Obesity Surgery to Treat Type 2 Diabetes?

At the recent inaugural meeting of the Canadian Association of Bariatric Physicians and Surgeons in Toronto in June, I was asked to review the recent consensus statement released by the International Diabetes Federation on the use of bariatric (obesity) surgery to treat patients with obesity and type 2 diabetes.

(Skip to MY BOTTOM LINES below for a summary, or read through for the nitty gritty!)

The International Diabetes Federation consensus states:

1.  Bariatric surgery is an appropriate treatment for people with type 2 diabetes 
and obesity not achieving recommended treatment targets with medical 
therapies, especially when there are other major co-morbidities.

2.  Surgery should be an accepted option in people who have type 2 diabetes 
and a body mass index (BMI) of 35 or more.  (note - you can calculate your BMI in the right column here)

3.  Surgery should be considered as an alternative treatment option in patients 
with a BMI between 30 and 35 when diabetes cannot be adequately controlled 
by optimal medical regimen, especially in the presence of other major 
cardiovascular disease risk factors.


As I reviewed at the meeting, the literature shows that most patients with obesity and poorly controlled type 2 diabetes experience an improvement in their diabetes with obesity surgery (especially gastric bypass and sleeve gastrectomy).  We have more data for patients with a BMI ≥35 than we do for patients with a BMI of 30-35 at this point in time, but the literature for the latter group is growing.

A large proportion of patients with type 2 diabetes will go into remission from their diabetes (meaning their diabetes goes away) after bariatric surgery, which of course sounds like a very attractive possibility to the person who has to deal with diabetes on a daily basis.


HOWEVER: 

• Based on the data we have currently available, about half of these cases of diabetes that went into remission after gastric bypass surgery come back by 5 years after surgery (called 'recurrence'). 
• Almost all of the long term data for diabetes remission rates is in patients with a BMI ≥ 35; there is almost no data to help us understand what the long term recurrence rate of type 2 diabetes is in the BMI 30-35 group.  People who have diabetes with this lower BMI may have a stronger genetic predisposition towards having diabetes, so it is plausible that these people would be less likely to have their diabetes stay away over the long term.
• There is little data to help us understand long term recurrence rates of diabetes after sleeve gastrectomy (which is becoming increasingly popular - read more about the types of surgeries here).
• The definition of diabetes 'remission' was previously quite loose and has now become much stricter; therefore, the remission rates reported in the literature are overinflated.

MY BOTTOM LINES on this controversial topic are:

1.  For people with a BMI of ≥ 35, with POORLY CONTROLLED diabetes:   Bariatric surgery is an option that provides a good opportunity to improve diabetes control.

2.  For people with BMI 30-35, with POORLY CONTROLLED diabetes:  There is very little information to guide us in this group of patients, but so far, it appears that bariatric surgery could provide a good opportunity to improve diabetes control.

3.  For people with BMI of ≥ 35 with GOOD CONTROL of their diabetes: Bariatric surgery can offer an opportunity to make diabetes go away - but for at least half of these patients (and possibly more over the longer term), the diabetes will come back.

4.  For people with BMI of 30-35 with GOOD CONTROL of their diabetes: Bariatric surgery can make diabetes go away, but we don't yet know what percentage return to diabetes.  Due to genetics, their risk of return to diabetes may be higher than those with BMI ≥35.

5.  Any patient whose diabetes goes into remission after bariatric surgery MUST be followed for the rest of their life for screening for the possible return of diabetes.

And of course, for ALL people who are thinking about having bariatric surgery, the risks and benefits of the procedure as a whole must be carefully weighed by both patient and their health care providers, to decide if this intervention is the right thing for them.



Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

PS - Bariatric surgery has been shown to PREVENT development of Type 2 diabetes as well (scientists - recent follow up to the SOS study published in the New England Journal of Medicine) - a story for another day's blog!

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Top 10 Advantages of Being Diabetic

This week, I want to share with you a truly inspirational blog - an amazing example of how a very positive light can be shed on having diabetes, or any chronic medical condition for that matter.

My friend Tim (not my patient) happens to be a Type 1 Diabetic, and he's written a truly inspiring post on his blog, about his perspective on how he sees his diabetes being an advantage in his life.  This blog brought tears to my eyes, from laughter (he's funny!), yes, but mostly from being so moved and heart warmed that he can find so many positive things in the challenges that he faces ever day.  

Not to mention that he's using his blog to raise funds for the Juvenile Diabetes Research Foundation.

Check it out - and please share your thoughts!

Tim's amazing attitude is summed up in his catch line at the top of his blog about Type 1 Diabetes:
No longer a type, but more a skillset.

Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

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Sweeteners - Friend or Foe?

Artificial sweeteners have long been available, as a way to sweeten drinks and food while avoiding the calorie impact of sugar.  Recently, sweeteners have been on the hot seat, as it has been questioned whether these chemicals are friend or foe in the battle of the bulge.


There are several sweeteners currently available (as blogged previously), and the first thing that bears saying is that each of these chemicals is a very different compound, so the effects of each one could be different.   (to jump over the scientific part of this discussion, skip to The Bottom Line below)

Interestingly, in recent years, we have learned that sweeteners can activate not only the sweet receptors in our mouths, but also in our intestines and our pancreas (though it's only the receptors in our mouths that give us the feeling of eating something sweet).  It has therefore been suggested that artificial sweeteners may have an effect on the production of appetite regulating hormones, leading to weight gain.

As recently reviewed, some 'test tube' (in vitro) studies have shown that artificial sweeteners can affect the production of appetite hormones from gut cells, while other test tube studies have shown no effect.  In human and animal studies, most have NOT shown an effect of sweeteners on appetite hormones.  Thus, overall, the research suggests that sweeteners do not have an effect on appetite - though the research is far from complete, and there is still a lot of ongoing study in this area. 

In addition, several studies have shown that a higher consumption of sweeteners is linked with a higher risk of obesity.  However, what these studies are not able to separate is whether higher sweetener consumption is seen in people who are overweight because they are drinking the sweeteners in an attempt to lose the weight, or whether the sweeteners are actually causing the weight struggle.   There is much research being actively done in the area to give us an answer to this question.

The Bottom Line: As it stands now, there is not enough evidence to convince us that sweeteners lead to weight gain, while the evidence that excess sugar leads to weight gain is very clear.  There are many excellent clinical trials underway in this area, which will hopefully give us more clarity on the subject.

Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

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Bisphenol A Exposure from Canned Soup

There is mounting evidence that exposure to a widely used chemical called bisphenol A is associated with an increased risk of obesity, diabetes, and metabolic syndrome.  A recent study reveals that eating canned soup for just 5 days can dramatically increase exposure to this potentially dangerous chemical.

Bisphenol A is a widely used chemical, found in a variety of products ranging from plastics to cash register receipts.  Most of our exposure is thought to be through food; in addition to being present in many water bottles and plastic food storage containers, it is also present in the interior epoxy coatings of many canned goods used to prevent corrosion.

The study was eloquently simple.  Seventy-five students and staff at the Harvard School of Public Health were each asked to eat soup for lunch for 5 consecutive days, and were randomly assigned to eating either canned soup, versus homemade soup from scratch. The following week, they ate soup each day for lunch once again, but they ate the opposite kind of soup from what they had eaten the week previously (researchers: thereby providing a randomized, single blinded, crossover design). 

The results were, in my opinion, quite astonishing: the researchers found that the bisphenol A levels in the urine were nearly twenty times higher after a week of canned soup consumption, compared to after homemade soup consumption.  Further, the urine bisphenol A levels after the canned food week were 60% higher than the higher end of urine bisphenol A levels noted in the general population. 

The study did not test the bisphenol A levels in the blood, so we don’t know if these people quickly cleared the bisphenol A from their systems, or whether the bisphenol A levels in their blood or other tissues was also elevated, or for how long.  That being said, the study does clearly show that just 5 days of eating canned soup dramatically increases exposure to this potentially harmful compound. 

Let’s hope that this study gives an extra push towards using bisphenol A – free linings to canned goods, as well as yet another reason to cook and enjoy healthy food made at home!  

Thanks to my friend and colleague Jon for pointing out this study!

Dr Sue Pedersen www.drsue.ca © 2012

drsuetalks@gmail.com 

Follow me on Twitter for daily tips! @drsuepedersen 

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