American Diabetes Association Issues New Standards Bolstering Role of Metabolic Surgery in Diabetes Treatment

Published in January Issue             

The American Diabetes Association’s 2017 Standards of Medical Care include a new and important emphasis on metabolic surgery for the treatment of type 2 diabetes.

“This year, the Standards include critical, new evidence-based additions—psychosocial care, expanded physical fitness, metabolic surgery and hypoglycemia—all of which can impact effective diabetes care,” said the Association’s Chief Scientific and Medical Officer
Robert E. Ratner, MD, FACP, FACE in a news release.

The 2017 Standards of Care incorporate several new guidelines issued in 2016 by the ADA, including those on physical activity, psychosocial health, metabolic surgery and hypoglycemia.

It also outlines a tiered approach to obesity management, including lifestyle intervention, pharmacotherapy, and bariatric surgery. The Standards became available online on Dec. 15, 2016, and are published as a supplement to the January 2017 issue of Diabetes Care.

The annually updated guidelines provide health care providers with all components of diabetes care, general treatment goals, and tools to evaluate quality care.

The recommendations expand the indications for metabolic surgery to include patients with inadequately controlled diabetes who have a BMI as low as 30.
Here are the main recommendations from the ADA on metabolic surgery:

  • Metabolic surgery should be recommended to treat type 2 diabetes in appropriate surgical candidates with
    BMI >40 kg/m2 (BMI >37.5 kg/m2 in
    Asian Americans), regardless of the level
    of glycemic control or complexity of
    glucose-lowering regimens, and in
    adults with BMI 35.0–39.9 kg/m2
    (32.5–37.4 kg/m2 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy.

  • Metabolic surgery should be considered for adults with type 2 diabetes and BMI
    30.0–34.9 (27.5–32.4 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications
    (including insulin).

  • Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and gastrointestinal surgery.

  • Long-term lifestyle support and routine monitoring of micronutrient and nutritional status must be provided to patients after surgery, according to guidelines for postoperative management of metabolic surgery by national and international professional societies.

  • People presenting for metabolic surgery should receive a comprehensive mental health assessment. Surgery should be postponed in patients with histories of alcohol or substance abuse, significant depression, suicidal ideation, or other mental health conditions until these conditions have been fully addressed.

  • People who undergo metabolic surgery should be evaluated to assess the need for ongoing mental health services to help them adjust to medical and psychosocial changes after surgery.

Philip Schauer, MD

“With these new guidelines, we can confidently say that metabolic surgery, based on sound scientific evidence, is now part of the standard of care for diabetes management. It’s historic. This has important medical and legal implications for patients, physicians and payers,” said Philip R. Schauer, MD, bariatric surgeon and director of Cleveland Clinic's Bariatric & Metabolic Center in Ohio.

The ADA first included bariatric, that it now calls metabolic surgery, only in 2011 when at that time it recommended that bariatric surgery may be considered for adults with BMI >35 and type 2 diabetes, especially if the diabetes or associated comorbidities are difficult to control with lifestyle and pharmacologic therapy.

“The 2017 Standards are completely compatible with the previously ADA endorsed International Guidelines from June 2016. In effect, we now have a double endorsement for metabolic surgery from ADA who is the world’s largest and arguably most influential diabetes organization in the world. Their annual publication sets the standard of care,” added Dr. Schauer, a past president of the ASMBS.

In 2016, metabolic surgery was included as a standard treatment option in clinical practice guidelines for people with diabetes, even for those who have mild obesity. The evidence-based guidelines were published in the June 2016 issue of Diabetes Care, and carry the endorsement of more than 45 international professional organizations including the ADA, the International Diabetes Federation (IDF) and ASMBS.

The Standards are established and revised annually by a Professional Practice Committee. The committee is a multidisciplinary team of 12 leading experts in the field of diabetes care, and includes physicians, diabetes educators, registered dietitians and others who have experience in areas including adult and pediatric endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning and pregnancy care.

“It has been a long climb, but worth it if we can get more patients treated who could benefit,” said Dr. Schauer. “But while these guidelines are endorsed by nearly all major diabetes organizations, they must be adopted by caregivers, patients and payers to have impact. ASMBS should continue to take an active role, along with other medical organizations, in encouraging payers (both government and private) to modify current coverage policy to be compatible with the new standards. This is especially true for eligible patients with BMI 30-34 since they are currently not covered for surgery in nearly all current coverage policies throughout the U.S.”