A Big Bone of Contention: Should Bariatric Surgery Become a Standard Type 2 Diabetes Therapy?

A recent and contentious meeting of diabetes experts at the European Association for the Study of Diabetes in Vienna, Austria, has continued the intense international debate over whether bariatric surgery should become a treatment for type 2 diabetes or continue to be reserved only for the extremely obese.

In bariatric surgery, the stomach is either reduced in size or completely bypassed so that food directly reaches the small intestine. In either case, the amount of food that can be eaten and the appetite for it are lowered significantly. Bariatric surgery not only leads to dramatic weight loss by severely restricting food intake, but it also lowers the high risk of cardiovascular disease that comes with obesity.

But a fortuitous side effect has put the procedure front and center in a wide-ranging debate over how the surgery should be perceived and used. Most obese people with type 2 diabetes who undergo bariatric surgery see dramatic improvements in their blood glucose levels and insulin sensitivity within days, often to the point of complete remission of the disease. A Swedish meta-analysis of 600 studies of the long-term effects of bariatric surgery showed that 86.6 percent of type 2 patients who underwent it experienced improvement in their condition and 78.1 percent experienced “complete resolution” of their diabetes-essentially a cure.

However, current guidelines restrict the procedure to patients with a body mass index of 35 or greater-the “morbidly obese.” Many people with type 2, therefore, do not qualify for the surgery. It is this fact that is the center of the current controversy. The debate in Vienna, as reported in heartwire, focused on whether the surgery should become a staple therapy for treating type 2 diabetes.

Both sides acknowledged that while the surgery’s effects on type 2 diabetes are compelling, there are no data on people with BMIs of less than 35 who have undergone the surgery. Until there are such data, it will be difficult to determine whose argument will carry the day. Consequently, the proponents of bariatric surgery for type 2 patients are in a chicken-and-egg situation: They can’t prove their thesis until they have more surgeries on non-morbidly obese people under their belts, but they can’t perform those surgeries because such people-for the foreseeable future-are denied access to it.

Advocates for the surgery on type 2 patients said that BMI should not be the primary factor in determining eligibility because there are other markers in type 2s that indicate a vulnerability to cardiovascular disease. In such patients, whose BMI may not qualify them for bariatric surgery, the fact that they have a known risk that can be mitigated by a known procedure should be grounds enough to let them undergo it. They also pointed out that some U.S. insurance companies and health plans are mulling over whether to accept the surgery as a treatment for metabolic disorders like diabetes and not just as an exclusive therapy for morbid obesity.

Opponents argued that allowing bariatric surgery to become more common might ultimately end in the realization that the medical community had taken a wrong path. One expert recalled the popularity in the 1930s and 1940s of the lobotomy, a surgery on the prefrontal lobes that was designed to treat or even cure severe psychoses or behavioral disorders. Not only did the surgeries irreparably harm patients, but the need for them disappeared with the introduction of drugs to control many of the conditions that lobotomies were intended to address. In that vein, one endocrinologist asked if there might not at some point be drug combinations that could produce the same results as bariatric surgery, but without its body-altering effects.

The next step toward resolving the debate is a long-term study of the effects of bariatric surgery on lower-weight type 2s. There is some talk that Britain may fund a 10-year study, but other than that, there is no major research underway on the topic.

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Experts debate bariatric surgery as a cure for diabetes

October 8, 2009 | Lisa Nainggolan

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