IDF Endorses Early Bariatric Surgery for Type 2 Diabetics

The International Diabetes Federation (IDF) has issued what it calls a “radical statement” at an international conference today. Saying that gastric banding and similar surgeries should no longer be a last resort for severely obese people with type 2 diabetes, it is recommending that surgery be considered at a much earlier stage.

A Position Statement released at the 2nd World Congress on Interventional Therapies for Type 2 Diabetes meeting in New York City today said: "The dramatic rise in the prevalence of obesity and diabetes has become a major global public health issue. The problem is complex and will require strategies at many levels to prevent, control and manage.

According to the IDF Statement, there is increasing evidence that the health of obese people with type 2 diabetes, including the metabolic control of diabetes and its associated risk factors, can benefit substantially from bariatric surgery – that is, surgical procedures to produce substantial weight loss.”
Gastric bypass surgery works by reducing the size of the stomach so a person can’t eat as much and shortening the length of the intestine so that the body doesn’t absorb too many calories. But it might also have the side effect of normalizing blood sugar.

Gastric bypass surgery works by reducing the size of the stomach so a person can’t eat as much and shortening the length of the intestine so that the body doesn’t absorb too many calories. But it might also have the side effect of normalizing blood sugar.

Although such operations cost anywhere from $20,000 to $30,000, they will reduce healthcare expenditures in the long run, according to a new IDF position paper on the subject. The surgery, the IDF explains, often normalizes blood glucose levels and reduces or avoids the need for medication.
In addition, curbing diabetes can stave off costly complications such as blindness, limb amputations, and dialysis, says Francesco Rubino, MD, director of the IDF’s 2nd World Congress on Interventional Therapies for Type 2 Diabetes.

“When we talk about whether we can afford bariatric surgery, we have to ask what will be the cost if we don’t treat the patient. Studies have shown the surgery to be cost-effective. So there is a return on investment,” says Francesco Rubino, MD, director of the IDF’s 2nd World Congress on Interventional Therapies for Type 2 Diabetes.

The IDF puts the lifetime cost of diabetes in the United States at $172,000 for a person diagnosed at
age 50 years and $305,000 at age 30 years. More than 60% of this amount is incurred in the first 10 years after diagnosis.

The new recommended indications for performing bariatric surgery on patients who are both diabetic and obese match those announced last month by the US Food and Drug Administration for expanded use of the Lap-Band Adjustable Gastric Banding System (Allergan) to treat obesity.

The IDF recommendations dovetail with Dr Rubino’s previous research on how bariatric surgery alleviates diabetes. He showed that the effect on diabetes is not entirely explained by a person’s weight loss. In fact, the gastrointestinal tract serves as an endocrine organ and a key player in the regulation of insulin secretion, body weight and appetite, which is why altering the GI tract has such profound metabolic effects.

However, the use of bariatric surgery to treat diabetes has sparked controversy in healthcare circles.
Critics question the wisdom of wielding a scalpel to solve a medical problem, especially when clinicians have more drugs at their disposal to deal with diabetes.

A study published online last week in the Archives of Surgery has raised doubts about the efficacy of LAGB. Researchers following 151 patients who underwent LAGB for obesity concluded that the procedure yielded “relatively poor long-term outcomes,” with nearly half the patients needing their bands removed and 60% overall requiring some kind of reoperation. The authors, who performed the surgeries in question during the mid-1990s, added a caveat: they had used an older dissection technique.

Indeed, the biggest danger is that new weight-loss options like EndoBarrier (developed in the UK), Lap-Band, Roux-en-Y gastric bypass and sleeve gastrectomy surgery have the potential to encourage overweight people to abandon traditional diet and exercise for procedures that carry some serious risks. That should be a big worry for all diabetes educators and activists.

See my full blogpost here

My feeling about gastric surgery it that it’s a lot like putting a bucket under a leaky sink instead of calling a plumber to fix the leak. Yes, the bucket “stops” the leak from getting water all over the floor, but did you really fix the problem? Or are you just delaying it until the bucket gets full?

I am clinically (morbidly) obese. I didn’t get this way from eating too much lettuce, too much broccoli, too much asparagus or cabbage – or lean protein – or blueberries, for that matter. Creating a stomach that is too small/constricted to hold/process celery or romaine or collards or other “fibrous” veggies makes no sense to me. Having to sip water all day long because you can’t just drink a glass of water? How is that healthy or helpful if you want to get out and exercise during the summer?

It’s not the size of the stomach, it’s what you choose to put in it.

Plenty of post-op people game the system by sipping on milkshakes or frozen yogurt or smoothies. Why? Because they still crave simple carbohydrates mixed with fat. I remember telling someone once, in response to a question about “the perfect food”, that if I was limited to only one food for the rest of my life (health being no issue in this hypothetical) that I would choose chocolate covered macadamia nuts. Why? Because that’s the most fat-plus-sugar you can fit into one square inch.

The desire to binge on carbs mixed with fat resides in the brain chemistry, not the stomach capacity. If your brain cannot properly process/manage neurotransmitters like dopamine and serotonin, then having a smaller stomach capacity won’t fix this problem – that’s why so many people gain back so much of the initial weight loss – the surgery doesn’t fix the underlying brain chemistry problem – they’re still driven to self-medicate their feelings of pain and discomfort with things like frosting and fudge (fat plus simple carbs).

I have read about post-surgery folks going right over to becoming pot abusers or drug abusers because they feel awful but can’t get their “fix” via food; they feel driven to other drugs/chemicals/addictions.

How is that helping them as a whole person? Maybe they (temporarily) have better blood glucose readings, but now they’re drug addicts or losing their job to a ganja habit or slowly regaining due to “cheating” with blended drinks? Are they better off?

The surgery can run from $30,000 to over $100,000 (with complications). Did anyone get their money’s worth?

The surgery may help some people, but the idea of wholesale cutting out of body parts with such a dismal compendium of complications, deaths, relapses, rejections of devices, repeated surgeries and post-op addictions, it all seems like a really poorly designed experiment with fat people as the guinea pigs.

Would we accept the same rate of negative outcomes if the surgery candidates were cute little toddlers, instead of the culturally despised morbidly obese?

I saw something intersting on this topic this morning. They said that making the stomach smaller was not the reason that type 2 diabetes would “reverse” according to the segment. It was the chemical reactions they were triggering that was causing the reversal.

Here is what they said

Patients will not have any component of malabsorption that happens with the gastric bypass and the biliopancreatic diversion. It’s suggested that the hormonal and chemical changes that happen with the gastric bypass and biliopancreatic diversion, don’t happen with banding so the weight loss is less effective and takes longer time for the weight loss to occur.

It appears they are triggering some kind of chemical change. I think only some people could benefit from this and not all people. I think we have all seen that even within type 2 diabetes there are different types.

Who knows maybe if they can reproduce the chemical change that occurs some good knowledge would come from that.

Any comments on 2 other options: EndoBarrier (a British procedure) and DIAMOND system (a German implantable device)?

(I’ve written about both on my blog Diabetes Dialectics. Would appreciate comments)