- Weight management is crucial for patients with type 2 diabetes.
- Recommendations suggest certain people with diabetes would benefit from bariatric surgery.
- It’s important that the surgery is done at a reputable center with a comprehensive weight management program.
If you have type 2 diabetes, you know that it is vitally important to control your weight. However, that can be difficult if you are dealing with the disease of obesity and struggling to take off the extra pounds. If you feel you have been unsuccessful with weight loss attempts, you may be considering bariatric, or weight loss, surgery. Is that a good choice for you? Fran Broyles, MD, Swedish’s medical director of diabetes/endocrinology and nutrition, discusses what you should know before making that decision.
First of all, why is weight management so important with type 2 diabetes?
“Carrying extra body weight increases insulin resistance. This increases the work the pancreas — the gland that produces insulin — has to do to maintain normal blood sugars. Insulin resistance makes the insulin your body produces less effective, and this causes blood sugars to rise. It also results in a faster loss of pancreas function/pancreas failure. Data that came out in 2015 showed that 50% of the adult American public has either diabetes or prediabetes. And data that came out this year from the Centers for Disease Control and Prevention showed that 70 percent to 80 percent of the adult American public is obese or overweight, and that there are now more obese American adults than there are adults of normal weight. So, we have a significant epidemic on our hands. It is a very complex scenario that involves not only the food industry and what we eat, but also issues surrounding activity levels, genetics, and epigenetics. There is a lot of research being done in this area about what is driving this epidemic.
“One of the things that’s been a big shift in the field of medicine, which is way overdue, is the recognition that obesity is a disease, not a character flaw, and it needs to be treated as such. I think that has opened the door for those of us in the diabetes world to aggressively treat body weight since it absolutely can have an impact on diabetes management as well as diabetes risk. There are now multiple medications approved by the FDA for the treatment of obesity, as well as multiple medications that help to treat diabetes and that also help weight loss.“
Why should I consider bariatric surgery if I am suffering from diabetes and obesity?
“In June 2016, the American Diabetes Association released new guidelines on bariatric surgery. When those recommendations came out, they were driven by an extensive and exhaustive review of the safety and efficacy of bariatric surgery. One of the reasons that a number of organizations worldwide got behind the recommendations was that bariatric surgery is safe and effective, and it can markedly reduce the co-morbidities that are associated with the disease of obesity. It showed significant improvements in the morbidity and mortality around diabetes and obesity. The science is really powerful.
“Further, a study recently published in the Journal of the American Medical Association showed that patients with severe obesity and type 2 diabetes who underwent obesity surgery had a 40 percent lower risk of experiencing cardiovascular complications such as heart attack or stroke over 5 years, compared with patients treated medically. Heart disease is the number one cause of death for patients with diabetes.”
What are the recommendations?
“The guidelines were based on body mass index (BMI), which is height versus weight. Normal body mass index is considered 20 to 25; if you are of Asian descent, subtract 2.5 from that. Overweight is 25 to 29.9, 30 is considered medical obesity, and greater than 40 is considered class 3 obesity, a level where body weight begins to affect morbidity and mortality.
“The American Diabetes Association recommends that if you have diabetes and a BMI that is equal to or greater than 40 that you should be on the fast track for bariatric surgery. The second recommendation is that if you have out-of-control diabetes and your BMI is equal to or greater than 35, you should also be on the fast track to bariatric surgery. Finally, if your BMI is greater than 30 and your diabetes is out of control, you should consider bariatric surgery. Again, if you are Asian you can subtract 2.5 from all those calculations.”
What else should I know about the surgery?
“The reality is that even though 70 percent to 80 percent of Americans are overweight or obese, and many of those individuals either have diabetes or are at risk for it, insurance companies in the United States still do not robustly cover bariatric surgery despite meeting multiple criteria that are widely accepted to cover the surgical procedure. Also, many patients are not ready to consider bariatric surgery. It’s a big step; it’s a permanent change in your anatomy. And I think, to a large extent, that physicians in this country still carry a lot of misconceptions about the efficacy and safety of bariatric surgery.
“It’s also important to note that the American Diabetes Association recommends bariatric surgery should be done only in reputable centers that have integrated programs that include long-term follow up and encompass psychological evaluation and support with a medical approach to weight loss. Bariatric surgery is only a tool for weight loss, it is not a panacea. So these individuals need to be counseled on behavioral changes and understand how to modify their eating patterns as well if they undergo bariatric surgery. There are bariatric surgery centers that are freestanding and don’t have all these elements, and that is not supported by the American Diabetes Association. We know that the rates of long-term success, as well as complications, are the best in integrated centers. At reputable centers with well-trained surgeons that do this procedure routinely, the rate of complications is lower than gallbladder surgery—it’s even lower than natural childbirth.
“In our program, if you have bariatric surgery you belong to us for the rest of your life. It is like getting an organ transplant and you will follow up with us forever. It’s not an end-game procedure; you can’t just go under the knife. You need behavioral tools — weight loss is a skill that has to be learned and surgery is only one piece of that. Oftentimes people are highly successful getting behavioral modification and tools with medical weight loss.
We have a highly successful medical weight loss program that works closely with the surgical weight loss program. We had a patient with really out-of-control diabetes who was educated and counseled by one of our dietitians — the patient lost 70 pounds, he is off of his medications, his diabetes is in remission, and he has his life back. He is absolutely thrilled, and that is a medical weight-loss approach. The statement that I make to my patients is that if weight loss were easy we’d all be thin. One of the last OK bastions of non-pc behavior/judgement is obesity, and that is devastating and one reason people don’t seek help. People feel ashamed and that they should be able to solve it on their own. We don’t shame people with high blood pressure or depression, we treat them. It’s critical that all of us recognize that obesity is a disease and needs to be treated just like diabetes, depression or high blood pressure. And we need to put all the resources towards it to help people be successful.”
What if I have prediabetes?
“We know that individuals who have prediabetes, which is the stage before type 2 diabetes, have about 10 years of abnormal blood sugar levels before being diagnosed with diabetes, and during that time frame the pancreas is failing. By the time patients are diagnosed with type 2 diabetes, up to 80 percent of their pancreas may have failed. At prediabetes, 25 percent to 50 percent of the pancreas has failed. So, patients with prediabetes benefit from bariatric surgery or medical weight loss programs as well.
“I think it’s critically important for people who have a family history, prediabetes or diabetes to work with a physician and a program that aggressively addresses not only their diabetes management but also body weight.”
If you are considering surgical or nonsurgical weight loss options, learn more about Swedish Weight Loss Services at the Swedish Digestive Health Institute. You can also attend a free seminar on our programs by registering here. Learn more about Swedish Endocrinology and the Swedish Diabetes Education Center.
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This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.
