Diabetes and Weight Loss Surgery

Diabetes Mellitus (DM) is a chronic disease of blood sugar management. Insulin is produced in order to get sugar (or glucose) from the blood stream into the body’s cells where it is then utilized. Diabetes is where this system doesn’t work properly. Type I DM is genetic, and has to do with inadequate insulin production. Adult Onset or Type II DM is often associated with weight gain. This is the most common type of diabetes, affecting 90-95 % of Americans with diabetes.

In Type II DM, also called non-insulin dependent DM, the glucose is constantly high in the blood stream and the pancreatic cells producing insulin cannot keep up or become overstimulated so they are no longer responding to the high blood glucose level. The result is the blood glucose levels remain high, and the body’s cells are not able to utilize the glucose.

Risk factors for Type II DM include increased body fat, especially that fat that is carried centrally in a person’s mid section (central obesity). There may also be a genetic component to the development of Type II DM.

There are prediabetic states; which may mean a person is predisposed to developing Type II DM. The HgbA1c is a blood test that can be done to check for diabetes. Typically levels above 6 is considered diabetic, up to 5.5 is normal. Levels between 5.5 and 6 indicate a predisposition to Type II DM. A glucose tolerance test is another way blood test to diagnosis diabetes.

Metabolic Syndrome describes a cluster of conditions that are associated with an increased risk of heart disease, stroke and diabetes. The conditions include elevated blood pressure, glucose and cholesterol levels, along with central obesity.

Type II DM is a progressive disease and affects the nerves and blood vessels throughout the body.

When obese patients lose weight, Type II DM often will be easier to control and in some cases, resolve. Bariatric surgery has been used as a tool to help patients stay on track with proper eating habits and lifestyle changes that lead to long term weight loss and improved health.

As more and more bariatric surgery is being done, we know now that bariatric surgery can actually cure Type II DM.

The gastric bypass has a cure rate of 83% for Type II DM, 60 % with the sleeve gastrectomy, and 35 % with the adjustable gastric band.

Blood sugars are controlled very early after surgery, before weight loss has occurred, even before patients leave the hospital. Some of this has to do with the initial postoperative diet which consists of a very low calorie, low carbohydrate liquid diet. Also, as a person’s weight drops, their sugars often lower because of the lower fat mass.

What is unique with the gastric bypass is that the first portion of the small intestine (the duodenum and proximal jejunum) is bypassed. Because food is no longer going into that first part of the intestines there is a change in the hormone balance released by the gut that allows better control of diabetes. We do not yet know how this works but some of the hormones involved include Leptin (which suppresses appetite) and gut peptide hormones. In addition, there may be some improvement in insulin sensitivity by the body’s cells so glucose is better utilized.

• Schauer PR. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Annals of Surgery 2003;238: 467-482.
• Buchwald H. Bariatric surgery: A systematic review and meta-analysis. JAMA 2004;292: 1724-37.
• Leonetti F. Obesity, type 2 diabetes mellitus, and other comorbidities. A prospective cohort study of laparoscopic sleeve gastrectomy vs medical treatment. Arch Surg. 2012;147(8): 694-700.

Gastrointestinal surgery may be the next step for people who remain severely obese after trying nonsurgical approaches. Candidates for surgery:

• BMI of 40 or more
• Life-threatening obesity-related health problem such as diabetes, severe sleep apnea, or heart disease and a BMI of 35 or more
• Obesity-related physical problems that interfere with employment, walking, or family function.
• No endocrine cause of obesity
• Absence of drug or alcohol problems
• Nonsmoker
• No uncontrolled psychological conditions
• Dedicated to life-style change and follow-up

If you fit the profile for surgery, answers to the following questions may help you decide whether weight-loss surgery is appropriate for you. Are you:

• Unlikely to lose weight successfully with nonsurgical measures, including medically supervised programs?
• Well informed about the surgical procedures and the effects of treatment?
• Determined to lose weight and improve your health?
• Aware of how your life may change after the operation (adjustment to the side effects of the surgery, including the need to chew well and inability to eat large meals)?
• Aware of the potential for serious complications, dietary restrictions, and occasional failures?
• Committed to lifelong medical follow-up?

Remember: Not every sufferer is a candidate for surgery. Bariatric surgery is an elective operation and the benefits of surgery must outweigh the potential risks of surgery. There are no guarantees for any method, including surgery, to produce and maintain weight loss. Once the decision has been made to pursue surgery, treatment does not end with the operation. That is merely the beginning. Success is possible only with maximum cooperation and commitment to behavioral change and medical follow-up—and this cooperation and commitment must be carried out for the rest of your life.*