Treatment Options for Type II Diabetes
Bariatric surgery has been known to improve or even put Type II diabetes into remission. For this reason a summit was held in London last September 2015 (2nd Diabetes Surgery Summit DSS-II). It was a multi specialty group of 48 international scholars, of which 75% were non surgeons from Asia, Europe, and North and South America. Their task was to define the surgical options for Type II diabetes based on the evidence in the medical literature. Their results and recommendations were reported this month in the ADA Journal Diabetes Care. Following is a summary of their important findings.
Over the past 20 years, remission of Type II diabetes has been observed in a high percentage (75-80%) of morbidly obese patients who undergo bariatric surgery. The remission occurred quickly, often in 2-3 days, and was not dependent on weight loss. The surgery resulted in a metabolic change, although the exact mechanism of action is yet to be clearly defined. These bariatric operations lead to changes in gut hormones, types of bile salts secreted, and changes in the makeup of bacteria. The overall impact is better control of Type II diabetes from surgery versus medical treatment.
The DSS-II then looked at the types of surgery to see which most effectively impacted Type II diabetes. They found that the duodenal switch was better than gastric bypass, which was better than the sleeve gastrectomy. However, all of the bariatric procedures mentioned were more effective for remission of Type II diabetes than medical therapy. In addition, safety for these metabolic bariatric procedures has also improved dramatically over the past 15 years. The mortality rates are about the same as having your gallbladder or appendix removed. And major complications are also much less common.
In summary: The new recommendations from DSS-II that have been endorsed by 45 international societies are:
- Metabolic surgery should be recommended for patients with Type II diabetes and a BMI > 40 regardless of glycemic control.
- Metabolic surgery should be recommended for patients with Type II diabetes and a BMI of 35-40 with poor glycemic control.
- Metabolic surgery should be considered for BMI of 30-35 with inadequate control of Type II diabetes.
The major change in these recommendation is for those patients with a BMI of 30-35. With metabolic surgery, remission of Type II diabetes can be achieved in about 75-80% of patients with a BMI of 30-35, which is the same as it is for the higher BMI patient. In addition, the weight loss anticipated for the patient with a BMI of 30-35 is less and no problem has been associated with too much weight loss.
This change in metabolic surgery recommendations for Type II diabetes is very important. Currently, only 50% of patients with Type II diabetes meet their treatment goals and symptoms continue to worsen over time. Now we have another option to better treat someone not meeting their goals. It is also important to highlight that the sooner you opt for surgery if you have poor control of your diabetes, the better chance you have at achieving remission, so don’t delay.
Finally, most insurance carriers are slow to endorse these new recommendations. So talk to your HR people and convince them to help you get coverage. It is also an election year so ask your candidates to support care for Type II diabetes as part of their health care policy.
Enjoy your summer!
Dr. Tom Brown
Colorado Bariatric Surgery Institute