Is Controlling Type 2 Diabetes a Benefit of Bariatric SurgeryJune 1, 2020
In most weight-loss surgery stories, increased mobility is one of the star benefits. But perhaps the most important life-changing “side effect” of bariatric surgery is its ability to improve or even cure type 2 diabetes.
Type 2 Diabetes
More than 30 million people in the United States have diabetes. The vast majority, 90 to 95 percent, are type 2. Obesity is a potent risk factor for type 2 diabetes, which is responsible for millions of death and disabilities each year. But unlike type 1 diabetes, we can often cure or prevent type 2, and not just with diet and exercise. I've done it many times, in a matter of hours.
It's not simple or easy, but the right type of bariatric surgery can immediately cure type 2 diabetes, even before weight loss occurs.
First, let’s talk about why obesity doesn’t just put you at risk for diabetes but makes the disease worse if you develop it. There seem to be three different mechanisms at work. First, obesity causes more insulin resistance by making changes in the way your cells respond to insulin.
Second, we know that obesity causes inflammation, which makes blood sugars rise, along with putting a strain on your cardiovascular system. And finally, adipose tissues -- fat cells -- produce hormones that raise blood sugar levels.
Now, your doctor may have told you that you are diabetic or prediabetic and suggested that you lose some weight. That seems like great advice because we know that losing 5 to 10 percent of your body weight reduces your diabetes risk and significantly improves your overall glucose control. The problem is, most people aren’t able to do that and maintain it on their own.
Doctors are Starting to Understand Obesity
Medical providers still offer that advice because, for a long time, we thought obesity was simply a matter of lifestyle choices. As doctors, we are just now really starting to understand obesity. When I started out, they still told me that people were overweight because they ate too much or didn’t exercise enough. Today we know there is a huge genetic factor in how you metabolize food. There are hormones that we didn't know what they did or where they were from. Today we have a better understanding of how they contribute to obesity.
So, if you can't lose weight and maintain it, you'll need to be treated medically. We have several types of medications available to help your body respond to insulin. There is even a drug now that prompts your body to dump excess glucose into your urine to get rid of it. But none of these are a cure. Often, the damage to the cardiovascular system, vision, and kidney function is slowed with the use of medications. But it doesn't stop it altogether.
Eventually, many type 2 diabetes patients end up needing daily insulin injections as the disease progresses. Folks who are morbidly obese are most at risk of becoming insulin-dependent and of suffering side effects ranging from kidney failure to limb amputation resulting from neuropathy and chronic infections. Diabetes is the 7th leading cause of death in the U.S.
Is Bariatric Surgery a Hope for a Cure of Type 2 Diabetes?
Bariatric surgery can offer hope for a complete cure for type 2 diabetes. Yes, successful weight-loss surgery requires a commitment to significant lifestyle changes. You can't have surgery then go back to the old way of doing things and expect lasting change. But not all of the lifestyle changes are difficult. You won't eat the same way you are used to. But you also won't be pricking your fingers for blood tests multiple times a day, injecting insulin into your belly or just plain feeling lousy when your blood sugars aren't in check. Virtually all of my patients are thrilled to make this trade-off.
How successful is bariatric surgery in treating and curing type 2 diabetes? In 86-87 percent of patients, diabetes becomes significantly easier to control after weight-loss surgery. Some who were insulin-dependent become able to manage the disease with oral medications. Most spectacularly, up to 78 percent of patients will see a complete cure.
For many patients, their diabetes improves right along with their weight loss.
That makes sense, given the connection between obesity and diabetes. But we now know that certain types of procedures are better than others at curing diabetes, often even before weight loss occurs.
Bariatric surgery has two major types. The first is restrictive. This includes the gastric sleeve and lap-band procedures that restrict the amount of food you can consume at one time. The second type is malabsorptive procedures, such as gastric bypass and duodenal switch. These procedures don’t just restrict your capacity, and they create a shortcut through the digestive tract that prevents your body from absorbing as much of what you eat.
Restrictive procedures do a nice job of treating diabetes, especially if you haven’t had it more than a few years, and you aren’t using insulin injections. At a year after surgery, malabsorptive and restrictive procedures work about the same for these patients.
But if you’ve had diabetes 10 years or more or if you need insulin injections to manage your diabetes, a malabsorptive procedure offers a much better chance of a cure. There are a couple of theories about why this is. One theory is that when we bypass the duodenum, it raises the level of a specific hormone that helps the body use insulin efficiently. The other theory is that simply because food makes it further down the bowel before it’s digested, it helps stabilize glucose. What we do know for sure is that bypassing the duodenum can cure type 2 diabetes, even if we don’t know exactly why or how.
Indeed, in my practice, a lot of patients are cured before the operation is finished. After surgery, they never go back on diabetes medication again. I’ve had patients who are highly insulin resistant, taking hundreds of units of insulin a day, come off it completely. These are the patients whose lives change most dramatically after weight loss surgery.
Factors to Consider in Terms of Bariatric Surgery
There are a lot of factors to consider in terms of bariatric surgery. If you have diabetes or prediabetes, you should begin an aggressive weight loss program. If you are at a BMI of 35 or higher and can’t lose weight on your own, you should seek a consultation with a bariatric surgeon. Don’t assume you won’t be a candidate because of age -- I’ve operated on patients into their 80s and patients already on kidney dialysis. The improvements in blood pressure and overall health are still dramatic. And don’t delay. The longer you have diabetes, the less likely it is surgery will offer a cure, and the more likely it is, you will suffer complications from the disease.
Some factors relating to obesity and diabetes are out of your control. You can’t change your genetics. Significant weight loss when you are morbidly obese is extremely difficult on your own. But with the help of an experienced bariatric surgeon, you can take charge of your health.
ABOUT THE AUTHORDr. James Sebesta, MD is a Fellow of the American College of Surgeons & a Fellow of the ASMBS. He is a Bariatric Surgeon at MultiCare Tacoma General Hospital in Tacoma, WA &
MultiCare Center for Weight Loss & Wellness in Olympia, WA. He treats obesity, gastroesophageal reflux disease, abdominal wall hernias, breast cancer, as well as other gastrointestinal surgical diseases. Dr. Sebesta understands that achieving — and maintaining — a healthy weight means different things to different people and the path that you take to get there is as unique as you.