How Bariatric Surgery Impacts Type 2 DiabetesApril 20, 2020
Find out how Bariatric Surgery impacts Type 2 Diabetes!
It is important to know how bariatric surgery impacts Type 2 Diabetes. Blood sugar, like many other physiologic parameters, is regulated by the body. The brain and all the cells in your body require sugar as one of the molecules that act as currency to support the metabolic processes that occur within each cell, tissue, and organ. I'll discuss Type 2 Diabetes in this article.
The Process of Gluconeogenesis
Sugar comes from our diets; it is stored as glycogen and is also produced by the body through a process that is called gluconeogenesis. The regulation and transport of sugar throughout the body is a complex system that includes insulin, which is a hormone produced by the pancreas, which helps to transport glucose out of the bloodstream and into the cells.
Our bodies must be able to produce and utilize insulin properly to keep blood sugar parameters within normal range so that we can go about our daily lives and pursue any activities and sports of our choosing, all sustained by food intake concentrated into just a few meals per day.
In general, when the regulation of blood sugar is impaired, that person can be at risk for extremely low blood sugar (hypoglycemia) or extremely high blood sugar (hyperglycemia leading to ketoacidosis). Both can be fatal if not immediately treated.
Monitoring Blood Sugar Levels
Diabetes is a chronic disease that impairs the body’s ability to regulate blood sugar. Diabetic patients must closely monitor their blood sugar levels because even mildly elevated blood sugar levels can cause damaging effects to the lining of blood vessels, which causes damage to organs over time. If left untreated, diabetes can lead to heart attacks, strokes, kidney damage, and blindness, among other health problems.
Type 2 diabetes is a chronic disease where the body either doesn’t make enough insulin or is unable to utilize insulin properly due to insulin resistance.
The result is that too much sugar stays in the bloodstream and is unable to reach the cells. A multitude of medications exists to treat diabetes, including numerous forms of insulin as well as oral medications whose mechanisms of action range from stimulation of glucose uptake into cells, to promoting insulin release from the pancreas, to affecting glucose reabsorption by the kidneys.
Exercise can also help lead to positive changes in blood sugar regulation over time by improving how the body utilizes insulin. Exercise also helps improve lipid profiles, which reduce the overall risk for heart attack, stroke, and vascular disease.
Type 2 Diabetes is a Progressive Disease
What we do know about Type 2 Diabetes, and diabetes, in general, is that it is both a complex disease and a progressive disease.
Because of this, every case of diabetes is serious; thinking of it as anything less only allows the disease to progress more rapidly and results in more potential damage in the end. Once diagnosed, diabetes should be treated and monitored by a team of healthcare professionals able to help manage the disease and help prevent its progression as much as possible.
Every patient with diabetes has a different level of severity, and each patient will have their own response to the various treatments for diabetes. Hemoglobin A1c (HbA1c) is a blood test that is commonly done to diagnose diabetes. It is a way to estimate how well the body has been regulating blood sugar over the past 2-3 months.
- If the HbA1c level is high, it indicates that the patient has diabetes and/or needs better diabetic control. It is used along with blood glucose checks to monitor how well someone is doing with their diabetic treatment regimen.
- If the HbA1c is greater than or equal to 6.5%, that indicates diabetes, and blood sugar goals of around 80-120mg/dL are used to tailor therapy.
Therefore, every diabetic patient needs individualized and ongoing care from the time they are diagnosed and must be monitored for life. Due to the need for monitoring, multiple supplies, and medications to keep this disease in check, as well as the end-organ effects that it can cause, diabetes incurs extreme costs to our healthcare system.
The estimated annual cost for treating and managing diabetes in the United States is 327 billion dollars. It is estimated that about 85% of people with diabetes are overweight.
As you can see, diabetes is a big problem. It is difficult to treat, causes multiple other health problems, and remains without a cure in sight. Put that together with the obesity epidemic (70 million adults in the US), and the result is that obese patients with diabetes are at a high risk of death from cardiovascular disease.
To top it all off, glycemic control is even more difficult to achieve in obese patients with medications and lifestyle modifications alone. But what if there were yet another untapped tool to help these patients achieve better and longer-lasting control over diabetes in addition to medications, specialized diabetes-care teams, and exercise?
Diabetes and Bariatric Surgery
Enter bariatric surgery as the lesser-known David to the age-old Goliath problems known as Diabetes and Obesity. Check out how bariatric surgery to treat diabetes, you may be asking yourself, well, it’s true.
This topic has been the subject of intense study for at least the past decade in multiple clinical studies comparing conventional diabetes management (medications and lifestyle changes) with bariatric surgery—namely sleeve gastrectomy and gastric bypass, as these operations are the most commonly performed in the US. Bariatric surgery was endorsed as an official treatment for Type 2 diabetes in obese patients by the International Diabetes Federation, American Diabetes Association, and American College of Surgeons in 2016.
In addition to being more effective than diet and exercise alone, bariatric surgery is effective for long-term weight loss and is associated with remission rates of up to 70% for Type 2 diabetes in short to medium-term follow up.
In the STAMPEDE trial (Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently), patients who underwent gastric bypass or sleeve gastrectomy were significantly more likely to achieve an HbA1c level of 6.0% or less at five years post-surgery with or without medications (29% for bypass, 23% for sleeve), as opposed to 5% of non-surgical patients on medications alone who were able to achieve the same HbA1c endpoint.
More than 88% of the sleeve or bypass patients achieved glycemic control of 7.0% without the use of insulin, and the majority of patients that achieved the HbA1c target of 6.0% did so without the use of diabetes medications. In contrast, none of the patients in the medical-treatment-alone arm achieved the same HbA1c without medications.
Duration of Diabetes and Bariatric Surgery
The duration of the disease was also important, with patients having diabetes for less than eight years as the main predictor of achieving the HbA1c of 6.0% or less. Long-term diabetes remission (more than five years post-surgery) rates seem to be higher amongst post-bypass patients (49%) compared to post-sleeve patients (28%).
However, the ultimate choice of the bariatric operation must also take into account all of the patient’s comorbidities and medical conditions. For example, high-risk patients, patients with Crohn’s disease, patients who are on the organ transplant list or currently have a transplanted organ, and those that employ frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs) are better candidates for the sleeve gastrectomy.
The ultimate decision of which surgery to have is decided between the patient and the surgical team for the best outcome. In the end, if Type 2 diabetes is on your list of current medical problems, could you too be among those who can escape the damaging effects of diabetes?
Ask yourself how life might be different without the need for insulin anymore, or how your life will be improved with weight loss and less need for medications in general. To learn more, check out what the ASMBS says about escaping diabetes.
ABOUT THE AUTHORLora Melman MD, FACS, FASMBS is a Fellowship-trained, Board-certified, and daVinci robot-certified Specialist at Advanced Surgical & Bariatrics of NJ, PA. She offers patients the latest in cutting-edge surgical techniques together in combination with Enhanced Recovery Protocols (ERAS) and the benefits of Multi-modal peri-operative Pain Management. Her extensive experience in combining these strategies helps to reduce recovery time and hastens return to normal activity. Dr. Melman's goal is to work closely with patients to help them achieve optimal outcomes while also minimizing risk(s) of postoperative complications.