Surgery might be the right choice for some patients in the prediabetes stage and those diagnosed with metabolic syndrome, preventing or delaying diabetes, one presenter said. Moving forward in this area would be best achieved by cooperation between diabetologists and bariatric surgeons, he said.
“If people have hypertension, dyslipidemia, sleep apnea, and a BMI that’s very high, the presence of prediabetes is pushing some buttons for some urgency to exhaust diet and drug therapy, but you can tell whether you’re winning with that in a very short time,” John B. Dixon, MBBS, FRACGP, FRCP Edin, PhD, said in an interview with Endocrine Today. “The idea that surgery is a last opportunity is really inappropriate in diabetes because that’s going to mean people who have had diabetes for 5, 10, 15 years and then get referred. There’s a general consensus that you need to get in before beta cells are damaged, so therefore think about patients early in their history with diabetes and those that have a lot of other comorbidities and prediabetes and prevent the diabetes or at least delay the onset of diabetes.”
Dixon, who is head of clinical obesity research at Baker IDI Heart and Diabetes Institute in Melbourne, Australia, said although the guidelines on surgical intervention were previously “ad hoc,” the International Diabetes Federation issued Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes to assist in the presurgical decision-making and criteria for measuring outcomes in patients with diabetes who undergo bariatric surgery.
In a comparison of bariatric surgery eligibility guidelines from the NIH and five other organizations, Dixon said the common elements are appropriate nonsurgical weight-loss measures tried and failed; provisions for, and a commitment to, long-term follow-up; and individual risk/benefit ratio evaluation.
These organizations are also looking at how physicians define success in patients with diabetes after bariatric surgery, he said.
“Indeed, the evidence suggests that early partial remissions are common, complete remissions are rarer and prolonged remissions rarer still, so that we see a lot of people developing diabetes 5 to 10 years after they appear to go into remission,” Dixon said. “Should we look at younger people with prediabetes because of the horrendous years of life lost due to obesity and diabetes? Should we be looking at people’s weight trajectory? It’s taking a critical look at the whole patient and working out perhaps where we have the greatest benefit in those that would be seeking surgery.”
The recent Swedish study showed “very clearly” that bariatric surgery was “exceptional” at preventing diabetes, he added. Yet, the current number of patients undergoing surgery is relatively small.
“Bariatric surgeons tend to work in isolation from diabetologists. If they were linking more closely, if there were a bariatric surgical service coordinated with a large diabetes service, then perhaps we would see much better uptake and provision for those particular patients,” Dixon said. “There are more and more papers coming out that bariatric surgery is paying for itself in patients with diabetes in a relatively reasonable time — 5 to 10 years — and that’s unusual for almost any surgery.” – by Katrina Altersitz
For more information:
Dixon JB. Metabolic surgery update: Physiology, new procedures, clinical trends. Presented at: Obesity Week; Nov. 11-15, 2013; Atlanta.
Disclosure: Dixon reports financial relationships with Allergan, Bariatric Advantage, Nestle Australia, ResMed; I-Nova, Dendrite Clinical Systems, RACGP, BUPA, NHMRC and Nestec Ltd.