By Marika Sboros
I’m always somewhat unnerved when doctors encourage diabetics to have bariatric (stomach) surgery before they’ve tried more effective, safer, less invasive methods. Like simple dietary changes.
Yet diabetes specialists across the world are calling for a radical mindset shift in treatment for type 2 diabetes. They say that the surgery is close to the medical holy grail of a type 2 diabetes “cure”.
In a special issue of Diabetes Care, 45 international organisations published a joint consensus statement. It contains new guidelines recommending stomach surgery for type 2 diabetics even for patients who are only mildly obese.
The groups say that extensive clinical trials show that the surgery can improve blood-sugar levels more effectively than lifestyle or drug intervention methods. They also say that surgery may lead to long-term remission.
Risks v benefits
The statement follows the second Diabetes Surgery Summit in September 2015 at King’s College London. Joint organisers were Diabetes UK, the American Diabetes Association, International Diabetes Federation, Chinese Diabetes Society and Diabetes India.
Bariatric surgery is the umbrella term for metabolic, gastrointestinal procedures originally designed to induce weight loss in morbidly obese patients. It involves the cutting, manipulating or bypassing parts of the stomach or intestines.
It includes Roux-en-Y gastric bypass (RYGB). RYGP is a common stapling method that reduces the size of the stomach to a small pouch. Bariatric surgery also creates biliopancreatic diversion – the effect of surgery to remove large sections of the stomach.
There is robust evidence to show that bariatric surgery can be life-saving for morbidly obese people. However, it is invasive and the success rate is not high. Complications can also be lethal and include heart attack, stroke, pulmonary embolism, internal bleeding and premature death.
So it should be worrying when doctors advise this as first resort, especially for diabetics who are only mildly obese.
Twin epidemics of obesity, type 2 diabetes
Below is a revised article I wrote in Business Day newspaper in 2016. It followed diabetes groups globally who are still calling for routine use of stomach surgery to treat type 2 diabetes.
Diabetes is a major cause of kidney failure, blindness, nerve damage, amputations, heart attack and stroke. Type 2 diabetes is a global epidemic. Research shows that the number of diabetic adults quadrupled from 108-million in 1980 to 422-million in 2014.
SA is facing the twin epidemics of obesity and type 2 diabetes. The incidence of both has increased so rapidly that doctors now refer to it as “diabesity”.
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The authors say that most cases of diabetes (about 90%) are type 2. They also say that fewer than 50% of patients are able to control their blood-sugar levels adequately with diet, exercise, or drugs. Therefore, this makes bariatric surgery a viable option, they say.
But other experts say this finding is unscientific. They describe it as “dangerous” and a “dark day for patients, possibly a gift for lawyers”.
Surgery a boost ‘independent of weight loss’
UK professor of metabolic and bariatric surgery Dr Francesco Rubino is a major advocate of the new guidelines. Rubino, of King’s College London, has been researching the link between gastrointestinal surgery and glucose homeostasis since the late 1990s.
He was one of the first to provide experimental evidence that bariatric surgery can improve diabetes independently of weight loss.
Rubino is lead author of a study in Diabetes Care investigating costs and benefits of meeting potential demand for metabolic surgery in the UK and US.
In a commentary in Nature, Rubino says that the new guidelines come nearly 100 years after the first clinical observations that stomach surgery can improve or resolve diabetes. He has witnessed “first-hand how getting to this point has required many clinical scientists to put aside long-standing preconceptions”.
Future progress will require “more thinking outside the box”, Rubino says.
A strong case for surgery?
Prof Jennifer Rubin, from King’s College London Policy Institute, says that the case for increasing the uptake of bariatric or metabolic surgery appears strong enough. It should engage policymakers and practitioners in “a concerted discussion of how best to use surgical resources in conjunction with other interventions in good diabetes practice”.
South African endocrinologist Dr Tessa van der Merwe is honorary clinical professor and researcher at the University of Pretoria. She is also chair of the South African Society of Surgery for Obesity and Metabolism and CEO of Centres of Excellence for Metabolic Medicine and Surgery in SA.
Van der Merwe says that currently “the only means of achieving complete or partial remission of diabetes” is surgery. It can also resolve other comorbidities (coexisting diseases) and improve quality of life drastically, she says.
Metabolic and bariatric surgery is rigorously controlled in SA, Van der Merwe says. The most frequently performed bariatric surgery in SA is laparoscopic RYGB. It remains “the gold standard for metabolic surgery”.
Cost to patients
Costs to patients vary, depending on their medical aid. Most large medical aids will contribute “a significant amount towards treatment costs. However, at this stage, schemes will only consider patients at a BMI (body mass index) above 35kg/m²”.
As a general rule, the total co-payment for patients on medical aid is about R30,000 for RYGB and R50,000 for BPD, she says.
Worldwide, the criteria for acceptance of a diabetic into a metabolic surgery programme have shifted downwards. These now include a BMI of 30 and above, says Van der Merwe.
“This is not a radical step”, she says. Rather, it is a “carefully considered move, based on many years of research and outcome data”. And anyway, doctors who are overly critical usually “don’t have significant experience or knowledge of this field”.
A different view
South African-born Dr Robert Cywes, a bariatric surgeon and researcher in the US, begs to differ. Cywes says that the data showing that surgery resolves Type 2 diabetes are “at best currently anecdotal and associative”.
The data do not show that surgery is the reason that diabetes resolved. Nor is resolution a result of weight loss, he says.
Doctors must understand the causes of diabetes and how bariatric surgery resolves symptoms. There is currently “no causal pathway directly linking surgery to the resolution of type 2 diabetes”.
There is research to show a 95% resolution in type 2 diabetes symptoms after RYGB in adolescents. However, doctors need to understand the mechanism “far more carefully than simply assigning the correlation between (the) surgery and resolution of Type 2 diabetes as causal”.
Type 2 diabetes may be associated with an increase in weight or with obesity. However, this relationship is not causal, Cywes says. The duration of any resolution of diabetes can be permanent – but only if the patient understands and maintains “the true reason why it resolved transiently after surgery”.
Real cause of type 2 diabetes …
Cywes is clear about the real cause of type 2 diabetes: It is chronic, excessive total carbohydrate consumption. Research shows that excess carb intake is causal both to obesity and type 2 diabetes, he says.
“When people consume more carbohydrates over time than the pancreas can produce insulin, the gap is called type 2 diabetes,” Cywes says.
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“Once insulin production peaks, weight gain plateaus. That’s because there’s not enough insulin to convert all the excess sugar to fat. Blood glucose rises and this leads to type 2 diabetes.”
Cywes says that weight loss after bariatric surgery lasts no more than one to three years. After that, few patients lose any further weight — unless there are complications.
Eating through ‘dumping syndrome’
If patients don’t change their eating behaviour radically, and in particular tackle their carbohydrate addiction, both the weight and the diabetes return over time.
This is especially true of patients who figure out a way to eat through the “dumping syndrome”, also called “rapid gastric emptying”. It is common following bariatric surgery procedures that bypass or remove some or all of the stomach.
“Only a radical reduction in total carbohydrate consumption can cause type 2 diabetes to go into remission,” says Cywes.
The truth, therefore, is that you cannot have type 2 diabetes if you do not consume carbohydrates, he says.
US professor of cellular biology at New York State University, Dr Richard Feinman, is similarly critical of the new approach.
He says that groups that have endorsed bariatric surgery for type 2 diabetes have given themselves a privilege. That is “to ignore the scientific data on differences in diets and the evidence that low-carb is first choice”.
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