BMI 37 have to have 40 should I get it up there or do sleeve

HI Everyone
My first post
210 lb  - BMI 37
46 yrs old
Type 2 diabetes
Slight cardiomyaphy from chem/radiation 12 yrs ago

I was cleared for surgery

I am interested in the DS but right now my doctor requires BMI 40 and I am 37. They advised to do the sleeve. I have 80 lbs to lose.and would like to lose the Type 2 diabetes   I don't think the sleeve alone will do it

I am concerned if I do the sleeve my insurance won't cover the DS later.
Question -- should I just get my BMI up to 40 ( we all know 20 lbs can't be too hard)  I can have  the DS  OR just do the sleeve since my insurance has approved it and it would not cost me anything to do this year.

I am really stressing over this.
I went to class for the Rouen Y but it was not for me. 
Appreicate input

If you only need to lose 80 pounds, why do you feel you need the malabsorption of the DS?  Personally I'd go with the sleeve.  Will your surgeon even operate on you if you purposely gain weight just to get a different surgery?

Kelly

Sounds to me like they want the DS primarily for the type 2 diabetes, not because of the "only" 80 pounds to lose.

This is a stupid rule on your surgeon's part - can you consult with another surgeon? I don't believe Inman is the only DS surgeon in your neck of the woods. I know multiple people who had the DS at a BMI lower than 40 and did very well. With a BMI of 35+ and a major comorbidity (type 2 diabetes), you qualify for whichever WLS procedure YOU choose. IF your surgeon won't do what YOU know you need, fire them and get a new one.

I agree with what Jillybean said---find another surgeon. Given you have Type II diabetes, you REALLY want to get the full DS.

If at 210 your BMI is 37, I'm guessing you're 5'3". Gaining 15 pounds will give you a BMI of 39.9. Is there any chance you're actully a trifle shorter? We do tend to shrink in height as we age...

Wow!  I actually wanted the sleeve, but my ins only covers the band or RNY.  I don't think gaining weight is a good option to qualify for a surgery, but everyone has to do what's right for them.  I do know that with my dr. if you gained even 1lb durring the 6 months of pre-op dieting, you had to start the process all over again.  Make sure you have all of the facts before you try something like that.  Good luck!

 I was 59 when I had the sleeve last year and was dx with type 2 diabetes about 12 years ago.  From the day of the surgery, I took no more diabetes meds and my A1C has been between 5 and 6 on every test.  I am so grateful that I got the sleeve because I had no issues with absorption, can eat anything I want without fear of digestive issues, and don't have to worry about taking a potload of vitamins for the rest of my life.   It's like I have a normal life!  

As a "lightweight", you may do quite well with a sleeve, especially if you are a volume eater, and just need help with portion control.

The main things that would make me push for DS (and you may already know this) is if your weight problem is from metabolism issues whether from genetics, years of dieting or whatever, rather than volume eating, and the resolution of the T2 diabetes.

You do not have to get your BMI higher for the DS. The BMI should only have to be 35 if you have co-morbs, so it's not hard to fight the insurance on that one.

I would NOT get the sleeve if the DS is what you want, since insurance companies are increasingly adding a "one WLS per lifetime" clause, so you may lose your chance to revise in the future.

Also, if you don't lose enough, you may have a lower BMI, making harder to get approved, but still be obese, so if you don't feel the sleeve is what you actually want, then don't just get is thinking it can be part one, withe the rest of the surgery later. Besides, surgery is hard enough, so putting your body through one surgery instead of 2 or more is best.

I will be the first to say I know NOTHING about having diabetes (other then my mother had it) but I do know several people on the VSG forum who said they had diabetes before surgery and don't have it now.  You might want to post on the VSG forum and ask them all about it.

Best of luck to you!

Ms Shell

Okay, I went round and round trying to decide. When I first started I was going for the Sleeve but my primary insurance doesn't allow for that. And my previous surgeon would not do a LW (my BMI is 35.4) so after finding the info I did about the RNY, I went hunting for another surgeon. I only have 68 lbs to lose.

Now, the sleeve doesn't have enough long term info on diabetes resolution. It may do as well as the DS but we won't know for a few more years (10-15) and I don't have that kind of time.

I am insulin dependent and on a pump. I also have PCOS. Both have a much higher resolution that any other surgery at this point in time.

Now, I hope you are allowed if you want to do a revision later on from the sleeve to the DS but some of us have insurance companies that leave us a "one shot deal".

So after doing research on many aspects of both, the DS is better not just for resolving diabetes but for keeping it away from your door down the road. I spent much time over on the RNY board and time after time, I saw threads about hypoglycemia. So I looked it up on my favorite diabetes format, the endocrinologists that TREAT diabetes.

Here is what I found:
Endocrine News
Patients who undergo Roux-en-Y gastric bypass surgery (RYGBP) experience many benefits such as dramatic weight loss and type 2 diabetes remission. Yet, they also face a risk for developing severe postprandial hypoglycemia due to gastric dumping.

Researchers have observed elevated levels of the incretin glucagon-like peptide 1(GLP-1) postsurgery, which has been linked to increased β-cell proliferation and differentiation. A research team led by Josep Vidal, M.D., Ph.D., at the Hospital
Clínic Universitari in Barcelona, Spain, investigated whether a rise in this hormone could over time cause this severe setback.

The team divided 24 women into three groups according to time after RYGBP (9–15 mo, 21–30 mo, and > 30 mo). Controls were 8 additional normal weight and 8 morbidly obese women. The subjects fasted overnight and ate a standardized test meal the following day. Blood samples to measure GLP-1, immunoreactive insulin, plasma glucose, and glucagon were taken beforeeating and 10, 30, 60, 90, and 120 minutes after the meal. The patients also underwent an intravenous glucose tolerance test to look for insulin secretion and insulin sensitivity and used a continuous glucose monitoring system to record their postprandial glucose profiles.

In an upcoming article in The Journal of Clinical Endocrinology & Metabolism,* the researchers report that although GLP-1 rose steadily after RYGBP, it did not eventually cause inappropriate insulin secretion. Additionally, their data did not reflect a link between asymptomatic postprandial hypoglycemia in the RYGBP-operated women and an unsuitable relationship between β-cell function and insulin sensitivity. The researchers called for further studies to examine why some patients develop severe postprandial hypoglycemia.

While that article says there wasn’t enough evidence at this time, it did give me pause in that they are even considering the issue.

Then there was a blog article from the EndocrineToday that intrigued me:

Hypoglycemia after Roux-en-Y surgery for weight reduction
Posted by Michael Kleerekoper, MD, MACE April 7, 2009 11:26 AM
Endocrine Today Blog

Seven years ago, my patient had a Roux-en-Y procedure to fight her obesity, and the result was just what she wanted — substantial weight reduction and “no more diabetes" as she reported with a huge smile. Her weight had been stable for a few years, and she was comfortable with it. Four months before her office visit, and for reasons she could not explain, she felt the need to go on a weight-reduction diet during which she lost 12 lb. Two months before she was referred to me, she began to experience episodic hypoglycemia. In her early post-surgery period, she had experienced very typical “dumping syndrome" symptoms, but they had finally cleared and the recent episodes of hypoglycemia seemed quite different.

At 10 p.m. one evening, she felt weak and her capillary blood glucose was 50 mg/dL. This was several hours after dinner. Over the next several weeks, she had a CBG of 53 at 7:45 p.m., 59 at 10:30 p.m., 45 at 3:30 p.m., and most worryingly to her, she woke at 1 a.m. one night feeling very unwell and disoriented, and her CBG was 45 mg/dL. She never experienced fasting hypoglycemia.

Physical examination was essentially normal aside from a suggestion of hyper-pigmentation of her abdominal scar and palmar creases. Pulse and blood pressure were normal as were visual fields and the thyroid examination. Her laboratory findings were also all normal, including electrolytes, fasting blood glucose of (89), insulin, C-peptide, cortisol and adrenocorticotropic hormone.

The history had many characteristics of the dumping syndrome, but several pieces of information did not quite fit. Dumping syndrome is not uncommon in the early months after a Roux-en-Y procedure, but patients generally adapt well by taking frequent very small meals, and over time, the syndrome seems to resolve. Additionally, why did the hypoglycemia occur only several hours after a meal and not sooner? She tried several approaches to changing her eating habits, but these episodes persisted.

I discussed this case with my colleague Dr. Anu Puttagunta, who had cared for a patient with much the same history. This late (post-weight-reduction surgery ) and delayed (post-meal) hypoglycemia has been reported,1, 2 but the mechanism remains elusive as far as I could tell from my reading. The articles reported that some patients did respond to frequent small meals that had little carbohydrate while others only responded when the diet change was accompanied by acarbose.

In some patients, it appears that acarbose alone was sufficient. Dr. Puttagunta’s patient did well with diet modification plus acarbose, so I have begun that same therapy on my patient. She had found those same articles on her own, had modified her diet and had no subsequent episodes of hypoglycemia, but that was not reassuring to her because they were so episodic. When adding the acarbose it was important to remind her to take the tablet (I started with 25 mg three times per day) as soon as she takes her first bite of food. I will report her progress after a few months.

1: Kellogg TA. Surg Obes Relat Dis. 2008;4:492-499. PMID: 18656831.
2: Moreira RO. Obes Surg. 2008;18:1618-1621. PMID: 18566871.

But was was the final straw that pushed me into the DS camp were the guidelines published for the Endocrine Society in March 2009.
Evaluation and Management of Adult Hypoglycemic Disorders:
An Endocrine Society Clinical Practice Guideline
First published in the Journal of Clinical Endocrinology & Metabolism, March 2009, 94(3): 709-728

Hypoglycemia can occur as a result of hyperinsulinism in the absence of previous gastric surgery or after Roux-en-Y gastric bypass for obesity. (pg8)

Some persons who have undergone Roux-en-Y gastric bypass for obesity have endogenous hyperinsulinemic hypoglycemia most often due to pancreatic islet nesidioblastosis, but occasionally due to an insulinoma (48–50). With nesidioblastosis, spells of neuroglycopenia usually occur in the postprandial period and develop many months after bariatric surgery. Spells of neuroglycopenia that occur in the fasting state soon after bariatric surgery are more likely due to a preexisting insulinoma (51). The predominance of women with post-gastric-bypass hypoglycemia may reflect the gender imbalance of bariatric surgery. The precise mechanisms of hypoglycemia remain to be determined (52–54). The incidence of this disorder is unknown, but at the Mayo Clinic the number of cases exceeds, by a considerable degree, that of insulinoma. Partial pancreatectomy is recommended for nesidioblastosis in patients who do not respond to dietary or medical (e.g. an a-glucosidase inhibitor, diazoxide, octreotide) treatments. (pg11)

I checked the document for any mention of the DS and there weren’t any but there were the two references to the RNY.

I have reactive hypoglycemia within my diabetes already. I don’t need a surgery that will make that worse.

Those are my reasons...you need to really research all options and yes, the sleeve may suit you quite well. IF I could get the sleeve, I may have been still be heading that way.

And come join us on the LW board where you will find many of us in your boat.

Liz