is still alive and kicking (and not even retired) in his mid-seventies, I don’t know anyone who has lived with weight loss surgery for 30 years.

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  5. Oh – and I’m not convinced that the diabetes remission in weight loss surgery patients lasts more than a few years. If that’s the case, then it’s an even worse tradeoff.

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  6. Hi Arya,
    I agree with your analysis as well as the concerns of your readers. There was very little in the statement about the nutritional complications that affect many patients including vitamin and mineral deficiencies and weight regain. I don’t think the statement about long-term multidisciplinary follow-up is very specific!

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  7. Hi there,

    My take from the article is that I don’t think it is saying bariatric surgery is appropriate for all type II Diabetic patients who are obese. But, that it may be an option for those patients who are type II diabetic, obese and have uncontrolled diabetes where complications will almost certainly shorten their quality and length of life. In these cases the side effects of the surgery would be annoying to say the least but it is a trade off in order to live longer with less complications from the diabetes itself.

    I base my comments on:

    “* Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially when there are other major co-morbidities.” and

    ” * Surgery should be considered as an alternative treatment option in patients with a BMI between 30 and 35 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors.”

    Also, you will notice that this article is not conclusive in that further research is needed.

    “* In order to optimise the future use of bariatric surgery as a therapeutic modality for type 2 diabetes further research is required.”

    The realities of the complications of those with type II diabetes are many. Some of them:

    Kidney disease as a complication may result in the need for dialysis.

    Nerve damage: The lack of feeling in patients with type II diabetes may lead to sores that are not noticed, particularly on the feet. If they get infected amputations may even be required.

    Blindness is also common.

    There are many more complications. But my point is that I think it is good that a person with uncontrollable type II diabetes has the option of bariatric surgery. The lifestyle changes necessary after the bariatric surgery may be far more tolerable than the alternative of the much more serious complications of loss of sight and limbs.

    Thanks for listening,
    Rosemary D. from Edmonton

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  8. Hello:
    My take on the artical is that not everything works for everyone. I know that are certain persons who should not take certain medications or have certain procedures due to other health or allergy issues. For those of us who know a person with out of control weight and out of control blood sugar at least mentioning the option in better then nothing. I do know one person who enjoys eating enough that this kind of surgery would not be a good idea for her–however, she is only one person not the entire group of Type 2 diabetics to choose from. The useless old mantra of eat less move more is just not for many of us with obesity issues including diabetics. Thanks for your time

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  9. My husband has type 2 diabetes and a BMI of 37.2. If his doctor recommended WLS for him, he would be looking for another doctor. I had a VBG almost 14 years ago and the complications I have from it are not something I would wish on my worst enemy (and to top it off, the VBG failed, I’m fatter than I was before I had it). If I were diagnosed with t2d, I would NEVER consider any kind of WLS to control it, I know all too well what the complications of WLS are, and I know very well how to control t2d with medication and diet (exercise is out for me because of mobility issues worsened by the complications from the VBG).
    From what I have read, WLS only puts t2d into remission for a short period of time – while the patient is still losing weight. Once weight loss stops, and is maintained (or weight starts to be regained), the t2d comes out of remission and needs to be controlled again, either with diet and exercise or medication or a combination of the three. Which means the WLS was pretty much a waste of time as it puts the patient right back where they started.

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  10. intersting to read the comments, having diabetes increases the chances of going blind, needing dialysis for renal failure, loosing a leg, having a stroke, having a heart attack, being impotent. Gastric Bypass surgery will prevent these by making the glucose normal in 85% of pts, so yes I would definatly have the gastric bypass. To vesta44, who had a VBG, sorry its not a useful operation, but that was not well known in 1995. Still please don’t punish your husband becuase your VBG failed. He should strongly consider RNY. To Ms. Dinsdale, I think any type 2 diabetic who is obese should very strongly consider RNY. To Ms. AcceptanceWomen, I know its just about impossible to imagine your life after RNY, because you sort of feel ok now, and things might be worse, BUT I can tell you for sure things can be a whole lot better.

    thanks

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  11. Bill, your comment to AcceptanceWoman is so incredibly condescending.

    I know its just about impossible to imagine your life after RNY, because you sort of feel ok now, and things might be worse, BUT I can tell you for sure things can be a whole lot better.

    Her life might be better than yours right now, and that surgery can kill. Your suggestion that being thin leads to a better life, even if it’s achieved through damage to a healthy digestive system, is absurd. What makes you think that she isn’t already feeling as good as a human being could expect to feel? Her quality of life sounds excellent to me.

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  12. Dr. Bill Graber, You should have disclosed that you are some kind of weight management doctor. Are you a surgeon performing RNYs? Of course you want more patients.

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  13. Dear Dr Sharma,

    I’m certainly not disagreeing with “keeping lost horses from jumping off a cliff”, to continue the metaphor.

    My point is that we still haven’t locked the barn door, and there are more and more horses dashing out and heading straight for the cliff.

    (May be those Disney lemmings would be a better analogy.)

    We need the kind of awareness campaign for the dangers of obesity that we have for smoking. Explicit and graphic in portrayal of risks.

    Some people don’t want to believe risk applies to them – as if they themselves are sure to be the lucky smoker who lives to be 101, the lucky motorcyclist who never wears a helmet and never has an accident, the lucky drunk who always manages to drive home ok, the lucky morbidly obese person who is healthy.

    But if the health hazards and risks were publicized like the risks of smoking and drunk driving, there are many people who would take the danger to heart and avoid gaining weight, or even lose weight.

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  14. Thanks, DeeLeigh, I do have what I would consider a good, happy, healthy life WITH type 2 diabetes. I volunteer about 5 hours a week on top of a full-time job, and I’m considered by my daughter to be a great mom, by my husband a great wife, by my family a great family member, and by many to be a great friend. There would be a serious toll on my life if I were to stop everything for a period of time to have the surgery and recovery. The impact would be not only on my life, but the lives of the many people who depend on me.
    I’m not on course to have major complications of type 2 diabetes, seeing how well it is controlled. My father, who does not have type 2 diabetes, has heart disease, so if I end up with that, I’m pretty sure it’s not something that could have been avoided — my mom with type 2 diabetes is now in her mid-70s and hasn’t had a heart attack or stroke — she has health problems consistent with many people her age. My dad is in his 80s.
    Ultimately, it’s my decision. But for ANYONE to assume that I’m making the wrong decision by not having a major surgery is beyond arrogant.

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  15. This statement from the guidelines:
    Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially when there are other major co-morbidities.
    I am meeting the recommended treatment targets with medical therapies, and have no other major co-morbidities.

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  16. I think that the key to prevent people from getting diabetes is properly implanting the subject of healthy diet and highlighting the importance of daily exercise. These way young children can benefit from knowing what the risks are and at an early age – so they won’t develop bad habits and would be much more aware of the problems the country has with obesity to a high percentage of the population.

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  17. Anonymous, being fat isn’t like smoking or drunk driving. It isn’t a bad habit or an antisocial act that’s dangerous to others. It’s a body type that’s largely determined by heredity.

    You might as well graphically publicize the risks of being male, since that’s responsible for similarly increased health and mortality risks. You might as well tell men that they can’t expect to live long and healthy lives, because they’re just like smokers and drunk drivers. But don’t despair, men! You can always get a sex change operation. Give me a break.

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