Should Bariatric Surgery for Diabetes Take Place at an Earlier Stage?

Bariatric surgery should be considered earlier in the treatment of eligible patients to help stem the serious complications that can result from diabetes, according to an International Diabetes Federation (IDF) position statement presented by leading experts at the 2nd World Congress on Interventional Therapies for Type 2 Diabetes in New York.

The statement was written by 20 leading experts in diabetes and bariatric surgery who have made a series of recommendations on the use of weight-loss surgery as a cost-effective treatment option for severely obese people with type 2 diabetes.

The combination of obesity and type 2 diabetes is looming as the biggest epidemic and public health issue in human history. Type 2 diabetes is one of the fastest growing diseases today with close to 300 million people affected worldwide and 450 million people forecast to have diabetes by 2030.

According to the statement there is increasing evidence that the health of obese people with type 2 diabetes, including their glucose control and other obesity-related comorbidities, can benefit substantially from bariatric surgery under certain circumstances.

The IDF's Taskforce on Epidemiology and Prevention of Diabetes convened the expert group with specific goals to:

• Develop practical recommendations for clinicians on patient selection and management
• Identify barriers to surgical access
• Suggest health policies that ensure equitable access to surgery
• Identify priorities for research.

Co-chairperson Professor Sir George Alberti, Senior Research Investigator, Imperial College, 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-points for action may be lower in Asian populations because of their increased risk of diabetes and heart disease.

Professor Paul Zimmet AO, Director Emeritus, Baker IDI Heart and Diabetes Institute, Melbourne, and co-chairperson, said, "Bariatric surgery is a treatment that can be recommended for people with type 2 diabetes and obesity not achieving recommended treatment targets with existing medical therapies, especially when there are other major co-morbidities such as hypertension, high cholesterol or sleep apnoea. Surgery should be an accepted option in people who have type 2 diabetes and a body mass index (BMI) of 35 or more. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment prior to surgery and on-going care as well. "

Professor Francesco Rubino, Chief of the Gastrointestinal Metabolic Surgery Program at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and Director of the 2nd World Congress on Interventional Therapies for Type 2 Diabetes, said, "This is the first time the International Diabetes Federation or any major international organization has made recommendations on this rapidly developing area of therapy. It did so because of the urgent need for worldwide expert guidance on the use of bariatric surgery because of the increasing usage. We note the need to establish appropriate measures in education and selection of patients and safe and standardized surgical procedures. Long-term follow-up after surgery is essential."

Professor John Dixon, Head of Obesity Research Unit, Department of General Practice, Monash University, Melbourne, said: "It is very important for health authorities and policy makers to understand that almost all severely obese patients cannot achieve and maintain significant weight loss. They should be treated where appropriate with bariatric surgery, which can lead to remission of diabetes in up to 80% of patients. National guidelines and registers for bariatric surgery need to be developed and implemented for people with type 2 diabetes."

The expert group warns the situation in low- and middle-income nations presents special problems because severe obesity is increasing at an alarming rate. As health care resources are limited, bariatric surgery should only be performed where the health budget can afford it, and when the expertise is available for both the surgery and the long-term follow-up.

Source: NewYork-Presbyterian Hospital/Columbia University Medical Center and NewYork-Presbyterian Hospital/Weill Cornell Medical Center