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Bariatric surgery: new paradigm in type 2 diabetes management?

Bariatric surgery has a dramatic effect on diabetes and other heart disease risk factors. Bariatric Solutions/

Type 2 diabetes is the fastest growing epidemic worldwide. By 2020, it is expected to be the number one disease in Australia in men and second only to breast cancer in women.

Treating this illness has always been the ambit of physicians but big changes are afoot.

Diabetes specialists have recently seen a paradigm shift as surgeons invade our territory, laying claim to significant success in treating obese people with type 2 diabetes with bariatric surgery.

The rise of bariatric surgery

Bariatric surgery refers to operations on the stomach and/or intestines that help people with extreme obesity lose weight.

And the outcomes are very promising indeed: surgery can improve metabolic control of diabetes, as well as remission in many instances.

Lifestyle interventions including weight loss and exercise remain the first line treatment for type 2 diabetes but are successful for very few.

Usually, treatment with blood sugar lowering tablets is required and even then diabetes progresses.

It’s often necessary to use a combination of two or more tablets and insulin injections to control blood sugar levels.

While oral drugs and insulin play an important role, they can also cause significant weight gain: this is counter-intuitive for treatment of type 2 diabetes.

So we end up a “catch 22” situation as doctor and patient struggle to treat diabetes by using drugs that can increase weight.

This scenario raises questions about the best strategy for treating diabetes.

So it’s little wonder that bariatric surgery has appeal – it has a dramatic effect on diabetes as well as other heart disease risk factors and it’s cost effective.

Guidance from an international body

The increasing number of bariatric operations for people with type 2 diabetes globally led the International Diabetes Federation (IDF) to issue guidance to health professionals involved in caring for diabetics.

A multidisciplinary group of diabetologists and surgeons met in Belgium in December 2010 to develop a position statement.

The major objective of the statement was to place the role of bariatric surgery in a public health, clinical and socio-economic perspective.

The IDF statement recognises bariatric surgery as an appropriate treatment for obese people with type 2 diabetes who don’t achieve recommended targets with available medical therapies, especially when they face other major heart disease risk factors, such as high blood pressure and high cholesterol.

Surgery should now be accepted as a standard option in people with diabetes with a BMI of 35 or more.

Body mass index (BMI) is a standard way of measuring obesity. It is derived with the formula BMI = weight/height2. The World Health Organisation recommendation is that a BMI of less than 25 is normal, 25 to less than 30 is overweight and greater than 30 is obese.

Surgery should also be considered for patients with BMI between 30 and 35 when diabetes is inadequately controlled despite optimal medical therapy, especially in the presence of other major risk factors.

The IDF report stresses the importance of having a long-term multidisciplinary care team as well as use of safe and standardized surgical procedures.

It now recommends surgery be provided as an option in treatment protocols for obese patients with type 2 diabetes.

Harmonising voices

This builds on the view of an expert group of Australian and New Zealand diabetologists who published their consensus on bariatric surgery in the journal Obesity Research and Clinical Practice.

Bariatric surgery is expensive and, while freely available in the private health system, there is currently very limited access to it in the public arena.

But economic studies have shown it to be cost-effective compared with the lifelong costs of treating type 2 diabetes.

Equity of access to this surgery is a very important issue and there is increasing pressure for greater availability in the public system as argued recently in a widely reported article published in the Medical Journal of Australia.

Such surgery should now be considered earlier in the treatment of type 2 diabetes and no longer held out as a last resort.

The $64-million dollar question is whether there will be a dramatic change in the way type 2 diabetes is managed as a result of introducing what is initially a riskier surgical option.

It’s introduction into treatment protocols could transform diabetes care at large, particularly as up to 60% of people with type 2 diabetes could theoretically qualify.

The IDF position statement is intended to create awareness of the availability of surgery in treating type 2 diabetes when existing medical therapies fail.

Most governments, federal and state, have hugely underestimated the financial costs of obesity and type 2 diabetes.

While bariatric surgery will never be the answer to the public health crisis caused by the obesity and diabetes epidemics, it’s cost effective over the life of an obese person with type 2 diabetes.

Not only that, it can significantly improve the length and quality of life for people with type 2 diabetes.

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