Should BMI or diabetes control determine who receives bariatric and metabolic surgery?
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BMI should determine who receives surgery.
It is more appropriate to use BMI as the determinant for metabolic and bariatric surgery in treatment of type 2 diabetes.
The 1991 NIH consensus statement on metabolic and bariatric surgery was recently updated by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), reflecting our enhanced understanding that surgery is a safe and effective tool for treating obesity and adiposity-related comorbidities, and people will benefit from bariatric surgery at lower BMI than proposed in the older guidelines.
The American Diabetes Association’s 2022 Standards of Care in Diabetes: Obesity and Weight Management for the Treatment of Type 2 Diabetes proposes surgery for those with type 2 diabetes and BMI of at least 30 kg/m2 or at least 27.5 kg/m2 for Asian American patients. Several randomized controlled trials and many other studies demonstrate the benefits of surgery for diabetes prevention, treatment and possible remission. Beyond this, for those who undergo surgery, there are significant reductions in microvascular complications, cardiovascular events, cancer occurrence and mortality.
Factors that improve chances for remission of type 2 diabetes after surgery include shorter duration of type 2 diabetes, better glycemic control and not requiring insulin therapy. While there are data showing significant postsurgical improvements in glycemic control for those with uncontrolled type 2 diabetes, there is a much greater chance for remission of type 2 diabetes if surgery is performed earlier in the course of disease and with better glycemic control — arguing against using diabetes control as the primary determining factor for metabolic and bariatric surgery.
A postsurgical weight loss of 20% or higher appears to impart the greatest odds of achieving diabetes remission, and procedures that lead to greater weight loss are associated with greater improvements in glycemia and likelihood for diabetes remission. This tracks with what we know about the impact of excess and dysfunctional adiposity on insulin resistance and the pathogenesis of type 2 diabetes.
By performing metabolic and bariatric surgery earlier during type 2 diabetes, or even before insulin resistance and metabolic syndrome have become type 2 diabetes, our patients have greater chances of having adiposity-related complications of obesity into remission. This will, in turn, lead to improvements in morbidity, mortality and quality of life.
Jaime Almandoz, MD, MBA, FTOS, is medical director of the weight wellness program and associate professor of internal medicine in the division of endocrinology at University of Texas Southwestern Medical Center. He can be reached at jaime.almandoz@UTSouthwestern.edu.
Diabetes control should be a component in determining who receives surgery for diabetes treatment.
Diabetes control is important, but it is not the endgame because diabetes does not come in isolation.
The way obesity affects patients and how it needs to be treated draws the closest analogy to cancer and cancer treatment. For example, patients who develop cancer don’t develop a disease that can be treated with one specialty — they need a multidisciplinary team. Depending on the stage of the cancer, they may need different treatments, and the more delays in treatment, the worse outcomes are. Obesity and diabetes are similar.
Obesity and type 2 diabetes are partners — a patient is diagnosed with one, is often diagnosed with the other, and if one improves then the other improves as well.
The longer a patient has diabetes and the more diabetes goes uncontrolled, the less chance that diabetes improves after bariatric or metabolic surgery. As early referral and treatment for cancer lead to better outcomes, the earlier referral of patients with type 2 diabetes and severe obesity to bariatric or metabolic surgery also yields better diabetes resolution. As patients with obesity gain more weight, their type 2 diabetes gets worse. When the patient has surgery to reduce their weight, the surgery has a metabolic effect before the person loses any weight.
Most patients will have severe obesity and type 2 diabetes together. Many patients also have high blood pressure, high cholesterol and sleep apnea. When we treat type 2 diabetes with specific medications, we are not addressing any of these other problems. With surgery, the improvement is not only to weight and quality of life, but also to diabetes, cardiovascular risk and cancer risk. In addition, today, metabolic and bariatric surgery is as safe as gallbladder surgery and hip replacement when done in appropriate centers of excellence.
Even for patients who are not diabetic and only have obesity, when they undergo metabolic and bariatric surgery, they are 80% less likely to develop diabetes 15 to 20 years later, which has been shown in the Swedish Obese Subjects study.
Diabetes control is important, but it’s not the only goal.
Abdelrahman Nimeri, MD, FACS, FASMBS, is associate professor of surgery and section chief of bariatric and metabolic surgery at Wake Forest School of Medicine and Carolinas Medical Center at Atrium Health. He can be reached at abdelrahman.nimeri@atriumhealth.org.
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