Susan B. Sloane, BS, RPh, CDE, has been a registered pharmacist for more than 20 years and a Certified Diabetes Educator for more than 15 years. Her two sons were diagnosed with diabetes, and since then, she has been dedicated to promoting wellness and optimal outcomes as a patient advocate, information expert, educator, and corporate partner.
In the times we live in, it seems everyone is out for the “quick fix.” Many patients have asked me about gastric bypass surgery and whether it actually cures diabetes.
The surgery has certainly helped a lot of people get healthy, but it is not a simple procedure, not without some significant risks and requires a lot of careful post-surgical care.
Still, some studies have shown that for some people bariatric surgery can extend their lives and help with their diabetes. The International Diabetes Foundation (IDF) has established guidelines for patients who may qualify for this type of surgery. The IDF recommends surgery be considered in a patient with diabetes whose BMI is 35 kg/m2 or higher or when it is between 30 and 35 kg/m2 and their diabetes cannot be controlled by medicine and lifestyle changes. This figure can vary slightly depending on the individual patient.
There have been countless studies done to evaluate the potential “cure” of type 2 diabetes seen in some patients who have had bariatric surgery. It seems that often blood sugar control gets normalized before weight loss has even occurred. This fact has led researchers to believe that changing the gastric anatomy changes hormone secretion, which leads to less insulin resistance right from the start. Every person affected by diabetes would love a quick fix cure but it is crucial to keep in mind that bariatric surgery is not for everyone.
One of the first things to consider if you are chosen as a candidate for surgery is that your blood glucose should be in the best control possible prior to surgery. This will aid in your recovery and help prevent post-operative infections that could be devastating. You will also need to go through extensive counseling on what to expect and most likely a psychiatric evaluation as well to make sure you can handle the many changes you will go through. Some of your current medications for diabetes may be discontinued to prevent hypoglycemia post-operatively. You probably will need to monitor your blood sugars for a period of time after surgery because post-prandial hypoglycemia can be a problem for some patients initially. The types of foods you are allowed to eat, as well as portion size recommendations, will change after surgery. Usually several small meals or snacks throughout the day will be a person’s new normal eating pattern after the procedure.
Types of weight loss surgery
Weight loss surgeries are not all alike. The three most common procedures in the United States are the laparoscopic adjustable gastric band (LAGB), the Roux-en-Y gastric bypass (RYGB) and the laparoscopic sleeve mastectomy.
The gastric bypass is the most popular procedure performed in the United States. This may be because it seems to produce some of the best results as far as weight loss and has the potential to help those who have tried unsuccessfully to lose weight by other means. During this surgery, the upper stomach gets stapled creating a pouch that is divided from the rest of the stomach. This is an invasive surgery, which can sometimes be performed laporascopically depending on surgeon preference and feasibility on an individualized patient basis. It generally takes about two hours and patients are hospitalized for two to three days, resuming normal activities in one to three weeks.
Patients lose between 60-80 percent of their body weight on average as a result of the surgery. The smaller stomach creates a feeling of fullness when eating, but also does block absorption of some vitamins, which often need to be supplemented. This malabsorptive element is because this surgery bypasses the distal stomach, the entire duodenum and varies the length of the jejunum. For a quick physiology refresher, the duodenum is where folate, calcium, magnesium and iron are absorbed with help from stomach and pancreatic enzymes. You can quickly see that if food bypasses the duodenum, many nutrients you would normally get from a healthy diet are unable to be absorbed.
The LAGB or banding is the procedure most of the public has become familiar with as it is more straightforward and subsequently gets more publicity. It is for the most part, a less complicated procedure than RYGB, but does not generally result in as much weight loss as gastric bypass surgery. In LAGB, an adjustable, restrictive band is placed around the upper stomach. The surgeon can control the amount of restriction by the addition or removal of saline through a subcutaneous port. It can be reversed if necessary.
The third type of gastric bypass, a laparoscopic sleeve mastectomy, actually removes a good portion of the stomach and is reserved for extreme cases with very specialized surgeons. This translates to more risk for the patient and a longer recovery.
Weighing benefits and risks
So, we’ve concluded that bariatric surgery, regardless of the method, results in weight loss. The question now becomes whether or not the procedure makes it more likely the weight will stay off compared to other less invasive means of weight loss.
A recent study published in the science journal “Nature” compared the amount of weight regain, behaviors and psychological characteristics in national weight control registry (NWCR) participants. The participants were equally successful in losing and maintaining large amounts of weight through either bariatric surgery or non-surgical methods. The surgical and non-surgical groups did not differ in the amount of weight regained after one year. But the surgical group participants reported less physical activity, more fast food and fat consumption, less dietary restraint, and higher depression and stress at one year after the procedure. The key point here is that no matter how the weight is lost, in order to maintain the loss and the accompanying health benefits, major behavioral changes must be made as well.
Weight loss surgery is not without complications and, as with any decision, the benefits need to be weighed against the risks. It is a good suggestion to exhaust other means of weight loss and control before electing to try the surgery. The surgery certainly has merit and can help people lose weight and achieve better control of their diabetes, but the decision should not be made lightly. Close monitoring after surgery is essential for positive outcomes. Patients need to be re-trained on how to eat or they can become very sick very quickly. The good news for patients with type 2 diabetes is that in many cases the diabetes seems to improve drastically as weight comes off, and even before weight comes off in many cases. Can we call it a cure or simply a remission? The jury is still out and there are different opinions on the subject.
Prior to any weight loss surgery a full psychological evaluation should occur. Any aspirin, ibuprofen, or any medications in the class of NSAID’s are not recommended after surgery due to the risk of ulcers. Alcohol is not recommended as well because the stomach will be especially sensitive to irritants. A dietician should be consulted prior to surgery and follow the patient post-operatively as well. I have often said education is the best prescription. In the case of bariatric surgery, extensive patient education is imperative for a good outcome.
This surgery is not for everyone, but this article is meant to give you, as Joe Friday would have said, just the facts. Adherence to the diet program post-operatively is critical as even with surgery, weight gain can occur if you are not careful. In the RYGB procedure the newly created “pouch” is delicate, and especially while it is healing, isn’t strong enough to tolerate overfilling that can result from overeating. Even when they drink water patients who have had gastric surgery are instructed to drink slowly, taking small sips of fluid at a time. Sugary foods can cause problems because they pass through the digestive system quickly, causing more cramping and pain than other foods. Learning how to eat is a very important component of post-operative care. The surgery is meant to be only a part of a much broader weight loss program with the goal of not only losing the weight, but maintaining that loss as a result of behavioral change and good, old-fashioned hard work.
Many patients ask about the cost of surgery, which can range into the thousands. Many insurance companies will pay for the surgery or pay some part of it if a patient meets certain criteria. You can check with your providers for more detailed information.
Have you considered bariatric surgery? Share your experiences and thoughts in the comments below and check out this related discussion thread.