Should Youth With Type 2 Diabetes Be Prioritized for Metabolic Surgery?

One alarming and direct consequence of the obesity epidemic, is the marked increase in the incidence of type 2 diabetes in children and youth. 

According to a recent paper by the TODAY study group, published in the New England Journal of Medicine, these youth face disastrous outcomes with regard to diabetic microvascular complications. 

Thus, amongst the 500 individuals observed over 5 years in the study (average age 26, average duration of diabetes 13 years), the cumulative incidence of hypertension was 68%, the incidence of dyslipidemia was 52%, the incidence of diabetic kidney disease was 55%, the incidence of nerve disease was 33%, and the incidence of retinal disease was 51%. 

Notably, the average BMI of this group was 35 kg/m2!

These disastrous outcome were seen despite the fact that all participant were treated with metformin with or without insulin to maintain glycemic control during the first 2 years of the study, which the authors note, is probably more than the average youth with type 2 diabetes receives in the real world.  

While several factors including minority race or ethnic group, hyperglycemia, hypertension, and dyslipidemia were associated with increased risk, the authors also point out that,

“…youth-onset type 2 diabetes is characterized by a suboptimal response to currently approved medical therapies, which is compounded by major challenges in adherence and management because of age and characteristic socioeconomic factors.


“The only medications approved by the Food and Drug Aministration (FDA) for youth-onset type 2 diabetes are metformin and insulin, with the recent addition of a glucagon-like peptide-1 (GLP-1) receptor agonist. Sodium–glucose cotransporter 2 (SGLT2) inhibitors, which impede progression of cardiovascular and kidney disease in patients with adult-onset type 2 diabetes, are not yet approved by the FDA for youth-onset type 2 diabetes.”

These challenges aside, the authors also discuss whether more consideration should be given to metabolic surgery in this group. Not only does metabolic surgery result in durable weight loss and improvement in glycemic control in the majority of patients, but data from the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) showed a greater effect of bariatric surgery than medical therapy on both glycemic and nonglycemic outcomes . Furthermore, Teen-LABS showed greater regression and earlier attenuation of kidney disease in youth with type 2 diabetes than in adults with type 2 diabetes.”

While metabolic surgery in adolescents comes with its own challenges, it seems that the alternative of trying to conservatively manage obesity and type 2 diabetes (let alone other obesity related medical, psychological and social complications) is clearly not quite doing the job. 

In light of this rather disastrous prognosis, I wonder if metabolic surgery should be seriously and regularly discussed as a viable alternative to conservative management when counselling youth with type 2 diabetes and their parents. 

Berlin, D