metabolic surgery

Should BMI or diabetes control determine who receives bariatric and metabolic surgery?

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BMI should determine who receives surgery.

It is more appropriate to use BMI as the determinant for metabolic and bariatric surgery in treatment of type 2 diabetes.

Jaime Almandoz

The 1991 NIH consensus statement on metabolic and bariatric surgery was recently updated by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), reflecting our enhanced understanding that surgery is a safe and effective tool for treating obesity and adiposity-related comorbidities, and people will benefit from bariatric surgery at lower BMI than proposed in the older guidelines.

The American Diabetes Association’s 2022 Standards of Care in Diabetes: Obesity and Weight Management for the Treatment of Type 2 Diabetes proposes surgery for those with type 2 diabetes and BMI of at least 30 kg/m2 or at least 27.5 kg/m2 for Asian American patients. Several randomized controlled trials and many other studies demonstrate the benefits of surgery for diabetes prevention, treatment and possible remission. Beyond this, for those who undergo surgery, there are significant reductions in microvascular complications, cardiovascular events, cancer occurrence and mortality.

Factors that improve chances for remission of type 2 diabetes after surgery include shorter duration of type 2 diabetes, better glycemic control and not requiring insulin therapy. While there are data showing significant postsurgical improvements in glycemic control for those with uncontrolled type 2 diabetes, there is a much greater chance for remission of type 2 diabetes if surgery is performed earlier in the course of disease and with better glycemic control — arguing against using diabetes control as the primary determining factor for metabolic and bariatric surgery.

A postsurgical weight loss of 20% or higher appears to impart the greatest odds of achieving diabetes remission, and procedures that lead to greater weight loss are associated with greater improvements in glycemia and likelihood for diabetes remission. This tracks with what we know about the impact of excess and dysfunctional adiposity on insulin resistance and the pathogenesis of type 2 diabetes.

By performing metabolic and bariatric surgery earlier during type 2 diabetes, or even before insulin resistance and metabolic syndrome have become type 2 diabetes, our patients have greater chances of having adiposity-related complications of obesity into remission. This will, in turn, lead to improvements in morbidity, mortality and quality of life.

Jaime Almandoz, MD, MBA, FTOS, is medical director of the weight wellness program and associate professor of internal medicine in the division of endocrinology at University of Texas Southwestern Medical Center. He can be reached at jaime.almandoz@UTSouthwestern.edu.

Diabetes control should be a component in determining who receives surgery for diabetes treatment.

Diabetes control is important, but it is not the endgame because diabetes does not come in isolation.

The way obesity affects patients and how it needs to be treated draws the closest analogy to cancer and cancer treatment. For example, patients who develop cancer don’t develop a disease that can be treated with one specialty — they need a multidisciplinary team. Depending on the stage of the cancer, they may need different treatments, and the more delays in treatment, the worse outcomes are. Obesity and diabetes are similar.

Abdelrahman Nimeri

Obesity and type 2 diabetes are partners — a patient is diagnosed with one, is often diagnosed with the other, and if one improves then the other improves as well.

The longer a patient has diabetes and the more diabetes goes uncontrolled, the less chance that diabetes improves after bariatric or metabolic surgery. As early referral and treatment for cancer lead to better outcomes, the earlier referral of patients with type 2 diabetes and severe obesity to bariatric or metabolic surgery also yields better diabetes resolution. As patients with obesity gain more weight, their type 2 diabetes gets worse. When the patient has surgery to reduce their weight, the surgery has a metabolic effect before the person loses any weight.

Most patients will have severe obesity and type 2 diabetes together. Many patients also have high blood pressure, high cholesterol and sleep apnea. When we treat type 2 diabetes with specific medications, we are not addressing any of these other problems. With surgery, the improvement is not only to weight and quality of life, but also to diabetes, cardiovascular risk and cancer risk. In addition, today, metabolic and bariatric surgery is as safe as gallbladder surgery and hip replacement when done in appropriate centers of excellence.

Even for patients who are not diabetic and only have obesity, when they undergo metabolic and bariatric surgery, they are 80% less likely to develop diabetes 15 to 20 years later, which has been shown in the Swedish Obese Subjects study.

Diabetes control is important, but it’s not the only goal.

Metabolic Surgery Helps Protect Against COVID-19 Complications

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In people with obesity, weight loss achieved through metabolic surgery was associated with improved outcomes after COVID-19, according to a study published in JAMA Surgery (2021 Dec 29. doi:10.1001/jamasurg.2021.6496).

The finding comes from a retrospective cohort of 5,053 adult patients who underwent weight loss surgery between Jan. 1, 2004, and Dec. 31, 2017, at the Cleveland Clinic Health System and 15,159 propensity score–matched patients who did not have metabolic surgery.

Patients tested positive for SARS-CoV-2 at about the same rate in both groups: 9.1% among surgical patients and 8.7% in the nonsurgical arm. However, individuals who had undergone weight loss surgery had a 49% lower risk for hospitalization, 63% lower risk for need for supplemental oxygen and a 60% lower risk for severe disease during a 12-month period after contracting COVID-19.

The researchers, led by Ali Aminian, MD, the director of the Bariatric and Metabolic Institute at Cleveland Clinic, said the findings “represent the best available evidence on the implications of a successful weight loss intervention for COVID-19 outcomes.”

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There is an established link between obesity and poor outcomes after COVID-19 infection. But this study demonstrates that obesity is a modifiable risk factor. By losing weight several years earlier with surgery, patients had a reduced risk for adverse outcomes with COVID-19.

At the time of their COVID-19 diagnosis, patients in the surgical group had achieved 20.0 kg lower body weight and better glycemic control compared with presurgical levels. They’d lost 18.6% more body weight over time compared with patients who didn’t undergo surgery.

Patients with substantial and sustained weight loss “were likely physically and physiologically better equipped to cope with an infection that has the potential for multiorgan involvement,” the authors concluded.

Three-fourths of patients were female; they were a mean age of 46 years. The study excluded anyone with a history of organ transplant, cancer or precancerous diagnosis, alcohol use disorder or alcohol-related medical condition, dialysis, ascites, cardiac ejection fraction less than 20%, HIV, peptic ulcer disease, or a recent emergency department admission before surgery.

The study has significant limitations due to its retrospective design, including unknown confounders, misclassification bias, patients lost to follow-up and control selection bias. Moreover, the study did not compare patients who were actively pursuing medical or behavioral interventions for obesity. It shows only that successful weight loss can be protective against severe COVID-19 complications.

In an invited commentary, Paulina Salminen, MD, PhD, of the Department of Surgery at the University of Turku, in Finland, and her colleagues argued that metabolic surgery should be considered medically necessary (JAMA Surg 2021 Dec 29. doi:10.1001/jamasurg.2021.6549).

At many places around the country, weight loss surgery is classified as an elective procedure and was put on hold during surges of COVID-19 to preserve scarce healthcare resources.

“As the COVID-19 pandemic continues, health care professionals who make decisions regarding health care use must acknowledge the cumulating evidence of obesity as a modifiable disease that is a predisposing factor for COVID-19 infection, as supported by this current study,” Dr. Salminen and her colleagues wrote.

In June 2020, the American Society for Metabolic and Bariatric Surgery issued a statement, saying metabolic and bariatric surgery should not be considered elective (Surg Obes Relat Dis 2020;16[8]:981-982).

The organization said these operations are “medically necessary and the best treatment for those with the life-threatening and life-limiting disease of severe obesity.”

British doctors trial simple gut operation that ‘cures or controls’ diabetes

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A nurse giving a patient a diabetes test
A nurse giving a patient a diabetes test 

Asimple gut operation that sees a plastic film inserted into the stomach could cure or control diabetes, British doctors have found.

Patients taking part in trials at King’s College Hospital and University College Hospital in London and City Hospital in Birmingham found their diabetes had disappeared or become much milder after the operations.

Francesco Rubino, professor of metabolic surgery at King’s, told The Sunday Times: “About 50 per cent of patients are diabetes-free after these procedures.

The increased number of people with diabetes has been linked to rising levels of obesity
The increased number of people with diabetes has been linked to rising levels of obesity 

“The remaining people demonstrate big improvements of blood sugar control and can drastically reduce their dependence on insulin or other medication.

“In many patients, blood sugar levels go back to normal within days, long before declines in fat levels or weight.”

The treatments stem from a new view of the causes of diabetes, a condition in which there is too much glucose in the blood.

Diabetes has previously been blamed on the pancreas not secreting enough insulin, the hormone that controls glucose levels – but Rubino and his colleagues believe the gut is the key player.

Andrea Midmer, 59, a nurse, took part in the trial, in which a plastic liner or “endobarrier” was fitted into her stomach to stop the walls of her upper gut coming into contact with the food she ate.

“The effect was immediate,” said Midmer, who weighed 20 stone and was on insulin when the trial started. I stopped feeling hungry, I ate much smaller meals and I lost 4½ stone.”
Type 2 diabetes, which is often linked to obesity, is one of Britain’s biggest health problems and affects about four million people.

Treatment costs £10 billion a year – about 10 per cent of the NHS budget. That figure is expected to rise to 17 per cent if the numbers suffering from the condition his five million, as is predicted, by 2025.

The increased number of people with the disease has been linked to rising levels of obesity.

Between 1993 and 2010 the proportion of obese people in the UK went from 13 per cent to 26 per cent for men and from 16 per cent to 26 per cent for women.