Surgery for obesity & metabolic diseases
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Before answering the question of whether weight loss surgery cures diabetes or not we should have a clearer perspective of what is diabetes and the importance of seeking adequate control of this disease.
If you think you know enough about diabetes then we invite you to go straight to the answer to this importanpost.t question: How is that obesity surgery can cure diabetes? So please scroll through to the mid section of this.
Diabetes is often known as diabetes mellitus and belongs to a group of metabolic diseases in which the patient develops high blood glucose levels and can be due for two main reasons: either because of inadequate production of insulin (the hormone that controls blood glucose levels) or because the body’s cells are non-responsive or do not respond properly to this hormone or a combination of both.
Diabetes is categorized as type 1 and type 2, the first is where the levels of insulin production are insufficient and therefore glucose levels in blood are high and the latter corresponds to the inadequate response of the cells to insulin’s action even if present and in proper concentrations.
Type 1 Diabetes usually appears on early stages of life, could be during childhood or adolescence. In theory this type of diabetes is harder to control and because of the fact that it appears earlier in the person’s life it can lead to higher long term damage if is not controlled properly.
Type 2 Diabetes has a much higher incidence than type 1, accounting for 90% of the cases of diabetes and it is usually developed around te fourth decade of life, unfortunately due to the constant increases in obesity trends worldwide, it is being diagnosed at earlier stages of life because of its close relation to obesity and inactivity.
Unfortunately, over twenty-three million Americans (nearly 8% of the U.S. population) have diabetes and nearly 6 million Americans suffer from it and don’t know it
It is no accident that the epidemic of obesity is increasing along with the incidence of type 2 diabetes. From 1986 to 2000, the prevalence of obesity with BMI of 30 doubled, while obesity with BMI greater than 40 quadrupled and obesity as BMI 50 has increased. It has been proved that there is a close relationship between these two diseases (obesity and diabetes) and is also known that the longer the patient suffers from obesity the higher the risk of developing diabetes.
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Being overweight or obese and therefore having excess body fat is directly related to the development of type 2 diabetes. Patients with obesity are at a much higher risk of developing this disease than patients with normal weight.
Long term obesity causes the body to suffer an inability to manage or adequately control the levels of glucose circulating in the blood, so the insulin that the body produces will eventually be insufficient to maintain adequate levels of glucose, leading to the development of type 2 diabetes.
Represented in numbers, it is estimated that 90% of people with type 2 diabetes are overweight. This trend has unfortunately been increasing since the 90’s and it is expected that the incidence of diabetes continues to rise due to increasing population of overweight or obese people.
The general guidelines and recommendations for the control and management of type two diabetes include:
What is sought with the measures mentioned above is to keep the blood glucose levels within normal parameters or as close as possible to them, which may vary slightly depending on the source consulted but the ideal is to stay between 70 and 110 gr/dl under fasting and ideally maintaining a glycosylated hemoglobin less than 6.
Achieving this is an extremely difficult task especially when the patient leaves all the "work" to medications. Some don’t even take drugs at the frequency or dosage indicated by their physician, and even after taking drugs "religiously" and routinely is very commonly insufficient if the rest of the aspects mentioned above are not monitored and changed.
Diabetes, like most chronic degenerative diseases are silent enemies that do not necessarily show signs or symptoms of their presence. In case of having symptoms, they may be so mild initially, that the patient believes that it is well controlled when in truth it is not.
The main objective of maintaining adequate glucose levels is to avoid micro/macro vascular and nerve damage which leads to the deterioration of a countless number of organs and systems within the human organism.
Just to mention and without going deep into each of them, we list the various organ systems affected due to poor diabetes control:
The claim that obesity surgery can cure diabetes is controversial among us surgeons who support bariatric surgery as a cure for diabetes and non-surgical physicians who see this as a very risky statement.
What we can definitely say is that if you are considering bariatric surgery as a cure for your diabetes is that when suffering from obesity, it does not matter if you cure completely from the illness or "only" manage to have better control, from all possible points of view, surgery is a well worth risk, taking in consideration that even if remission of diabetes does not happen you will give quality to your life and getting away from many another obesity related diseases.
There are serious scientific studies published in journals of international recognition as The New England Journal of Medicine that confirm bariatric surgery as an effective way to treat diabetes.
It's been over 10 years since the resolution of type 2 diabetes was observed as an additional outcome after treatment of morbid obesity with surgery. It has been shown unequivocally that the morbidity and mortality associated with diabetes significantly decreases in the postoperative period and that the effect on the improvement in the control of diabetes is a long-term effect.
Without going too much into the question of which method is the best to cure or control diabetes, because of its long term existence, the two most studied procedures regarding if weight loss surgery cures diabetes are the gastric bypass and duodenal switch (or biliopancreatic diversion), both procedures are considered to be more effective as a treatment for diabetes compared to others such as the gastric banding.
Both procedures show that shortly after being performed, glucose, insulin and glycosylated hemoglobin level normalization occurs in 80 to 100% of postoperative patients with morbid obesity. Studies show that this improvement in glucose levels are present even before there is a significant weight loss, only a few days after the procedure has been performed. This suggests that surgery alone is not sufficient explanation for this phenomenon.
Other factors include the decrease in the amount of food eaten, partial malabsorption of nutrients and anatomical alteration of the gastrointestinal tract that incites changes in incretin system*, thus altering the balance of glucose. In recent years the gastric sleeve surgery has also earned its place as an effective procedure but with a lower resolution rate for type 2 diabetes, but to a degree that makes it very a acceptable procedure for this purpose considering the few long term negative effects of the gastric sleeve when compared to the other two procedures.
*Incretins: Group of gastrointestinal hormones that stimulate decreased blood glucose levels. Incretins accomplish this by increasing insulin levels that are released by pancreatic cells after food intake.
To put into perspective the great benefit that weight loss surgery represents as a cure for diabetes in obese patients is that programs to change lifestyle through diet therapy, behavioral changes, exercise programs and pharmacotherapy are widely used in combination as a treatment of obesity and unfortunately only in exceptional cases clinically significant weight loss is achieved, usually just a transient and modest weight loss, particularly in patients who presented severe obesity. It is estimated that the failure rate of these programs is around 95% after one year of starting with the program.
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As previously mentioned, it is considered that the gastric bypass and duodenal switch are the two most effective methods for the treatment of diabetes, but the gastric sleeve has gained ground as another considerable effective procedure leading to a better control or even curing diabetes with the added benefit of its very few negative secondary effects.
A thorough analysis in the case of each patient by his/her bariatric surgeon in conjunction with the patient's opinión, is what will determine which procedure is ideal for the particular case. It is noteworthy that despite bypass or duodenal switch being considered more effective, the effectiveness of gastric sleeve is not far behind and it is not accompanied by the complications or known adverse effects of malabsorptive procedures such as bypass or duodenal switch.
Like most of the factors involving the decision to undergo bariatric surgery, you should put in the scale the risks and benefits to make the choice that you consider most appropriate for both, the decision of undergoing weight loss surgery to cure your diabetes and for the selection of the procedure.
It is difficult to answer this question with certainty because there are no studies on the matter that closely analyze each and every one of the factors involved in each patient, besides the difficulty of having long-term follow up to each of the patients, it is almost impossible assert a given duration of the positive effects but it is considered by most that is for the long term.
At Obesity Free, we believe that regardless of the procedure, the determining factor in the long-term success of a weight loss procedure to cure diabetes is the determination and dedication that the patient puts to the necessary changes in their lifestyle after surgery, this is what truly defines the future of the patient and its relationship with diabetes.
As we have explained, even though there are still not well known factors by which cure, improvement or remission of diabetes happen after weight loss surgery, it is also true that a determining factor is precisely the the decrease in body fat percentage and weight loss per se, both of which if are maintained during years it will positively influence the proper control or remission of type 2 diabetes.
The effect of bariatric surgery on hypertension and hypercholesterolemia (high cholesterol) is similar to that observed on diabetes, changes in the anatomical conformation of the patient in relation to the percentage of body fat and decreased weight lead to very favorable results in the decrease (better control with less medication) or disappearance of such diseases.
Healthy eating and a more active lifestyle are factors that usually surround the postoperative period of the patient having weight loss surgery and this, almost unequivocally leads to the improvement of these and any other obesity related diseases.
A very important thing to consider when it comes to patients suffering from obesity and family history of diabetes mellitus, hypertension and other related "metabolic syndrome" diseases is that the longer they suffer from obesity the more likeness to develop diabetes and other diseases related to obesity.
Another factor to consider is that the time since diabetes is diagnosed until the time a bariatric procedure is performed is a determining factor in the chances of success in curing the disease. That is, the longer the diabetic patient takes to undergo definitive treatment for weight control, the less likely that diabetes will disappear. It is considered that a patient can be cured from diabetes with weight loss surgery if it is performed during the first 5 years after the diagnosis of diabetes mellitus and something similar is considered for high blood pressure.
It is considered cured from diabetes if the achieved levels of blood sugar are 120 mg/dl or less without drugs, while the resolution of high blood pressure is achieved when the patient takes no medications and has a systolic blood pressure 135 mmHg or less and diastolic pressure of 85 mmHg or less.
Even if these optimal results are not reached after a few months of bariatric surgery, it is a fact that these diseases can be controlled much more easily than before surgery, making weight loss surgery an excellent alternative when the patient wants to have a better quality of life and wants to reduce the amount of medications required to control such diseases which are so deteriorating to the human organism.
All this information makes us think that weight loss surgery should be proposed to the patient at an early stage when they are obese either to prevent diseases, to control them or even cure them permanently.
Remember that this kind of diseases are silent enemies. It is extremely common on my practice and every physician’s practice who has contact with these diseases, that generally the patients do not openly accept that they suffer from a chronic disease and they ignore the fact that not having symptoms does not mean that their diabetes or high blood pressure are well controlled.
Usually when they have symptoms they are vague or transient and they do not pay attention to them or when perceiving severe signs and symptoms there is not much to do since they reflect a severe damage to one or more vital organs and this is what we actually try to avoid with a proper body weight control by any means including bariatric surgery.
Your turn, tell us if you consider the idea of controlling your diabetes by having bariatric surgery and if you already had it done let us know what has been your experience.
Written by: Gabriel Rosales
Dr. Gabriel Rosales is a highly skilled, board certified surgeon in constant pursuit of learning the latest innovations in the weight loss surgery field to give his patients the best care possible.
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Rodrigo Andalon St # 112 Suite C
Colonia Burocratas. Piedras Negras, Coahuila. México
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Monterrey, Nuevo León. México
Baja California 3401, Jardín 88260
Nuevo Laredo, Tamaulipas. México
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