Health Sense: Treating Diabetes with Surgery

Rhas been obese all his life. Aged sixteen, doctors told him he was diabetic.

There was no cure, they said; only the hope of controlling the disease through strict dieting, medication and a lifetime of careful living. Through his teens, R steadily gained weight and his diabetes worsened. Soon, his lab tests began to show worrying signs of early stages of diabetic kidney disease.

Struggling to keep his weight and diabetes under control, R chose to undergo weight loss (bariatric) surgery last year. He opted for laparoscopic sleeve gastrectomy, a relatively new weight loss procedure that is quickly gaining popularity. Today, he has lost 48 kilograms and no longer needs drugs to control his diabetes. Doctors tell him that, for the moment at least, his blood sugar levels are completely normal and he seems to be “cured” of the disease.

The twin epidemics of obesity and Type 2 diabetes are major public health challenges for this century. Type 2 diabetes is one of the fastest growing diseases with more than 300 million people worldwide affected today. This figure is projected to rise to 450 million people by 2030. Obesity and diabetes are closely interlinked diseases:

Obesity interferes with the body’s ability to process sugar and maintain proper glucose levels in the blood. Not surprisingly, approximately 80 to 90 percent of Type 2 diabetics are either overweight or obese.

The combination of obesity and diabetes in an individual is particularly lethal and magnifies the risk of heart attacks and stroke. Many patients manifest a cluster of the most dangerous heart attack risk factors; these include abdominal or central obesity, diabetes, elevated cholesterol levels and high blood pressure. The medical term for this cluster of risk factors is metabolic syndrome. Patients with metabolic syndrome are twice as likely to die from, and three times as likely to have a heart attack or stroke compared to people without the syndrome.

There is no cure for diabetes. For many patients, the diagnosis of diabetes means a lifetime of medication. Lifestyle changes are also essential — doctors advocate strict dieting, calorie restrictions and exercise. Losing those extra kilograms is crucial for diabetics who are obese or overweight because excess body fat has an adverse effect on sugar levels in the blood. Unfortunately, many patients are unable to comply with the dietary restrictions and treatment regimen.

Kilograms lost are ultimately regained, blood glucose levels start to soar resulting in damage to multiple organs including the eyes, kidneys, nerves and limbs. Still drugs, dieting and exercise remained the mainstay of diabetes treatment for decades.

For years, bariatric (weight loss) surgeons have been reporting that obese, diabetic patients showed remarkable improvement in their diabetes after weight loss surgery.

Many patients had normal blood glucose levels and no longer required medication. These results were extraordinary in that no other treatment exists which was able to produce this “remission” of diabetes. Over the years, evidence continued to accumulate that Type 2 diabetes related to obesity frequently improved, and was often “cured” after weight loss surgery.

Recently, at the Second World Congress on Interventional Therapies for Type 2 diabetes in New York, the International Diabetes Federation (IDF) announced a new position statement stating that bariatric surgery should be considered earlier in the treatment of eligible patients to help stem the serious complications that can result from diabetes.

In this statement, the IDF comments that “in addition to behavioural and medical approaches, various types of surgery on the gastrointestinal tract, originally developed to treat morbid obesity (bariatric surgery), constitute powerful options to ameliorate diabetes in severely obese patients, often normalising blood glucose levels, reducing or avoiding the need for medications and providing a potentially cost effective approach to treating the disease.”

Co-chairperson George Alberti of the Imperial College in London said, “Bariatric intervention is a health and cost-effective therapy for Type 2 diabetes and obesity with an acceptable safety profile. Bariatric surgery for severely obese people with Type 2 diabetes should be considered much earlier in management rather than held back as a last resort.

“It should be incorporated into Type 2 diabetes treatment protocols.” He also pointed out that the cut-off points for action may be lower in Asian populations because of their increased risk of diabetes and heart disease.

Bariatric procedures performed in Singapore include gastric banding, sleeve gastrectomy and gastric bypass. Bariatric surgery involves manipulation of the stomach (and sometimes also the intestines) in such a way that food intake is restricted. At present, only obese diabetics are eligible for surgery. Could these surgical procedures also benefit diabetic patients in the lower weight ranges? Physicians anxiously await the results of clinical trials designed to provide answers to this question. In future, surgery may well become an established tool in your doctor’s armamentarium in the fight against diabetes.

Eric Gan is a doctor and consultant surgeon at Mount Elizabeth Medical Centre. He has a special interest in minimally invasive, upper GI (esophageal & gastric) & cancer surgery.