Bariatric Surgery Sends Diabetes Into Remission

For years, many physicians have considered bariatric surgery to be a last resort for treatment of obesity and its complications, like type 2 diabetes. But new evidence has changed that.

“Many physicians aren’t up to date,” says Philip Schauer, MD, Director of Advanced Laparoscopic & Bariatric Surgery for Cleveland Clinic’s Bariatric and Metabolic Institute, who is a co-author of the statement and wrote the section on surgery. “Recent studies show how effective surgery is for improving diabetes and also reducing the risk factors involved in heart attack and stroke and death. And, how safe it is.”

What’s behind the conclusion?

A panel of 19 experts reviewed the literature and took two years to craft the scientific statement. It concludes that patients with type 2 diabetes are at high risk for developing heart disease — and that risk extends beyond the fact that most people who have both also are obese.

For many years, the ADA has recognized lifestyle changes, including diet and exercise, and drug therapies, including medications to lower blood sugar, blood pressure and cholesterol, to be the key treatments for type 2 diabetes mellitus. The statement also includes the latest research in these treatment areas.

But it’s the findings on the profound impact of surgery to send diabetes into remission that Dr. Schauer says is momentous. It demonstrates that the ADA and AHA now realize that surgery is as important a treatment option for patients with type 2 diabetes as lifestyle changes and medications. In fact, in severely obese patients, lifestyle changes rarely work. But research shows that the effect of metabolic surgery goes beyond just weight loss to put diabetes into remission.

Sometimes almost immediate impact

“Although the surgery causes weight loss and weight loss is good for diabetes, we now think of the operations as anti-diabetes procedures or metabolic surgery,” Dr. Schauer explains. “They improve diabetes by mechanisms other than just weight loss.”

And, the remission of type 2 diabetes can happen quickly following surgery.

“It isn’t unusual to see patients who are on high doses of insulin prior to the surgery leave the hospital on no insulin at all and have relatively normal blood sugar,” says Dr. Schauer.

There are several types of metabolic surgery available and the scientific statement outlines risks, benefits and outcomes of each type. In general, Dr. Schauer says gastric bypass tends to be the “most powerful in terms of weight loss and diabetes improvements.” However, the type of surgery a patient has depends on their overall health and comorbidities.

Cleveland Clinic leads the state of Ohio performing up to 800 metabolic surgeries each year.

“The AHA issued this statement because, in addition to diabetes, bariatric surgery does reduce cardiovascular risk factors, but a benefit on cardiovascular outcomes has not yet been established. Studies are ongoing in this area,” says Steven Nissen, MD, Director of the Department of Cardiovascular Medicine at Cleveland Clinic.

Hope for more help sooner, better insurance coverage

With diabetes as the leading cause of blindness and kidney failure in the United States, patients should be referred sooner says Dr. Schauer. And, if they have poorly controlled diabetes, they also should be referred to surgery with a BMI as low as 30. In the past, physicians recommended surgery only for those patients with a BMI of 35 or greater.

“It’s one of the key studies that showed that folks with type 2 diabetes and a BMI between 30 and 35 had just as good an improvement in their diabetes as those with a BMI greater than 35,” says Dr. Schauer. “This is extremely important because the majority of patients with type 2 diabetes, about 65 percent, have a BMI of less than 35.”

The issue, says Dr. Schauer, is that most insurance companies won’t pay for metabolic surgery for patients with a BMI less than 35. And, at a cost of about $25,000 each, only about half of all insurance companies cover weight loss surgeries at all.

“We hope that not only physicians who refer or manage patients with type 2 diabetes will appreciate these findings and recommendations, but we also hope that insurance companies will look at this and modify their coverage policies,” says Dr. Schauer.

Later this year, diabetes organizations from around the world will gather in London to write more formal guidelines for physicians treating patients with type 2 diabetes. Dr. Schauer says metabolic surgery will definitely be a critical part of those guidelines.

For more information, contact Dr. Schauer at schauep@ccf.org.